Employer Name
Employee Name Employee Social Security #
Current Address City State ZIP
Home Phone Work Phone
please enter all dates in mm/dd/yyyy format
Primary and Contingent Beneficiaries
– Unless you designate a percentage, proceeds are
paid to primary surviving
beneficiaries in equal shares. Proceeds are paid to contingent
beneficiaries only when there are no surviving primary
beneficiaries. If you designate contingent
beneficiaries and do not designate percentages, proceeds are paid to the surviv
ing contingent
beneficiaries in equal shares. Unless otherwise provided, the share of a beneficiary who dies
before the
insured will be divided proportionately among the surviving beneficiaries in the respective
category (primary or contingent).
Basic Term Life Insurance, Life Insurance Company of North America - Policy No.
Employee’s Primary Beneficiary(ies):
Relationship
Social Security Number
Date
of Birth
% (total must
equal
100%
)
Employee’s Contingent Beneficiary(ies):
Relationship
Social Security Number
Date
of Birth
% (total must
equal
100%
)
Basic Accident Insurance, Life Insurance Company of North America - Policy No.
Employee’s Primary Beneficiary(ies):
Relationship
Social Security Number
Date
of Birth
% (total must
equal
100%
)
Employee’s Contingent Beneficiary(ies):
Relationship
Social Security Number
Date
of Birth
% (total must
equal
100%
)
If you need additional space using the above format, attach a separate piece of paper with the appropriate policy
number,
the date, and your signature.
Note: This form is not complete without your signature. Please sign the form where indicated.
Community Property Laws
- If you are married, reside in a community property state (Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin), and name someone other than your spouse as
beneficiary, it is possible that payment of benefits may be delayed or disputed unless your spouse also signs the
beneficiary designation.
Spouse Signature
Date / /
Owner Signature
Date / /
BENEFICIARY DESIGNATION FORM
Life Insurance Company of North America
Kellogg Community College
SGM604636
SOK603110
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GUIDELINES FOR DESIGNATION OF BENEFICIARIES
General
- Please be sure to include the beneficiary’s full name, social security number and
relationship to you. Providing
this information can help expedite the claim process by making it
easier to locate and verify beneficiaries.
Minors - While you may designate minors as beneficiaries, please note that claim payments may
be delayed due to special issues raised by these designations. In the event of a claim and the
beneficiary is a minor child, the insurance proceeds will not be released to the minor child. The
insurance proceeds may be paid to a duly appointed guardian of the
child’s estate. You may want to
obtain the assistance of an attorney in drafting your beneficiary designation.
Trust as Beneficiary - You may designate a trust as beneficiary, using the following form: “To
[name of trustee], trustee of the [name of trust], under a trust agreement dated [date of trust].”
If you wish to designate a testamentary trust as beneficiary (i.e., one created by will), you should
recognize the possibility that your will which was intended to create this trust may not be admitted
to probate (because it is lost, contested, or superseded by a later will). Claim payment delays can
result if the beneficiary designation doesn’t provide for this situation.
Life Status Changes
- We recommend that you review your beneficiary designation when
significant life status events occur, such as marriage, divorce, or birth of a child.
See an Attorney!
The above guidelines are general and are not intended to be relied on as legal
advice. Unless your designation is a simple one, we recommend that you obtain the assistance of
an attorney in drafting your beneficiary designation. A qualified attorney can help assure that your
beneficiary designation correctly reflects your intentions, is clear and unambiguous, and meets
legal requirements.
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