Beneficiary Change Form

Rank or Prefix
Name*
First Middle Initial Last
Last Four of Social Security Number*
Phone*
Email*
Beneficiary(ies) Change(s) for Basic Coverage
Last Name First Name Relationship DOB (MM/DD/YYYY) % Primary or Alternate

Please remember that the total percentage(s) must equal 100%. More specifically, if more than one person is the primary beneficiary then the percentages of the individuals must ultimately equal 100%. Further, you may list an alternate beneficiary(ies) but it is not required.
Beneficiary(ies) Change(s) for Enhanced Coverage
Last Name First Name Relationship DOB (MM/DD/YYYY) %

Please remember that the total percentage(s) must equal 100%. More specifically, if more than one person is the primary beneficiary then the percentages of the individuals must ultimately equal 100%. Further, you may list an alternate beneficiary(ies) but it is not required.
Member's Signature*
Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Last Name	First Name	Relationship	DOB (MM/DD/YYYY)	%	Primary or Alternate

Last Name	First Name	Relationship	DOB (MM/DD/YYYY)	%