Form F68444 - Group Life Insurance Beneficiary Designation
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Illinois Department of Central Management Services
State of Illinois Group Life Insurance Program
Beneficiary Designation Instructions
Personally identifiable information such as your Social Security number, date of birth, etc., will not be used for
any purpose other than for the administration of the State of Illinois Group Life Insurance Program life insurance
benefits.
BENEFICIARY DESIGNATION
WHO COMPLETES A
If you are a member of the State of Illinois: a state employee, retiree or certified survivor, you may file a Beneficiary
Beneficiary Designation
Designation. If no
is on file, group life insurance benefits will be paid according to the
statutory standard sequence in effect on the date of death as explained in the State of Illinois Group Life
Insurance Program Booklet.
Naming standard sequence. If you do not name a beneficiary, we will pay the death benefit according to the
standard sequence: 1) your lawful spouse, if living; otherwise 2) your natural or legally adopted child (children) in
equal shares, if living; otherwise 3) your parents in equal shares, if living; otherwise 4) your brothers and sisters in
equal shares, if living; otherwise 5) the personal representative of your estate. While this may be acceptable to you,
please note that it could delay settlement due to issues in attempting to locate and identify family members.
BENEFICIARY DESIGNATION
COMPLETING A
Objective. Our objective is to ensure prompt payment of any death benefits available upon your death, as specified
by you on the Beneficiary Designation form.
Top of form. Your name, address, Social Security number, birth date and telephone number should be typed or
printed in ink (not pencil) at the top of the Beneficiary Designation form.
Sign and date. After designating a beneficiary or beneficiaries, sign and date the designation at the bottom of the
form. Unsigned and/or undated forms will be rejected and returned to you. The form must be dated as of the date
signed; forms dated with a future date will be rejected.
Guardian/Conservators. A legal guardian or conservator of the estate may sign a Beneficiary Designation form on
behalf of a participant. The guardian or conservator must also submit a copy of the order of guardianship or
conservatorship.
Power of Attorney: A person with Power of Attorney may sign a Beneficiary Designation form on behalf of a
participant. They must also submit a copy of the Power of Attorney papers, and the papers must specifically state
that the person with Power of Attorney has the right to name and/or change the beneficiaries for the participant.
Payment progression. Your death benefits will be paid first to your Primary beneficiaries. If some of your Primary
beneficiaries die before you, your death benefit will be divided among those Primary Beneficiaries who are still
living. Secondary beneficiaries will receive benefits only if no Primary beneficiary survives you.
Questions. If you have questions about this form, please contact Minnesota Life Insurance Company by calling our
toll free number 1-888-202-5525.
PLEASE MAIL THE FORM TO MINNESOTA LIFE INSURANCE COMPANY, Springfield Branch Office, PO Box 2327,
Springfield, IL 62705-2327. (Only forms with original signatures will be accepted. Facsimiles are not acceptable.)
OPTIONS AVAILABLE FOR DESIGNATING A BENEFICIARY
Equal shares unless otherwise specified. If you name two or more persons as beneficiaries in one category (Primary
or Secondary), payment will be made in equal shares to the beneficiaries in that category unless you specify
percentages for different beneficiaries. If you specify percentages to be paid to beneficiaries in a category, the
percentages in each category must total 100%. If you choose to designate specific percentages, please write the
percentage next to each name.
Per Stirpes distribution. Per stirpes means that the deceased person's issue or lineal descendants take the share of
the insurance proceeds that the deceased would have taken had he or she survived. If you wish to specify who shall
receive a Primary beneficiary's share if a Primary beneficiary is deceased, (i.e., their children), write "Per Stirpes"
next to the beneficiary's name. Do not specifically name the descendants.
F68444 Rev 12-2011
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