Fillable SAG-AFTRA HEALTH PLAN (SAG-AFTRA Plans)

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SAG-AFTRA HEALTH PLAN (SAG-AFTRA Plans)

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SAG-AFTRA HEALTH PLAN
3601 W. Olive Ave., Burbank, CA 91505 • Mailing Address: P.O. Box 7830, Burbank, CA 91510-7830
P (800) 777-4013 • F (818) 953-9880 • www.sagaftraplans.org/health
Designation of Beneficiaries Form
Use this form to designate the beneficiaries of your SAG-AFTRA Health Plan (Plan) benefits in the event of
your death. You may choose anyone to be your beneficiary, and you may change your designation at any
time. This is a confidential legal document, which the participant or legal guardian of the participant must sign.
About you:
First and last names:
Date of birth (MM/DD/YYYY):
/ /
SSN:
- -
Instructions: You must list at least one primary and one secondary beneficiary. (See sample on reverse
side.) You cannot list yourself as a beneficiary. Be sure to indicate the share to be paid to each beneficiary.
Benefits will not be paid to any secondary beneficiary unless all primary beneficiaries are deceased. For
example, if you name two primary beneficiaries and one of them dies, the surviving primary beneficiary will
receive all of the benefits upon your death even if you name one or more secondary beneficiaries.
You must complete a separate
Designation of Beneficiaries Form
from the SAG-Producers Pension Plan and/or
the AFTRA Retirement Plan for possible pension benefits that may be payable upon your death.
Primary beneficiary — If you have additional primary beneficiaries, please list them on the back of this form.
Name:
Relationship:
Share of benefit: %
Address:
Email:
Phone:
Name:
Relationship:
Share of benefit: %
Address:
Email:
Phone:
Secondary beneficiary — If you have additional secondary beneficiaries, please list them on the back of this form.
Name:
Relationship:
Share of benefit: %
Address:
Email:
Phone:
Name:
Relationship:
Share of benefit: %
Address:
Email:
Phone:
Signature of participant or legal guardian Date
2
Sample beneficiary designation
Primary beneficiary
Secondary beneficiary
NAME
MARY SMITH
RELATIONSHIP
MOTHER
SHARE OF BENEFIT 100%
ADDRESS 12345 ANY STREET, ANY TOWN, STATE, ZIP CODE
EMAIL
MARYSMITH@MARYSMITH.COM
PHONE NUMBER (800) 777-4013
NAME
N/A
RELATIONSHIP
N/A
SHARE OF BENEFIT N/A
ADDRESS N/A
EMAIL
N/A
PHONE NUMBER N/A
NAME
NANCY WHITE
RELATIONSHIP
FRIEND
SHARE OF BENEFIT 50%
ADDRESS 12345 ANY STREET, ANY TOWN, STATE, ZIP CODE
EMAIL
NANCYWHITE@NANCYWHITE.COM
PHONE NUMBER (800) 777-4013
NAME
JAMES SMITH
RELATIONSHIP
BROTHER
SHARE OF BENEFIT
50%
ADDRESS 12345 ANY STREET, ANY TOWN, STATE, ZIP CODE
EMAIL
NANCYWHITE@NANCYWHITE.COM
PHONE NUMBER (800) 777-4013
Additional beneficiary designation (optional)
Additional primary beneficiary
Name:
Relationship:
Share of benefit: %
Address:
Email:
Phone:
Name:
Relationship:
Share of benefit: %
Address:
Email:
Phone:
Additional secondary beneficiary
Name:
Relationship:
Share of benefit: %
Address:
Email:
Phone:
Name:
Relationship:
Share of benefit: %
Address:
Email:
Phone:
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Completed 20 January 2021

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