Beneficiary Designation Form
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Beneficiary Designation Form
Use this form if you want to:
• add a primary or contingent beneficiary to your account
• change an existing primary or contingent beneficiary
If you do not complete, sign (including spouse signature, if applicable), and submit this form to the plan administrator, you will not have a valid beneficiary
designation. If you do not have a valid Beneficiary Designation Form on file, the Plan document will determine the designated beneficiary upon your
death. Please refer to Beneficiary Designation Instructions on page 3 for more information about designating a beneficiary.
• Married Participants – If you want to designate a beneficiary other than your spouse, you must obtain spousal consent for that designation. If you
divorce or become legally separated, please contact your Plan Administrator to determine whether the divorce or separation automatically results in
removal of your former spouse, as beneficiary.
• Unmarried Participants – If you are unmarried at the time you complete this form and later marry, this form will no longer be valid once the Plan
recognizes your spouse. At that time if you want to name someone other than your spouse as designated beneficiary, you will need to complete a
new form and obtain spousal consent.
Note: If your plan's normal form of benefit is an annuity, please contact your Plan Administrator to obtain a copy of a Qualified Pre-Retirement
Survivor Annuity Notice. If you are married, your spouse has survivor rights to your account that are important for you to understand before
you complete this form. Refer to your plan's Summary Plan Description to determine the normal form of benefit.
Section A - Plan Information
Plan ID
Plan Name
Section B - Participant Information (Participant completes)
SSN
Participant Name
Daytime Phone Number
* Legal Address
City
State
Zip Code
Marital Status: (select one)
Date of Hire
Married
Unmarried
Section C - Primary Beneficiary
I hereby name the following as my Primary Beneficiary(ies) to receive the Plan’s death benefit upon my death:
Name and address of Primary Beneficiary(ies)
SSN or Taxpayer ID No.
Date of Birth
Relationship
Whole Percent
%
%
%
%
Total 100%
Section D - Contingent Beneficiary
In the event there is no living Primary Beneficiary(ies) upon my death, I hereby name the following as my Contingent Beneficiary(ies):
Name and address of Contingent Beneficiary(ies)
SSN or Taxpayer ID No.
Date of Birth
Relationship
Whole Percent
%
%
%
%
Total 100%
Page 1 of 3
BEN DES Rev 11/10
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