Beneficiary Designation Form

This document is intended to replace any and all prior beneficiary designations for the specified policy.

1. Policy Holder / Insured Information

Full Legal Name of Insured

First Name

Middle Name

Last Name

Date of Birth

Contact Phone Number

Email Address

Current Mailing Address

Street Address Line 1

Street Address Line 2

City

State/Province

Zip/Postal Code

Policy Number

Policy Type

2. Primary Beneficiary Designation

Primary Beneficiaries will receive the policy proceeds if they are living at the time of the Insured's death. The percentages designated below must total 100%.

	Full Legal Name	Relationship to Insured	Date of Birth	Social Security / Tax ID No.	Share (%)
	A	B	C	D	E
1
2
3

Per Stirpes vs. Per Capita: (Check one, if applicable)

Per Stirpes: If a named beneficiary predeceases the insured, their share passes to their children/descendants.

Per Capita: If a named beneficiary predeceases the insured, their share is divided equally among the remaining named beneficiaries.

Important Note for Minor Beneficiaries (Under legal age):

If a minor is named as a beneficiary, payment will typically be made to a legally appointed Guardian or Trustee. You may designate a Custodian for the funds under a local Uniform Transfers to Minors Act (UTMA) or similar legislation.

	Minor's Name	Custodian's Full Legal Name	Custodian's Address	Relationship to Minor
	A	B	C	D
1
2
3

3. Contingent Beneficiary Designation

Contingent Beneficiaries will receive the policy proceeds only if all Primary Beneficiaries predecease the Insured. The percentages designated below must total 100% of the contingent share.

	Full Legal Name	Relationship to Insured	Date of Birth	Social Security / Tax ID Number	Share (%)
	A	B	C	D	E
1
2
3

4. Trustee or Entity Designation

If the beneficiary is a Trust, Estate, or other legal entity, please provide the following details:

Name of Trust/Entity

Date of Trust Document

Tax ID Number of Trust/Entity

Please provide the following details:

	Full Name of Trustee	Trustee's Address
	A	B
1
2
3

5. Signature and Certification

I hereby revoke any prior beneficiary designations and designate the individuals/entities named above as the beneficiaries for the policy specified. I certify that the information provided is true and correct to the best of my knowledge. I understand that this designation will not be effective until recorded by the policy administrator/insurance company.

Insured's Full Legal Signature

6. Witness/Company Representative (If required by the policy issuer)

Witness's Full Legal Signature

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