Designation Of Beneficiary For Unpaid Compensation Form - Alaska

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STATE OF ALASKA
DESIGNATION OF BENEFICIARY FOR UNPAID COMPENSATION
INITIAL AUTHORIZATION
CHANGE
Name (Last, First, M.I.)
Date of Birth
Social Security Number
Address
City
State
Zip Code
PRIMARY BENEFICIARY(IES)
CONTINGENT BENEFICIARY(IES)
Name
Name
Address
Address
City, State, & Zip Code
City, State, & Zip Code
Relationship
Percentage
Relationship
Percentage
Name
Name
Address
Address
City, State, & Zip Code
City, State, & Zip Code
Relationship
Percentage
Relationship
Percentage
Employee Signature
Date
Witness
Date
INSTRUCTIONS
1. You may nominate one beneficiary who would be the sole beneficiary.
2. You may nominate a beneficiary and contingent beneficiary or beneficiaries, in which case the benefit would be payable to the first
listed who survives you.
3. You may nominate any number of beneficiaries to share in any manner you wish. In this case, any benefit would be paid in
accordance with your wishes to all of the beneficiaries named. Please designate the percentage to go to each beneficiary. If you list
more than one beneficiary, be sure to state if the additional name or names are contingent beneficiaries or if they are to share in the
benefits and if so in what manner they are to share.
4. Should you wish to change or alter your designation of beneficiary, be sure to complete a new form
02-200 (Rev 4/92)
unpdcomp.doc

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