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
