Fillable BENEFICIARY DESIGNATION FORM (Washington College)

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BENEFICIARY DESIGNATION FORM (Washington College)

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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 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, Suf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 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 (04/15)
X
#629360 LIFE #629361 VOL LIFE
Washington College
✔
✔
✔
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.
• If you wish to designate different 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.
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Completed 1 September 2020

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