Life Insurance Beneficiary Form

							                                          Group-Term BASIC & SUPPLEMENTAL LIFE INSURANCE
                                                            BENEFICIARY DESIGNATION FORM

As a benefit-eligible full-time or part-time employee of Summa Health System, you are provided a basic group
life insurance and AD&D (accidental death & dismemberment) benefit at no cost. In addition to the basic life
benefit, you may also be enrolled in supplemental group life insurance. It is important that you name a
beneficiary(ies) to your life insurance benefit in the event of your death.


EMPLOYEE NAME: _______________________________________________________ EMPLOYEE NUMBER: _______________
                                                (Please Print)

If you designate more than one beneficiary, you must specify the percentage each should receive, or all
beneficiaries will share the benefit equally. Attach a separate sheet if necessary. If no percentages are
indicated, an equal division is assumed. If this section is not completed, benefits will be paid to your Estate.

PRIMARY BENEFICIARY INFORMATION: The undersigned hereby
requests that all previous primary beneficiary designations and settlement
options elected be revoked and makes the following designations (If no entry
is made, previous designations and/or elections will remain unchanged):

                  NAME (last name, first, middle initial):                       RELATION TO YOU:     BENEFIT PERCENTAGE:




CONTINGENT (SECONDARY) BENEFICIARY INFORMATION: The
undersigned hereby requests that all previous contingent beneficiary
designations and settlement options elected be revoked and makes the
following designations (If no entry is made, previous designations and/or
elections will remain unchanged):
                                                                                 RELATION TO YOU:     BENEFIT PERCENTAGE:
                  NAME (last name, first, middle initial):




 ________________________________________________                    _______________   ________________   ________________
                    Employee Signature                                      Date            Work Phone        Home Phone

           RETURN THIS COMPLETED FORM TO EMPLOYEE BENEFITS, SUMMA ST. THOMAS HOSPITAL

7/09