Beneficiary Designation Form - Personnel Kentucky (Page 2 of 2) in pdf

Beneficiary Designation Form - Personnel Kentucky Page 2

Designation of Beneficiary (may be completed on-line using KHRIS Employee Self Service Center)

Instructions



Print all information using black or blue ink.



If additional space is needed, a separate paper listing all beneficiary information may be included. This paper

must be signed and dated the same as the original form.



Complete location name.



Employee signature and date is required.



Include the relationship of the beneficiary to the employee and the percentage of benefit to be paid.



One or more beneficiaries may be named. If you do not name a beneficiary, or if you are not survived by one,

benefits payable because of your death will be paid in equal shares to the first surviving class of the following: (a)

Your spouse, (b) Your children, (c) Your parents, (d) Your brothers and sisters, and (e) Your estate. If utilizing

KHRIS ESS, the Designation of Beneficiary will be effective immediately upon submission. If utilizing the paper

form, the Designation of Beneficiary is not valid unless the form is signed and dated.



The Designation of Beneficiary must be on file with your Employer and/or Life Insurance Branch at the time of

your death to be accepted. KHRIS requires that all percentages be whole numbers. For example, an employee

can no longer list 3 beneficiaries at 33 1/3% each. It must be entered as 33%, 33% and 34%. The percentages

shall total 100%. Beneficiaries may be named or changed at any time without the consent of a beneficiary.



If a trust or trustee is named beneficiary, the written trust must be identified in the beneficiary designation. For

example, “Dorothy Q. Public, Trustee under the trust agreement dates _____.” Show name and address of the

trustee and effective date of the trust agreement.



Insurance Coordinator should verify all information.

NSHEB-6009 CWKY(03-2012)

Underwritten by Nationwide Life Insurance Company

Beneficiary Designation Form - Personnel Kentucky Page 2