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BENEFICIARY DESIGNATION INSTRUCTIONS AND GUIDELINES
Please follow these instructions carefully when submitting this
form to prevent any delays caused by unclear or omitted
information. Be sure to read and fill out the form completely and
return all pages. This instruction page does not need to be
returned to us.
INSTRUCTIONS AND GUIDELINES
1. Print clearly! Cross-through and initial any corrections or
changes. Do not use correction fluid.
2. Death proceeds shall be paid as shown on the
acknowledged and recorded Beneficiary Designation form. If
the terms of the contract conflict with the items listed in the
form, the terms of the contract prevail.
3. Use percentages in your designation. All proceeds must total
100 percent (%) in each category (Primary, Contingent,
Tertiary). If no percentages are listed, proceeds will be paid
equally.
4. If you are adding beneficiaries but not changing existing
beneficiaries, you must restate all existing beneficiaries.
5. When children are beneficiaries and not named individually,
all living and future children born to or adopted by the
insured are included unless otherwise designated. Unless
named individually, stepchildren are not included. This
designation should be listed as “all children of the insured.”
6. An irrevocable beneficiary is a designation that cannot be
changed without the irrevocable beneficiaries’ written consent.
If you designate an irrevocable beneficiary, the Company will
require the irrevocable beneficiary to consent in writing to
requests for other policy changes (i.e., assignment, contract
changes, loan or surrender requests, annuity withdrawals,
etc.). If you are naming an irrevocable beneficiary, state
“irrevocable” after the named beneficiary.
7. If the owner is a company, provide a corporate resolution
or similar document that lists all of the officers and/or
individuals authorized to sign on behalf of the company.
8. If this form is signed by a power of attorney, guardian or
conservator, a copy of the appropriate documentation is
required.
9. You may choose to designate a Testamentary Trust as your
beneficiary. A Testamentary Trust is created by that
instrument admitted to probate as the Last Will and
Testament of the insured. The funds shall be paid to the
trustee, or successor, named in that trust. This designation
should be listed as “Testamentary Trust”.
BENEFICIARY CLASS DEFINITIONS
PRIMARY or the first person(s)/entity(ies) in line to receive the
death proceeds after the insured is deceased. Funds are paid
to all primary beneficiaries who are living/existing when the
insured dies. If no primary beneficiaries are living/existing when
the insured dies, then funds are paid to contingent beneficiaries
who are living/existing.
CONTINGENT or the second or subsequent person(s)/
entity(ies) in line to receive the death proceeds after the
insured is deceased and there are no surviving primary
beneficiaries. If no contingent beneficiaries are living/existing
when the insured dies, then funds are paid to tertiary
beneficiaries.
TERTIARY or the third or subsequent person(s)/ entity(ies) in
line to receive the death proceeds after the insured is
deceased and there are no surviving primary or contingent
beneficiaries.
NOTE: If no beneficiaries are living/existing when the Insured
dies, funds are paid to the owner or the owner’s estate.
Assurity is a marketing name for the mutual holding company, Assurity Group, Inc. and its subsidiaries.
Those subsidiaries include, but are not limited to, Assurity Life Insurance Company and Assurity Life
Insurance Company of New York. Insurance products and services are offered by Assurity Life Insurance
Company in all states except New York. In New York, insurance products and services are offered by
Assurity Life Insurance Company of New York, Albany, NY. Product availability, features and rates may vary
by state.
18-612-05055 (R09-19) Page A [R.10.11.19]
Insured’s Name
First, Middle, Last
Policy/Certificate No.
Owner’s Home/Cell Phone
( ) / ( )
Owner’s Email
See attached
If additional space is needed, check the box to the left and attach a separate page, signed and dated, including the policy/certificate
number. Each beneficiary’s relationship to the Insured, Social Security number (SSN) or Tax Identification number (TIN) and/or Date
of Birth are REQUIRED.
1. Primary Beneficiary(ies)
No.
Name:
DOB:
(MM/DD/YYYY)
SSN/TIN:
Phone Number:
Percentage:
1
/ /
( )
Address:
Email:
Relationship
to Insured:
2
/ /
( )
Address:
Email:
Relationship
to Insured:
3
/ /
( )
Address:
Email:
Relationship
to Insured:
4
/ /
( )
Address:
Email:
Relationship
to Insured:
Full Name of Trust
Date of Trust
Name of Trustee(s)
Full Address of Trustee(s)
TOTAL
100%
2. Contingent Beneficiary(ies)
No.
Name:
DOB:
(MM/DD/YYYY)
SSN/TIN:
Phone Number:
Percentage:
1
/ /
( )
Address:
Email:
Relationship
to Insured:
2
/ /
( )
Address:
Email:
Relationship
to Insured:
3
/ /
( )
Address:
Email:
Relationship
to Insured:
4
/ /
( )
Address:
Email:
Relationship
to Insured:
Full Name of Trust
Date of Trust
Name of Trustee(s)
Full Address of Trustee(s)
TOTAL
100%
18-612-05055 (R09-19) Page 1 [R.10.11.19]
Assurity
®
Life Insurance Company
402- 476-6500 | 800-869-0355 | FAX 888-255-2060
Assurity
®
Life Insurance Company of New York
844-401-7585 | FAX 888-255-2060
Admin: Office: P.O. Box 82533, Lincoln, NE 68501-2533
Beneficiary Designation
Insured’s Name
First, Middle, Last
Policy/Certificate Number
3. Tertiary Beneficiary(ies)
No.
Name:
DOB:
(MM/DD/YYYY)
SSN/TIN:
Phone Number:
Percentage:
1
/ /
( )
Address:
Email:
Relationship
to Insured:
2
/ /
( )
Address:
Email:
Relationship
to Insured:
3
/ /
( )
Address:
Email:
Relationship
to Insured:
4
/ /
( )
Address:
Email:
Relationship
to Insured:
Full Name of Trust
Date of Trust
Name of Trustee(s)
Full Address of Trustee(s)
TOTAL
100%
YOUR CONFIRMATION –
By signing below:
I acknowledge this request is subject to the provisions and conditions of my policy/contract(s) and Assurity may request additional information in
order for my request to be processed.
I understand by submitting this document, I revoke any existing beneficiary designations with respect to any proceeds payable at the death of the
insured.
I acknowledge that payment to any designated trust as directed by this beneficiary designation ends the company’s responsibility in full. If a trust is
named as beneficiary but does not exist when the insured dies, or no trustee qualifies or makes claim within six (6) months after the insured dies, or the
company receives proof that no trustee will qualify or make claim, then the funds shall be paid as if that trust ceased to exist before the insured died.
/ /
Signed Date
(MM/DD/YYYY)
Signature of Owner
Signature of Joint Owner or Irrevocable Beneficiary (if
applicable)
Owner Title (if applicable)
(Trustee, Power of Attorney, Guardian, Conservator or Company Officer)
Signature of Witness (Required in MA only)
(A non-related person with no financial interest in the policy)
SPOUSAL CONSENT–
If you live in a community property state (residents of AZ, CA, ID, LA, NM, NV, TX, WA or WI) and your spouse is NOT listed as the sole primary
beneficiary, spousal consent is required to make a beneficiary change.
No current spouse Check this box if you do not have a spouse or if your spouse is deceased.
I have read the information above and have seen the beneficiary designation made by my spouse. I understand that I have not been named as the sole
primary beneficiary of my spouse’s policy/certificate and have waived my right to the policy/certificate’s proceeds. I acknowledge that I have been advised to
consult a tax advisor prior to signing this agreement.
/ /
Signed Date
(MM/DD/YYYY)
Signature of Spouse
FOR HOME OFFICE USE ONLY—The insurer has acknowledged and recorded the above designation.
Date (MM/DD/YYYY)
Authorized Signature
Title
18-612-05055 (R09-19) Page 2 [R.10.11.19]
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Completed 8 March 2021

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