Please check one: Beneciary Designation Beneciary Change Beneciary Name Change
SI 1628-101770-A (5/17)
Signature of Employee Date
Instructions
Please type or print clearly with a ball-point pen. All sections must be completed for processing. You must sign and date
for the beneciary designation to be valid. This beneciary designation cancels all prior designations for your Voluntary
Term Life coverage. Upon completion, please send form to the address above. You will receive an acknowledgment that
your beneciary designation or change has been recorded.
Employee and Plan Information
Member Name (Last, First, M.I.) Social Security Number
Address City State Zip
Employer Name Policy Number
THE CALIFORNIA STATE UNIVERSITY - (campus)
101770-A
Beneciary Designation
Complete for Employee-paid Voluntary Term Life Insurance only. If you designate a trust or a trustee, you must have a written
trust agreement. If you designate a minor (a person not of legal age) it may be necessary to have a guardian or a legal representative
appointed before any death benet can be paid. This means legal expense for the beneciary and delay in payment of the
insurance. Please take this into consideration when naming your beneciary.
Beneciary Examples:
Two Primary Beneciaries:
Peter Smith 60% 77 America St, Anytown, USA 77777 000-00-7777 Husband
Anna Smith 40% 777 USA St, Anytown, USA 77777 000-00-7899 Daughter
One Primary & One Contingent Beneciaries:
Primary:
Peter Smith 100% 77 America St, Anytown, USA 77777 000-00-7777 Husband
Contingent:
Quincy Smith 100% 789 Tree St, Anytown, USA 77777 000-00-7900 Son
*If any death occurs and a minor is the beneciary, it may be necessary to have a guardian or a legal representative appointed before any death benet
can be paid.
PRIMARY
% of
Full Name Benet Address (street, city, state, zip) Social Security # Relationship Date of Birth
CONTINGENT
% of
Full Name Benet Address (street, city, state, zip) Social Security # Relationship Date of Birth
Standard Insurance Company
900 SW Fifth Avenue Portland OR 97204
Voluntary Term Life Insurance
Beneciary Designation
and Change Form
