Symetra Beneficiary Change Form
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Symetra Life Insurance Company
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777 108th Avenue NE, Suite 1200 | Bellevue, WA 98004-5135
Mailing Address: Benefits Division | PO Box 34690 | Seattle, WA 98124-1690
Phone 1-800-426-7784 | Fax 1-866-348-0056 | TTY/TDD 1-800-833-6388
CHANGE OF BENEFICIARY DESIGNATION
Please attach to original enrollment form
POLICY # __________________________________________________________
EMPLOYER/POLICYHOLDER NAME __________________________________________________________________
EMPLOYEE INFORMATION
NAME
PHONE NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
PRIMARY BENEFICIARY(IES):
NAME
DATE OF BIRTH
ADDRESS
BENEFIT PERCENT
RELATIONSHIP
NAME
DATE OF BIRTH
ADDRESS
BENEFIT PERCENT
RELATIONSHIP
CONTINGENT BENEFICIARY(IES):
NAME
DATE OF BIRTH
ADDRESS
BENEFIT PERCENT
RELATIONSHIP
NAME
DATE OF BIRTH
ADDRESS
BENEFIT PERCENT
RELATIONSHIP
DEFINITIONS
Primary Beneficiary: The person or persons you want to receive the life insurance benefit if you die. If more than one primary beneficiary has
been named, and the specific percentage has not been designated, then each will receive an equal share of the benefit.
Contingent Beneficiary: The person or persons you want to receive the life insurance benefit if you die and if no primary beneficiary is alive on
that date. If more than one contingent beneficiary has been named, and the specific percentage has not been designated, then each will
receive an equal share of the benefit.
I, the undersigned, reserve the right to change the beneficiary(ies) without the consent of said beneficiary(ies).
EMPLOYEE SIGNATURE
DATE SIGNED
LG-12008 5/12
®
Symetra
is a registered service mark of Symetra Life Insurance Company.
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