BENEFICIARY DESIGNATION FORM FOR
GROUP LIFE AND GROUP ACCIDENT INSURANCE
Unum Life Insurance Company of America
Provident Life and Accident Insurance Company
The Paul Revere Insurance Company
Please fully complete this form and sign it if you wish to designate a beneciary or if you want to change your existing
beneciary designation.
SECTION 1: Employee’s Information
Name (First, Middle initial, Last) Social Security Number
Name of current employer- Division
Policy Number (s)
SECTION 2: Primary Beneficiary (ies)
I designate the person(s) named below as my primary beneciary (ies) to receive payment under the policy in the event of
my death. The share of any primary beneciary who is no longer living or is otherwise disqualied by law at the time of my
death, will pass to any remaining beneciary (ies) in equal shares.
1. ______________________ ________ _________ _____________________ _____%
Name Date of birth Relationship Address 1
______________________ _____________________
Social Security Number Address 2
2. ______________________ ________ _________ _____________________ _____%
Name Date of birth Relationship Address 1
______________________ _____________________
Social Security Number Address 2
3. ______________________ ________ _________ _____________________ _____%
Name Date of birth Relationship Address 1
______________________ _____________________
Social Security Number Address 2
SECTION 3: Contingent Beneficiary (ies)
I designate the person(s) below as my contingent beneciary (ies) who will receive payment only if all primary beneciary
(ies) predecease me or are otherwise disqualied by law.
1. ______________________ ________ _________ _____________________ _____%
Name Date of birth Relationship Address 1
______________________ _____________________
Social Security Number Address 2
2. ______________________ ________ _________ _____________________ _____%
Name Date of birth Relationship Address 1
______________________ _____________________
Social Security Number Address 2
3. ______________________ ________ _________ _____________________ _____%
Name Date of birth Relationship Address 1
______________________ _____________________
Social Security Number Address 2
SECTION 4: Authorization and Signatures
By signing this document, I understand and agree to the following: This beneciary designation revokes all prior designa-
tions. This beneciary designation form will apply to my Unum Insurance plan established in connection with my employ-
er’s plan. If more than one primary beneciary is named and no percentages are indicated, payment will be made in equal
shares to my primary beneciary (ies) who survive(s) me or if the percentages listed do not add up to 100%, Unum will
disburse the benet pursuant to its discretion and/or pursuant to the above policy provisions if applicable.
_______________________________ ______________
Employee Signature
Date
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
1095-04 (7/07)
