Fillable Unclassified Faculty Enrollment Form (Wichita State University)

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Unclassified Faculty Enrollment Form (Wichita State University)

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KPERS - 7/99A
Revised 6/08
KPERS Use Only
Designation of Beneciary for Life Insurance
Kansas Board of Regents Members
Please type or print clearly in black ink.
Important – The beneciary designations on this form replace all previous designations.
Read instructions on page 2, especially if you have any KPERS service credit. If you have more
beneciaries than spaces in any category, please use an Additional Life Insurance Beneciaries page.
Do not attach plain paper or continue on the back of this form. Additional pages must be attached
to this completed form to be valid.
Mark this box if you are using additional pages.
Contact Us – toll free: 1-888-275-5737 • phone: 785-296-6166 • fax: 785-296-6638
e-mail: kpers@kpers.org • web site: www.kpers.org • mail: 611 S. Kansas Ave., Suite 100, Topeka, KS 66603
Part A – Member Information
1. Social Security Number: ______-____-_____ 2. Name (First, MI,Last): __________________________
3. Telephone Number: (_____) ______________________ 4. Mailing Address: ______________________________
5. Employer: ____________________________________ City, State, Zip: _______________________________
Part B – Primary Beneciary for Life Insurance Benets – For basic and optional group life insurance.
Each beneciary will share your benet equally.
Name: ______________________________________________________ Social Security Number: ______-____-_____
 Estate  Trust  Person (state relationship): _________________ Date of Birth: ____/____/____
Name: ______________________________________________________ Social Security Number: ______-____-_____
 Estate  Trust  Person (state relationship): _________________ Date of Birth: ____/____/____
Name: ______________________________________________________ Social Security Number: ______-____-_____
 Estate  Trust  Person (state relationship): _________________ Date of Birth: ____/____/____
Part C – Contingent Beneciary for Life Insurance Benets – For basic and optional group life insur-
ance. Each beneciary will share your benet equally if your primary beneciary(ies) is not living.
Name: ______________________________________________________ Social Security Number: ______-____-_____
 Estate  Trust  Person (state relationship): _________________ Date of Birth: ____/____/____
Name: ______________________________________________________ Social Security Number: ______-____-_____
 Estate  Trust  Person (state relationship): _________________ Date of Birth: ____/____/____
Name: ______________________________________________________ Social Security Number: ______-____-_____
 Estate  Trust  Person (state relationship): _________________ Date of Birth: ____/____/____
Part D – Member Signature – Only the member may designate a beneciary. Conservators, guardians and those
with power of attorney cannot name a beneciary. Member’s signature must be witnessed by a disinterested party. Witness
may not be a beneciary. *Second witness required only if member signs with an “X.”
Member Signature: ____________________________________________ Month/Day/Year: ____/____/____
Witness Signature: ____________________________________________ Month/Day/Year: ____/____/____
*Witness Signature: ____________________________________________ Month/Day/Year: ____/____/____
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Who Can Use This Form?
This form is for Board of Regents members who do not have any KPERS service credit. This form designates a beneciary
for your KPERS life insurance benets only. Please see your designated agent about designating a beneciary for your Board
of Regents benets.
Who Can You Name as Beneciary?
You can choose:
A living person
A trust
Your estate
Any combination of these options.
If you choose more than one beneciary, each will share your life insurance benet equally. You can also name a contingent
beneciary to receive your benet if your primary beneciary is not living. Only members can complete the designation
form. Conservators, guardians and those with power of attorney cannot select or change a beneciary. Each time you com-
plete a beneciary form, it cancels all those you have previously completed. Every time you complete the form, ll in
both the primary and contingent beneciary sections if you intend to have a contingent beneciary. If you complete only the
contingent section and leave the primary blank, you will have no primary beneciary, even if a past form names one. When
completed, this form stays with your employer.
Naming a Trust or Estate
If you name a trust, provide the name of the trust (e.g., Your Name, Trust #1). If you name your estate, write “Estate of (Your
Name)” or “My Estate.” You can name another primary or contingent beneciary in addition to your estate or a trust, and
each will share your benet equally.
Naming Additional Beneciaries
If you need to name more beneciaries than space allows, please use an Additional Life Insurance Beneciaries page.
This page must be with your completed Designation of Beneciary for Life Insurance form to be valid. You can download
additional pages at www.kpers.org or get one from your designated agent.
If You Have Any KPERS Service Credit
This form is for Board of Regents members who do not have any KPERS service credit. If you are a Regents member and
have any KPERS service credit, you need to complete a Designation of Beneciary form (KPERS-7/99) instead. This form
will allow you to name a single beneciary or separate beneciaries for your life insurance benets and KPERS retirement
benets. You can get one at www.kpers.org or from your designated agent.
If you do not name a beneciary on a Designation of Beneciary form (KPERS-7/99), your KPERS retirement benets
will be paid according to the line of descendency in K.S.A 74-4902(7).
For additional information on designating a beneciary, please visit www.kpers.org.
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Unclassified Faculty Enrollment Form (Wichita State University)

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Completed 19 July 2020

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