Cigna Beneficiary Designation Form - Life Insurance Company Of North America
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1
2BENEFICIARY DESIGNATION FORM
Life Insurance Company of North America
Group Insurance
Life Accident Disability
Employer Name _____________________________________________
Employee Name_____________________________________________ Employee Social Security #_________________
Current Address__________________________________________ City__________________State______ Zip _______
Home Phone____________________Work Phone____________________
please enter all dates in mm//dd/yyyy format.
Please review page 2 of the form for Guidelines for Designation of Beneficiaries.
Primary and Contingent Beneficiaries – Unless you designate a percentage, proceeds are paid to primary surviving
beneficiaries in equal shares. Proceeds are paid to contingent beneficiaries only when there are no surviving primary
beneficiaries. If you designate contingent beneficiaries and do not designate percentages, proceeds are paid to the
surviving contingent beneficiaries in equal shares. Unless otherwise provided, the share of a beneficiary who dies before
the insured will be divided proportionately among the surviving beneficiaries in the respective category (primary or
contingent).
Basic Life Insurance, Life Insurance Company of North America - Policy No. __________
Date
% (total must
Employee’s Primary Beneficiary(ies):
Relationship to Employee
Social Security Number
of Birth
equal 100%)
Date
% (total must
Employee’s Contingent Beneficiary(ies):
Relationship to Employee
Social Security Number
of Birth
equal 100%)
Voluntary Term Life Insurance, Life Insurance Company of North America - Policy No. __________
Date
% (total must
Employee’s Primary Beneficiary(ies):
Relationship to Employee
Social Security Number
of Birth
equal 100%)
Date
% (total must
Employee’s Contingent Beneficiary(ies):
Relationship to Employee
Social Security Number
of Birth
equal 100%)
If you need additional space, using the above format, please attach a separate piece of paper with the appropriate
policy number, the date and your signature.
Minors - While you may designate minors as beneficiaries, please note that claim payments may be delayed due to
special issues raised by these designations. In the event of a claim and the beneficiary is a minor child, the insurance
proceeds will not be released to the minor child. The insurance proceeds may be paid to a duly appointed guardian of the
child’s estate. You may want to obtain the assistance of an attorney in drafting your beneficiary designation.
Community Property Laws - If you are married, reside in a community property state (Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin), and name someone other than your spouse as
beneficiary, payment of benefits may be delayed or disputed unless your spouse also signs the beneficiary designation.
Spouse Signature________________________________________________________________Date____/____/____
Owner Signature___________________________________________________________________Date____/____/____
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