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Get Application For Modification Of Certificate Contract

Il to: info wsalife.com or Fax to: 303-451-5112 Please call WSA at 303-451-1494 or 800-451-7528 with questions. I, the undersigned (hereinafter referred to as the Insured ) member of Lodge, Number of W.S.A. Fraternal Life (hereinafter referred to as the Association ), request the following changes for Certificate Number : I hereby revoke all other designations of beneficiaries heretofore made by me. Upon the surr.

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