Indiana University
Supplemental Group Life Insurance Plan Change of Beneficiary Designation
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BENEFICIARY DESIGNATION

The most recently dated beneficiary designation shall always control.

 

PARTICIPANT data

Name: Last   First   Middle

Social Security #: - -           Date of Birth: / /     Date Employed : / /

The following beneficiary designation will apply to Supplemental Group Life only. Fill in the name(s) of the beneficiaries you wish to have for your Supplemental Group Life coverage. Indicate the beneficiaries' month/day/year of birth, complete address, Social Security Number (SSN) and relationship to yourself. See instructions and sample designations.

PRIMARY BENEFICIARY - 1

Name:

Last   First   Middle

Date of Birth :     SSN#:     Relationship:

Address:

Street

 

City      Zip

Percent:

PRIMARY BENEFICIARY - 2

Name:

Last   First   Middle

Date of Birth :     SSN#:     Relationship:

Address:

Street

 

City      Zip

Percent:

PRIMARY BENEFICIARY - 3

Name:

Last   First   Middle

Date of Birth :     SSN#:     Relationship:

Address:

Street

 

City      Zip

Percent:

 

contingent benficiary - 1

Name:

Last   First   Middle

Date of Birth :     SSN#:     Relationship:

Address:

Street

 

City      Zip

Percent:

contingent benficiary - 2

Name:

Last   First   Middle

Date of Birth :     SSN#:     Relationship:

Address:

Street

 

City      Zip

Percent:

contingent benficiary - 3

Name:

Last   First   Middle

Date of Birth :     SSN#:     Relationship:

Address:

Street

 

City      Zip

Percent:

Participants may change the above beneficiaries in accordance with the policy provisions. Unless stated otherwise, the death benefit will be paid in equal shares to surviving beneficiaries, if more than one has been chosen. If none of the beneficiaries is alive, payment will be made under the policy provisions.

I understand that I may change my beneficiary designation at any time and that it is my responsibility to make such changes.

 

Participant's Signature____________________________________________________________Date____________________

DO NOT WRITE BELOW THIS SPACE

INSTRUCTIONS

This form is to be completed in duplicate. Print two copies. Submit one copy to Human Resources. The second copy is to be retained by the participant. Please type or print, except where the participant's signature is required.

The full legal name of each beneficiary should be included. (For example, MARY E. SMITH, not M.E. SMITH or MRS. JOHN J. SMITH.) Also include the beneficiaries' month/day/year of birth, complete address, SSN, and relationship to you.

ORDER OF PAYMENT AND DIVISION OF BENEFITS - Unless otherwise provided:

  1. Payment at my death is to be made to a Primary Beneficiary if he or she is then living. If there is no Primary Beneficiary living, then payment is to be made to a Contingent Beneficiary.
  2. If a Class of Beneficiaries contains more than one person, the benefits due the Beneficiaries in such Class at my death are to be apportioned in equal shares to the then living Beneficiaries in the Class.
  3. Unless otherwise provided, if all Beneficiaries predecease me, all interest in the benefits will vest in me or my estate.

DEFINITION OF TERMS - Unless otherwise provided, these terms have the meanings indicated:

Illustrative Beneficiary Designations

1. Possible family situation: Spouse as Primary Beneficiary and Children as Contingent Beneficiaries. (Names of guardians should not be stated.)

PRIMARY BENEFICIARY - 1
Name: Doe, Martha B.
Date of Birth: 1/1/50     SSN#: 555-55-5555     Relationship: Wife
Address: 12 W. St., Any Town, IN 47444
Percentage: 100

CONTINGENT BENEFICIARY - 1
Name: Doe, John K.
Date of Birth: 7/1/78     SSN#: 555-55-5555     Relationship: Son
Address:12 W. St., Any Town, IN 47444
Percentage: 50

CONTINGENT BENEFICIARY - 2
Name: Doe, Mary L.
Date of Birth: 8/5/81    SSN#:555-55-5555     Relationship: Daughter
Address: 12 W. St., Any Town, IN 47444
Percentage: 50

2. More than one beneficiary in a category: Each to share equally in benefits.

PRIMARY BENEFICIARY - 1
Name: Smith, Jane B.
Date of Birth:3/6/45     SSN#: 555-55-5555     Relationship: Sister
Address: 100 Main St., Any Town, IN 47444
Percentage: 33

PRIMARY BENEFICIARY- 2
Name: Black, Robert C.
Date of Birth: 5/24/50    SSN#: 555-55-5555     Relationship: Brother
Address: 15 First. St., Any Town, IN 47444
Percentage: 33

PRIMARY BENEFICIARY- 3
Name: Gray, Hazel B.
Date of Birth: 7/14/58    SSN#: 555-55-5555     Relationship: Sister
Address: 22 Park Ave., Other Town, IN 47444
Percentage: 33

3. Estate as beneficiary: My estate

4. Trustee named in inter vivos (living) trust agreement: First Bank & Trust Co., Ohio, or its successors, as trustee under trust agreement dated October 10, 1985.

5. Trustee named in your Will (testamentary trustee): The trustee(s) qualified under my Last Will and Testament and/or any codicil thereto.

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Mail to your campus HR Office.

UHRS 3/2004