Human Resources Department – Retain for your records.
SI 11210 1 of 1 (8/13)
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.
Your Name (Last, First, Middle)
• 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%.”
Signature of Member/Employee