Form F68444 - Group Life Insurance Beneficiary Designation Page 3
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Illinois Department of
State of Illinois
Central Management Services
Group Life Insurance
Beneficiary Designation
REFER TO INSTRUCTIONS ON PREVIOUS PAGES
TYPE OR PRINT IN INK
MEMBER'S INFORMATION
First name
Middle initial
Last name
Social Security number
Street address
Date of birth
City
State
Zip code
Weekday telephone number
Any benefits payable by the Group Life Insurance Program at my death shall be paid in EQUAL SHARES, unless otherwise
specified, to the following Primary beneficiary(ies) who survive me.
Beneficiary name (last, first, middle)
Address
Street
Relationship
Social Security number (optional)
City, state, zip code
Birthdate (mo/day/year)
P
R
I
M
A
R
Y
If all of the aforesaid Primary beneficiary(ies) die prior to my death, the benefit shall be paid in EQUAL SHARES, unless
otherwise specified, to the following Secondary beneficiary(ies) who survive me, if any.
Beneficiary name (last, first, middle)
Address
Street
Relationship
S
Social Security number (optional)
City, state, zip code
Birthdate (mo/day/year)
E
C
O
N
D
A
R
Y
I hereby designate the above named beneficiary(ies). I reserve the right, without consent of the beneficiary, to further
change the beneficiary subject to any statutory restrictions. The above designation supersedes all prior designations of
beneficiaries I have made.
Member's signature
Date
X
Form must be signed and filed with Minnesota Life Insurance Company to validate designation.
Minnesota Life Insurance Company
SEND FORM TO:
Springfield Branch Office
PO Box 2327
Springfield, IL 62705-2327
F68444 Rev 12-2011
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