Fillable Vgli Beneficiary Designation/change Form printable pdf download

Office of Servicemembers'

VGLI Beneficiary Designation/Change

Group Life Insurance

VETERAN INFORMATION

(please print clearly using capital letters)

All the information in this section is required.

First Name:

MI:

Last Name:

(See Billing Statement)

Social Security #:

Control #:

Address:

City:

State:

ZIP Code:

Check here if your address has changed

Email:

Daytime Phone:

Evening Phone:

By Law – If you do not name a specific beneficiary, your insurance will be paid to your survivors as follows:

1. Widow or widower; if none to

2. Child(ren) in equal shares, with the share of any deceased child distributed among the descendants of that child; if none to

3. Parent(s) in equal shares; if none to

4. A duly appointed executor or administrator of the insured’s estate, and if none, to

5. Other next of kin

Check here if you want by law designations, and complete and return only sections 1 and 4.

INSTRUCTIONS FOR COMPLETING THIS FORM

Use this form to designate or make changes to the beneficiary(ies) of your VGLI death proceeds. The information on this form will replace any prior beneficiary

designation. You may name anyone or any entity as your beneficiary without anyone knowing or consenting to it. You may change your beneficiary at any time

by completing a new VGLI Beneficiary Designation/Change form. This form cannot be used to reinstate your coverage if your insurance is not in force due to

failure to pay timely premiums.

INSTRUCTIONS FOR DESIGNATING A PRIMARY OR SECONDARY BENEFICIARY (SECTION 2)

•

You may name more than one primary and more than one secondary beneficiary. This form allows you to name up to three primary and three

secondary beneficiaries.

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You can name an individual, corporation/organization, trust, or an estate as a beneficiary. The following examples may be helpful in

designating beneficiaries:

Individual : “Mary A Doe”

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Each name should be listed as first name, middle name, last name (“Mary A Doe,” not “Mrs M Doe”).

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