Address Change Form - Long Term Care & Life Insurance ...
Genworth Life & Annuity Genworth LIfe Genworth Life of New York P.O. Box 6158 Lynchburg, VA 24505 Tel: 888 322.4629 NY Tel: 888 253.2288
Address Change Form
from Genworth Life and Annuity Insurance Company, Genworth Life Insurance Company, and Genworth Life Insurance Company of New York
Page 1 of 1
? It is important that you maintain a current mailing address with the Company so that your checks are received on a timely basis. If you have chosen to have your payments sent directly to your bank, it is still very important that we maintain a current address of residence for general correspondence and tax forms where applicable.
Only Genworth Life Insurance Company of New York is admitted in and conducts business in New York.
Address change information
Include title if applicable for each signature. i.e. Co-Trustee, Co-Executor, Joint Owner
Change of Address of: Payee
Measuring Life/Annuitant
Owner
Contract number Use only the spaces needed
Name(s)
Date of birth
Social Security Number
Old address
City
State
Zip
New address
City
Phone number
State
Zip
This address change is for my residence address only.
Signature
X
Trustee Guardian
Attorney-in-fact POA Title/office:
Date of signature
Other required signature
Date of signature
X
Trustee Guardian
Attorney-in-fact POA Title/office:
*The owner's approval of this address change may be necessary.
Owner signature
X
Trustee Guardian
Attorney-in-fact POA Title/office:
Address change acknowledged and processed
Date of signature
Date
602ADDUFL 04/25/11
................
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