BENEFICIARY DESIGNATION FORM
GROUP LIFE AND GROUP ACCIDENTAL DEATH
& DISMEMBERMENT INSURANCE
Unum Life Insurance Company of America
Provident Life and Accident Insurance Company
The Paul Revere Life Insurance Company
Instructions: Please complete, sign and date this form to designate your bene ciary(ies) or to change your existing
bene ciary(ies). This form cancels all prior designations. If more than one bene ciary is named and no percentages
are indicated, payment will be made to them in equal shares. If there are more than three (3) primary and/or contingent
bene ciaries, please attach a separate sheet of paper. Return the completed form to your employer.
SECTION 1: Employee Information
Name (Last Name, Suf x, First Name, MI) Social Security Number
Employer Name Check the coverages listed below to which this
bene ciary designation applies:
Basic Life Supplemental Life AD&D All
SECTION 2: Primary Benefi ciary (ies)
I choose the person(s) named below to be the primary bene ciary(ies) of the Life Insurance bene ts that may be payable
at the time of my death. If any primary bene ciary(ies) is disquali ed or dies before me, his/her percentage of this bene t
will be paid to the remaining primary bene ciary(ies).
Name & Address Relationship Social Security Date of Percentage
Number Birth
Total Must
Equal 100%
SECTION 3: Contingent Benefi ciary (ies)
If all primary bene ciaries are disquali ed or die before me, I choose the person(s) named below to be my contingent
bene ciary(ies).
Name & Address Relationship Social Security Date of Percentage
Number Birth
Total Must
Equal 100%
SECTION 4: Signature
______________________________________________________________ ________________________________
Employee Signature Date
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
CS-1110 (12/09)
X
Important Information About Designation of Benefi ciaries
Benefi ciary Information
Primary Benefi ciary(ies) means the person(s) you choose to receive your life insurance bene ts. Please specify
the percentage of the bene t you want paid to each bene ciary; these percentages should total 100%. If any primary
bene ciary is disquali ed or dies before you, his/her percentage of the bene t will be paid to the remaining primary
bene ciary(ies).
Contingent Benefi ciary(ies) means the person(s) you choose to receive your life insurance bene ts only if all
primary bene ciaries are disquali ed or die before you. Please specify the percentage of the bene t you want paid
to each bene ciary; these percentages should total 100%. If any contingent bene ciary is disquali ed or dies before
you, his/her percentage of the bene t will be paid to the remaining contingent bene ciary(ies).
Minor Benefi ciary(ies) When you designate minors as bene ciaries, it is important to understand that insurance
bene ts may not be released to a minor child. They may, however, be paid to a court appointed guardian of the child’s
estate. The regulations governing minor bene ciaries vary by state.
Trust You may designate a valid trust as a bene ciary.
Types of Coverage Information
Basic Life is life insurance provided by your employer for which they pay the premiums.
Supplemental Life is life insurance elected by you for which you pay the premiums.
AD&D is Accidental Death & Dismemberment coverage.
If you wish to designate different bene ciaries for any of the above coverages, please complete a separate form.
General Information
Updates to Your Benefi ciary Designation – You can change your bene ciary designation at any time. You may
wish to review your designation periodically.
Consult an Attorney – This information is not intended to be relied on as legal advice. You may wish to get the
assistance of an attorney to help ensure your bene ciary designation correctly re ects your intentions.
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