Fillable Form 3 - Designation Of Beneficiary printable pdf download

FORM 3 - DESIGNATION OF BENEFICIARY

Step One - Fill in Participant Information

Name of Plan:

_______________________________________________________________________________________________

Name of Participant: ________________________________________________________________________________________

Address: _________________________________________________________________________________________________

City:___________________________________________ State:______________________________ Zip:___________________

Step Two - Designate the Beneficiary (ies)

Primary Beneficiary : _______________%

Name of Beneficiary : __________________________________

Name of Beneficiary : _______________________________

Relationship with Beneficiary: ___________________________

Relationship with Beneficiary: _________________________

If none of the above named Primary Beneficiaries survive me, pay any interest I may have under the account in equal portions unless otherwise indicated, to the

Secondary beneficiary (ies) then surviving:

Secondary Beneficiary : _____________%

Name of Beneficiary : __________________________________

Name of Beneficiary : _______________________________

Relationship with Beneficiary: ___________________________

Relationship with Beneficiary: _________________________

I understand the above beneficiary designation will remain in force until I request a change in accordance with the provisions of the plan.

Participant Signature:

___________________________________________

Date: ___________________________________

I hereby acknowledge receipt of the Summary Plan Description and agree to abide by all of the rules and regulations set forth in the plan. Alternatively, I am already

a Participant of the plan and I hereby update my Designation of Beneficiary for death benefits to be paid under the Plan.

Step Three - Spouse Signature Required Only if You’re Married and Listing Someone Other than Your

Spouse as a Primary Beneficiary

If you designate someone other than your spouse as beneficiary or designate someone in addition to your spouse as joint beneficiary, the following statement must

be signed by your spouse and notarized.

Consent of Spouse:

As spouse, I have read and consent to the above designation of beneficiary(ies) and understand that I am waiving my right to be named as the sole primary benefi-

ciary. I further understand and agree to the following result of my waiver:

No benefit from the Plan(s) will be payable to me upon my spouse’s death if I am not listed at all as a primary beneficiary.

Only a partial benefit from the Plan(s) will be payable to me upon my spouse’s death in accordance with any joint beneficiary designation indicated above.

Signature of Spouse:

______________________________________________

Date: _________________________________________

Notary Public: ____________________________________________________

Date: _________________________________________

Seal : _________________________________________

Received By (Plan Administrator) : ___________________________________

Date: __________________________________________

PLEASE DO NOT SEND THIS FORM BACK TO WELLINGTON. RETAIN IN COMPANY EMPLOYEE FILE.