Fillable Beneficiary Designation Form

Fill Online, Printable, Fillable, Blank Beneficiary Designation Form Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Beneficiary Designation Form

On average this form takes 18 minutes to complete

The Beneficiary Designation Form form is 2 pages long and contains:

  • 0 signatures
  • 34 check-boxes
  • 56 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Use this form if you want to:
• add a primary or contingent beneficiary to your account
• change an existing primary or contingent beneficiary
If you do not complete, sign (including spouse signature, if required), and submit this form to the plan administrator, you will not have a valid
beneficiary designation. If you do not have a valid Beneficiary Designation Form on file, the Plan document and applicable law will determine
the designated beneficiary upon your death. Please refer to Beneficiary Designation Instructions on page 3 for more information about
designating a beneficiary.
• Married Participants – If you want to designate a beneficiary other than your spouse, you must obtain spousal consent for that designation. If
you divorce or become legally separated, please contact your Plan Administrator to determine whether the divorce or separation automatically
results in removal of your former spouse, as beneficiary.
• Unmarried Participants – If you are unmarried at the time you complete this form and later marry, this form will no longer be valid because
your spouse may have certain claims on your plan benefits under applicable law. At that time if you want to name someone other than your
spouse as designated beneficiary, you will need to complete a new form and obtain spousal consent.
Note: If your plan's normal form of benefit is an annuity, please contact your Plan Administrator to obtain a copy of a Qualified Pre-
Retirement Survivor Annuity Notice. If you are married, your spouse has survivor rights to your account that are important for you to
understand before you complete this form. Refer to your plan's Summary Plan Description to determine the normal form of benefit.
Beneficiary Designation Form
Plan ID Plan Name
Section A - Plan Information
Section B - Participant Information
Legal Address
Daytime Phone No.
Zip CodeStateCity
Date of Hire
Participant NameSocial Security Number
Marital Status: (select one)
UnmarriedMarried
Section C - Primary Beneficiary
I hereby name the following as my Primary Beneficiary(ies) to receive the Plan’s death benefit upon my death:
Name, address and phone no. of Primary Beneficiary(ies) Whole PercentDate of Birth
%
%
%
%
SSN or Taxpayer ID No. Relationship
Total 100%
Whole PercentRelationshipDate of BirthSSN or Taxpayer ID No.Name, address and phone no. of Contingent Beneficiary(ies)
In the event there is no living Primary Beneficiary(ies) upon my death, I hereby name the following as my Contingent Beneficiary(ies):
Section D - Contingent Beneficiary
%
%
%
%
Total 100%Page 1 of 3 BEN DES RS-35912-01 Rev 1.21
Spouse
Trust
Child
Other___________
Spouse
Trust
Child
Other___________
Spouse
Trust
Child
Other___________
Spouse
Trust
Child
Other___________
Spouse
Trust
Child
Other___________
Spouse
Trust
Child
Other___________
Spouse
Trust
Child
Other___________
Spouse
Trust
Child
Other___________
Note: If you intend to name a Trust or Child as a Beneficiary, please see the Instructions on page three (3) before completing this section.
BENEFORM
Section E - Participant Certification and Authorization (you must sign this section)
I, the participant, hereby instruct the Plan to distribute my death benefit to the designated beneficiary(ies) herein. I acknowledge that:
• If I am married, I must obtain spousal consent if all or a portion of my death benefit is to be paid to someone other than my spouse.
• If the Plan’s normal form of benefit is an annuity, I have read the Qualified Pre-Retirement Survivor Annuity Notice and provided a
properly executed waiver. If not, this designation is not valid.
• I reserve the right to revoke or change any beneficiary designation (with spousal approval, if required) by submitting a new form.
• This form supersedes any prior beneficiary designation and, if my beneficiary designation is valid under the Plan, identifies all current Primary
and Contingent beneficiary(ies).
• I understand that if I do not provide a valid beneficiary designation, and the Plan does not provide for a default beneficiary, then my
beneficiary will be my estate.
_____________________________________________________________ __________________________
Participant’s Signature Date
Section F - Spousal Consent (complete only if the participant is married)
I certify that I am the spouse of the participant and I hereby voluntarily consent to the participant’s (i.e., my spouse) beneficiary designation
herein. I acknowledge that:
• If the Plan’s normal form of benefit is an annuity, I have received and read the Qualified Pre-Retirement Survivor Annuity Notice.
• I understand the effect of such beneficiary designation is to cause my spouse’s (i.e. the Participant) death benefit, or portion of it, to be paid
to a beneficiary other than me.
• Each beneficiary designation is not valid unless I consent to it.
• My consent is irrevocable unless my spouse revokes or changes the beneficiary designation.
Section G - Witness Certification and Signature (Plan Administrator or Notary completes)
I certify that the married participant’s spouse personally appeared before me and acknowledged that she/he signed the Section F - Spousal
Consent as her/his free act and deed.
If the plan administrator does not witness the spouse’s signature, a Notary must witness it.
If witnessed by a Notary Public the Signature/Stamp must be also provided below for this form to be considered valid.
____________________________________________________________________
Signature of Witness (Plan Administrator or Notary Public)
If signed by a Notary Public, please complete the following:
Sworn before me this day: _________________________________________
In the State of ___________, County of _______________________________
Commission Expiration Date: ____________________________________________
Participants must submit this form to the Plan Administrator.
Notary Public stamp here:
Page 2 of 3 BEN DES
____________________________________________________________ _________________________
Participant Spouse’s Signature Date
Beneficiary Designation Instructions
A beneficiary is a person, institution, charitable organization, or irrevocable or revocable trust named by you, the Plan participant, to receive
payment of benefits provided under the Plan in the event of your death. You may designate more than one Primary Beneficiary who will share
in the Plan’s death benefit. You may also designate one or more Contingent Beneficiary(ies). A Contingent Beneficiary would receive payment
only if the Primary Beneficiary(ies) you named were not able to receive payment at the time that payment was to be made.
The beneficiary designation should not include wording such as “either/or” or “and/or.” Use only whole-number percentages equaling 100%.
For example, designations such as 33 1⁄3 or 33.3 are not acceptable. If there is more than one designated beneficiary the percent payable
under each category must add up to 100%. If multiple beneficiaries are named and no percentages are indicated, the beneficiaries will share
equally.
Beneficiary Names: A married individual should be indicated by their full given name and not that of his/her spouse. For example: use Jane
Doe and not Mrs. John Doe.
Multiple Beneficiaries: If you name more than one beneficiary in either the Primary or Contingent Beneficiary category, beneficiaries in the
affected category will share equally unless you provide specific percentages.
Naming Your Estate: If you designate your estate as the beneficiary you must indicate on the beneficiary form “PAY TO THE ESTATE OF…”.
You should contact a tax or estate planner before designating your estate as your designated beneficiary.
Naming a Trust: If you designate a revocable or irrevocable trust as your beneficiary, please include the trust’s name and address, the date
the trust was created, the trustee’s name and the trust’s Tax Identification Number on the Beneficiary Designation Form. You may wish to
provide a copy of the executed trust agreement to the Plan Administrator at the time of your designation. Please note there are special required
distribution rules that apply to trusts under Treasury regulations §1.401(a)(9)-4. You should contact a tax or estate planner before designating a
trust as your designated beneficiary.
Naming a Minor: If you designate a minor as your beneficiary, you must generally provide information about the appointed guardian (or
custodian under the minor beneficiary’s state Uniform Gift (or Transfer) to Minor Act) who will act on the behalf of the minor’s property from the
date of your death until the minor attains legal age. Provide the minor beneficiary’s social security number. You cannot designate unborn
children as beneficiaries. You should contact a tax or estate planner before designating a minor as your designated beneficiary.
No Beneficiary Designation: If you do not have a valid Beneficiary Designation Form on file, the Plan document will determine the designated
beneficiary(ies) upon your death, and if the Plan document does not provide the beneficiary, your Plan benefit will be paid to your Estate.
If you would like to name more than four primary and four contingent beneficiaries, make a copy of page 1 and attach it to this form.
Page 3 of 3 BEN DES
Securities offered and/or distributed by GWFS Equities, Inc., Member FINRA/SIPC. GWFS is an affiliate of Empower Retirement, LLC; Great-West
Funds, Inc.; and registered investment advisers, Advised Assets Group, LLC and Personal Capital.
Insurance contracts are issued by Massachusetts Mutual Life Insurance Company, Springfield, MA, or Talcott Resolution Life Insurance Company, Windsor,
CT (formerly named Hartford Life Insurance Company), as applicable.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Beneficiary Designation Form

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 April 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document