Fillable Form 110: Basic Life State of Idaho P97650 (Boise State University)

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Form 110: Basic Life State of Idaho P97650 (Boise State University)

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GP39859-09 Page 1 of 2 08/2012
110
RETURN THIS FORM TO:
Your Human Resources Office
State of Idaho P97650
Beneficiary Designation/
Change of Beneficiary/Change of Name
Employee full name Employee social security number
Date of birth Date of hire State agency
Basic Life
Basic Life Beneficiary Designation
This form applies to the State of Idaho Group Term Life Insurance Plan. The following designated beneficiaries will be in
force until revoked by me with a new form. If more than one primary or contingent beneficiary, payment will be made
in equal shares or to the survivors in equal shares unless otherwise stated below.
If any beneficiary is designated as trustee, it is understood and agreed that Principal Life Insurance Company shall not be
a party to nor bound by the conditions of any trust and payment of the proceeds of said policy on the death of the insured
to the then designated beneficiary shall be a complete discharge as to said company.
Primary Beneficiary Designation
Beneficiary full name(s) Relationship Share %
In the event said primary beneficiary(ies) predecease me, I designate as contingent beneficiary(ies):
Contingent Beneficiary Designation
Beneficiary full name(s) Relationship Share %
Voluntary Term Life
I hereby certify that I have been given the opportunity to apply and wish to purchase additional Voluntary Term Life
insurance.
Please complete and attach the Voluntary Term Life enrollment form.
I hereby certify that I have been given the opportunity to apply and purchase additional Voluntary Term Life and
hereby waive my right to purchase such additional Voluntary Term Life insurance.
Signatures Necessary to Process
Employee full signature Date signed
Signature of witness (cannot be same as beneficiary) Date signed
If you are designating a beneficiary other than your spouse and you reside in one of the following community property
states: Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, or Washington (state), your spouse must also
sign the beneficiary designation.
Signature of spouse Date signed
GP39859-09 Page 2 of 2 08/2012
Change of Member’s Name
Reason for change Change my name from:
marriage
divorce
court decree
Date of marriage, divorce or decree To:
State Agency to Complete
Date recorded By
Instructions for Designation of Beneficiary
Be sure to use given names such as “Mary M. Doe,” not “Mrs. John Doe.” The following sample designations may be
helpful to you.
Type of Beneficiary Standard Wording
1. insured’s estate
my estate
2. one beneficiary
Anna L. Doe, wife
3. two beneficiaries
John A. Doe, father, and Mary I. Doe, mother, equally or to the survivor
4. three or more beneficiaries
John A. Doe, father, and Mary I. Doe, mother, and Henry J. Doe, son, equally or
to the survivors or survivor
5. one beneficiary and one
contingent beneficiary
Anna L. Doe, wife, if living; otherwise, Henry J. Doe, son
6. one beneficiary and two
contingent beneficiaries
A
nna L. Doe, wife, if living; otherwise Henry J. Doe, son, and Alice G. Doe,
daughter, equally or to the survivor
7. one beneficiary and three or
more contingent beneficiaries
Anna L. Doe, wife, if living; otherwise Henry J. Doe, Alice G. Doe and Charles B.
Doe, children, equally or to the survivors or survivor
8. two beneficiaries and one
contingent beneficiary
John A. Doe, father, and Mary I. Doe, mother, equally or to the survivor, if living;
otherwise, Anna L. Doe, wife
9. two beneficiaries in unequal
portions
seventy-five percent (75%) of the proceeds to John A. Doe, father, if living, and
twenty-five percent (25%) to Anna L. Doe, mother, if living, the share of a
deceased beneficiary to be paid to the survivor, if any. Total must equal 100%.
10. trust with individual trustees
Richard Doe and John Smith, trustees, or a successor in trust under (trust name)
established (date of trust agreement)
11. trust with corporate trustee
ABC Bank and Trust Company, Des Moines, Iowa, Trustee or successor in trust
under (trust name) established (date of trust agreement)
12. testamentary trust
Trustee of the Mary I. Doe Trust or successor in trust established by the last will
& testament of the insured dated (insert date of will)
13. minor beneficiary
When either the primary or contingent beneficiary designation includes one or
more minor children, you need to complete an additional form. Beneficiary
designation with UTMA custodian, see your employer for this form.
Do not attempt to erase or make corrections; use a new form.
Original – agency Human Resources Office Make copy for employee
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Form 110: Basic Life State of Idaho P97650 (Boise State University)

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Completed 22 July 2020

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