Because you are a New Jersey resident senior citizen (age 62 or older) and because you are insured by a life certificate or annuity contract with us, Polish Women's Alliance of America, you have a right to designate a third party to receive a copy of any notice of cancellation, nonrenewal, conditional renewal and lapse.

A third party may be designated by completion of the information requested in the Third Party Designation form below and return to us by certified mail, return receipt requested. The designation will be effective upon our receipt of all of the information below including signature of the Third Party acknowledging acceptance of the designation.

Designation of a third party does not constitute the acceptance of any liability for the services provided to the person by the third party or us.

The third party designation may be terminated by: the third party by written notice to both the person and to us: or, the owner/insured by written notice to us.