USAble Beneficiary Form

MEMBERSHIP ADVANTAGES
Term Life Beneficiary Designation or Change Form

Important notice: This form replaces all other beneficiary forms on file and must be signed and dated to be valid. Group Life and Disability insurance is underwritten by USABle Life, Group # 50059083.

Section 1 - Member Information

Member Name*

Member Date of Birth*

Date

Gender*

MaleFemale

Member Email*

example@example.com

Social Security Number

Agency Employed*

Home/Cell Phone*

Address*

Mailing Address

Street Address Line 2

City and State

Zip

Work Phone

Marital Status*

SingleMarriedWidowedDivorcedDomestic Partnership (per Affidavit of Domestic Partnership)Domestic Partner (if enrolling a domestic partner you must complete a SEIU Local 503 Affidavit of Domestic Partnership Form)

Section 2 - Beneficiary Designation

You may choose a beneficiary(s) to receive life benefits. If no beneficiary survives, payment will be made in accordance with the terms of the policy. Unless designated otherwise, beneficiary designations for all life coverage will be the same. For Spouse/Partner and Child Term Life, you are the beneficiary.

Primary 1 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Primary 2 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Primary 3 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Primary 4 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Primary 5 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Primary 6 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Contingent 1 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Contingent 2 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Contingent 3 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Contingent 4 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Contingent 5 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Contingent 6 - Name of Beneficiary, Social Security #, Date of Birth, Phone Number, Address, and Relationship

Section 3 - Signature for Beneficiary Designation

Signature

Date

Signature This form must be signed, dated and on file at SEIU Local 503 for the beneficiary to be valid.

Please keep a copy for your records and mail the original to: SEIU Local 503 at P.O. Box 12159, Salem, Oregon 97309, email to membershipadvantages@seiu503.org, or fax to 503-776-7341.