Beneficiary Worksheet

You are able to designate as many beneficiaries as you wish but the total of all percentages must equal 100%.

The Primary Beneficiary is the one who will receive the benefit first.

The Contingent Beneficiary will only receive the benefit if the primary beneficiary does not survive you.

Basic Life / AD&D Primary Beneficiary Name SSN Relationship Date of Birth Percentage Address / Phone # Jack Sample 123-987-456 Son Jan 1, 1980 50% Jill Sample 234-789-654 Spouse Jan 1, 1960 50%

Basic Life / AD&D Contingent Beneficiary Name SSN Relationship Date of Birth Percentage Address / Phone #

Voluntary Life / AD&D Primary Beneficiary** Name SSN Relationship Date of Birth Percentage Address / Phone #

Voluntary Life / AD&D Contingent Beneficiary** Name SSN Relationship Date of Birth Percentage Address / Phone #

** Unless designated otherwise, the employee is the beneficiary for the spouse and child life insurance policies. If a separate beneficiary is desired, please contact your Benefits or Human Resources Department.

** Beneficiaries for the employee Voluntary AD&D policy will be the same as for the Voluntary Life policy if it is elected. Otherwise, they will be the same as the Basic Life beneficiaries.