AGENT CHANGE OF ADDRESS FORM
ManhattanLife Insurance and Annuity Company | The Manhattan Life Insurance Company Standard Life and Casualty Insurance Company | Western United Life Insurance Company
10777 Northwest Freeway, Houston, Texas 77092 Fax: 713-821-6472 Email: Commissions@ManhattanLife.com
ATTN: Commissions
Agent Signature_ _______________________________________________________ Social Security Number or EIN_____________________________________________ Agent Number__________________________________________________________
Agent Information
Old Address_ __________________________________________________________ _____________________________________________________________________ New Address___________________________________________________________ _____________________________________________________________________ Old Phone #_ ______________________ New Phone #_ _____________________ Old Email__________________________ New Email_________________________ Old Address_ __________________________________________________________ _____________________________________________________________________ New Address___________________________________________________________ _____________________________________________________________________ Old Phone #_ ______________________ New Phone #_ _____________________ Old Email__________________________ New Email_________________________
Business Information
Personal Information
Form not intended to change a Policyholder’s address.
AGT-ADDCHFRM 0625
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