Fillable BENEFICIARY DESIGNATION FORM (Lesley University)

Fill Online, Printable, Fillable, Blank BENEFICIARY DESIGNATION FORM (Lesley University) Form

Use Fill to complete blank online LESLEY UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

BENEFICIARY DESIGNATION FORM (Lesley University)

On average this form takes 10 minutes to complete

The BENEFICIARY DESIGNATION FORM (Lesley University) form is 1 page long and contains:

  • 0 signatures
  • 6 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Lesley University

BROWSE LESLEY UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
BENEFICIARY DESIGNATION FORM
GROUP LIFE, ACCIDENTAL DEATH & DISMEMBERMENT
CRITICAL ILLNESS AND ACCIDENT INSURANCE
Unum Life Insurance Company of America
Unum Insurance Company
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, Sux, First Name, MI) Social Security Number
Policy Number(s) Division Number(s)
Employer Name Check the coverages listed below to which this
beneciary designation applies:
o Basic Life o Critical Illness o Accident
o Supplemental Life o AD&D o All
  SECTION 2: Primary Bene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 Bene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 (06/19)
X
Important Information About Designation of Beneciaries
Beneciary Information
  •  Primary Bene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 Bene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 Bene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.
• Critical Illness is insurance elected by you for which you pay the premium.
• Accident is insurance elected by you for which you pay the premiums.
• If you wish to designate dierent beneciaries for any of the above coverages, please complete a separate form.
General Information
  •  Updates to Your Bene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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

BENEFICIARY DESIGNATION FORM (Lesley University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document