Beneficiary Designation Form
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F-H-AD-RB-003 - Beneficiary Designation Form (1)
- Bu sahifa navigatsiya:
- 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
- PRIMARY BENEFICIARY 2
- 3 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
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:
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:
4 Signature Signature: ________________________ Witness Signature: ________________________ Date: ________________________ Date: ________________________ F-H-AD-RB-003, 02Jan’18 Download 310.47 Kb. Do'stlaringiz bilan baham: |
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