Life Insurance Beneficiary Registration Form

Team Member Life Insurance

Beneficiary Registration Form
Coverage for your life insurance benefit will become effective six months from your date of hire.

However, it is important that the beneficiary information be completed at this time to ensure your selections are in place as soon as your benefit becomes available.
Team Member McGee ID
Team Member Social Security Number
Name

First NameLast Name
Email
example@example.com
Primary Beneficiaries
Primary Beneficiary 1, Individual or Organization?
Primary Beneficiary 1 U.S. Citizenship Status
Primary Beneficiary 1 Organization Name
Primary Beneficiary 1 Name

First NameMiddle NameLast Name
Primary Beneficiary 1 Relationship
NOTE: You CANNOT list yourself as a beneficiary on a life insurance policy.
Primary Beneficiary 1 Address

Street Address

Street Address Line 2

CityState

Postal CodeCountry
Primary Beneficiary 1 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Primary Beneficiary 1 EIN
Primary Beneficiary 1 Social Security Number
SSN
Additional Primary Beneficiary?
Primary Beneficiary 2, Individual or Organization?
Primary Beneficiary 2 U.S. Citizenship Status
Primary Beneficiary 2 Organization Name
Primary Beneficiary 2 Name

First NameMiddle NameLast Name
Primary Beneficiary 2 Relationship
NOTE: You CANNOT list yourself as a beneficiary on a life insurance policy.
Primary Beneficiary 2 Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Primary Beneficiary 2 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Primary Beneficiary 2 EIN
Primary Beneficiary 2 Social Security Number
SSN
Additional Primary Beneficiary?
Primary Beneficiary 3, Individual or Organization?
Primary Beneficiary 3 U.S. Citizenship Status
Primary Beneficiary 3 Organization Name
Primary Beneficiary 3 Name

First NameMiddle NameLast Name
Primary Beneficiary 3 Relationship
NOTE: You CANNOT list yourself as a beneficiary on a life insurance policy.
Primary Beneficiary 3 Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Primary Beneficiary 3 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Primary Beneficiary 3 EIN
Primary Beneficiary 3 Social Security Number
SSN
Additional Primary Beneficiary?
Primary Beneficiary 4, Individual or Organization?
Primary Beneficiary 4 U.S. Citizenship Status
Primary Beneficiary 4 Organization Name
Primary Beneficiary 4 Name

First NameMiddle NameLast Name
Primary Beneficiary 4 Relationship
NOTE: You CANNOT list yourself as a beneficiary on a life insurance policy.
Primary Beneficiary 4 Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Primary Beneficiary 4 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Primary Beneficiary 4 EIN
Primary Beneficiary 4 Social Security Number
SSN

Primary Disbursement Percentages (MUST total 100)

Rows	Primary Beneficiary 1	Primary Beneficiary 2	Primary Beneficiary 3	Primary Beneficiary 4
Percentage

Total Primary Disbursement Percentage
Error: Total for all primary beneficiaries MUST equal 100!
Contingent Beneficiaries

Recommended, in case payout to primary beneficiaries is impossible due to illness, inability to locate, etc.
Contingent Beneficiary 1, Individual or Organization?
Contingent Beneficiary 1 U.S. Citizenship Status
Contingent Beneficiary 1 Organization Name
Contingent Beneficiary 1 Name

First NameMiddle NameLast Name
Contingent Beneficiary 1 Relationship
NOTE: You CANNOT list yourself as a beneficiary on a life insurance policy.
Contingent Beneficiary 1 Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Contingent Beneficiary 1 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Contingent Beneficiary 1 EIN
Contingent Beneficiary 1 Social Security Number
SSN
Additional Contingent Beneficiary?
Contingent Beneficiary 2, Individual or Organization?
Contingent Beneficiary 2 U.S. Citizenship Status
Contingent Beneficiary 2 Organization Name
Contingent Beneficiary 2 Name

First NameMiddle NameLast Name
Contingent Beneficiary 2 Relationship
NOTE: You CANNOT list yourself as a beneficiary on a life insurance policy.
Contingent Beneficiary 2 Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Contingent Beneficiary 2 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Contingent Beneficiary 2 EIN
Contingent Beneficiary 2 Social Security Number
SSN

Total Contingent Disbursement Percentage
Error: Total for all contingent beneficiaries MUST equal 100!
Form contains errors.

Please correct in order to proceed.
If you need to come back to this form to complete it or to make any changes in the future, please click “Save”. You’ll be asked to create a password, and you will not need to re-enter your beneficiary information.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour Minutes
Should be Empty:

Team Member Life Insurance

Primary Beneficiaries

Contingent Beneficiaries