LG-12008 3/17 Symetra
®
is a registered service mark of Symetra Life Insurance Company.
Symetra Life Insurance Company
77 108th Avenue NE, Suite 1200 | Bellevue, WA 98004-5135
Mailing Address: Benefits Division | PO Box 34690 | Seattle, WA 98124-1690
Phone 1-800-426-7784 | TTY/TDD 1-800-833-6388
CHANGE OF BENEFICIARY DESIGNATION
Please attach to original enrollment form
POLICY # __________________________________________________________
EMPLOYER/POLICYHOLDER NAME __________________________________________________________________
EMPLOYEE INFORMATION
NAME PHONE NUMBER
STREET ADDRESS CITY STATE ZIP CODE
PRIMARY BENEFICIARY(IES):
NAME DATE OF BIRTH
ADDRESS
RELATIONSHIP
BENEFIT PERCENT
NAME DATE OF BIRTH
ADDRESS
RELATIONSHIP
BENEFIT PERCENT
CONTINGENT BENEFICIARY(IES):
NAME DATE OF BIRTH
ADDRESS
RELATIONSHIP
BENEFIT PERCENT
NAME DATE OF BIRTH
ADDRESS
RELATIONSHIP
BENEFIT PERCENT
DEFINITIONS
Primary Beneficiary: The person or persons you want to receive the life insurance benefit if you die. If more than one primary beneficiary has
been named, and the specific percentage has not been designated, then each will receive an equal share of the benefit.
Contingent Beneficiary: The person or persons you want to receive the life insurance benefit if you die and if no primary beneficiary is alive on
that date. If more than one contingent beneficiary has been named, and the specific percentage has not been designated, then each will
receive an equal share of the benefit.
I, the undersigned, reserve the right to change the beneficiary(ies) without the consent of said beneficiary(ies).
EMPLOYEE SIGNATURE DATE SIGNED
