Form Gr-Ad-Bene-Emp-Csea - Metlife Accidental Death (Ad) Beneficiary Designation - 2014
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1
2
3Accidental Death (AD) Beneficiary Designation
•
This form MUST be signed before you return it. See “SECTION IV – Signature” on page 3.
SECTION I - Insured Information
Customer Number
Group Policyholder Name
TS 05050044-G
Civil Service Employees Association, Inc.
First Name
Middle Name
Last Name
Address – Street
City
State
ZIP Code
Date of Birth
Phone Number
SSN
(
)
SECTION II - Plan Information
I elect that the beneficiary designation shown on this form apply only to the plan insured by MetLife indicated below:
Accidental Death
SECTION III - Beneficiary Information
• You MUST designate at least one primary beneficiary. A person may only be listed once. Anyone listed in the primary section cannot
be listed in the contingent section.
• The sum of the Primary Beneficiary percentages MUST equal 100%. The sum of the Contingent Beneficiary percentages MUST equal
100%. Dollar amounts, fractions and decimals will not be accepted.
•
If you need more space for additional beneficiaries, attach a separate page. Include all beneficiary information, and sign/date the page.
Please complete the section that pertains to the type of beneficiary you are designating.
A. Individual Beneficiaries
PRIMARY BENEFICIARY -
Your first choice to receive your life insurance proceeds in the event of your death. If any primary
beneficiaries predecease you, that person’s share will be equally divided among any remaining primary beneficiaries.
First Name
Middle Initial
Last Name
Share:
%
Address – Street
City
State
ZIP Code
Relationship to Employee
Social Security Number
Date of Birth
Phone Number
(
)
First Name
Middle Initial
Last Name
Share:
%
Address – Street
City
State
ZIP Code
Relationship to Employee
Social Security Number
Date of Birth
Phone Number
(
)
First Name
Middle Initial
Last Name
Share:
%
Address – Street
City
State
ZIP Code
Relationship to Employee
Social Security Number
Date of Birth
Phone Number
(
)
Metropolitan Life Insurance Company
Page 1 of 3
GR-AD-BENE-EMP-CSEA (04/14) Fs
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