Beneficiary Designation Form
It's important to keep your beneficiary
designations current.
To Add or Change Beneficiaries for Your Mutual of America Contracts:
1. Complete and sign the Beneficiary Designation Form.
2.
For those contracts subject to the spousal waiver, have your spouse
complete and sign the Spouse's Waiver in the presence of a Notary or
Authorized Representative of your employer.
3.
If you are designating a Trust as Beneficiary OR if you are required to
provide an Irrevocable Designation of Beneficiary, contact Mutual of
America using the address and phone number below.
4.
Send the completed, signed form to Mutual of America at the following
address:
MUTUAL OF AMERICA LIFE INSURANCE COMPANY
Somerset Square
95 Glastonbury Blvd
Suite 410
Glastonbury, CT 06033-4414
(860) 659-3610
If you have any questions, please call a Mutual of America representative at the
number listed above weekdays between 8:00 AM and 5:00 PM local time or, toll
free, at 1-800-468-3785, weekdays between 9:00 AM and 9:00 PM Eastern Time.
mutualofamerica.com
BENEFICIARY DESIGNATION
If you are designating a Trust, you must use Mutual of America’s “Designation of Trust as Beneficiary” Form 6475.
(To the Employer: Trust designations cannot be processed through Mutual of America SponsorConnect
SM
.)
IF THIS DESIGNATION APPLIES TO A NEW ENROLLMENT, IT MUST BE DATED ON OR AFTER THE DATE ON THE
ENROLLMENT FORM. If you are now enrolling in a plan, employer’s name and mailing address below may be left blank.
For the plans indicated, THIS DESIGNATION COMPLETELY REPLACES ANY PREVIOUS BENEFICIARY DESIGNATION.
EMPLOYER’S NAME EMPLOYER NUMBER
CUSTOMER IDENTIFICATION NUMBER PARTICIPANT’S NAME First Initial Last
MARRIED UNMARRIED
(Single, Widowed
__ __ -__ __ __ __ __ __-__
or Divorced)
MAILING ADDRESS Street and Number (Include Apartment Number) City State Zip Code DAY TELEPHONE NUMBER
( )
IF FOREIGN RESIDENT Province Country
I wish to designate one or more beneficiaries under:
All my group coverages with current and prior Employers, and all SEP, IRA, VUL and FPA Programs.
Only the coverages listed below:
Type of Plan (Pension, TDA, etc.)
___________________________
Employer/Plan Number
______________________
Spouses Waiver on reverse must be completed if participant
is married and designating a primary beneficiary other than a
spouse for the following plan types: Defined Contribution
Pension, Th
rift, 401(k), certain TDA plans (check Summary Plan
Description), and VEC (Voluntary Employee Contributions).
___________________________
___________________________
______________________
______________________
Married Defined Benefit Plan Participants must designate
their spouse as primary beneficiary. The spouse of a Defined
Benefit Plan participant cannot waive their right to be named
as primary beneficiary.
___________________________ ______________________
___________________________ ______________________
To Empl oyer using Spon sorC onnect: After entering data,
you must send this form to your Service Manager for any
SEP, IRA or FPA plan. Retain a copy for your files.
Designation is pending until Mutual receives form.
BENEFICIARY DESIGNATIONS (Complete Reverse Side)
In the event of your death, and subject to the Eligible Spouse Waiver requirements, the total value of your account will be paid to the person
or persons you name as your primary beneficiary. If no one you have named as a primary beneficiary survives you, the person(s) you name
as your secondary beneficiary will receive the death benefit. If there is no living designated beneficiary at your death, the amount payable
will be paid to the first surviving class of the following: (a) your surviving spouse (as determined under state law), (b) your surviving children
in equal shares, (c) your surviving parents in equal shares, (d) your surviving brothers and sisters in equal shares, or (e) the executors or
administrators of your estate.
If you name more than one primary beneficiary, or more than one secondary beneficiary, the death benefit will be paid in equal shares to the
primary beneficiaries who survive you, or if none, to the secondary beneficiaries who survive you, unless you show below the percentage
you want each of them to receive. If you specify percentages you want each beneficiary to receive, be sure your percentages for all beneficiaries
in each beneficiary type total 100%.
Name your primary and secondary beneficiaries in the space provided on the reverse side. If you need more space, attach a page providing
the information asked for each beneficiary. Please add your name, the last four digits of your Social Security number, signature and the date.
M
UTUAL OF AMERICA LIFE INSURANCE COMPANY, 320 PARK AVENUE, NEW YORK, NY 10022-6839
6463.R 7/17
_____________________________________________________ __________
_____________________________________________________ ___________
BENEFICIARY DESIGNATIONS
Beneficiary Type :
X
Primary
Relationship: Spouse Child Parent Estate Other
Beneficiary Type : Primary Secondary
Relationship: Spouse Child Parent Estate Other
FULL NAME First Initial Last
FULL NAME First Initial Last
DATE OF BIRTH
/ /
SOCIAL SECURITY # PHONE #
( )
DATE OF BIRTH
/ /
SOCIAL SECURITY # PHONE #
( )
ADDRESS Street
ADDRESS Street
City State Zip Code
City State Zip Code
IF FOREIGN RESIDENT Province Country BENEFIT PERCENT
%
IF FOREIGN RESIDENT Province Country BENEFIT PERCENT
%
Beneficiary Type : Primary Secondary
Relationship: Spouse Child Parent Estate Other
Beneficiary Type : Primary Secondary
Relationship: Spouse Child Parent Estate Other
FULL NAME First Initial Last FULL NAME First Initial Last
DATE OF BIRTH
/ /
SOCIAL SECURITY # PHONE #
( )
DATE OF BIRTH
/ /
SOCIAL SECURITY # PHONE #
( )
ADDRESS Street
ADDRESS Street
City State Zip Code
City State Zip Code
IF FOREIGN RESIDENT Province Country BENEFIT PERCENT
%
IF FOREIGN RESIDENT Province Country BENEFIT PERCENT
%
PARTICIPANT’S SIGNATURE
(FOR NEW ENROLLMENT, YOU MUST SIGN AND DATE ON OR AFTER THE DATE ON ENROLLMENT FORM.)
SIGNATURE DATE
/ /
SPOUSE’S WAIVER (Witnessed by a Notary Public or Authorized Representative of Employer)
My spouse is a participant in a Mutual of America Plan under which I am entitled to be the beneficiary. As such, I would receive the total death
benefit after my spouse’s death. However, I agree to waive my right to be the beneficiary. I agree to let my spouse designate the beneficiary or
beneficiaries named on this form. My spouse may withdraw this designation at any time but may not designate a different primary beneficiary without
my consent.
SIGNATURE OF SPOUSE DATE
SIGNATURE AND SEAL OF NOTARY PUBLIC OR SIGNATURE OF AUTHORIZED REPRESENTATIVE DATE
Note: At the discretion of the Notary, an acknowledgement form may be stapled to this form.
The Spouse’s Waiver is invalid for Defined Benefit Plan participants.
For Mutual of America Use Only
MUTUAL OF AMERICA’S CONFIRMATION (if applicable) SIGNATURE DATE
/ /
6463.R 7/17
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