Beneficiary Form by qbQK4BBT



                   Your Beneficiary (ies) For Term Life Insurance
Beneficiary    Relationship     Social        Date of        Code*                 %
  Name               to        Security        Birth      (see below)         Percentage
                Participant    Number                                           to each

I hereby designate the listed beneficiary (ies) under my said plan(s) in the event of my
death. If more than one beneficiary is named, amounts payable under the plan shall be
paid in equal shares to the designated beneficiaries who survive me, unless otherwise
indicated. If no beneficiary survives me, payment will be made in accordance with the
terms of the plan. I understand that the designation of a beneficiary on this form revokes
a prior beneficiary designation for the same plan. Beneficiary designations for plans
other than those listed above are not affected by this form. This form does not
change beneficiary designations under PSERS.

Participant’s Signature

Social Security Number (REQUIRED)


This form is not valid without an original signature and date by the participant and must
be returned to the Phoenixville Area School District Benefits Office prior to the
participant’s death. Remember to keep a copy for your records.

*-Codes: P= primary beneficiary; C = contingent beneficiary

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