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Beneficiary-Designation

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11/07/16 Page 1 of 1
Statement on the Collection and Use of Social Security Numbers
Human Resources
In accordance with the requirements of Florida law (Section 119.071, Florida Statutes), the University of West Florida
collects social security numbers only if specifically authorized or required by law or if imperative for the performance of
the University’s duties and responsibilities. The University may collect social security numbers for some or all of the
following purposes: identity tracking and management; billing and payments; credit worthiness; data collection;
reconciliation and tracking; benefit processing; tax and scholarship reporting; financial aid processing; student health
services, and reporting to authorized state and federal government agencies. Federal and state laws require us to protect
social security numbers from disclosure to unauthorized parties. Students and employees are assigned UWF
identification numbers to assist in tracking and protecting their personal information.
UWF Forms
Form Purpose
Purpose for SSN#
Statutory Authority
Mandated,
Authorized or
Business Imperative
FRS Certification Form
Eligibility to be employed
Applicant
Identification
Section 119.071(5)(a)6.g,
F.S.
Mandated
Level II Background
Screening Request Form
Eligibility to be employed in
a position of special trust
Applicant/employee
identification
Section 119.071(4)(a)2.b.,
F. S.
Mandated
Verification of Employment
Authorization Release
Employment verification
Employee
identification
Section
119.071(5)(a)(2)(a)(ll), F.S.
Business Imperative
Third Party Non-UWF
Forms
Purpose
Purpose of SSN#
Statutory Authority
Mandated,
Authorized or
Business Imperative
Form I-9, Employment
Eligibility Verification (US
Department of Homeland
Security)
Verify each new employee
(both citizen and noncitizen)
hired after Nov 6, 1986, is
authorized to work in the
United States.
Citizen and
noncitizen
identification
U.S. Dept. of Homeland
Security, U.S. Citizenship
and Immigration Services;
Immigration Reform and
Control Act of 1986, Pub. L.
99-603(8 USC 1324a)
Mandated
Form W-4, Employee’s
Withholding Allowance
Certificate
Tax reporting
For employee
identification
I.R.C. Section 6109
Mandated
Florida retirement
contribution reports and
forms (Florida Department of
Revenue)
Administration of pension
benefits
For employee
identification
Section 119.071(6)(g), F.S.
Business Imperative
Worker’s Compensation
Amerisys forms on behalf of
Risk Management, STARS
reports of lost wages and
First Report of Injury
For report and
documentation of work-
related injury and follow up
For employee
identification
Section 440.185(2)(b), F.S.
Mandated
I.R.C. Section 403b,457b
contribution reports (Internal
Revenue Service)
Employee enrollment and
claims
For employee
identification
I.R.C. Section 6109
Mandated
State of Florida New Hire
Report (Department of
Revenue)
Administration of various
programs: child support
enforcement, Medicaid,
unemployment
compensation, Food Stamp,
aid to disabled, etc.
New hire
identification
Section 409.2576, F.S.
Mandated
State sponsored insurance
enrollment forms and reports
(group health, life, and
dental coverage) (limited to
dependents)
Administration of health
benefits
Dependent
identification
Section 119.071(6)(f), F.S.
Business Imperative
Agency for Workforce
Innovation Unemployment
Compensation forms
Verification of benefits
eligibility
Employee
identification and
verification with
Social Security
Administration
Section 443.091(1)(g), F.S.
Mandated
FICA Alternative Plan Forms
(OPS Retirement)
Selection of 401(a)
Investment options
and Beneficiaries
Reporting
(OBRA 90) IRC
3121(b)(7)(F).
Business Imperative
INSTRUCTIONS:
F83345-010533 9-2018
Beneficiary Designation
Securian Financial Group, Inc.
Securian Life Insurance Company • Minnesota Life Insurance Company
Tallahassee Branch Office • PO Box 14289, Tallahassee, FL 32317-9804
1-888-826-2756 • Fax 1-850-878-0048
1. Clearly print or type the information.
2. Sign and date the completed form.
• Completing this Beneficiary Designation form will revoke all current beneficiary designations.
• The same person(s) cannot be named as both a primary and contingent beneficiary.
• To receive a death benefit, a beneficiary must survive the insured. If the named beneficiary does not
• Primary Beneficiary: This is the individual(s), trust, charity, or estate that you want to receive the
• Contingent Beneficiary: If all the primary beneficiary(ies) are no longer living, eligible, or able to
• Naming Minor Children: You may name your children (by name) directly, or to a trust. Minors
• Trust: Provide the trust name, effective date and tax ID or Social Security number (if applicable)
• Charity: Provide the full name, address, tax ID number.
GENERAL BENEFICIARY INFORMATION:
survive the insured, that beneficiary’s portion shall be equally distributed to the remaining beneficiaries
within that category.
insurance benefit. You can divide the insurance proceeds between primary beneficiaries. The total
shares must equal 100%
receive the benefits, it will be paid to the contingent beneficiary(ies) designated. You can divide the
insurance proceeds between your named contingent beneficiaries. The total shares must equal 100%.
cannot directly receive life insurance proceeds; however, they may be paid to a court-appointed
guardian or held until the minor child is legal age.
- i.e., “John Smith Trust dated 01/01/20xx.”
Insurance products are issued by Minnesota Life Insurance Company or Securian Life Insurance Company, a New York authorized insurer.
Page 1 of 2
• When the completed beneficiary form has been accepted, you will be mailed a confirmation.
3. Return to: Tallahassee Branch Office
PO Box 14289
Tallahassee, FL 32317-9804
or Fax to: 1-850-878-0048
• If you need more space, attach an additional sheet of paper with all of the information required.
Be sure to sign and date this additional information page.
CONTINUE ON TO NEXT PAGE
Visit www.lifebenefits.com/florida to designate your beneficiary.
SIGNATURE REQUIRED - This beneficiary revokes all prior designations.
CONTINGENT BENEFICIARY(IES) - Receives a benefit ONLY if all primary beneficiaries are no longer living.
PRIMARY BENEFICIARY(IES) - The person or persons named will receive the benefit.
Insured’s name (first, middle initial, last)
Address (street, city, state, zip)
Insured’s date of birth Policyowner (if different than insured)
ID (or last four of SSN)
Policyowner’s phone number
Employer name
State of Florida
Policy number
33503
This designation applies to all coverages.
Beneficiary full name/trust name
Address (street, city, state, zip)
Date of birth/trust date Tax ID (SSN or EIN) Share %
Relationship to insured
Beneficiary full name
Address (street, city, state, zip)
Date of birth Tax ID (SSN) Share %
Relationship to insured
Beneficiary full name
Address (street, city, state, zip)
Date of birth Tax ID (SSN) Share %
Relationship to insured
Beneficiary full name
Address (street, city, state, zip)
Date of birth Tax ID (SSN) Share %
Relationship to insured
Beneficiary full name
Address (street, city, state, zip)
Date of birth Tax ID (SSN) Share %
Relationship to insured
Beneficiary full name
Address (street, city, state, zip)
Date of birth Tax ID (SSN) Share %
Relationship to insured
Beneficiary full name/trust name
Address (street, city, state, zip)
Date of birth/trust date Tax ID (SSN or EIN) Share %
Relationship to insured
Beneficiary full name
Address (street, city, state, zip)
Date of birth Tax ID (SSN) Share %
Relationship to insured
Policyowner’s signature Date
X
Beneficiary full name
Address (street, city, state, zip)
Date of birth Tax ID (SSN) Share %
Relationship to insured
Page 2 of 2
Email address
Beneficiary full name
Address (street, city, state, zip)
Date of birth Tax ID (SSN) Share %
Relationship to insured
Total Primary Shares Must Equal 100%
Total Contingent Shares Must Equal 100%
Insurance products are issued by Minnesota Life Insurance Company or Securian Life Insurance Company, a New York authorized insurer.
Beneficiary Designation
Securian Financial Group, Inc.
Securian Life Insurance Company • Minnesota Life Insurance Company
F83345-010533 9-2018
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Beneficiary-Designation

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Completed 11 February 2020

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