GP5500US (11/2014)
NameSignature of Employee Date
Married Participant
Unmarried Participant
I understand that I must elect my spouse as sole Primary Beneficiary under this Plan unless he/she consents
in writing to my naming another Primary Beneficiary. (Please see your Plan Administrator for a Spousal
Consent Form if naming a Primary Beneficiary other than your spouse.)
I understand that the following designation becomes null and void in the event of my marriage. I will promptly
inform my Plan Administrator of any change in my marital status.
I understand that if I outlive my Primary Beneficiary(ies), benefits will be paid to my estate on my death unless I designate a Contingent
Beneficiary(ies). For additional space, please attach a separate page providing all designation information and the percentage share for each.
Beneficiary Designation of Plan Participant
Participant Name (Last Name, First Name, Initial)
• This Form is provided solely for the convenience of the Plan Administrator.
• None of the information provided in this Form shall be maintained or acted upon by John Hancock Retirement Plan Services.
• This Form will be retained by the Plan Administrator and need not be submitted to John Hancock Retirement Plan Services.
Participant Social Security Number
The Trustee of Plan (the “Plan”)
Contractholder Name Contract Number
1. General Information
Both John Hancock Life Insurance Company (U.S.A.) and John Hancock Life Insurance Company of New York do business under certain instances using the John
Hancock Retirement Plan Services name. Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.),
Boston, MA 02210 (not licensed in New York) and John Hancock Life Insurance Company of New York, Valhalla, NY 10595. Product features and availability
may differ by state. Plan administrative services may be provided by John Hancock Retirement Plan Services LLC or a plan consultant selected by the Plan.
2. Beneficiary Designation
3. Authorization
Page 1 of 1
A - Primary Beneficiary
B - Contingent Beneficiary(ies)
Street Address, City, State, Zip Code
Date
of Birth
Month Day Year
Name (Last Name, First Name, Initial) Social Security Number
Relationship to Participant Share
%
Street Address, City, State, Zip Code
Date
of Birth
Month Day Year
1. Name (Last Name, First Name, Initial) Social Security Number
Relationship to Participant Share
%
Street Address, City, State, Zip Code
Date
of Birth
Month Day Year
2. Name (Last Name, First Name, Initial) Social Security Number
Relationship to Participant Share
%
Street Address, City, State, Zip Code
Date
of Birth
Month Day Year
3. Name (Last Name, First Name, Initial) Social Security Number
Relationship to Participant Share
%
- please print
