Beneficiary Designation Form
Employee Name:
First Name
Last Name
Employee Social Security Number:
Current Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Primary and Contingent Beneficiaries - Unless you designate a percentage, proceeds are paid to primary surviving beneficiaries in equal shares. Proceeds are paid to contingent beneficiaries only when there are no surviving primary beneficiaries. If you designate contingent beneficiaries and do not designate percentages, proceeds are paid to the surviving contingent beneficiaries in equal shares. Unless otherwise provided, the share of a beneficiary who dies before the insured will be divided proportionately among the surviving beneficiaries in the respective category (primary or contingent). If you need additional space to indicate your beneficiary designations, attach a separate piece of paper using the below format including the appropriate policy number, the date, and your signature.
Basic Life Insurance Policy No. SGM0604143
Rows
Employee's Primary Beneficiary(ies):
Relationship
Date of Birth
% (total must equal 100%
1
2
3
Rows
Employee's Contingent Beneficiary(ies):
Relationship
Date of Birth
% (total must equal 100%)
1
2
3
Voluntary Life Insurance
Check here if you want to use the same designations here that you used for Basic Life Insurance, and do not complete the rest of this section.
Rows
Employee's Primary Beneficiary(ies):
Relationship
Date of Birth
% (total must equal 100%
1
2
3
Rows
Employee's Contingent Beneficiary(ies):
Relationship
Date of Birth
% (total must equal 100%
1
2
3
Community Property Laws - If you are married, reside in a community property state (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin), and name someone other than your spouse as beneficiary, payments of benefits may be delayed or disputed unless your spouse provides their signature in the space provided below.
Spouse's Signature:
Date:
-
Month
-
Day
Year
Date
Owner's Signature:
*
Date:
-
Month
-
Day
Year
Date
Note: This form is not complete without your signature. Please sign the form on the next page where indicated.
©2021, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the New York Life box logo are registered trademarks of New York Life Insurance Company. Life Insurance Company of North America and New York Life Group Insurance Company of NY are subsidiaries of New York Life Insurance Company. Connecticut General Life Insurance Company is not affiliated with New York Life Insurance Company.
Back
Next
Guidelines for Designation of Beneficiaries
General
- Please be sure to include the beneficiary's full name, social security number and relationship to you. Providing this information can help expedite the claim process by making it easier to locate and verify beneficiaries.
Minors
- While you may designate minors as beneficiaries, please note that claim payments may be delayed due to special issues raised by these designations. In the event of a claim and the beneficiary is a minor child, the insurance proceeds will not be released to the minor child. The insurance proceeds may be paid to a duly appointed guardian of the child's estate. You may want to obtain the assistance of an attorney in drafting your beneficiary designation(s).
Trust as Beneficiary
- You may designate a trust as beneficiary, using the following form: "To [name of trustee), trustee of the [name of trust), under a trust agreement dated [date of trust]."
If you wish to designate a testamentary trust as beneficiary (i.e. one created by will), you should recognize the possibility that your will which was intended to create this trust may not be admitted to probate because it is lost, contested, or superseded by a later will. Claim payment delays can result if the beneficiary designation does not provide for this situation.
Domestic Partner
- If you wish to designate your domestic partner as your beneficiary, you must complete a beneficiary form. Otherwise, your death benefit will be paid according to the provisions of the policy.
Life StatusChanges
-Werecommend that you review your beneficiary designation(s) when significant life status events occur, such as marriage, divorce, or birth of a child.
See an Attorney!
The above guidelines are general and are not intended to be relied on as legal advice. Unless your designation is a simple one, we recommend that you obtain the assistance of an attorney in drafting your beneficiary designation(s). A qualified attorney can help assure that your beneficiary designation correctly reflects your intentions, is clear and unambiguous, and meets legal requirements.
924616 05/2021
Preview PDF
Submit
Should be Empty: