Group Insurance Beneficiary Designation/change Form

Group Insurance Beneficiary Designation/Change Form

1. EMPLOYEE INFORMATION

(please print)

Last Name

First Name

MI

Social Security

Marital Status(check One)

Married

Widowed

Gender (check one)

Has this insurance been assigned?

No

Male

Female

Yes

Single

Divorced

Address

City

State

ZIP Code

Daytime Phone

Home Phone

Date of Birth

Date of Retirement (if applicable)

Name of Employer/Group

Group Policy No

Unless otherwise indicated below, this Beneficiary Designation/Change form applies to ALL coverages offered under my employer’s group plan.

Val Verde USD

09867000

This form applies only to my

coverage(s).

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

Address (include city, state, ZIP)

Relationship

Social Security Number

% Share

Individual

Other____________________

%

Trust

Corporation/Organization

Individual

Other____________________

Trust

Corporation/Organization

Individual

Other____________________

Trust

Corporation/Organization

Individual

Other____________________

Trust

Corporation/Organization

TOTAL: (must equal 100)

%

B. Contingent Beneficiaries

Beneficiary Description (check One)

First Name

MI

Last Name

Address (include city, state, ZIP)

Relationship

Social Security Number

% Share

Individual

Other____________________

%

Trust

Corporation/Organization

Individual

Other____________________

%

Trust

Corporation/Organization

Individual

Other____________________

Trust

Corporation/Organization

Individual

Other____________________

Trust

Corporation/Organization

TOTAL: (must equal 100)

%

3. TRUST DESIGNATION – COMPLETE IF A TRUST HAS BEEN NAMED AS A BENEFICIARY IN SECTION 2

Trustee’s Name (First, MI, Last)

Address (include city, State, ZIP)

And successor(s) in trust(s) under

dated

As amended and executed by me and said trustee.

Title of Agreement

Date of Agreement

4. AUTHORIZATION/SIGNATURE I authorize Prudential or my employer to record and consider the individuals/institutions 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 Prudential assumes no obligation as to the validity or sufficiency of any executed Trust Agreement and does not pass on its legality. In making

payment to any Trustee(s), Prudential has the right to assume that the Trustee(s) is acting in a fiduciary capacity until notice to the contrary is received by Prudential at its Group Life Claim office. I agree that if

Prudential make any payment(s) to the Trustee(s) before notice is received, Prudential will not make payment(s) again.

X

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.

GL.2001.169 Ed. 5/2003 Prudential Financial is a service mark of Prudential Insurance Company of America, 751 Broad Street, Newark, NJ 07102, USA and its affiliates.

5/2003-50M