Group Life Insurance Portability Form Page 3
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4The Standard Life Insurance Company of New York
Benefi ciary Designation and Agreement
800.378.4668 Tel 800.331.3397 Fax
920 SW Sixth Avenue Portland OR 97204-1203
This benefi ciary designation: (1) revokes all prior designations, and (2) applies to basic and additional insurance, if
any, on your life that you continue under the Portability Of Insurance provision. A separate designation must be
completed for Supplemental Life Insurance, if any. Insurance on your Spouse or other Dependents, if any, is pay-
able to you, if living, or as provided under the terms of the Group Policy.
•
Benefi ts are only payable to a contingent Benefi ciary if you are not survived by one or more primary
Benefi ciary(ies).
•
If you name two or more Benefi ciaries in a class:
1. Two or more surviving Benefi ciaries will share equally, unless you provide for unequal shares.
2. If you provide for unequal shares in a class, and two or more Benefi ciaries in that class survive, we will pay
each surviving Benefi ciary his or her designated share. Unless you provide otherwise, we will then pay the
share(s) otherwise due to any deceased Benefi ciary(ies) to the surviving Benefi ciaries pro rata based on
the relationship that the designated percentage or fractional share of each surviving Benefi ciary bears to
the total shares of all surviving Benefi ciaries.
3. If only one Benefi ciary in a class survives, we will pay the total death benefi ts to that Benefi ciary.
PRIMARY
Address
Social Security #
Date of Birth
Relationship
Full Name
CONTINGENT
Address
Social Security #
Date of Birth
Relationship
Full Name
I hereby apply to continue Insurance available under the terms of the Group Policy.
I agree that no coverage will take effect until it is approved in writing by The Standard Life Insurance Company of
New York. I understand that if my request is not accepted, any premium advanced by me will be refunded.
I understand that if I do not provide the benefi ciary designation form on fi le with the Policyholder, or if I do not
designate a benefi ciary in the Benefi ciary section above, payment of any benefi t will be made in accordance with
the Benefi ciary Provisions of the Group Policy.
I hereby represent that all statements contained herein are complete and true to the best of my knowledge and
belief, and that I meet all eligibility requirements for continued insurance under the Group Policy’s Portability Of
Insurance provision. I have read and understand the information herein.
Signature: _________________________________________________________________________________
Dated______________________________________
Printed 05/11/2010
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SNY 15159
(4/10)
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