Form Gp34795-10 - Beneficiary Designation/change

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Mailing Address:
Principal Life
Beneficiary Designation/
Des Moines, IA 50392-0002
Insurance Company
Change
Company Name
Account/Unit Number
Employee Information
Your name (last, first, middle initial)
Social security number
Section I
Group Term Life Beneficiary Designation (Complete if covered for group term life coverage.)
All primary and contingent beneficiaries, whether adults or minors, should be included in the beneficiary
designation below. If designating a minor, please check the applicable box and complete the Minor Beneficiary –
UTMA section on Page 3.
Primary Beneficiaries:
Name
Check here if a Percentage
Relationship
minor
Address
Social security number
Name
Check here if a Percentage
Relationship
minor
Address
Social security number
Name
Check here if a Percentage
Relationship
minor
Address
Social security number
Name
Check here if a Percentage
Relationship
minor
Address
Social security number
Name
Check here if a Percentage
Relationship
minor
Address
Social security number
Contingent Beneficiaries:
Name
Check here if a Percentage
Relationship
minor
Address
Social security number
Name
Check here if a Percentage
Relationship
minor
Address
Social security number
Name
Check here if a Percentage
Relationship
minor
Address
Social security number
Name
Check here if a Percentage
Relationship
minor
Address
Social security number
Name
Check here if a Percentage
Relationship
minor
Address
Social security number
Page 1 of 4
GP34795-10
(Spanish SP776) 05/2014

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