HumanaLife Beneficiary Designation

HumanaLife Beneficiary Designation
This form needs to be provided to Humana prior to, or at time of claim.
Employee Name

First NameLast Name
Employee social security number
Member contract ID
Primary beneficiary designation
Name

First NameLast Name
Relationship
Address of beneficiary
City
State
ZIP
Percentage
Name of another primary beneficiary (optional)
Relationship
Address of beneficiary
City
State
ZIP code
Percentage
Secondary beneficiary designation
First and last name
Relationship
Address of beneficiary
City
State
ZIP code
Percentage
First and last name
Relationship
Address of beneficiary
City
State
ZIP code
Percentage
Employee signature
Date

MonthDayYear
If two or more primary beneficiaries are named, and you do not list the benefit percentages, proceeds will be paid in equal shares to the named primary beneficiaries who survive you. If no primary beneficiary survives you, proceeds will be paid to the contingent beneficiaries. If no designated beneficiary survives you, the beneficiary will be determined according to the provisions of the group life insurance contract.
Should be Empty: