Form 1938 - Universal Beneficiary Designation Change Form Page 2
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3B. Contingent 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 %)
3. Trust Designation (complete if a trust has been named as a beneficiary in section 2)
Trust designations will not be reflected in Oracle, Oracle beneficiary information will remain blank.
Address (include city, state, and zip)
Trustee’s Name (First, Last, MI)
Add successor(s) in trust, as Trustee(s) under _________________________________________ dated ________________ as amended and executed by me and said Trustee.
Title of Agreement
Date of Agreement
4. Authorization Signature
I authorize LANS or my Group Contracts Provider(s) to record and consider the individuals/institution that I have named on this form as beneficiaries for benefits under the
applicable employee benefit plans. If designating a trust as a beneficiary, I understand LANS and my Group Contracts Provider(s) assume no obligation as to the validity or
sufficiency of any executed Trust Agreement and does not pass on its legality. In making payment to a Trustee(s), LANS and my Group Contracts Providers have the right to
assume that the Trustee(s) is acting in a fiduciary capacity until notice to the contrary is received by LANS at the LANL Benefits Office. I agree that if LANS or my Groups
Contracts Providers make any payment(s) to the Trustee(s) before notice is received, LANS or my Groups Contracts Providers will not make payment(s) again.
Employee’s Signature: _______________________________
Date: ____________
The employee must sign and date this form. The signature date must be the date the employee actually signed the form.
* Life, Business Travel Accident, Special Accident, Accidental Death and Dismemberment, Survivor Income Benefit, and other certain Group Contracts Providers if applicable
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)
Page 2 of 3
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