Group Insurance
Life Accident Disability
BENEFICIARY DESIGNATION FORM
Life Insurance Company of North America
Employer Name _____________________________________________
Employee Name_____________________________________________ Employee Social Security #_________________
Current Address__________________________________________ City__________________State______ Zip _______
Home Phone____________________Work Phone____________________
Primary and Contingent Beneficiaries – Unless you designate a percentage, proceeds are paid to primary surviving
beneficiaries in equal shares. Proceeds are paid to contingent beneficiaries only when there are no surviving primary
beneficiaries. If you designate contingent beneficiaries and do not designate percentages, proceeds are paid to the
surviving contingent beneficiaries in equal shares. Unless otherwise provided, the share of a beneficiary who dies before
the insured will be divided proportionately among the surviving beneficiaries in the respective category (primary or
contingent).
Basic Life Insurance, Life Insurance Company of North America - Policy No. ________________
Date % (total must
Employee’s Primary Beneficiary(ies): Relationship SS # of Birth equal 100%)
Date % (total must
Contingent(s): Relationship SS # of Birth equal 100%)
Basic Accident Insurance, Life Insurance Company of North America - Policy No. ________________
Date % (total must
Employee’s Primary Beneficiary(ies): Relationship SS # of Birth equal 100%)
Date % (total must
Contingent(s): Relationship SS # of Birth equal 100%)
Please refer to page 2 to review
Guidelines for Designation of Beneficiaries
. If you need additional space, using the above
format, attach a separate piece of paper with the appropriate policy number, the date, and your signature.
Community Property Laws - If you are married, reside in a community property state (Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin), and name someone other than your spouse as
beneficiary, it is possible that payment of benefits may be delayed or disputed unless your spouse also signs the
beneficiary designation.
Spouse Signature________________________________________________________________Date____/____/____
Owner Signature___________________________________________________________________Date____/____/____
please enter all dates in mm//dd/yyyy format.
Plymouth-Canton Community Schools
LK 963665
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GUIDELINES FOR DESIGNATION OF BENEFICIARIES
General - Please be sure to include the beneficiary’s full name, social security number and relationship to you. Providing
this information can help expedite the claim process by making it easier to locate and verify beneficiaries.
Minors - While you may designate minors as beneficiaries, please note that claim payments may be delayed due to
special issues raised by these designations. In the event of a claim and the beneficiary is a minor child, the insurance
proceeds will not be released to the minor child. The insurance proceeds may be paid to a duly appointed guardian of the
child’s estate. You may want to obtain the assistance of an attorney in drafting your beneficiary designation.
Trust as Beneficiary - You may designate a trust as beneficiary, using the following form: “To [name of trustee], trustee of
the [name of trust], under a trust agreement dated [date of trust].”
If you wish to designate a testamentary trust as beneficiary (i.e., one created by will), you should recognize the possibility
that your will which was intended to create this trust may not be admitted to probate (because it is lost, contested, or
superseded by a later will). Claim payment delays can result if the beneficiary designation doesn’t provide for this
situation.
Life Status Changes - We recommend that you review your beneficiary designation when significant life status events
occur, such as marriage, divorce, or birth of a child.
See an Attorney! The above guidelines are general and are not intended to be relied on as legal advice. Unless your
designation is a simple one, we recommend that you obtain the assistance of an attorney in drafting your beneficiary
designation. A qualified attorney can help assure that your beneficiary designation correctly reflects your intentions, is
clear and unambiguous, and meets legal requirements.
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