Request For Group Coverage/enrollment Form Page 3
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64. Life Insurance
PLEASE NOTE: DO NOT USE THIS FORM TO CHANGE THE BENEFICIARY DESIGNATION.
Employer Name:
Location #:
Employee
Name:
Social Security
#:
Primary Beneficiary Designation
(If additional Beneficiaries, please attach additional page)
Full Name
Relationship Date of Birth
Share %
(Last, First, MI)
Payment will be made in equal shares or all to the survivor unless otherwise indicated.
In the event said primary beneficiary(ies) predecease(s) the insured, I designate as contingent beneficiary(ies)
Contingent Beneficiary Designation
(If additional Beneficiaries, please attach additional page)
Full Name (Last, First, MI)
Relationship
Date of Birth
Share %
Payment will be made in equal share or all to the survivor unless otherwise indicated.
If no beneficiary or contingent beneficiary designated shall be living following the insured’s death, the
amount payable by reason of the insured’s death shall be payable as provided in the Group Policy.
Signature of
Date:
Employee:
POPULAR BENEFICIARY DESIGNATIONS (SEE NEXT PAGE)
Rev 6/13/2013
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Parent category: Medical