Form 1938 - Universal Beneficiary Designation Change Form
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Form 1938
Universal Beneficiary Designation/Change Form
Instructions: The information on this form will replace any prior beneficiary designation. You may name anyone or any entity as your beneficiary and you may change your beneficiary at any time by
completing a new Universal Beneficiary Designation/Change Form. Common designations include individual, estates, corporations/organizations and trusts. Payment will be made to the named
beneficiary. If there is no named beneficiary, or the named beneficiary predeceases the insured, settlement will be made in accordance with the terms of certain Group Contract providers.
The form or change form will take effect the date the request is signed, but the change will not affect any action before LANS receives the request.
Please note that this form does not designate the beneficiaries for your 401k. 401k beneficiaries must be designated by logging on to
1. Employee Information
Z Number
Last Name
First Name
MI
Social Security No.
Date of Birth
Address
City
State
Zip
Daytme Phone
Home Phone
Martial Status (check one)
Gender (check one)
Married
Single
Widow
Divorced
Domestic Partner
Male
Female
This Beneficiary/Designation/Change Form applies to the following coverage’s offered under my employer’s group plan.
All Coverages
Basic Life Insurance
Business Travel Accident
AD&D
Supplemental Life Insurance
2. Beneficiary Designation
I hereby revoke any previous designations of primary beneficiary(ies) and contingent beneficiary(ies), if any, and in the event of my death, designate the following.
A. Primary Beneficiaries
Beneficiary Description (check one)
First Name
Mi
Last Name
Individual
Other: __________
Trust
Corp./Organization
Address (include city, state, and zip)
Relationship
Social Security Number
% of Share
Beneficiary Description (check one)
First Name
Mi
Last Name
Individual
Other: __________
Trust
Corp./Organization
Address (include city, state, and zip)
Relationship
Social Security Number
% of Share
Beneficiary Description (check one)
First Name
Mi
Last Name
Individual
Other: __________
Trust
Corp./Organization
Address (include city, state, and zip)
Relationship
Social Security Number
% of Share
Beneficiary Description (check one)
First Name
Mi
Last Name
Individual
Other: __________
Trust
Corp./Organization
Address (include city, state, and zip)
Relationship
Social Security Number
% of Share
Total: (must equal 100 %)
0
Note: This form shall be protected as LANS Employment Sensitive and/or LANS Employment Sensitive/PII when one or a combination of the following personal information is revealed in a LANS record:
Education, salary, medical history, employment history, social security number, date and place of birth, or mother’s maiden name.
Form 1938 (3/14)
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