Life Insurance Beneficiary On Health Insurance Form

Not required if the enrollee or assignee has not filed a previous designation of beneficiary and is satisfied with the standard order of precedence.

Life insurance beneficiary on health insurance form. Beneficiary ies unless you assigned the insurance or there is a valid court order contingent and your beneficiary does not live long enough to qualify ofegli will pay according to the order listed in the first column. Phone street address please include apartment as applicable city. Designation of beneficiary form sf 2823 designation of beneficiary section in fegli handbook. Beneficiary form group term life insurance ua1 2020 important note.

However the please refer to the eligibility and enrollment guide for further information. This beneficiary designation cancels any prior beneficiary designation and shall be effective on the date received by the company policyholder. Address relationship to insured to be paid to beneficiary name date of birth social security no. Coverage is dependent upon the plan s eligibility requirements and all plan benefits are subject to the rules adopted by the board of trustees of unite here health.

Name date of birth social security no. We recommend that you designate beneficiaries to receive your life insurance benefits. The beneficiary for the policy shall be. Opm designations of beneficiary page.

If you would like a copy of your forms please make a copy or print a second copy for your records. Va life insurance forms and downloads forms and downloads life insurance apply for and manage the va benefits and services you ve earned as a veteran servicemember or family member like health care disability education and more. Fa 1005 rev 9 15 complete beneficiary designation on back of this application and return to your agency benefits coordinator. Attachments are also available for designating a trust.

Primary beneficiary name address ssn and dob relationship to the covered person of death benefit payable to beneficiary must total 100 in the event and only in the event that all primary beneficiaries predecease me then the proceeds shall be payable to the following contingent beneficiaries. Fegli enrollees and assignees use this form to designate who should receive the death benefits. This form replaces all previous beneficiary designations and must be signed and dated to be valid. If enrolling in health coverage covered dependents will also receive life insurance benefits.

Please fill out the following forms print them sign them and mail the original copy to the office of human resources. Address relationship to insured to be paid to beneficiary name date of birth social security no. Individual covered person ssn and dob.