Beneficiary Designation

Member's Name*

ID Number*

Date of Birth*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Daytime Telephone Number*

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

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.

Signature*

Date

Primary and Contingent Beneficiaries

*Unless you designate a percentage, proceeds are paid to primary surviving beneficiaries in equal amounts. 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

Full Name

First Middle Last

Relationship

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Number of Shares %

Please enter a number from 0 to 100.

Primary Beneficiary Designation

Full Name

First Middle Last

Relationship

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Number of Shares %

Please enter a number from 0 to 100.

Primary Beneficiary Designation

Full Name

First Middle Last

Relationship

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Number of Shares %

Please enter a number from 0 to 100.

*Total Primary Beneficiary Share % must equal 100%

Contingent Beneficiary Designation

Full Name

First Middle Last

Relationship

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Number of Shares %

Please enter a number from 0 to 100.

Contingent Beneficiary Designation

Full Name

First Middle Last

Relationship

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Number of Shares %

Please enter a number from 0 to 100.

Contingent Beneficiary Designation

Full Name

First Middle Last

Relationship

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Number of Shares %

Please enter a number from 0 to 100.

*Total Contingent Beneficiary Share % must equal 100%

Please see below for additional guidance.

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 and the beneficiary is a minor child, the insurance proceeds will not be released to the minor child. 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.