Fillable form to the address or fax number listed

Fill Online, Printable, Fillable, Blank form to the address or fax number listed Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

form to the address or fax number listed

On average this form takes 26 minutes to complete

The form to the address or fax number listed form is 3 pages long and contains:

  • 0 signatures
  • 27 check-boxes
  • 92 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Beneficiary Designation Form
Instructions
Insured(s)
Phone Number
Policy Number(s)
• For each new Beneficiary designation please complete all required information; review for accuracy, sign and return the
form to the address or fax number listed below. For more detailed instructions, please see page 5 of this form.
• Please note this designation form revokes all previous Beneficiary designations with the exception of Irrevocable Beneficiary
Designations. Therefore, even if a Primary Beneficiary or Contingent Beneficiary is to remain the same, such Beneficiary must
be restated on this form.
Insured Information
Primary Beneficiary Information: This is the individual/party you select to receive the Death Benefit after the Insured’s
death. (Select from options A, B or C)
Current Policy Owner(s)
Name (First, Middle, Last) Relationship to Insured Sex
Female Male
Social Security/Tax ID # Date of Birth (mm/dd/yyyy)
Phone Number
% of Benefit
Address (Street) (City) (State) (Zip)
A. To the individual(s) or party(ies) listed below: Benefit will be divided equally among all Surviving Primary Beneficiaries
unless otherwise indicated. If naming more than 3 Primary Beneficiaries, please attach a signed, dated sheet including all
details required for each Beneficiary.
Relationship to Insured Sex
Female Male
Relationship to Insured Sex
Female Male
Name (First, Middle, Last)
Social Security/Tax ID # Date of Birth (mm/dd/yyyy) Phone Number % of Benefit
Address (Street) (City) (State) (Zip)
Name (First, Middle, Last)
Social Security/Tax ID # Date of Birth (mm/dd/yyyy)
Phone Number
% of Benefit
Address (Street) (City) (State) (Zip)
C. The Executors or Administrators of the Estate of the Insured
Name of Trust
Name of Trustee(s)
Address (Street)
Social Security/Tax ID # Date of Trust (mm/dd/yyyy)
Phone Number
(City)
(State) (Zip)
B. To the Trust described below:
Please include a Certification of Trust form (PM6389) with this beneficiary designation
for a revocable or irrevocable trust.
Testamentary Revocable Irrevocable
PM6532
Page 1 of 5
01/21
The Penn Mutual Life Insurance Company, Philadelphia, PA 19172
% of Benefit
Type of Trust:
Contingent Beneficiary Information (optional): This is the individual/party you select to receive the Death Benefit after the
Insured’s death if no Primary Beneficiary survives the Insured. If you selected the Estate of the Insured as a Primary Beneficiary,
no Contingent Beneficiary may be named. (Select from options A, B or C)
A. To the individual(s) or party(ies) listed below: Benefit will be divided equally among all Surviving Contingent
Beneficiaries unless otherwise indicated. If naming more than 3 Contingent Beneficiaries, please attach a signed, dated
sheet including all details required for each Beneficiary.
B. To Trust described below: Please include a Certification of Trust form (PM6389) with this beneficiary designation for
a revocable or irrevocable trust.
Name of Trust
Name of Trustee(s)
Address (Street)
Social Security/Tax ID # Date of Trust (mm/dd/yyyy)
Phone Number
(City) (State) (Zip)
C. The Executors or Administrators of the Estate of the Insured
Final Beneficiary: If you select the Estate of the Insured as a Primary or Contingent Beneficiary, no Final Beneficiary may be
named. In the event that no named Beneficiary survives the Insured, the proceeds shall be paid to:
Additional Provision
The Executors or Administrators of the Estate of the Insured
The Executors or Administrators of the Estate of the Last Surviving Beneficiary
Payment by Representation – Applies only to the children of the Insured.
If the Insured's Child is designated as a Beneficiary, whether by name or relationship, and that child dies before the Insured,
the share of the child will be paid in equal shares to living children of the deceased child. If the Insured's child has no living
children, that share will be paid in equal shares to the Insured's surviving children named in the same class.
Name (First, Middle, Last) Relationship to Insured Sex
Female Male
Social Security/Tax ID # Date of Birth (mm/dd/yyyy)
Phone Number
% of Benefit
Address (Street) (City) (State) (Zip)
Relationship to Insured Sex
Female Male
Relationship to Insured Sex
Female Male
Name (First, Middle, Last)
Social Security/Tax ID # Date of Birth (mm/dd/yyyy)
Phone Number
% of Benefit
Address (Street) (City) (State) (Zip)
Name (First, Middle, Last)
Social Security/Tax ID # Date of Birth (mm/dd/yyyy)
Phone Number
% of Benefit
Address (Street) (City) (State) (Zip)
PM6532
Page 2 of 5
01/21
% of Benefit
Testamentary Revocable Irrevocable
Type of Trust:
PM6532
Page 3 of 5
01/21
Authorizations
Signatures
Remarks: Please review this form for accuracy, sign and return the form to the address or fax number listed below. If there
is more than one Owner, all Owners must sign. Upon receipt of the signed form, we will record the change in Beneficiary
designation and send a confirmation to the Owner that the change has been processed.
Representation: The Policy Owner(s) represent(s) that no bankruptcy or insolvency proceedings are pending with respect
to Policy Owner(s). General Provisions constitute a part of this designation.
The signature of all owners will be required to exercise any contractual right under policy. If you are signing the form in any
capacity other than an individual, an appropriate title is required.
Owner
Individual(s)
Corporation, Bank or Financial
Institution
Signature of one officer with title, and a corporate resolution or secretary certificate
which names all officers authorized to sign on behalf of the corporation; or two officer
signatures, with title, without corporate resolution or secretary certificate.
Signature example: John Doe, President, ABC Corporation.
Partnership or LLC We require one general/managing partner signature with title and a copy of the Partner-
ship agreement for Partnerships OR one managing member’s signature with title and a
copy of the operating agreement for LLCs.
Signature example: John Doe, Partner.
Conservator, Guardian of
Estate or Power of Attorney
Agent
Signature of Conservator, Guardian of Estate or Power of Attorney Agent with title. We
require Letters of Conservatorship/Guardianship of Estate along with court order desig-
nating conservator/guardian of estate or a copy of the Power of Attorney document to
be on file.
Signature example: John Doe, Conservator for Jane Doe.
Trust
Signature of all Trustee(s) with title as authorized by the Trust documentation. We
require Trust documentation such as a Certification of Trust form (PM6389) to be on
file. If there has been a change in trustee(s) since the trust became owner, we will also
require any Resignation of Trustee or Termination of Trustee, Appointment of New
Trustee and Acceptance of New Trust documents.
Signature example: John Doe, Trustee.
Policy Owner(s)
Custodian on behalf of a Minor
We require UGMA or UTMA paperwork.
Signature example: John Doe, custodian for Baby Doe under (state) UTMA
Signed with an “X” If signor is unable to sign and must sign with an “X” we require signature be notarized.
All other interested parties Contact customer service to verify signature(s) needed.
Stamped signatures
We will not knowingly accept a stamped signature.
Signature(s) Requirements - Please be aware that a Certificate of Completion must
accompany any electronic signature.
Signed on ___________ _____, ________ at ___________________________________(city) State of ________________
Print Name of Current Policy Owner Signature of Current Policy Owner (Please see requirements below)
Print Name of Joint Policy Owner Signature of Joint Policy Owner (Please see requirements below)
Print Name of Witness* Witness Signature
*The policy owner's signature must be witnessed by a disinterested person on policies that were issued in the state of Massachusetts
or the policy owner is residing in the state of Massachusetts.
General Provisions
Definitions
• Brothers and Sisters - include those of half-blood.
• Children and Grandchildren - includes natural born and legally adopted children, but does not include stepchildren not adopted.
Eligibility of Beneficiaries
• Payment will be made to each class of Beneficiary in the following order:
• Primary Beneficiary(ies)
• Contingent Beneficiary(ies)
• Final Beneficiary, or, if none, to Insured's executors or administrators.
• To be entitled to payment, Beneficiary must be living on date of Insured's death, subject to any payment by
representation.
• If no Beneficiary in a class is then living, proceeds will be paid to Beneficiaries named in next lower class who are
entitled to payment.
• No one in a class will receive payment while there is a Beneficiary entitled to payment in a prior class.
• If more than one Beneficiary is named in a class, proceeds will be divided equally among all Beneficiaries entitled to
payment, unless stated otherwise.
• When distribution is directed as stated amounts in conjunction with percentage shares, the stated amount will be
distributed first.
• The share of a Beneficiary who dies before the Insured and who otherwise would have been entitled to payment will
be paid in equal shares to the other surviving Beneficiaries in the same class, subject to any payment by
representation.
• When unequal distribution among a class is stated, the deceased Beneficiary's share will be paid proportionately to the
surviving Beneficiaries of the same class.
Payment to a Trustee Under a Will (Testamentary Trustee)
• A one sum payment will be paid to a testamentary Trustee after satisfactory proof is received that a representative of
the estate has been authorized to act.
• Payment will be made to the next class of Beneficiary if proof is received that no testamentary Trustee will act.
Payment to Trustee(s) Under A Trust Agreement
• Company reserves the right to require written evidence satisfactory to it that the Trust is in effect and evidence of the
identity of the Trustee(s) who are qualified to act on behalf of the Trust.
• If evidence is received that the Trust agreement is not in effect at the Insured's death, proceeds will be paid to
Beneficiaries entitled to payment named in the next lower class.
Source of Information
• Company may rely upon written evidence in its discretion to determine the identity, date of birth, name, address or
other facts concerning a Beneficiary or Policy Owner.
Applicability of Designation
• This designation applies to all policies numbered on it.
• This designation replaces all prior designations, including the designation in the application to the policy, and will apply
until a later designation is filed with the Company.
PM6532
Page 4 of 5
01/21
Mailing Instructions
Or by fax to:
215-956-7699
Attention: Client Services
Please return the forms either by mail to:
Penn Mutual Life Insurance Company or Penn Insurance & Annuity Company
P.O. Box 178
Philadelphia, PA 19105-0178
The following instructions have been enclosed to assist you with the completion of the Beneficiary Designation Form.
Please read these instructions carefully before completing the application.
• Completing this form: It is important that you fully complete the Primary Beneficiary section of this form, even if you are
not making any changes to a Primary Beneficiary (i.e., fully writing out the designation including names and percentages if
applicable). We will not accept wording such as “same” or “no change” in the Primary Beneficiary section or the
Contingent Beneficiary section or forms where the Primary Beneficiary section is left blank. This information is requested
to assist us in identifying and contacting your Beneficiary(ies) in the event of a claim/distribution and ensure benefits are
paid out appropriately. State regulations may require benefits be paid to the State if the Beneficiary cannot be located in
a timely manner.
• Multiple Policies: Complete a separate Beneficiary Designation request for each policy to be changed, unless the Policy
Owner and all information is the same for all policies.
• Corrected Form: A form which has been altered or on which there has been an erasure cannot be accepted unless the
alteration or erasure is initialed by the Policy Owner.
• Authority: Only the Owner(s) of the insurance policy is/are authorized to make changes to the policy.
• Qualified Plans: The Plan Trustee must be the Beneficiary of the policies issued under a Qualified Plan. Personal
Beneficiaries should be filed with the Plan Trustee. The Insured’s estate is the Beneficiary if the plan terminates or a plan
was erroneously designated as Owner and Beneficiary.
• Minor Beneficiaries: Having a Minor Beneficiary can be problematic if the Insured dies before the minor reaches the age
of majority, since a minor cannot accept the Death Benefit. In such a situation, unless State Law makes the parent the
natural guardian of the estate of the minor, or direct distribution to someone acting on behalf of the minor is permitted
by statute, Penn Mutual will hold the Death Benefit, at interest, until either: (a) the minor reaches majority, at which time
we pay the Beneficiary directly; or (b) we are provided with court certified guardianship papers for the minor, at which
time Penn Mutual will pay the guardian. Alternatively, you should consult an attorney with whom you may consider the
following options:
• Name a custodian for the minor under your state’s Uniform Transfer to Minors Act (UTMA). For this option, you
would simply need to use the following wording on a Beneficiary designation: “(minor’s name) c/o (custodian’s
name), custodian under the (state) UTMA.” At death, the custodian will be able to collect the Death Benefit on the
minor’s behalf.
• Provide for the minor in the Insured or Owner’s Last Will and Testament and designate Insured or Owner’s estate as
the Beneficiary of the policy. Penn Mutual will pay the proceeds to the executor of the estate.
• Provide for the minor in a Trust and designate the Trust as the Beneficiary of the policy. Penn Mutual will pay the
death benefit to the Trustee. Penn Mutual requires a copy of the Trust.
• Beneficiaries not specified by name: If Beneficiary(ies) are not specified by name (i.e., all children living), the Company is
authorized to rely on an affidavit from any Beneficiary listed on this form in determining the names of the Beneficiaries at
time of claim. The Company is discharged from all liability upon making settlement based on such affidavit.
• Trust Beneficiaries: If any Trustee fails to make claim for the policy proceeds within 12 months after the company is
notified of the Insured’s death or if the Company receives written evidence satisfactory to it that the Trust is not in effect,
payment shall be made as if the Trust was not named as a Beneficiary. Before making payment to any Trust, the Company
reserves the right to require written evidence satisfactory to it that the Trust is in effect and evidence of the identity of
the Trustee(s) who are qualified to act on behalf of the Trust. The Company shall be fully protected in acting in reliance
upon such evidence. The Company’s responsibility for the payment of proceeds ends with the payment to the Trustee(s);
it has no responsibility regarding any subsequent distribution.
• Dollar Amounts: Specific dollar amounts are generally not permitted. Instead, please designate a percent in the % column.
Percentage totals must equal 100 percent. If you must designate a specific dollar amount, please contact our Home Office
for instructions.
PM6532
Page 5 of 5
01/21
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

form to the address or fax number listed

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 October 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document