Group Insurance
Life Accident Disability
BENEFICIARY DESIGNATION FORM
Life Insurance Company of North America
Employer Name _____________________________________________
Employee Name_____________________________________________ Employee Social Security #_________________
Current Address__________________________________________ City__________________State______ Zip _______
Home Phone____________________Work Phone____________________
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
surviving 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 Life Insurance, Life Insurance Company of North America - Policy No. ________________
Date % (total must
Employee’s Primary Beneficiary(ies): Relationship SS # of Birth equal 100%)
Date % (total must
Contingent(s): Relationship SS # of Birth equal 100%)
Basic Accident Insurance, Life Insurance Company of North America - Policy No. ________________
Date % (total must
Employee’s Primary Beneficiary(ies): Relationship SS # of Birth equal 100%)
Date % (total must
Contingent(s): Relationship SS # of Birth equal 100%)
Please refer to page 2 to review
Guidelines for Designation of Beneficiaries
. 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.
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____/____/____
please enter all dates in mm//dd/yyyy format.
