Beneciary Designation Form
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Beneciary Designation Form
Subject to the terms and conditions of the insurance contract, applicable laws, and any rights of a valid assignee of record, it is requested the beneciary of any
benets payable upon death of the insured be distributed as follows:
Insured’s Name (Last, First, Middle):
Policy Number: Insured’s Date of Birth:
___/___/___ (MM/ DD/YYYY)
Insured’s Signature: X ____________________________________________ Witness Signature: X _____________________________________________
Printed Name: Printed Name:
Date:
___/___/___ (MM/ DD/YYYY) Date: ___/___/___ (MM/ DD/YYYY)
Spouse’s Signature and Consent (if applicable)
2
:
X _______________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
It is understood and agreed upon receipt of this completed, signed, dated designation by iTravelInsured, such designation will be eective and relate back to the
date it is signed but without prejudice to iTravelInsured on account of any payment made prior to receipt and acknowledgement of the validity of the designation by
iTravelInsured. iTravelInsured shall not be obligated to honor this designation until it has been received, acknowledged, and determined by iTravelInsured to comply
with applicable laws. This designation supersedes and cancels all prior designations by the Insured for any coverage administered by iTravelInsured.
The undersigned represents and warrants he/she has not been declared incompetent and no court order or law prevents naming the above beneciary(ies). It is
agreed iTravelInsured assumes no responsibility for the validity or eect of any attempted designation or transfer of rights under the insurance contract.
The undersigned also represents and warrants any information and documents provided by the undersigned prior to and after the eective date of coverage and
facts and other matters presented in this form are true and accurate to the best of the undersigned’s knowledge and belief. The undersigned understands and agrees
that a) any coverage or benets are contingent upon statements as being complete and correct and b) benets under any insurance contract will be paid only if the
insurer or iTravelInsured decides in its discretion the claimant is entitled to them.
Lack of Notice of Community Property Interest: If iTravelInsured has not previously received written notice of a community property interest and if the below consent
is not signed by the person having that interest, iTravelInsured shall be entitled to rely in good faith no such interest exists. iTravelInsured assumes no responsibility
to inquire or validate any such interest, and in consideration of submitting this designation, the Insured for himself/herself, his/her estate, heirs, successors, and
assigns, agrees to indemnify and hold the insurer and iTravelInsured harmless from any consequences of honoring this designation.
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Total percentage must equal 100% otherwise benets will be paid on a pro-rata basis according to the percentages shown. If no percentage is identied, benets will be paid equally.
2
Spouse’s signature needed only if the Insured or Beneciary resides in a community property state (ie AZ, CA, ID, LA, NM, NV, TX, WA, & WI).
PRIMARY BENEFICIARY(IES)
Name Relationship Address
DOB
(MM/ DD/YYYY)
SSN Percentage
___/___/___
___/___/___
___/___/___
___/___/___
Total
1
CONTINGENT BENEFICIARY(IES) if all Primary Beneciary(ies) predecease you
Name Relationship Address
DOB
(MM/ DD/YYYY)
SSN Percentage
___/___/___
___/___/___
___/___/___
___/___/___
Total
Version 0520IN01200991A200518
Please print legibly and complete ALL SECTIONS (front and back) of this application. Mail, fax, or email application by secure means only:
Address: IMG iTravelInsured® Claims, P.O. Box 3231, Farmington Hills, MI 48333-3231 USA,
Call: 1.866.243.7524 or 1.317.655.9798; Fax: +1.317.927.6882
Email: itravelclaims@itravelinsured.com
www.itravelinsured.com
