Life With Dues Beneficiary Designation Form

TEAMSTERS LIFE WITH DUES BENEFIT PLAN

Beneficiary Designation / Change of Beneficiary
Local Union No.*
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Soc. Sec. No.*
Employer*
In the space provided below, you may designate any person or your estate as your beneficiary.
IF MORE THAN ONE BENEFICIARY IS NAMED, CHECK ONE OF THE TWO BOXES.

I request that any death benefits be paid in equal shares to the beneficiaries listed.I request that any death benefits be paid to the first beneficiary named below who survives me.
Beneficiary Full Name
Sex
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beneficiary Full Name
Sex
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beneficiary Full Name
Sex
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CHECK THIS BOX IF YOU WISH ANY DEATH BENEFITS TO BE PAID ONLY TO YOUR ESTATE. (NO BENEFICIARIES NAMED ABOVE)

CHECK THIS BOX IF YOU WISH ANY DEATH BENEFITS TO BE PAID ONLY TO YOUR ESTATE. (NO BENEFICIARIES NAMED ABOVE)
Executor / Administrator
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member's Signature*

Clear
Date*

MonthDayYear
Date
If you designate your spouse as beneficiary but become divorced, the designation as to that spouse only shall be void. You may redesignate that former spouse as beneficiary, relationship - "other".

Any death benefits payable to a minor beneficiary shall be paid to the court appointed guardian/coservator of the minor's estate or to a custodial account for the benefit of the minor beneficiary.

If you fail (or are unable) to make a valid designation of a beneficiary, or if no designated beneficiary survives you, your beneficiary will be the survivor(s) in the first surviving class among the following: (1) surviving spouse; (2) children; (3) parents; (4) brothers and sisters; (5) estate. You may change, or revoke the designation of your beneficiary at any time. To be effective, the designation, change, or revocation must be made in writing on an accepted form and must be received by your local union office before your death. This beneficiary designation cancels any previous designation you have made.

In all instances, the terms and conditions of the Group Policy and the Plan Document will determine your insured benefits and how they are paid, insofar as permitted by law.
Please verify that you are human*
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TEAMSTERS LIFE WITH DUES BENEFIT PLAN