TEAMSTERS LIFE WITH DUES BENEFIT PLANBeneficiary Designation / Change of Beneficiary
Local Union No.
Email Address (PRINT)
example@example.com
PRINT Member Name
First Name
Last Name
Cell Phone
Format: (000) 000-0000.
Member Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Social Security No.
Current Employer
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
In the space provided below, you may designate any person or your estate as your beneficiary.
IF MORE THAN ONE BENEFICIARY IS NAMED, CHECK ONE OF THE TWO BOXES:
I request that any death benefits be paid in equal shares to the beneficiaries listed.
I request that any death benefits be paid to the first beneficiary named below who survives me.
Beneficiary 1 Name
First Name
Last Name
Beneficiary 1 Sex
Beneficiary 1 Relationship
Beneficiary 1 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Beneficiary 2 Name
First Name
Last Name
Beneficiary 2 Sex
Beneficiary 2 Relationship
Beneficiary 2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Beneficiary 3 Name
First Name
Last Name
Beneficiary 3 Sex
Beneficiary 3 Relationship
Beneficiary 3 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CHECK THIS BOX IF YOU WISH ANY DEATH BENEFITS TO BE PAID ONLY TO YOUR ESTATE (NO BENEFICIARIES NAMED ABOVE)
Executor / Administrator
First Name
Last Name
Executor / Administrator Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Member's Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If you designate your spouse as beneficiary but become divorced, the designation as to that spouse only shall be void. You may redesignate that former spouse as beneficiary, relationship - "other".
Any death benefits payable to a minor beneficiary shall be paid to the court appointed guardian/ conservator of the minor's estate or to a custodial account for the benefit of the minor beneficiary.
If you fail (or are unable) to make a valid designation of a beneficiary, or if no designated beneficiary survives you, your beneficiary will be the survivor(s) in the first surviving class among the following: (1) surviving spouse; (2) children; (3) parents; (4) brothers and sisters; (5) estate. You may change, or revoke the designation of your beneficiary at any time. To be effective, the designation, change, or revocation must be made in writing on an accepted form and must be received by your local union office before your death. This beneficiary designation cancels any previous designation you have made.
In all instances, the terms and conditions of the Group Policy and the Plan Document will determine your insured benefits and how they are paid, insofar as permitted by law.
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