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Designation of Beneficiary Under IBM Group Life/Travel ... Flipbook PDF

Rev 3/17 Designation of Beneficiary Under IBM Group Life/Travel Accident Insurance Policies IBM Confidential When Comple

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Designation of Beneficiary Under IBM Group Life/Travel Accident Insurance Policies IBM Confidential When Completed You can choose your beneficiary or change your beneficiary designation at any time by completing this form. Beneficiary designations are effective as of the date they are received in good order by the IBM Employee Services Center (or as of your date of employment, if they are received prior to this date). You may use this form to designate the same beneficiary(ies) for both the IBM Group Life Insurance and IBM Travel Accident Insurance Policies, or you may complete a separate form for each policy if you wish to designate different beneficiaries. Note: If you submitted a beneficiary designation form while previously employed by IBM, you must complete and submit a new form. Your previous beneficiary designations do not apply. If no form is on file, the proceeds from these policies will be distributed in the following manner: • IBM Group Life Insurance (GLI): To your spouse, if living; otherwise, in equal shares/percentages to your surviving children; if none survives, to your surviving parents equally. If no spouse, child or parent is then living, payments are made to the executors or administrators of your estate. • IBM Travel Accident Insurance: Unless otherwise specified on the designation form, your beneficiary will be the same as for your IBM Group Life Insurance. Any changes you make to your beneficiary designations will replace all other previous designations you may have made for these plans. Be sure to review your beneficiary designation periodically so that it reflects your current choice. INSTRUCTIONS: All information must be typed or printed neatly, using uppercase letters and black ink. Show all names in full, such as Mary Ann Doe, not Mrs. John Doe or M.A. Doe. Provide address information for named beneficiary(ies) and their relationship to you (the employee). To make corrections to the beneficiary section, you must place your initials next to the corrected or crossed-out words; otherwise, the form will be returned to you. If you have any questions or need to obtain additional beneficiary designation forms, please ® log on to Fidelity NetBenefits at http://netbenefits.com or call the IBM Employee Services Center at 1-800-796-9876 on business days (excluding holidays recognized by the New York Stock Exchange) between 8:00 a.m. and 8:00 p.m., Eastern time, to speak with a service representative. Select a Beneficiary Designation option (from options 1, 2, 3, 4, or 5 on the form). Please check the box next to the option you select and provide the required information. If you are designating an estate or trust as contingent beneficiary under option 3, do not select option 4 or 5. YOU MAY ONLY SELECT ONE OPTION. To Designate Multiple Primary Beneficiaries You may designate up to ten primary beneficiaries. If you designate more than one primary beneficiary, you must indicate the percentage each is to receive. The total of the percentages must equal 100%. If you choose to designate more than four beneficiaries, please attach a signed, dated letter to the form with your IBM serial number and the required information for the additional beneficiaries. To Designate Your GLI Benefit in Excess of $50,000 to a Charity You may designate the portion of your Group Life Insurance benefit in excess of $50,000 to one or more charity(ies) to avoid imputed income. To do so, complete option 1 of the form as follows: • Indicate the name, Social Security number, relationship, and address of the beneficiary you designate to receive the first $50,000 of your GLI benefit. Under the “% Benefit” column, indicate “first $50,000.” • Next, indicate the name(s) and address(es) of the charity(ies) you designate to receive the portion of your GLI benefit in excess of $50,000. Under the “% Benefit” column indicate: • “All amounts over $50,000” if you are designating one charity OR • “[specific percentage]% of amount over $50,000” if you are designating more than one charity. Note: You may designate a charity or charities as your beneficiary for the full amount of your GLI or Travel Accident Insurance benefit. To do so, supply the appropriate information under option 1 of the form. Sign and date the beneficiary form in the spaces provided. After you complete this form, please make a copy for your files and return the original in the enclosed envelope, or if using your own envelope, mail it to the following address: IBM Employee Services Center Attn: Beneficiary Processing Team 5411 Page Road Durham, NC 27703

Rev 3/17

Designation of Beneficiary Under IBM Group Life/Travel Accident Insurance Policies IBM Confidential When Completed Employee Serial Number

Last Name

First Name

Middle Initial

Date of Employment

Division

Location

Office #

Beneficiary Designation for: (Please note, Supplemental employees are only eligible for Travel Accident Insurance.) IBM Group Life Insurance Only _____ Travel Accident Insurance Only _____ Both _____ Please check and complete only one of the following 5 options below (either 1, 2, 3, 4, or 5).

1. DESIGNATION OF ONE OR MORE PERSONS OR CHARITIES AS PRIMARY BENEFICIARIES To each of the following named person(s), who shall be living at my death and/or charities in indicated percentages (Percentages must be indicated in whole numbers or fractions, totaling 100%. Decimals are not accepted.)*: Full Name

Social Security Number

Relationship

* I am canceling a previous Charity designation: Yes

Charity* Y/N

% of Benefit

Complete Address (Street or PO Box, City, State and Zip Code)

No

* If designating more than four primary beneficiaries, please attach a signed, dated letter, including your IBM serial number, with the required information for each beneficiary. For information about how to designate the portion of your Group Life Insurance in excess of $50,000, see the Instructions page.

2. DESIGNATION OF SPOUSE AS PRIMARY BENEFICIARY; CHILDREN OR ESTATE AS CONTINGENT BENEFICIARIES To _____________________________, my wife/husband; provided, however, if she/he shall not survive me, then in equal shares/percentages to my children (including my legally adopted children) who shall be living at my death; if none of said children shall be living at my death, then to the executors of my estate. (Note: strike words not applicable)

*3. DESIGNATION OF PRIMARY BENEFICIARY AND CONTINGENT BENEFICIARY(IES) Name (Enter information below)

Social Security Number

Relationship

Address

Primary (100% of benefit)

Contingent (if multiple beneficiaries, payment in equal shares)

* If you are designating an estate or a trust as a contingent beneficiary under option 3, do not complete option 4 or 5.

4. DESIGNATION OF ESTATE AS BENEFICIARY I designate my estate as my beneficiary. (Payments will be made to the executor(s) or administrator(s) of your estate.)

5. DESIGNATION OF TRUST AS BENEFICIARY Name of Trust

Date of Trust Agreement

Employee Signature

Date

For Office Use Only Authorized IBM Representative (Please print)

Signature of Authorized IBM Representative

Date

A confirmation, along with a copy of your completed form, will be sent to your address on file. Please return the completed original form to: IBM Employee Services Center Attn: Beneficiary Processing Team 5411 Page Road, Durham, NC 27703 Rev 3/17/06

benecard.pdf 7/2006