Fillable Beneficiary Designation Form 2019

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Beneficiary Designation Form 2019

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Human Resources Department – Retain for your records.
SI 11210 1 of 1 (8/13)
Beneficiary Designation/Change
This designation will apply to the following coverage(s) if available to you through your Employer: Life Insurance,
Life with Accidental Death & Dismemberment (AD&D) Insurance, AD&D Insurance and, unless specified
otherwise on a separate signed sheet of paper, Supplemental Life Insurance.
Designations made below, or on a separate sheet of paper, are not valid unless signed, dated, and delivered to your
Employer during your lifetime. Return the completed form to your Human Resources Department.
MEMBER/EMPLOYEE INFORMATION
Your Name (Last, First, Middle)
Date of Birth
Your Address
City
State
=LS
Group Name
Group No.
BENEFICIARY INFORMATION
• Your designation revokes all prior designations.
• Benefits are payable to a contingent Beneficiary only if you are not survived by one or more primary Beneficiaries.
•
If you name two or more Beneficiaries in a class (primary or contingent), two or more surviving Beneficiaries will
share equally, unless you provide for unequal shares.
If a minor (a person not of legal age) or your estate is the Beneficiary, it may be necessary to have a guardian or a
legal representative appointed by the court before any death benefit can be paid. If the Beneficiary is a trust or
trustee, the written trust must be identified in the Beneficiary designation. For example, “Dorothy Q. Smith, Trustee
under the trust agreement dated _______________ .”
•
A power of attorney must grant specific authority, by the terms of the document or applicable law, to make or
change a Beneficiary designation. If you have questions, consult your legal advisor.
• Dependents Insurance and Supplemental Life Insurance on your Spouse, if any, is payable to you, if living, or as
provided under your Employer’s coverage under the Group Policy.
• If you complete the “% of Benefit” box(es), the amounts should add up to 100% for each class (primary or
contingent). For example, “Primary - John Q. Doe, 60%; Jane Q. Doe, 40%.”
PRIMARY – Full Name
Date of Birth
Phone No.
Relationship
% of
Benefit
CONTINGENT – Full Name
Date of Birth
Phone No.
Relationship
% of
Benefit
Signature of Member/Employee
Date
Reset
City of Akron
500878
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Beneficiary Designation Form 2019

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Completed 10 July 2020

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