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LC Beneficiary for Group Life Insurance - University of ... Flipbook PDF
LC BenifChg09242014 Beneficiary for Group Life Insurance . How to Complete the “Your Life Insurance Beneficiary Designat
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LC University of Michigan
Beneficiary for Group Life Insurance Please print all information in black ink. Please note that this form is only for changing your life insurance beneficiaries. See the Benefits Office website at benefits.umich.edu/events/beneficiary.html for information on changing your retirement savings plan beneficiaries.
1. Faculty or Staff Member Information Name (Last, First, Middle Initial)
U.S. Social Security Number (if UMID unknown)
UMID
Date of Birth
Daytime Phone Number
Check the box next to the Life Insurance plan for which you wish to designate or change beneficiaries. If no box is checked, this beneficiary designation will apply to all life insurance plans in which you currently participate. You are automatically the beneficiary for Dependent Life plans. University Group Life Insurance
Optional Group Life Insurance
Retiree Group Life Insurance
2. Your Life Insurance Beneficiary Designation Primary Beneficiary (one or more). Primary beneficiaries receive payment first. Percentage amounts must total 100%. 1. Legal Name ______________________________________
2.
Legal Name ___________________________________
Address _________________________________________
Address ______________________________________
Date of Birth _____________________________________
Date of Birth ___________________________________
Relationship ______________________________________
Relationship ___________________________________
Percentage _______________________________________
Percentage _____________________________________
Contingent Beneficiary (one or more). A contingent beneficiary receives payment only if all primaries are deceased. Percentage amounts must total 100%. 1. Legal Name ______________________________________ 2. Legal Name ___________________________________ Address _________________________________________
Address ______________________________________
Date of Birth _____________________________________
Date of Birth ___________________________________
Relationship ______________________________________
Relationship ___________________________________
Percentage _______________________________________
Percentage _____________________________________
3. Certification and Signature. I have read the second page of this form and agree to the terms and conditions listed there. The information listed above is correct to the best of my knowledge.
__________________________________________________________ Signature of Faculty or Staff Member
BenifChg02092012
___________________________________________ Date Signed
LC Beneficiary for Group Life Insurance How to Complete the “Your Life Insurance Beneficiary Designation” Section To designate a beneficiary or beneficiaries, complete this form as follows. Under Primary Beneficiary, list person(s) whom you wish to be paid first. Under Contingent Beneficiary, list person(s) whom you wish to be paid only if no Primary beneficiary survives you. Percentage: If you list more than one beneficiary, and you wish the beneficiaries to receive specific percentages, enter the percentage in the space provided under the person’s name. List whole percentages only. Actual dollar amounts are not valid. Check your math to be sure the percentages listed equal 100%. If your beneficiary is not related to you, show the relationship as “Friend.” If you wish to name your estate, insert “Estate” on the Legal Name line in the first box under Primary Beneficiary. If you name a beneficiary who is a permanent resident of a foreign country, furnish that person’s full current address, to assist in locating the person. If you wish to name a trust, under Primary Beneficiary, write the complete name(s) of the trustee(s) and successor(s), and the date of the trust. Note: This document does not create a trust. If you wish to name more beneficiaries than there are spaces provided on this form, please attach a separate sheet. Include on that sheet your name, your UMID or U.S. Social Security Number (if UMID is unknown), and the name, address, relationship to you, and percentage (if you wish to indicate a specific percentage) for the additional named beneficiary or beneficiaries. Sign and date the separate sheet so that it will be valid. The beneficiary for the Travel Accident Insurance Plan will be the same as the beneficiary you designate for your Group Life Insurance Plan. If you wish to make a different designation you may do so by requesting a paper beneficiary form by calling the SSC Contact Center at 734‐615‐2000 or 866‐647‐7657 (toll free). Keep a copy of this form for your records.
Payment of Group Life Insurance Benefits
If you name your estate, a trust, or one beneficiary (and that one beneficiary survives you), payment will be made in full as designated after your death. If you name more than one beneficiary, payment will be made in equal shares to the named beneficiaries who survive you (or in full to the survivor if only one beneficiary survives you), unless you enter a specific percentage for each person. If no named primary or contingent beneficiary survives you, payment will be made to the first of the following: • Your surviving spouse • Surviving children in equal shares • Surviving parents in equal shares • Surviving siblings in equal shares • Estate Consider discussing your beneficiary designations with your attorney when completing this form. The Benefits Office cannot provide legal advice.
Important Note This form is only for changing your life insurance beneficiaries. There are separate beneficiary designation forms for the TIAA-CREF retirement savings plan and the Fidelity retirement savings plan. If you have money in both TIAA-CREF and Fidelity retirement accounts, you must complete a separate beneficiary form for each account. For more information and to download the beneficiary forms, see the Benefits Office website at benefits.umich.edu/events/beneficiary.html.
How to Return Your Signed and Complete Form: Make a copy for your records and mail to: MetLife National Benefit Center P.O. Box 14406 Lexington, KY 40512-4406 Or fax to MetLife:
859-825-6719
Questions? If you have any questions, view the Benefits Office website at benefits.umich.edu, call MetLife at 866-492-6983, or call the SSC Contact Center at 734-615-2000 or 866-647-7657 (toll free), Monday through Friday from 8 a.m. to 5 p.m. Keep a copy for your records and mail your signed and completed form to:
Or fax your signed and completed form to MetLife:
859-825-6719 MetLife National Benefit Center P.O. Box 14406 Lexington, KY 40512-4406 BenifChg09242014