Beneficiary Change Form - PDF by KevinCrouthers

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									                                                                     Beneficiary Change Form
Use this form to designate beneficiaries for your Group Term Life Insurance and, if applicable, Accidental
Death & Dismemberment (AD&D) Insurance and Cash Balance Retirement Plan. Attach a separate sheet if
you have more than one primary or two contingent beneficiaries for each benefit. You may name different
beneficiaries for each benefit. Contact your TSA vendor for a form to designate TSA beneficiaries. Sign and
date the end of this form; keep a copy for your records. Please mail this form to the Partners Benefits
Office, 101 Merrimac St., Fifth Floor, Boston, MA 02114 or fax it to the Benefits Office at 617-726-8428.
You may also update your Group Term Life Insurance and AD&D insurance beneficiaries online at:
https://ibridge.partners.org

SECTION I – EMPLOYEE INFORMATION

Employee Name _______________________________                      Employee ID ________________________

Marital Status: ____ Single      ____ Married     ____ Divorced      ____ Widowed ____ Separated

SECTION II – DESIGNATION OF BENEFICIARIES

Group Term Life Insurance                                       ___ Basic         ___ Optional

Primary Beneficiary(ies): (receive your benefit in the event of your death, in the percentages you list below)
______________________________________________________________________________________________________________
Name                                Address                                                      Phone Number
______________________________________________________________________________________________________________
Social Security #                   Relationship to employee       Date of Birth          % of benefit to be paid

Contingent Beneficiary(ies): (if primary beneficiary(ies) is/are deceased, contingent beneficiaries receive benefit in percentages
 you list below).
______________________________________________________________________________________________________________
Name                                Address                                                       Phone Number
______________________________________________________________________________________________________________
Social Security #                   Relationship to employee      Date of Birth             % of benefit to be paid

______________________________________________________________________________________________________________
Name                                Address                                                       Phone Number
______________________________________________________________________________________________________________
Social Security #                   Relationship to employee       Date of Birth            % of benefit to be paid

Accidental Death and Dismemberment (AD&D) Insurance ___ Basic ___ Optional
  Beneficiaries same as above (otherwise, please fill in below)

Primary Beneficiary(ies):
______________________________________________________________________________________________________________
Name                                Address                                                       Phone Number
______________________________________________________________________________________________________________
Social Security #                   Relationship to employee       Date of Birth            % of benefit to be paid

Contingent Beneficiary(ies):
_____________________________________________________________________________________________________________
Name                                Address                                                       Phone Number
______________________________________________________________________________________________________________
Social Security #                   Relationship to employee       Date of Birth            % of benefit to be paid

______________________________________________________________________________________________________________
Name                                Address                                                       Phone Number
______________________________________________________________________________________________________________
Social Security #                   Relationship to employee        Date of Birth           % of benefit to be paid
Cash Balance Retirement Plan
  Beneficiaries same as above (otherwise, please fill in below)

Note: If you are married and designate a primary beneficiary other than your spouse for the retirement plan, your
spouse must complete section III and it must be notarized or witnessed by a retirement plan representative.

Primary Beneficiary(ies):
______________________________________________________________________________________________________________
Name                                Address                                                        Phone Number
______________________________________________________________________________________________________________
Social Security #                   Relationship to employee         Date of Birth         % of benefit to be paid


Contingent Beneficiary(ies):
______________________________________________________________________________________________________________
Name                                Address                                                       Phone Number
______________________________________________________________________________________________________________
Social Security #                   Relationship to employee         Date of Birth          % of benefit to be paid

_____________________________________________________________________________________________________________
Name                                Address                                                       Phone Number
______________________________________________________________________________________________________________
Social Security #                   Relationship to employee         Date of Birth          % of benefit to be paid


 SECTION III- CONSENT OF SPOUSE:

(required only if you are married and your spouse is not the primary beneficiary of your retirement plan benefit)

I, the spouse of the employee completing this form, have read this Beneficiary Designation Form and understand that:

    •   As long as this beneficiary designation is in effect, I am relinquishing a right to a benefit which I am entitled by law.
    •   I may contact a Plan Representative to discuss my rights under the Plan and/or I may seek the advice of legal counsel
        before signing this consent.
    •   After I have signed this consent, I may not withdraw it.
    •   I understand that my signature must be witnessed by a notary public or an authorized representative of the Retirement
        Committee.

I consent to the beneficiary designation listed in Section II above and hereby waive my right to receive a death benefit to
which I am legally entitled.

Signed before me on this ___ day of _________, _______.           ___________________________________
                                                                     Signature of Spouse
_________________________________________
Signature of Notary Public or Plan Representative



Employee Signature: ___________________________________                          Today’s date __________

In the event of your death, payment of the above-listed benefits will be based on the most current designation on file in the
Benefits Office. This designation will remain in effect until changed by you in writing or as required by plan provisions.
.
                                                                                                    Form Revised 5/09

								
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