Beneficiary Designation Form

Beneficiary Designation Form
To designate, revoke, or change a beneficiary, please complete, sign, and date this Beneficiary Designation Form.
The designation/revocation/change will be effective as of the date this form is received.
Please print or type your own and your beneficiary(ies) information below.
1 Your Details
Policy No ______________________________________
Employee ID Number ______________________________________
Full Name ______________________________________
Date of Birth day|___|___| month |___|___| year |___|___|___|___|
Marital status Single Married other: ______________
Email Address ______________________________________
Phone number ______________________________________
2 Primary Beneficiary(IES)
Anyone listed as a primary beneficiary will receive the benefits first. If more than one person is listed as primary, they will be given the percentage listed. If any of the primary beneficiaries predecease you, their interest in the benefit will be divided equally and paid to the surviving primary beneficiary(ies). If all of the named primary beneficiaries predecease you, then the benefit will be paid to your secondary beneficiary(ies). Split percentages must equal 100%. Please refer to the back of this page, if you would like to add more than two beneficiaries.


In the event of my death, I designate the following as my PRIMARY BENEFICIARY/BENEFICIARIES
for any amount that may be payable after my death:

PRIMARY BENEFICIARY #1 Full Name ____________________________________ / Gender  Female  Male Benefit % _______ Passport/ID Card/Social security #________________________________ / Nationality _____________________________ Date of Birth day|___|___| month |___|___| year |___|___|___|___| Relationship ___________________________________________ Phone Number ___________________________________________ Address __________________________________________________________________________

PRIMARY BENEFICIARY #2 Full Name _________________________________ / Gender  Female  Male Benefit % _______ Passport/ID Card/Social security #________________________________ / Nationality _____________________________ Date of Birth day |___|___| month |___|___| year |___|___|___|___| Relationship ___________________________________________ Phone Number ___________________________________________ Address __________________________________________________________________________

3 Secondary Beneficiary
The secondary beneficiary will be paid only if all persons listed as Primary Beneficiary are deceased at the time of your death.If all named beneficiaries predecease you, your benefit will be paid to your estate. Please refer to the back of this page, if you would like to add more than one secondary beneficiary.


In the event of my death, if my Primary Beneficiary(ies) does/do not survive to receive any remaining payments,
I designate the following as my SECONDARY BENEFICIARY:

SECONDARY BENEFICIARY #3 Full Name ____________________________________ / Gender  Female  Male Passport/ID Card/Social security #________________________________ / Nationality _____________________________ Date of Birth day|___|___| month |___|___| year |___|___|___|___| Relationship ___________________________________________ Phone Number ___________________________________________ Address __________________________________________________________________________

4 Signature
Signature: ________________________ Witness Signature: ________________________
Date: ________________________ Date: ________________________

F-H-AD-RB-003, 02Jan’18