Optional Group Term Life Beneficiary Designation
PURPOSE
TCDRS-51 Revised 12/2007 Page 1 of 2
To designate a beneficiary for the Optional Group Term Life benefit. This beneficiary designation does not affect your retirement beneficiary. You can have different beneficiaries for this benefit and your retirement account.
INSTRUCTIONS
1. Complete the Member Information section. 2. Designate your primary and alternate beneficiary(ies) on this form. 3. Sign and date the bottom of the form. 4. If you want to name more than three primary or alternate beneficiaries, please include an Additional Beneficiary Attachment form (TCDRS-95). 5. Send the form to: TCDRS, Attn: Member Benefits, P.O. Box 2034, Austin,TX 78768-2034
REFERENCE
The Optional Group Term Life Program brochure.
ADDITIONAL INFORMATION
If you want the beneficiary for your retirement account to also receive your Optional Group Term Life benefit, please do not fill out this form. If you complete this form and later send in a new Beneficiary Designation form (TCDRS-06) for your retirement account, TCDRS will not change your Optional Group Term Life beneficiary. Once you’ve designated a beneficiary using this form you must send in a new Optional Group Term Life Beneficiary Designation form (TCDRS-51) to change your beneficiary.
CONTACTING TCDRS
If you have any questions, please call TCDRS Member Services at 800-823-7782.
TCDRS CANNOT ACCEPT
• An incomplete form • A form that is not signed • Changes that are not initialed by the person signing the form • Any form filled out in pencil
TCDRS ★ P.O. Box 2034 ★ Austin,TX 78768-2034 ★ (512) 328-8889 or 800-823-7782 ★ Fax: (512) 328-8887 ★ www.tcdrs.org
Optional Group Term Life Beneficiary Designation
MEMBER INFORMATION
First Name Address City State Zip Code Middle Initial or Name Last Name Birth Date Daytime Phone Number How else can we contact you?
TCDRS-51 Revised 12/2007 Page 2 of 2
Social Security Number
PRIMARY BENEFICIARY
Benefits will be divided equally among all persons listed as primary beneficiaries, unless otherwise noted by you on this form.
Beneficiary Name Address Beneficiary Name Address Beneficiary Name Address Birth Date City Birth Date City Birth Date City Relationship to You State Relationship to You State Relationship to You State Social Security Number Zip Code Social Security Number Zip Code Social Security Number Zip Code
Custodian under the Texas Uniform Transfers to Minors Act
To be named for those primary beneficiaries listed above who are under 18 years of age at my death. Custodian’s Name (must be at least 21 years of age) Relationship to You Daytime phone number Address City State Zip Code
ALTERNATE BENEFICIARY (OPTIONAL)
Benefits will be divided equally among all persons listed as alternate beneficiary, unless otherwise noted by you on this form.
Beneficiary Name Address Beneficiary Name Address Beneficiary Name Address Birth Date City Birth Date City Birth Date City Relationship to You State Relationship to You State Relationship to You State Social Security Number Zip Code Social Security Number Zip Code Social Security Number Zip Code
Custodian under the Texas Uniform Transfers to Minors Act
To be named for those primary beneficiaries listed above who are under 18 years of age at my death. Custodian’s Name (must be at least 21 years of age) Relationship to You Daytime phone number Address City State Zip Code
MEMBER CERTIFICATION
I hereby designate the beneficiary(ies) named on this form to receive any benefit payable from the Optional Group Term Life Insurance program. All previous beneficiary designations for the Optional Group Term Life Insurance Program are revoked by filing this form with TCDRS. Should a beneficiary designated on this form predecease me, or if I become divorced from the designated beneficiary, then this designation is revoked with respect to that beneficiary and benefits would be paid to the surviving primary beneficiaries, or to the surviving alternate beneficiaries if I am not survived by any primary beneficiary. Payments will be made in equal shares unless I have provided other instructions in writing on this form.
Member Signature Date
X
Any corrections or whiteouts must be initialed.
TCDRS ★ P.O. Box 2034 ★ Austin,TX 78768-2034 ★ (512) 328-8889 or 800-823-7782 ★ Fax: (512) 328-8887 ★ www.tcdrs.org