Transamerica Beneficiary Designation Form printable pdf download

Return Completed Forms to:

Beneficiary

Transamerica Employee Benefits

Designation

P.O. Box 8063

Little Rock, Arkansas 72203-8063

Form

Phone: (888) 763-7474

Fax: (866) 945-8691

Policy Owner Name

Social Security No.

(Last, First, M.I.)

Insured Name(s)

Social Security No.(s)

(Last, First, M.I.)

Policy No.

Employer Name

SD No.

I elect to designate the beneficiary(ies) under the above numbered policy issued as follows:

Primary Beneficiary(ies): For multiple beneficiaries, payment will be made in equal shares unless otherwise noted below.

Full Name (as it should

appear on company records)

Street Address

City/State/Zip

Relationship

Date of Birth

Contingent Beneficiary(ies): Receives proceeds only if all Primary Beneficiaries predecease the Insured. For multiple beneficiaries, payment will be

made in equal shares unless otherwise noted.

Full Name (as it should

appear on company records)

Street Address

City/State/Zip

Relationship

Date of Birth

It is understood and agreed that, unless otherwise directed, proceeds will be paid in accordance with the policy provisions.

I understand that this beneficiary designation will not become valid until the signed form is received by Transamerica Life Insurance Company at the

address listed above. Further, I understand that if benefits have been assigned under this contract, the Assignee must also sign this form in order for the

designation to become valid. I agree that this designation will replace any existing beneficiary designations on my contract, if applicable.

Signed in (City/State)

This

Day of (Month/Year)

Current Policy Owner

Witness

Policy Owner Marital Status  Married

 Single

Spouse (required in community

property states.)*

Witness

Assignee (if applicable)

Witness

Instructions

Section 1

Enter policy owner name and social security number, insured name and serial number, and policy or certificate number, if applicable. Include

the name of all Insured parties and Employer’s name. Please provide us with the Salary Deduction case number (if available).

Section 2

If you are selecting multiple beneficiaries, be sure to include the percentage amount that you would like for each beneficiary to receive,

otherwise payment will be made in equal shares. If the proposed beneficiary is a married woman, use her own given and maiden names and

her husband’s surname (e.g., “Mary Joan Smith Jones”, not “Mrs. John J. Jones”).

Section 3

The following signatures are required:

(a) Policy Owner (If there are 2 or more co-owners, the signatures of each co-owner are required)

*(b) Spouse of Policy Owner (If Married, Spouse of Policy Owner must sign if residence is in one of the community property states of:

Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin.)

(d) EACH SIGNATURE MUST BE WITNESSED BY A DISINTERESTED PARTY.

ALL SIGNATURES MUST BE WRITTEN IN INK AND WRITTEN EXACTLY AS THE NAME IS GIVEN IN THE POLICY OR ASSIGNMENT.

FOR ADMINISTRATIVE OFFICE USE ONLY

The above requested beneficiary designations are herby acknowledged and recorded on the books of the Company indicated above.

Date Recorded

TEB-Beneficiary-091211

* Spouse or equivalent, as defined by governing state law.

Transamerica Beneficiary Designation Form

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