Beneficiary Designation Form
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The Penn Mutual Life Insurance Company
Beneficiary Designation Form
The Penn Insurance and Annuity Company
Instructions
• For each new beneficiary designation please complete all required information; review for accuracy, sign and return the
form to the address or fax number listed below. For more detailed instructions, please see page 5 of this form.
• Please note the Application revokes all previous beneficiary designations. Therefore, even if a primary beneficiary or a
contingent beneficiary is to remain the same, such beneficiary must be restated on this form.
Insured Information
Policy Number(s)
Insured(s)
Daytime Telephone Number
(
)
Current Policy Owner(s)
Primary Beneficiary Information: This is the individual/party you select to receive the life insurance proceeds after the
insured’s death. (Select from options A, B or C)
A. To the individual(s) or party(ies) listed below: Benefit will be divided equally among all surviving primary beneficiaries
unless otherwise indicated. If naming more than 3 Primary Beneficiaries, please attach a signed, dated sheet including all
details required for each Beneficiary.
Name (First, Middle, Last)
Relationship to Insured
Male
Female
Address (Street)
(City)
(State)
(Zip)
SSN/EIN
Date of Birth
Telephone Number
% of Proceeds
/
/
(
)
Name (First, Middle, Last)
Relationship to Insured
Male
Female
Address (Street)
(City)
(State)
(Zip)
SSN/EIN
Date of Birth
Telephone Number
% of Proceeds
/
/
(
)
Name (First, Middle, Last)
Relationship to Insured
Male
Female
Address (Street)
(City)
(State)
(Zip)
SSN/EIN
Date of Birth
Telephone Number
% of Proceeds
/
/
(
)
B. To the trust described below: Please include a copy of the pages from your trust that contain the following information:
Title of Trust, Tax Identification Number of Trust, Date Trust Established, Trustees’ Names and Signatures. Certification
of Trust form (PM1174) may be submitted in lieu of the trust documents.
Name of Trust
Name of Trustee(s)
Address (Street)
(City)
(State)
(Zip)
SSN/EIN
Date of Trust
Telephone Number
/
/
(
)
Testamentary
Revocable
Irrevocable
C. The Executors Or Administrators Of The Estate of the Insured
The Penn Mutual Life Insurance Company, Philadelphia, PA 19172
PM6532 07/14
Page 1 of 5
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