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 benefi ciary(ies) or to change your existing
benefi ciary(ies). This form cancels all prior designations. If more than one benefi 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
benefi ciaries, please attach a separate sheet of paper. Return the completed form to your employer.
SECTION 1: Employee Information
Name (Last Name, Suffi x, First Name, MI) Social Security Number
Employer Name Check the coverages listed below to which this
benefi 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 benefi ciary(ies) of the Life Insurance benefi ts that may be payable
at the time of my death. If any primary benefi ciary(ies) is disqualifi ed or dies before me, his/her percentage of this benefi t
will be paid to the remaining primary benefi 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 benefi ciaries are disqualifi ed or die before me, I choose the person(s) named below to be my contingent
benefi 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)
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