Beneficiary Designation Form

Editor’s Note: This is an example of a beneficiary designation form that should be customized for your benefit plans. It may be necessary to have a separate beneficiary form for each benefit plan. You should consult with your benefit plan administrator or legal counsel for guidance. 

(Please print clearly)

Today's date: _______________

Employee name: ___________________________________________________

Social Security number (SSN): ________________________________________

Date of birth (mm/dd/yyyy): ___________________________________________

Address: _________________________________________________________

City, State, ZIP Code: _______________________________________________

Phone number: ___________________  Email address: ____________________

I hereby designate the person(s) named below as beneficiary(ies) for the following benefit plans, revoking any previous beneficiary designation.

Initial applicable plans:

Life insurance _____

Supplemental life insurance _____   

401(k) plan _____  

Employee stock ownership plan _____  

Employee Signature: ________________________________     Date: ______________

Spousal Signature (if applicable)

If you are married and name someone other than your spouse as beneficiary, payment of benefits may be delayed or disputed unless your spouse also signs this beneficiary designation.

Spouse Signature: ________________________________     Date: ______________

Primary and Contingent Beneficiaries

Proceeds are paid to primary surviving beneficiaries in equal amounts unless otherwise indicated. Proceeds are paid to contingent beneficiaries only when there are no surviving primary beneficiaries. If you designate contingent beneficiaries and do not designate percentages, proceeds are paid to the surviving contingent beneficiaries in equal amounts. Unless otherwise provided, the share of a beneficiary who dies before the insured will be divided proportionately among the surviving beneficiaries in the respective category (primary or contingent).

Primary Beneficiary Designation
*Total Primary Beneficiary Share % must equal 100%

Full name (Last, First, Middle Initial): ________________________________________

Relationship: ___________________________________________________________

Date of birth: ___________________________________________________________

Address (Street, City, State, Zip): ____________________________________________

Percentage:  ____________________________________________________________

Full name (Last, First, Middle Initial): ________________________________________

Relationship: ___________________________________________________________

Date of birth: ___________________________________________________________

Address (Street, City, State, Zip): ____________________________________________

Percentage:  ____________________________________________________________

Full name (Last, First, Middle Initial): ________________________________________

Relationship: ___________________________________________________________

Date of birth: ___________________________________________________________

Address (Street, City, State, Zip): ____________________________________________

Percentage:  ____________________________________________________________

Contingent Beneficiary Designation
*Total Contingent Beneficiary Share % must equal 100%

Full name (Last, First, Middle Initial): ________________________________________

Relationship: ___________________________________________________________

Date of birth: ___________________________________________________________

Address (Street, City, State, Zip): ____________________________________________

Percentage:  ____________________________________________________________

Full name (Last, First, Middle Initial): ________________________________________

Relationship: ___________________________________________________________

Date of birth: ___________________________________________________________

Address (Street, City, State, Zip): ____________________________________________

Percentage:  ____________________________________________________________

Full name (Last, First, Middle Initial): ________________________________________

Relationship: ___________________________________________________________

Date of birth: ___________________________________________________________

Address (Street, City, State, Zip): ____________________________________________

Percentage:  ____________________________________________________________

GUIDELINES FOR DESIGNATION OF BENEFICIARIES

General Please be sure to include the beneficiary's full name, social security number and relationship to you. Providing this information can help expedite the claim process by making it easier to locate and verify beneficiaries.

Minors While you may designate minors as beneficiaries, please note that claim payments may be delayed due to special issues raised by these designations. In the event of a claim, the insurance proceeds may be paid to a duly appointed guardian of the child's estate. You may wish to consult with an attorney when drafting your beneficiary designation.

Trust as Beneficiary You may designate a trust as beneficiary, using the following form: To [name of trustee], trustee of the [name of trust], under a trust agreement dated [date of trust]. If you wish to designate a testamentary trust as beneficiary (i.e., one created by will), please contact the Administrator for the appropriate form(s). You should recognize the possibility that your will, which was intended to create this trust, may not be admitted to probate (because it is lost, contested, or superseded by a later will). Claim payment delays can result if the beneficiary designation doesn't provide for this situation. A special form is therefore needed to address these possibilities.

Life Status Changes It is recommended that you review your beneficiary designation when various life status events occur, such as marriage, divorce, or birth of a child.

Please note: The above guidelines are general and are not intended to be relied on as legal advice. Unless your designation is a simple one, we recommend that you obtain the assistance of an attorney in drafting your beneficiary designation. Qualified legal counsel can help assure that your beneficiary designation clearly and correctly reflects your intentions for distribution of your benefits.