Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 756 MD (2004/09)
Maryland Life Insurance
Application Supplement -
Additional Beneficiaries
Use ACORD Maryland Life Insurance Application Supplement - Additional Beneficiaries
(ACORD 756 MD), when more space is required for Additional Beneficiaries.
IDENTIFICATION SECTION Company
Name and Address of Insurance
Name of Insurance Company must be inserted before this form is used. Use the actual
name of the company. Do not use group names.
PROPOSED INSURED
First Name
First name of the proposed insured.
PROPOSED INSURED
Middle Name
Middle name of the proposed insured.
PROPOSED INSURED
Last Name
Last name of the proposed insured.
PROPOSED INSURED
Case ID
Insert the identification number that identifies the case in the agency system.
ADDITIONAL BENEFICIARY
Notice: Unless you specify otherwise, payments will be shared equally by all primary
beneficiaries who survive the Proposed Insured(s) or, if none, by all contingent
beneficiaries who survive the Proposed Insured(s). The right to change the beneficiary is
reserved to the Owner unless otherwise stated. * Default is No if neither box is checked.
ADDITIONAL BENEFICIARY Irrevocable? Yes or No
Check the appropriate box to indicate whether or not the beneficiary is irrevocable.
ADDITIONAL BENEFICIARY Primary, Contingent or Other
Check the appropriate box to indicate whether or not the beneficiary is primary, contingent
or other. (Explain other in remarks section).
ADDITIONAL BENEFICIARY First Name
First name of the beneficiary.
ADDITIONAL BENEFICIARY Middle Name
Middle name of the beneficiary.
ADDITIONAL BENEFICIARY Last Name
Last name of the beneficiary.
ADDITIONAL BENEFICIARY Name of Trustee
Indicate the name of the Trustee.
ADDITIONAL BENEFICIARY Date of Trust Agreement
Indicate the date of the Trust Agreement. (MM/DD/YYYY)
ADDITIONAL BENEFICIARY Full Name
If other than individual, give full name of the beneficiary.
ADDITIONAL BENEFICIARY Address (No P.O. Box) Line 1
Indicate the address of the beneficiary. Do not use P.O. Box number. Check if this
address is the preferred method of mailing.
ADDITIONAL BENEFICIARY Line 2
Address - Line 2.
ADDITIONAL BENEFICIARY City
Indicate the city of the address.
ACORD 756 MD (2004/09)
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Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 756 MD (2004/09)
Maryland Life Insurance
Application Supplement -
Additional Beneficiaries
Use ACORD Maryland Life Insurance Application Supplement - Additional Beneficiaries
(ACORD 756 MD), when more space is required for Additional Beneficiaries.
ADDITIONAL BENEFICIARY State
State of the address.
ADDITIONAL BENEFICIARY Zip
Zip code, postal code, etc. (country dependent)
ADDITIONAL BENEFICIARY Country
Indicate the country of the address.
ADDITIONAL BENEFICIARY Date of Birth
Indicate the date of birth of the producer in MM/DD/YYYY format.
ADDITIONAL BENEFICIARY SSN # / TIN #
Social Security Number or Tax Identification Number of the beneficiary.
ADDITIONAL BENEFICIARY Relation To Proposed Insured
Indicate the relation to the proposed insured.
ADDITIONAL BENEFICIARY % Share
Indicate percentage of distribution for beneficiary.
SIGNATURE
Signature of Original Owner as
Shown on Part 1 of this
Application
Original Owner must sign the form, if other than proposed insured.
SIGNATURE
Date
Date original owner signed the form.
ACORD 756 MD (2004/09)
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