UNUM Beneficiary Designation Form

BENEFICIARY DESIGNATION FORM GROUP LIFE, ACCIDENTAL DEATH & DISMEMBERMENT AND CRITICAL ILLNESS INSURANCE

Unum Life Insurance Company of America Provident Life and Accident Insurance Company The Paul Revere Life Insurance Company
Instructions: Please complete, sign and date this form to designate your beneficiaryies or to change your existing beneficiaryies This form cancels all prior designations. If more than one beneficiary is named and no percentages are indicated, payment will be made to them in equal shares. If there are more than three 3 primary and/or contingent beneficiaries, please attach a separate sheet of paper. Return the completed form to your employer.
SECTION 1: Employee Information
Name (Last Name, Suffix, First Name, MI)
Social Security Number
Policy Number(s)
Division Number(s)
Employer Name
Basic LifeCritical IllnessSupplemental LifeAD&DAll
SECTION 2: Primary Beneficiary (ies)

I choose the person(s) named below to be the primary beneficiary(ies) of the Life Insurance benefits that may be payable at the time of my death. If any primary beneficiary(ies) is disqualified or dies before me, his/her percentage of this benefit will be paid to the remaining primary beneficiary(ies)
Name & Address
Relationship
Social Security Number
Date of Birth

MonthDayYear
Date
Percentage
Name & Address
Relationship
Social Security Number
Date of Birth

MonthDayYear
Date
Percentage
Name & Address
Relationship
Social Security Number
Date of Birth

MonthDayYear
Date
Percentage
Section 3: Contingent Beneficiary(ies)

If all primary beneficiaries are disqualified or die before me, I choose the person(s) named below to be my contingent beneficiary(ies)
Name & Address
Relationship
Social Security Number
Date of Birth

MonthDayYear
Date
Percentage
Name & Address
Relationship
Social Security Number
Date of Birth

MonthDayYear
Date
Percentage
Name & Address
Relationship
Social Security Number
Date of Birth

MonthDayYear
Date
Percentage
SECTION 4: Signature
Signature

Clear
Date

MonthDayYear
Date
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
Important Information About Designation of Beneficiaries
Beneficiary Information
- Primary Beneficiary(ies) means the person(s) you choose to receive your life insurance benefits. Please specify the percentage of the benefit you want paid to each beneficiary; these percentages should total 100%. If any primary beneficiary is disqualified or dies before you, his/her percentage of the benefit will be paid to the remaining primary beneficiary(ies)
- Contingent Beneficiary(ies) means the person(s) you choose to receive your life insurance benefits only if all primary beneficiaries are disqualified or die before you. Please specify the percentage of the benefit you want paid to each beneficiary; these percentages should total 100%. If any contingent beneficiary is disqualified or dies before you, his/her percentage of the benefit will be paid to the remaining contingent beneficiary(ies)
- Minor Beneficiary(ies) – When you designate minors as beneficiaries, it is important to understand that insurance benefits may not be released to a minor child. They may, however, be paid to a court appointed guardian of the child’s estate. The regulations governing minor beneficiaries vary by state.
- Trust – You may designate a valid trust as a beneficiary.
Types of Coverage Information
- Basic Life is life insurance provided by your employer for which they pay the premiums.
- Supplemental Life is life insurance elected by you for which you pay the premiums.
- AD&D is Accidental Death & Dismemberment coverage.
- Critical Illness insurance elected by you for which you pay the premium.
- If you wish to designate different beneficiaries for any of the above coverages, please complete a separate form.
General Information
- Updates to Your Beneficiary Designation – You can change your beneficiary designation at any time. You may wish to review your designation periodically.
- Consult an Attorney – This information is not intended to be relied on as legal advice. You may wish to get the assistance of an attorney to help ensure your beneficiary designation correctly reflects your intentions.
Should be Empty:

BENEFICIARY DESIGNATION FORM GROUP LIFE, ACCIDENTAL DEATH & DISMEMBERMENT AND CRITICAL ILLNESS INSURANCE

SECTION 1: Employee Information

SECTION 2: Primary Beneficiary (ies)

Section 3: Contingent Beneficiary(ies)

SECTION 4: Signature

Important Information About Designation of Beneficiaries

Beneficiary Information

Types of Coverage Information

General Information