Beneficiary Designation Form Page 2
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1
2BENEFICIARY DESIGNATION
Clear Form
Initial Beneficiary Designation(s) OR
Change of all prior beneficiary designation(s) (check only one box), I hereby revoke any
previous beneficiary designation(s), if any, for my group term life insurance and/or accidental death and dismemberment (AD&D) insurance issued to
this group or employer and direct that the insurance proceeds payable under the policy be paid as indicated below.
Employee Name:
Employee ID Number:
Social Security Number:
X X X
X X
Employee Address:
Telephone Number:
(
)
Policyholder/Employer:
Policy Number:
NAMING YOUR GROUP LIFE BENEFICIARY
It is important that your beneficiary designation be clear so there will be no question as to your intent. It is also important
that you name a primary and contingent beneficiary. If you need assistance, contact your Company representative or your
own legal counsel. Benefits payable for a Dependent’s death are payable, where applicable, to You if living, otherwise, We
may, at Our option, pay the benefit to Your surviving spouse or to the executors or administrators of Your
estate.
PRIMARY BENEFICIARY(IES)
Name:
Date of Birth:
Address:
Telephone Number: (
)
Social Security Number:
Relationship:
Benefit Percent:
%
Name:
Date of Birth:
Address:
Telephone Number: (
)
Social Security Number:
Relationship:
Benefit Percent:
%
Name:
Date of Birth:
Address:
Telephone Number: (
)
Social Security Number:
Relationship:
Benefit Percent:
%
CONTINGENT BENEFICIARY(IES)
Name:
Date of Birth:
Address:
Telephone Number: (
)
Social Security Number:
Relationship:
Benefit Percent:
%
Name:
Date of Birth:
Address:
Telephone Number: (
)
Social Security Number:
Relationship:
Benefit Percent:
%
Disclaimer: Spousal consent does not apply to ERISA plans.
Spousal Consent For Community Property States Only: If you live in a community property state - Alaska, Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin - you may complete the Spousal Consent section, which allows
your spouse to waive his or her rights to any community property interest in the benefit. Certain tribal jurisdictions may also require spousal
consent. Please see your Benefits Administrator for details.
This will certify that, as spouse of the Employee named above, I hereby consent to my spouse designating the person(s) listed above as
beneficiaries of group life and/or accidental death insurance under the above policy and waive any rights I may have to the proceeds of such insurance
under applicable community property laws. I understand that this consent and waiver supersede any prior spousal consent or waiver under this plan.
Signature of Employee’s Spouse:
Date:
I, the undersigned, reserve the right to change the beneficiary(ies) without the consent of said beneficiary(ies).
Signature of Employee:
Date:
Please note that in no event may a beneficiary be changed by a Power of Attorney (POA)
GR-11927-11
10/2012
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