Basic Group Life Insurance Plan Beneficiary Designation Form - Indiana University
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2UHRS 01/2011
Basic Group Life Insurance Plan
Beneficiary Designation Form
Complete and return form to your campus HR office. For Retirees, return to: Basic Group Life Plan, University Human Resource Services, Poplars E165,
400 East 7th Street, Bloomington, IN 47405.
Employee Information
:
Employee Name: ______________________________________ Date of Birth: _____/_____/________ Employee ID: __ __ __ __ __ __ __ __ __ __
Address: _____________________________________________________ City: _______________________ State: ________ Zip: ______________
Campus: _________________________ Phone: ______-______-_________ E-mail: ____________________________________________________
Beneficiary Designation
:
This is a(n): £ Initial Beneficiary Designation
£ Change in Beneficiary Designation
Primary Beneficiary(ies):
Name:
DOB
Address
SSN
Relationship
%
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Contingent Beneficiary(ies):
Name:
DOB
Address
SSN
Relationship
%
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Employee Certification:
Participants may change the above beneficiaries in accordance with the policy provisions. Unless stated otherwise, the death benefit will be paid
in equal shares to surviving beneficiaries, if more than one has been chosen. If none of the beneficiaries is alive, payment will be made under the
policy provisions.
I am aware that the beneficiary information included in this form becomes effective when delivered to Indiana University and will remain
in effect until I deliver to the university another completed and signed Beneficiary Designation Form. I understand that I may change my
beneficiary designation at any time and that it is my responsibility to make such changes.
Employee Signature: __________________________________________________________________ Date: _____/_____/________
See reverse side for instructions.
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