Beneficiary Designation

Beneficiary Designation
EMPLOYER NAME
EMPLOYEE NAME (LAST, FIRST MIDDLE)*
SOCIAL SECURITY*
EMPLOYEE HOME ADDRESS (STREET, CITY, STATE, ZIP)*
I AUTHORIZE Guardian or my employer to record and consider the individuals/instructions that I have named on this form as beneficiaries for benefits under the applicable employee benefits plan.
BENEFICIARY INFORMATION: (Complete to designate a beneficiary or change the beneficiary designation)
Primary Beneficiary Name #1*
Date of Birth*

MonthDayYear
Date
Relationship*
Social Security
% of Benefit
Address (Street, City, State, Zip)*
Primary Beneficiary Name #2 (if applicable)
Date of Birth

MonthDayYear
Date
Relationship
Social Security
% of Benefit
Contingenct Beneficiary Name #1
Date of Birth

MonthDayYear
Date
Relationship
Social Security
% of Benefit
Address (Street, City, State, Zip)
Contingenct Beneficiary Name #2
Date of Birth

MonthDayYear
Date
Relationship
Social Security
% of Benefit
Address (Street, City, State, Zip)
If more than one primary and/or contingent Beneficiary is designated and no percentage has been designated, settlement will be made in equal shares to such of the designated beneficiaries as survive the Insured, unless otherwise provided herein. If no designated beneficiary survives the Insured, settlement will be made to the estate of the Insured, unless otherwise provided in the Group Plan.
SIGNATURE OF INSURED

Clear
DATE

MonthDayYear
Date
Should be Empty: