RCUH Group Life Election/Beneficiary Designation Form
(Regular, 75-100% FTE Employees)
Deadline: Thursday, June 24, 2010
PART A: Employee Data:
Employee Name: ________________________________________ Birth Date: _________________________
Address: ______________________________________________ Daytime Phone: _____________________
City: _____________________ State: _____ Zip: ______ Email Address: ____________________________
PART B: RCUH Group Life Insurance Election Options:
Eligible employees will be automatically enrolled in the RCUH “default” life insurance plan which provides for:
Two (2) times annual earnings up to $600,000 (default option)
Internal Revenue Service (IRS) Code states that any life insurance coverage in excess of $50,000 provided by an employer, regardless of who
pays the premium, is subject to taxation in accordance with its imputed income tax table. You may decrease your life insurance benefit to reduce
or avoid “imputed income” by selecting from one of the three options below. Important: If you select one of these options now and wish to
increase your coverage at a later time, you will be required to complete a medical questionnaire (subject to review and approval by The Standard
Insurance Company).
Two (2) times annual earnings up to $200,000
Two (2) times annual earnings up to $100,000
Two (2) times annual earnings up to $50,000
PART C: Life Insurance Beneficiary Designation:
The Beneficiaries of my RCUH Group Life Insurance plan provided by The Standard Life Insurance Company are as follows
(total percentage for Primary or Contingent, if any, must equal 100%):
Primary Beneficiary Relationship % of Benefit
_____________________________________________________ _____________________________ ___________
_____________________________________________________ _____________________________ ___________
Secondary Beneficiary Relationship % of Benefit
_____________________________________________________ _____________________________ ___________
_____________________________________________________ _____________________________ ___________
**PLEASE NOTE: Life Insurance companies generally will not disburse payments directly to minor beneficiaries. Payment will normally be made to the legally recognized
guardian of the minor beneficiary, executor of the estate, or PGL who will retain the benefit amount until minor attains majority age. Your signature certifies the designation of
the beneficiary(ies) listed above.
PART D: Employee Certification:
I understand that this designation revokes all prior designations and that benefits are only payable to a contingent Beneficiary if I am not survived by one or
more primary Beneficiary(ies). I also understand that if I decrease my coverage, and elect to increase your coverage at a later time, I will be required to
submit a medical questionnaire, which will be subject to approval by The Standard Insurance Company.
Employee Signature: _____________________________________________ Date: __________________
