• South Central Hispanic District Council of the Assemblies of God Standard Life Insurance Enrollment/Beneficiary Designation Form

  • Section A - General Participant Information

  • Birth date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender:*
  • Format: (000) 000-0000.

  • Enrollment Questions:

  • (Additional contribution of $240.00) This is a dependent package that insures non-credentialed spouse or non-credentialed spouse and eligible children. (To age 21 or age 25, if attending college full-time)

  • Enroll Non-Credentialed Spouse and child(ren)

  • (No additional contribution needed) If you have a credentialed spouse, or no spouse, but you do have eligible children, check this box. If you and your spouse are both credentialed, only one of you can check this box on your form.

  • Enroll Child Only

  • Section B - Designation of Beneficiaries

  • The following individual(s) shall be my beneficiary(ies). (Please check primary or contingent for each individual beneficiary). If any primary beneficiary predeceases me, the contingent beneficiary(ies) shall acquire the designated share of my account.

  • #1. Beneficiary Information

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Beneficiary Type*

  • #2. Beneficiary Information

  • Format: (000) 000-0000.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Beneficiary Type

  • #3. Beneficiary Information

  • Format: (000) 000-0000.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Beneficiary Type

  • #4. Beneficiary Information

  • Format: (000) 000-0000.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Beneficiary Type
  • Please check just one:

  • Legal/Agreement

     The payor may rely fully on this designation, and I agree to promptly notify the payor if there is any change in the status of any primary or contingent beneficiary. 

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: