Vgli Beneficiary Designation/change Form Page 3
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4Control #:
(See Billing Statement)
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B. Secondary Beneficiaries are the person(s) or entity you choose to receive your life insurance proceeds if the primary beneficiary(ies) die (or
the entity dissolves) before you die. Payment will be made in equal shares unless otherwise specified. In the event that a designated secondary
beneficiary predeceases the insured, the proceeds will be paid to the remaining secondary beneficiaries in equal shares or all to the sole remaining
secondary beneficiary.
1. Type
Charitable Institution
Child
Parent
Spouse
Other Family
Other
Trust
Estate
(Select One)
Male
Female
Gender:
First Name:
MI:
Last Name:
Address:
SSN:
Phone:
Payment:
36 Equal Monthly Payments
Share:
%
Lump Sum*
2. Type
Child
Parent
Spouse
Other Family
Other
Trust
Estate
Charitable Institution
(Select One)
Gender:
Male
Female
MI:
First Name:
Last Name:
Address:
SSN:
Phone:
Payment:
36 Equal Monthly Payments
Share:
%
Lump Sum*
3. Type
Child
Parent
Spouse
Other Family
Other
Trust
Estate
Charitable Institution
(Select One)
Gender:
Male
Female
MI:
First Name:
Last Name:
Address:
SSN:
Phone:
Payment:
36 Equal Monthly Payments
Share:
%
Lump Sum*
TOTAL:
%
Please copy this page to list additional beneficiaries.
Must equal 100%
* If the insured member elects a lump sum payment, the beneficiary(ies) will be given the option of receiving the lump sum payment through the
Prudential Alliance Account
, by check, or Electronic Funds Transfer (EFT). Alliance Account is not available for payments less than $5,000,
®
payments to individuals residing outside the United States and its territories, and certain other payments. These will be paid by check.
The Bank of New York Mellon is the Administrator of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential Insurance Company
of America, located at 751 Broad Street, Newark, NJ 07102-3777. Draft clearing and processing support is provided by The Bank of New York Mellon. Alliance
Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). The Bank of New York Mellon is not a Prudential Financial company.
*06100B03*
GL.2006.100B Ed. 06/2014
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