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Get Bankers Life Proof Of Residence Form

Please mail Address Change Request Form to Policy Benefits Department PO Box 1902 Carmel IN 46082-1902 Or Fax to 312-396-5952 18895 8/12 Copyright 2012 Bankers Life and Casualty Company. ADDRESS CHANGE REQUEST www. bankers. com All address change requests must be submitted in writing. Use this form to request a permanent change of address. Please allow 30 days for the address change to be processed* Policyholder s Name Claimant s Name Policy Number s PLEASE CHANGE MY ADDRESS TO Address City State Zip code Effective Date of Change This address change will remain in effect until further written notification is received* Name of person completing this form please print Signature of Policyholder or Legal Representative Date Signed Month/Date/Year Policyholder or Legal Representative Name Please Print Signed at City/County/State If Legal Representative give relationship to Policyholder Attach a copy of your legal authority Power Of Attorney guardianship etc* if applicable PLEASE NOTE Statement Claim Checks Explanation of Benefits EOB. This form must be signed and dated by the policyholder or Legal Representative in order to be considered valid* Without proper signature s or documentation this document is null and void* If you have further questions please feel free to contact our Customer Service Department at 1-800-621-3724 between the hours of 8 00 AM 4 30 PM Central Time Monday through Friday. ADDRESS CHANGE REQUEST www. bankers. com All address change requests must be submitted in writing. Use this form to request a permanent change of address. Please allow 30 days for the address change to be processed* Policyholder s Name Claimant s Name Policy Number s PLEASE CHANGE MY ADDRESS TO Address City State Zip code Effective Date of Change This address change will remain in effect until further written notification is received* Name of person completing this form please print Signature of Policyholder or Legal Representative Date Signed Month/Date/Year Policyholder or Legal Representative Name Please Print Signed at City/County/State If Legal Representative give relationship to Policyholder Attach a copy of your legal authority Power Of Attorney guardianship etc* if applicable PLEASE NOTE Statement Claim Checks Explanation of Benefits EOB. Please allow 30 days for the address change to be processed* Policyholder s Name Claimant s Name Policy Number s PLEASE CHANGE MY ADDRESS TO Address City State Zip code Effective Date of Change This address change will remain in effect until further written notification is received* Name of person completing this form please print Signature of Policyholder or Legal Representative Date Signed Month/Date/Year Policyholder or Legal Representative Name Please Print Signed at City/County/State If Legal Representative give relationship to Policyholder Attach a copy of your legal authority Power Of Attorney guardianship etc* if applicable PLEASE NOTE Statement Claim Checks Explanation of Benefits EOB. This form must be signed and dated by the policyholder or Legal Representative in order to be considered valid* Without proper signature s or documentation this document is null and void* If you have further questions please feel free to contact our Customer Service Department at 1-800-621-3724 between the hours of 8 00 AM 4 30 PM Central Time Monday through Friday.

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