WSA Fraternal Life - Download Forms!

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The following forms are available for download:

Form:	Use this form to:	Notes:
Application for Modification of Certificate Contract	Change your beneficiary of your certificate Change the owner of your certificate Change the name of the insured on your certificate	Complete in duplicate All signatures must be notarized
Integricheck (EFT) Authorization	Authorize electronic funds transfer to pay your life premiums, annuity deposits, or mortgage payment to WSA	Include a voided blank check or deposit slip showing your pre-printed routing transit number and bank codes.
Operation/Dismemberment Claim	Request and document Operation and/or Dismemberment benefit claims	Must be completed and signed by the Physician or Surgeon
Application for Cash Surrender	Request cash surrender of life certificates	Must be signed by the insured and payer/owner All signatures must be notarized
Application for Change of Address	Request change of address for certificates and/or payer	Must be signed by the insured and payer/owner

Scholarship Program Application	Includes program requirements and application form	Requires additional documentation Subject to a submission deadline
Continuing Education Application	Includes program requirements and application form	Requires additional documentation Subject to a submission deadline

Terms & Conditions/Liability Waiver	You must sign and return this form prior to participating in any WSA sponsored event.	Requires parent signature for participants under 18 years of age

To request other forms via email, FAX, or postal service, click here.

800-WSA-LIFE
303-451-1494
FAX - 303-451-5112

11265 Decatur Street
Suite 100
Westminster, CO 80234

Mail:
PO Box 351920
Westminster, CO 80035-1920

E-mail:
info@wsalife.com

Privacy Policy

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WSA Fraternal Life is not licensed in all states. Nothing contained herein should be construed as
a solicitation for insurance or annuity products in any state in which WSA Fraternal Life is not licensed.

Click here for a compete list of states in which WSA Fraternal Life is licensed.

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Participation in any WSA Fraternal Life event constitutes agreement to the
Terms and Conditions for Participation in WSA Events