Fillable Vgli Beneficiary Designation/change Form (Page 4 of 4) in pdf

Vgli Beneficiary Designation/change Form Page 4

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(See Billing Statement)

Control #:

TRUST DESIGNATION –

COMPLETE IF A TRUST HAS BEEN NAMED AS A BENEFICIARY IN SECTION 2

Complete this section if you have named a trust as a primary or secondary beneficiary in Section 2. Fill in the name and address for each trustee.

Fill in the title and date of the Trust Agreement in the space provided.

Trust: “The John Doe Trust. A Trust with a trust agreement dated 1/1/2010 whose Trustee is Jane Smith.”

•

Select “Trust” as the Type in section 2.

•

Indicate the percentage to be assigned to the trust in section 2.

Complete the section below, Trust Designation.

•

1. Trustee Name:

(First, MI, Last)

Address:

2. Trustee Name:

(First, MI, Last)

Address:

And successor(s) in trust, as Trustee(s) under:

Title of Agreement

Dated

as amended and executed by me and said Trustee.

D D

M M

Date of Agreement

AUTHORIZATION / SIGNATURE

I authorize OSGLI to record and consider the individuals/institutions that I have named on this form as beneficiaries for VGLI benefits. If designating a

trust as beneficiary, I understand OSGLI assumes no obligation as to the validity or sufficiency of any executed Trust Agreement and does not pass on its

legality. In making payment to any Trustee(s), OSGLI has the right to assume that the Trustee(s) is acting in a fiduciary capacity until notice to the contrary

is received by OSGLI. I agree that if OSGLI makes any payment(s) to the Trustee(s) before notice is received, OSGLI will not make payment(s) again.

Veteran’s

Signature:

Date:

D D

The Veteran must sign and date this form.

M M

The signature date must be the date the Veteran actually signed the form.

Submit the completed form to:

The Prudential Insurance Company of America

Office of Servicemembers’ Group Life Insurance

P O BOX 41618