Beneficiary For Group Life Insurance Form

Download a blank fillable Beneficiary For Group Life Insurance Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Beneficiary For Group Life Insurance Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

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

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2