Mercer Voluntary Benefits Beneficiary Designation Form
ADVERTISEMENT
1MERCER VOLUNTARY BENEFITS BENEFICIARY DESIGNATION FORM
*This form is to designate a beneficiary for life insurance coverage for you and your spouse. Remember: When designating the
Primary, be sure that the total shares equal 100%. Your Contingent Beneficiary is the person who will receive the death benefit if
your primary beneficiary is no longer living.
Owner Name_____________________ SSN#____________
Please check
Daytime Phone: (___)______________ Certificate #_____________________
if new address
Address____________________________________ City/State/Zip_____________________
Owner’s Employer (or company insurance obtained from):____________________________
All previous beneficiary designations are hereby revoked and the following are designated as beneficiaries under this coverage.
No white outs, write overs, or cross outs allowed in this section.
Primary Beneficiary for Employee Coverage
Name: _________________________________________%Share________ Relationship___________________
Address: __________________________________________City/State/Zip______________________________
Date of Birth: _______________ SSN#_________________ Daytime Phone: (___)______________
Name: _________________________________________%Share________ Relationship___________________
Address: __________________________________________City/State/Zip______________________________
Date of Birth: _______________ SSN#_________________ Daytime Phone: (___)______________
Contingent Beneficiary for Employee Coverage (if Primary is not living)
Name: _________________________________________%Share________ Relationship___________________
Address: __________________________________________City/State/Zip______________________________
Date of Birth: _______________ SSN#_________________ Daytime Phone: (___)______________
Name: _________________________________________%Share________ Relationship___________________
Address: __________________________________________City/State/Zip______________________________
Date of Birth: _______________ SSN#_________________ Daytime Phone: (___)______________
Primary Beneficiary for Spouse Coverage
Name: _________________________________________%Share________ Relationship___________________
Address: __________________________________________City/State/Zip______________________________
Date of Birth: _______________ SSN#_________________ Daytime Phone: (___)______________
Name: _________________________________________%Share________ Relationship___________________
Address: __________________________________________City/State/Zip______________________________
Date of Birth: _______________ SSN#_________________ Daytime Phone: (___)______________
Contingent Beneficiary for Spouse Coverage (if Primary is not living)
Name: _________________________________________%Share________ Relationship___________________
Address: __________________________________________City/State/Zip______________________________
Date of Birth: _______________ SSN#_________________ Daytime Phone: (___)______________
Name: _________________________________________%Share________ Relationship___________________
Address: __________________________________________City/State/Zip______________________________
Date of Birth: _______________ SSN#_________________ Daytime Phone: (___)______________
(The beneficiary for dependent children’s coverage is the employee unless otherwise designated)
Community Property Laws- If you are married, reside in a community property state (Arizona, California, Idaho, Louisiana,
Nevada, New Mexico, Texas, Washington, and Wisconsin), and names someone other than your spouse as beneficiary, payment of
benefits may be delayed or disputed unless your spouse also signs the beneficiary designation.
Spouse’s Signature__________________________________________________ Date ________________
I represent the statements and answers given in this request form are true, complete, and correctly recorded to the best of my
knowledge and belief. I understand the request for service will not become effective until received at Mercer, and approved in
accordance with the terms of the coverage.
Owner’s Signature__________________________________________________
Date ________________
(Designations are invalid unless signature and date are completed)
Please send your signed change form to:
Mercer Voluntary Benefits
PO Box 9122
Fax:(515)365-1520
Des Moines, IA 50306-9279
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal