Fillable Sun Life Insurance Annuity Company of New York Beneficiary Designation 9/03

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Sun Life Insurance Annuity Company of New York Beneficiary Designation 9/03

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XNYGR/854 • Beneficiary Designation Page 1 of 2
Continued on next page
Sun Life Insurance and Annuity Company of New York
Beneficiary Designation
You may use this form to designate who will receive the Group Life Insurance proceeds
in the event of your death.
The designations you make on this form replace any prior beneficiary designations.
Designations apply to your Basic as well as any Optional Life Insurance you have under
your Group Policy. If you would like different beneficiaries for your Basic and Optional
coverages, please indicate that below.
See Page 2 of this form for sample beneficiary designations and more information.
1 Employee and employer information
Your Name (first, middle initial, last)
Social Security Number
Please print clearly
Employer’s Name
Group Policy Number
Billing Group Number
2 Beneficiary Designation
Please make your beneficiary designation(s) below. If you need more space, attach
another sheet to this form.
You may designate more than one Primary or Secondary Beneficiary. If you do, make
sure to indicate the percentage share each should receive. The total within each class
(Primary and Secondary) must equal 100%. If you do not specify percentages, surviving
beneficiaries within the class will share proceeds equally.
Social Security Relationship Percent Share
Primar
y
Bene
f
iciar
y(
ies
)
Number to Em
p
lo
y
ee o
f
Proceeds*
1.
Name:
Address:
%
2.
Name:
Address:
%
Social Security Relationship Percent Share
Secondar
y
(Contingent
)
Beneficiar
y
(ies
)
Number to Emplo
y
ee of Proceeds*
1.
Name:
Address:
%
2.
Name:
Address:
%
For Primary Benefic-
iaries, indicate who
should receive the
Group Life Insurance
proceeds in the event of
your death.
For Secondary (also
known as Contingent)
Beneficiaries, indicate
who should receive the
Group Life Insurance
proceeds in the event
that ALL of your
Primary Beneficiaries
are not living at the
time of your death.
* The total within each class (Primary and Secondary) must equal 100%.
3 Signature
Important: You must sign and date this form for your designation to become effective.
Make a copy for your records and return the signed original to your employer.
Employers: Keep the
signed original copy of
this form with the
employee’s records.
Signature of Employee
X
Date Signed
Clear
Sun Life Insurance and Annuity Company of New York is a member of the Sun Life Financial group of companies.
© 2003 Sun Life Insurance and Annuity Company of New York. New York, NY 10017. All rights reserved.
XNYGR/854 • Beneficiary Designation Page 2 of 2 9/03
Beneficiary Wording Alternatives
Proposed Beneficiary(ies) Suggested Wording
1. Estate Estate
2. One beneficiary Martha Doe, wife
3. More than one beneficiary in
equal shares
Jane Doe, Mary Doe and Richard Doe, children, or
survivor(s) of them, in equal shares.
4. Two beneficiaries, in
succession
Primary: Martha Doe, wife; Secondary: Richard
Doe, son. (Richard will only receive proceeds if
Martha Doe is not living at the time of the employee’s
death.)
5. One beneficiary followed by
two beneficiaries in equal
shares
Primary: Martha Doe, wife; Secondary: Jane Doe
and Mary Doe, children in equal shares, or the
survivor of them. (Jane and Mary will only receive
proceeds if Martha Doe is not living at the time of the
employee’s death.)
6. More than one Beneficiary in
equal shares per descendent
order
Jane Doe, Mary Doe and Richard Doe, or the
survivor(s) of them, in equal shares. However, if
any of my children predecease me and leave issue
who survive me, the issue of the deceased child
will receive their parents’ share in equal shares.
7. One or more minor children John Smith, as custodian for Jane Doe, a minor,
under the Uniform Transfers to Minors Act
(UTMA) so that proceeds can be paid before the
child reaches the age of majority.
8. To a church or non-profit
organization
Name and address of the beneficiary organization.
9. Beneficiaries shown in
percentages
John Smith, brother - 40%, or in the event of his
death, to my estate; Alan Smith, brother 60%, or
in the event of his death, to my estate.
10. Trust under Last Will and
Testament
Proceeds to be paid to the Trustee under my Last
Will and Testament.
11. Existing Trust Jane Doe, Trustee of the Doe Family Trust, dated
1/1/2001.
Please Note: You cannot name your employer as a beneficiary for Group Life Insurance
proceeds under the Group Policy.
Dependent Life Insurance benefits are payable to the employee, or the employee’s
estate if the employee does not survive the dependent.
Sun Life Insurance and Annuity Company of New York is not a tax or legal advisor and the
above information is provided as general information only. Before making beneficiary
designations, you may want to consult with your tax or legal advisor.
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Sun Life Insurance Annuity Company of New York Beneficiary Designation 903

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Completed 21 December 2019

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