Fillable Life Insurance Beneficiary Designation Form (Roger Williams University)

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Life Insurance Beneficiary Designation Form (Roger Williams University)

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Group insurance products and services described herein are issued by Liberty Life Assurance Company of Boston, a Lincoln Financial Group company. Home Office: Boston, MA.
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual
obligations. ©2018 Lincoln National Corporation. All rights reserved.
Roger Williams University
Beneficiary Designation Form
Employee Name (Last, First, Middle)
Social Security Number
Address (Street, City, State, ZIP Code)
Email Address
• This beneficiary information applies to all coverages applicable to the covered employee and will replace any prior beneficiary designation.
• The primary beneficiary is the individual(s) who will receive the insurance proceeds in the event of the insured’s death.
• In the event the primary beneficiary(ies) predecease(s) the insured, the contingent beneficiary(ies) will receive the insurance proceeds.
• If no beneficiary is named, or no beneficiary survives the insured, settlement will be made in accordance with the terms of the Group Contract.
• To change your beneficiaries, you must complete a new form.
• If you wish to name more beneficiaries than this form provides space for, complete your list on an additional copy of this form and attach it.
Primary Beneficiary (the total of all primary beneficiaries must equal 100%)
1.
Name (Last, First, Middle)
Date of Birth
Relationship
% of Benefit
Address
Phone Number
2.
Name (Last, First, Middle)
Date of Birth
Relationship
% of Benefit
Address
Phone Number
3.
Name (Last, First, Middle)
Date of Birth
Relationship
% of Benefit
Address
Phone Number
TOTAL
The total share of all primary beneficiaries must equal 100%.
Contingent Beneficiary (the total of all contingent beneficiaries must equal 100%)
1.
Name (Last, First, Middle)
Date of Birth
Relationship
% of Benefit
Address
Phone Number
2.
Name (Last, First, Middle)
Date of Birth
Relationship
% of Benefit
Address
Phone Number
3.
Name (Last, First, Middle)
Date of Birth
Relationship
% of Benefit
Address
Phone Number
4.
Name (Last, First, Middle)
Date of Birth
Relationship
% of Benefit
Address
Phone Number
TOTAL
The total share of all primary beneficiaries must equal 100%.
Employee Signature:
Date:
Complete this form and retain a copy for your records.
100%
Group insurance products and services described herein are issued by Liberty Life Assurance Company of Boston, a Lincoln Financial Group company. Home Office: Boston, MA.
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual
obligations. ©2018 Lincoln National Corporation. All rights reserved.
Beneficiary Designation
Remember the following when completing your Beneficiary
Designation form:
• Clearly identify your beneficiary(ies), providing each beneficiary’s full name, date of birth,
Social Security number, address, and relationship to you.
• You can name primary and contingent beneficiaries.
Primary:
The primary beneficiary is the individual(s) who will receive the insurance
proceeds at the time of your death.
Contingent:
A contingent beneficiary, or secondary beneficiary, is the individual(s)
who will receive the insurance proceeds if the primary beneficiary(ies) dies
before you. Naming a contingent beneficiary is important, as you may outlive the
primary beneficiary or die simultaneously.
• If you name more than one primary or contingent beneficiary, make sure the beneficiary
percentages add up to 100 percent for each class of beneficiary (primary and contingent).
•
Minor child:
A minor child can be named as a beneficiary, but benefits cannot be released
directly to the minor child. Benefits will be paid to the court-appointed guardian of the minor
child’s estate (or property). Parents are not automatically the guardians of a minor’s estate.
A parent may need to petition a local probate court where the child lives to be named
guardian of the child’s estate.
• Make sure you sign and date the beneficiary designation form.
• If no beneficiary is named, or if no beneficiary survives you, settlement will be made as
provided in the Group Contract.
To assist you, here are some examples of clear beneficiary
designations.
One primary and two contingent
beneficiaries
One primary and three contingent
beneficiaries
Primary Beneficiary:
Jane Smith, spouse, 100%
Primary Beneficiary:
Gayle Rich, spouse, 100%
Contingent Beneficiaries:
Paul Jones, brother, 50%
Mary Park, sister, 50%
Contingent Beneficiaries:
Teresa Rich, daughter, 40%
Susan Rich, daughter, 40%
Jason Rich, brother, 20%
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Life Insurance Beneficiary Designation Form (Roger Williams University)

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Completed 1 February 2021

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