Metlife Change Of Beneficiary/spousal Consent Form printable pdf download

ERISA/Non-ERISA

Change of Beneficiary/Spousal Consent

Participant’s Name _________________________________ Daytime Phone Number ( ___________ ) ______________________________

Social Security Number ___________ – ___________–____________ Marital Status: __________ Single _________ Married

Employer Name _________________________________________ Employer Group Number_____________________________________

Account Contract Number ________________________________

I hereby designate the following as my beneficiary(ies). I understand that this beneficiary designation replaces all prior

designations I may have made, to the extent permitted by applicable law.

If more than one beneficiary is designated, payment will be made in the designated percentages. Payments to contingent

beneficiary(ies)will only be made if no primary beneficiary(ies) survives me. If percentages are entered, the total percentage

must equal 100%. If no designated percentage is indicated, benefits will be paid to each surviving beneficiary in equal

shares.

If any portion of my death benefit is not disposed of by a designation of beneficiary, for any reason whatsoever, it will be paid

to my spouse if my spouse survives me, otherwise to my estate in a lump sum.

Primary Beneficiary(ies)

Are you married?

Yes

Primary

Contingent

Beneficiary Type

Name (First, Middle Initial, Last) and Address

Relationship

Beneficiary

Percentages

q Primary q Contingent

If percentages are entered, the total percentages in each column (Primary Beneficiary and Contingent Beneficiary) must equal

100%.Please use whole percentages ONLY. You must select either Primary or Contingent for each beneficiary.

NOTE: If a Trust is designated as a Primary Contingent a copy of the trust must be submitted.

I have read and understand this entire form and hereby elect the beneficiary designations indicated.

____________________________________________________________________________________

_____________________________

Participant’s Signature

Date

If your plan is subject to ERISA see spousal consent and waiver section on next page.

403B BENECHANGE (07/08)

Metlife Change Of Beneficiary/spousal Consent Form