BENEFICIARY DESIGNATION

ENROLLMENT FOR LIFE INSURANCE
Insured 's Name *
Last, First Middle Initial
Address
CITY, STATE, ZIP
Social Security Number
Date of birth (MM/DD/YYYY)
Place of birth(CITY, STATE)
Sex

MaleFemale
OCCUPATION
ANNUAL SALARY
EMPLOYMENT DATE

MonthDayYear
Date
EFFECTIVE DATE

MonthDayYear
Date
BENEFICIARY DESIGNATION
(Please Indicate a Primary and Contingent Beneficiary)
PRIMARY

The proceeds shall be divided equally among those of the following designated person or persons who survive the Insured.

	NAME	RELATIONSHIP	ADDRESS
1.
2.

CONTINGENT

The proceeds shall be divided equally among those of the following designated person or persons who survive the Insured, provided no Primary Beneficiary designated above has survived the Insured.

	NAME	RELATIONSHIP	ADDRESS
1.
2.

I understand that this coverage shall become effective only if this application is accepted by the Amalgamated Life Insurance Company.
DATE

MonthDayYear
Date
SIGNATURE X

Clear
NON-PARTICIPATION OPTION
I have been given an opportunity to apply for life insurance offered by Amalgamated Life Insurance Company. I understand this plan has been made possible for me through my Employer and I have had its benefits thoroughly explained to me. I choose not to apply at this time, and understand that a later application may require the submission of evidence of insurability. The Insurance Company will have the right to accept or reject my application.
DATE

MonthDayYear
Date
SIGNATURE OF INSURED

Clear
A member of the Amalgamated Family of Companies
Should be Empty:

ENROLLMENT FOR LIFE INSURANCE

BENEFICIARY DESIGNATION

PRIMARY

CONTINGENT

NON-PARTICIPATION OPTION