THIS FORM MUST BE RETURNED
LET US KNOW WHO YOUR BENEFICIARY IS.

IMPORTANT: Enclosed in your new member packet, you will find a "Schedule of Benefits" which represents the Accidental Death & Dismemberment policy that comes with your AHCA membership. If you have not already done so, this form should be returned to our office immediately for beneficiary verification. Please complete, sign and return to: AHCA, P.O. Box 3190, Cerritos, California 90703-3190.

PLEASE PRINT

Name of policyholder: Name of Insured:
DBA:
Certificate #: Policy Number:
BENEFICIARY DESIGNATION

(List name and relationship of beneficiary)
CHANGE OF NAME:
Change my name from: To:
Date: Signature of Insured: _________________________________