Please check one: Benefi ciary Designation Benefi ciary Change Benefi ciary Name Change
SI 1628-603267-W (6/13)
Signature of Employee Date
Instructions
Please type or print clearly with a ball-point pen. All sections must be completed for processing. You must sign and date for
the benefi ciary designation to be valid. This benefi ciary designation cancels all prior designations. Upon completion, please
sign and mail to the address above. You will receive an acknowledgment that your benefi ciary designation or change has
been recorded.
Employee and Plan Information
Member Name (Last, First, M.I.) Social Security Number
Address City State Zip
Employer Name Policy Number
THE CALIFORNIA STATE UNIVERSITY - (campus)
603267
Benefi ciary Designation
Complete for Employer-paid basic term Life and AD&D only. If you designate a trust or a trustee, you must have a written
trust agreement. If you designate a minor (a person not of legal age) it may be necessary to have a guardian or a legal
representative appointed before any death benefi t can be paid. This means legal expense for the benefi ciary and delay in
payment of the insurance. Please take this into consideration when naming your benefi ciary.
Benefi ciary Examples:
Two Primary Benefi ciaries:
Peter Smith 60% 77 America St, Anytown, USA 77777 000-00-7777 Husband
Anna Smith 40% 777 USA St, Anytown, USA 77777 000-00-7899 Daughter
One Primary & One Contingent Benefi ciaries:
Primary:
Peter Smith 100% 77 America St, Anytown, USA 77777 000-00-7777 Husband
Contingent:
Quincy Smith 100% 789 Tree St, Anytown, USA 77777 000-00-7900 Son
*If any death occurs and a minor is the benefi ciary, it may be necessary to have a guardian or a legal representative appointed before any death benefi t
can be paid.
PRIMARY
% of
Full Name Benefi t Address (street, city, state, zip) Social Security # Relationship Date of Birth
- -
- -
CONTINGENT
% of
Full Name Benefi t Address (street, city, state, zip) Social Security # Relationship Date of Birth
- -
- -
Standard Insurance Company, National Accounts – CSU Team, PSB3A
920 SW Sixth Avenue Portland OR 97204-9675
Employer Paid Life and AD&D
Benefi ciary Designation and
Change Form
