LIFE INSURANCE BENEFICIARY DESIGNATION FORM
This form may be used to designate beneficiaries for your basic life insurance, optional life insurance, accidental death and dismemberment, and business travel accident plans. Your completed form must be returned to your local Human Resources representative. Please be sure to sign your form and make a copy for your records.
Your Beneficiary(ies) (please print all information) Please provide the following information about the beneficiary(ies) you wish to designate. If you want to designate the same beneficiary for each plan, be sure to check, all the appropriate boxes. If you want to designate separate beneficiaries for each plan, provide the requested information for each beneficiary and check the appropriate plan boxes. If you need more room, provide the information requested on a separate piece of paper and attach to this form. Primary Beneficiary(ies) Name 1. Address Basic Life Insurance Supplemental Life Insurance AD&D Insurance Business Travel Accident Insurance Soc. Sec. No. Date of Birth Relationship Share(s) Must Total 100%
2. Address Basic Life Insurance Supplemental Life Insurance AD&D Insurance Business Travel Accident Insurance
3. Address Basic Life Insurance Supplemental Life Insurance AD&D Insurance Business Travel Accident Insurance
If any of the primary beneficiaries I've designated above are not living at the time of my death, I request that any amounts which would have been payable to them if still living, be made as follows: To my estate, or To the surviving primary beneficiary(ies) named above, if any, in proportion to their shares as indicated above, or To the contingent beneficiary(ies) indicated on the other side of this form.
Contingent Beneficiary(ies) Name 1. Address Basic Life Insurance 2. Address Basic Life Insurance 3. Address Basic Life Insurance Supplemental Life Insurance AD&D Insurance Business Travel Accident Insurance Supplemental Life Insurance AD&D Insurance Business Travel Accident Insurance Supplemental Life Insurance AD&D Insurance Business Travel Accident Insurance Soc. Sec. No. Date of Birth Relationship Share(s) Must Total 100%
Examples of Beneficiary Designations There are several ways to designate beneficiaries and beneficiary amounts:
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If you want to designate one beneficiary only, write the full name, soc. sec. no. , date of birth, relationship, and share of benefit amount (100%) If you want to designate two or more beneficiaries with equal amounts, write each full name, soc. sec. no., date of birth, relationship, and share of benefit amount
For example:
Mary J. Smith, 123-45-6789, 5/18/60, Spouse, 100%
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For example:
Mary J. Smith, 123-45-6789, 5/18/60, Spouse 33-1/3%; Alice C. Smith, 234-56-7890, 2/22/59, Sister, 33-1/3% Richard B. Smith, 346-67-8901, 12/13/55, Brother, 33-1/3%; or to the survivor(s) equally Mary J. Smith, 123-45-6789, 5/18/60, Spouse, 50%; Alice C. Smith, 234-56-7890, 2/22/59 Sister, 30%; Richard B. Smith, 345-67-8901, 12/13/55, Brother, 20%; or the share of any deceased beneficiary will be paid in equal shares to the survivor(s) Mary J. Smith, 123-45-6789, 5/18/60, Spouse, if living, 100%; Otherwise Marie A. Jones, 567-89-1088, 8/12/87, Child, 50%; Thomas W. Smith, 456-78-9011, 10/12/89, Child, 50%, or to the survivor The Trust Company of Smith, Illinois as Trustee under a Trust instrument dated November 30,1980 Estate of the Insured
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If you want to designate two or more beneficiaries with unequal amounts, write each full name, soc. sec. no., date of birth, relationship, and share of benefit amount If you want to designate a primary and contingent beneficiary, write each full name, soc. sec. no., date of birth, relationship, and share of benefit amount
For example:
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For example:
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If you want to designate a trustee beneficiary, write the full name of the trustee and date of the trust agreement If you want to designate an estate beneficiary
For example: For example:
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Authorization (please print) I designate the name(s) shown above as my beneficiary(ies) under these plans--in the shares specified--for amounts due under the plans as a result of my death I reserve the right to change these beneficiary designations at any time. Name First Social Security Number Signature Middle Work Location Date FOR OFFICE USE ONLY Date Received Date Processed Processors Initials 10/93 Last