GR-11927-11 10/2012
BENEFICIARY DESIGNATION FORM INSTRUCTIONS
You must select your beneficiary – the person (or more than one person) or legal entity (or more
than one entity) who receives a benefit payment if you die while covered by the plans. Please make
sure that you also name a contingent beneficiary – who would receive your benefit if your primary
beneficiary dies first.
The completion of this Beneficiary Form will revoke any previous beneficiary designation(s), if any,
for your group term life insurance and/or accidental death and dismemberment (AD&D) insurance
issued to this group/employer.
Please make sure your beneficiary designation is clear so that there will be no question as to your
meaning. If you name more than one primary or contingent beneficiary, show the percentage of your
benefit to be paid to each beneficiary. The listed percentages must add up to 100%. Please provide
all of the information requested. If your beneficiary is not related either by blood or by marriage,
insert the words, “Not Related” as their stated relationship. If you need assistance, contact your
Company’s benefits administrator or your own legal advisor.
A beneficiary for employee Life Insurance may be changed at any time upon written request.
Please note that in no event may a beneficiary be changed by a Power of Attorney (POA).
Sample wording for common beneficiary designations are shown below:
Example #1:
Jane Doe Relationship: Spouse Benefit Percentage: 100%
Example #2:
Jane Doe Relationship: Spouse Benefit Percentage: 50%
Susan Doe Relationship: Daughter Benefit Percentage: 25%
John Does Relationship: Son Benefit Percentage: 25%
If additional space is required, write, “See attached”, on the beneficiary line on the beneficiary
designation form and attach a separate sheet, listing all the required beneficiary information for each
beneficiary listed. This separate sheet should be signed by you (the Employee) and dated.
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life
andAccident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies is Simsbury,
CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations,
reduction of benefits and terms under which the policies may be continued in force or discontinued.
NAMING YOUR GROUP LIFE BENEFICIARY
Employee Name: Employee ID Number:
Social Security Number:
Policyholder/Employer:
Policy Number:
Employee Address:
Telephone Number:
BENEFICIARY DESIGNATION
Initial Beneficiary Designation(s) OR Change of all prior beneficiary designation(s) (check only one box), I hereby revoke any
previous beneficiary designation(s), if any, for my group term life insurance and/or accidental death and dismemberment (AD&D) insurance issued to
this group or employer and direct that the insurance proceeds payable under the policy be paid as indicated below.
Signature of Employee: Date:
Disclaimer: Spousal consent does not apply to ERISA plans.
Spousal Consent For Community Property States Only: If you live in a community property state - Alaska, Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin - you may complete the Spousal Consent section, which allows
your spouse to waive his or her rights to any community property interest in the benefit. Certain tribal jurisdictions may also require spousal
consent. Please see your Benefits Administrator for details.
This will certify that, as spouse of the Employee named above, I hereby consent to my spouse designating the person(s) listed above as
beneficiaries of group life and/or accidental death insurance under the above policy and waive any rights I may have to the proceeds of such insurance
under applicable community property laws. I understand that this consent and waiver supersede any prior spousal consent or waiver under this plan.
Social Security Number: Relationship: Benefit Percent: %
Name: Date of Birth:
Address: Telephone Number: ( )
Social Security Number:
Relationship: Benefit Percent: %
PRIMARY BENEFICIARY(IES)
CONTINGENT BENEFICIARY(IES)
Signature of Employee’s Spouse: Date:
Address:
Telephone Number: ( )
GR-11927-11 10/2012
( )
It is important that your beneficiary designation be clear so there will be no question as to your intent. It is also important
that you name a primary and contingent beneficiary. If you need assistance, contact your Company representative or your
own legal counsel. Benefits payable for a Dependent’s death are payable, where applicable, to You if living, otherwise, We
may, at Our option, pay the benefit to Your surviving spouse or to the executors or administrators of Your estate.
Please note that in no event may a beneficiary be changed by a Power of Attorney (POA)
Address: Telephone Number: ( )
Name: Date of Birth:
Name: Date of Birth:
Social Security Number:
Relationship: Benefit Percent: %
Name: Date of Birth:
Address: Telephone Number: ( )
Social Security Number:
Relationship: Benefit Percent: %
Social Security Number:
Relationship: Benefit Percent: %
Address: Telephone Number: ( )
Name: Date of Birth:
X X X X X
I, the undersigned, reserve the right to change the beneficiary(ies) without the consent of said beneficiary(ies).
Clear Form