Revised 02/2019
RETIREE
Fulton County, Georgia
Group Life Insurance Beneficiary Change Form
RETIREE NAME LAST FIRST MIDDLE INITIAL SEX DATE OF BIRTH
BENEFICIARY DESIGNATION: If two or more primary beneficiaries are named, and you do not list benefit percentages, proceeds will be paid in
equal shares to the named primary beneficiaries who survive you. If no primary beneficiary survives you, proceeds will be paid to the contingent
beneficiary (ies). If you list benefit percentages, the total must equal 100%. (Retiree is the beneficiary of proceeds from dependent coverage).
FIRST NAME LAST NAME SOCIAL SECURITY # RELATIONSHIP & ADDRESS BENEFIT
%
Primary
Primary
Contingent
Contingent
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of
claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties.
INFORMATION ON THIS FORM WILL OVERRIDE ANY PRIOR DESIGNATION SELECTION FOR THE POLICY (IES) LISTED ABOVE.
Subscribed and sworn before me on this the___________ day of _________________________, 20______
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she
signed the forgoing document: ________________________________________________
Notary public: _______________________________________
My commission expires: _______________________________
__________________________________________________________________ DATE ___________/_______________/_________________
RETIREE SIGNATURE
__________________________________________________________________
PRINTED RETIREE NAME
