City Of Minneapolis - Health Plan Enrollment Change Form (Page 4 of 4) in pdf

CITY OF MINNEAPOLIS - BENEFICIARY DESIGNATION

Beneficiary Designation for: (Please Print)

Please complete the following Beneficiary Designation for each type of Life

Insurance Plan in which you are enrolled. This information is requested for

Employee Name [Last, First, Middle Initial]

your Benefit records.

Employee Department

Employee Payroll ID#

Follow these instructions for completing Designations for each Plan in which you are enrolled.



(Box 1) Fill in the name of each Beneficiary who would receive

(Box 2) State the relationship

(Box 3) Beneficiary’s birthdate

payment of your Life Insurance in the event of your death.

(spouse, child, brother, friend, etc.)



(Box 4) ‘F’ Female or ‘M’ Male

(Box 5) Social Security Number

(Box 6) Percentage of the benefit to be

paid to each



(Box 7) ‘P’ for Primary Receiver or ‘C’ for the Contingent receiver in the event the Primary Beneficiary is also deceased.

PRIMARY (P) or

BASIC LIFE INSURANCE

RELATIONSHIP

DATE OF

SEX

SOCIAL SECURITY #

% OF AMOUNT

CONTINGENT (C)

BENEFICIARY NAME

BIRTH

OPTIONAL LIFE (if enrolled)

PRIMARY (P) or

RELATIONSHIP

DATE OF

SEX

SOCIAL SECURITY #

% OF AMOUNT

CONTINGENT (C)

BENEFICIARY NAME

BIRTH

_____________________________________________________________

____________________________

Employee Signature

Date

Return completed form to: Human Resources-Benefits, Room 100 Public Service Center, 250 S 4

Street, Minneapolis MN 55415-1339

Some of the information on this form is private data under the Minnesota Government Data Practices Act, Minn. Stat. Chapter 13. The data requested allows Benefit Staff and our death benefit provider to

verify eligibility and to process the payment of a death benefit, in the event of your death, to those you designate to receive the benefit. You are not required to provide this information, however, failure to

do so can result in death benefits being paid to your estate and can result in probate. This form may be available to City and plan provider employees or agents, labor union representatives, arbitrators

and administrative hearing examiners, State and Federal courts, and attorneys representing any of the mentioned individuals or entities

, or to others through a subpoena or pursuant to Federal and State law.