LC
University of Michigan
Beneficiary for Group Life Insurance
Please print all information in black ink. Please note that this form is only for changing your life insurance beneficiaries. See the Benefits
Office website at benefits.umich.edu/events/beneficiary.html for information on changing your retirement savings plan beneficiaries.
1. Faculty or Staff Member Information
Name (Last, First, Middle Initial)
UMID
U.S. Social Security Number (if UMID unknown)
Date of Birth
Daytime Phone Number
Check the box next to the Life Insurance plan for which you wish to designate or change beneficiaries. If no box is checked, this beneficiary
designation will apply to all life insurance plans in which you currently participate. You are automatically the beneficiary for Dependent Life
plans.
University Group Life Insurance
Optional Group Life Insurance
Retiree Group Life Insurance
2. Your Life Insurance Beneficiary Designation
Primary Beneficiary (one or more). Primary beneficiaries receive payment first. Percentage amounts must total 100%.
1. Legal Name ______________________________________
2.
Legal Name ___________________________________
Address _________________________________________
Address ______________________________________
Date of Birth _____________________________________
Date of Birth ___________________________________
Relationship ______________________________________
Relationship ___________________________________
Percentage _______________________________________
Percentage _____________________________________
Contingent Beneficiary (one or more). A contingent beneficiary receives payment only if all primaries are deceased. Percentage amounts
must total 100%.
1. Legal Name ______________________________________
2.
Legal Name ___________________________________
Address _________________________________________
Address ______________________________________
Date of Birth _____________________________________
Date of Birth ___________________________________
Relationship ______________________________________
Relationship ___________________________________
Percentage _______________________________________
Percentage _____________________________________
3. Certification and Signature.
I have read the second page of this form and agree to the terms and conditions listed there. The information listed above is correct to the
best of my knowledge.
__________________________________________________________
___________________________________________
Signature of Faculty or Staff Member
Date Signed
BenifChg02092012