Beneficiary Designation Form

Beneficiary Designation Form
Not for use with Qualified Plan owned policies
The Insurer identified below will be referred to herein as the “Company”
Massachusetts Mutual Life Insurance Company 1295 State Street, Springfield, Massachusetts 01111-0001
Unless subsidiary designated below:
 MML Bay State Life Insurance Company 100 Bright Meadow Boulevard, Enfield, Connecticut 06082-1981
 C.M. Life Insurance Company 100 Bright Meadow Boulevard, Enfield, Connecticut 06082-1981
____________________________________________________________________________________________________________________________________________
Indicate usage below:
 At time of application, use this form to designate Beneficiaries
 After issue, use this form to change the Beneficiary on existing MassMutual policies/contracts
A Personal Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
1.
2
3.
4.
Insured full legal name (First, MI, Last, Suffix): _______________________________________________________________________
Insured date of birth (mm/dd/yyyy): _________________________________________________________________________________
Policy Number (After issue): _____________________________________________________________________________________
Owner full legal name (First, MI, Last, Suffix): _________________________________________________________________________
5. Owner phone number: ( __________ ) __________ – _____________ Extension: __________________  Home  Work  Mobile
6. Owner email: ____________________________________________________  After issue, check to have confirmation sent by email.
B Beneficiary Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
1a. Class (Select one):  Primary  Secondary  Tertiary
Type (Select one):  Named Individual  Trust  Trust under Insured’s Will  Estate of Insured  Other Entity
Class of children (If selected, name living children below):
 Any lawful children of the Insured  Any children born of the marriage of and/or legally adopted by the Insured and (list other
parent full legal name): ____________________________________________________________________________________
Full legal name: _______________________________________________________________________________________________
Mailing address: _______________________________________________________________________________________________
Phone number: ( __________ ) ____________ – ______________
Extension: ________  Home  Work  Mobile  Unknown
Date of birth/Trust (mm/dd/yyyy): __________________________
TIN: ________________________  SSN  EIN  Unknown
Relationship to Insured: __________________________________
Distribution (If not equal shares): %/$ ______________________
Issue per stirpes?  Yes  No
1b. Class (Select one):  Primary  Secondary  Tertiary
Type (Select one):  Named Individual  Trust  Trust under Insured’s Will  Estate of Insured  Other Entity
Class of children (If selected, name living children below):
 Any lawful children of the Insured  Any children born of the marriage of and/or legally adopted by the Insured and (list other
parent full legal name): ____________________________________________________________________________________
Full legal name: ________________________________________________________________________________________________
Mailing address: _______________________________________________________________________________________________
Phone number: ( __________ ) ____________ – ______________
Extension: ________  Home  Work  Mobile  Unknown
Date of birth/Trust (mm/dd/yyyy): __________________________
TIN: ________________________  SSN  EIN  Unknown
Relationship to Insured: __________________________________
Distribution (If not equal shares): %/$ ______________________
Issue per stirpes?  Yes  No
page 1 of 4
Beneficiary Designation Form – 0413
F5159 US
B Beneficiary Information continued • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
To name additional beneficiaries, copy this page.
1c. Class (Select one):  Primary  Secondary  Tertiary
Type (Select one):  Named Individual  Trust  Trust under Insured’s Will  Estate of Insured  Other Entity
Class of children (If selected, name living children below):
 Any lawful children of the Insured  Any children born of the marriage of and/or legally adopted by the Insured and (list other
parent full legal name): ____________________________________________________________________________________
Full legal name: ________________________________________________________________________________________________
Mailing address: _______________________________________________________________________________________________
Phone number: ( __________ ) ____________ – ______________
Extension: ________  Home  Work  Mobile  Unknown
Date of birth/Trust (mm/dd/yyyy): __________________________
TIN: ________________________  SSN  EIN  Unknown
Relationship to Insured: __________________________________
Distribution (If not equal shares): %/$ ______________________
Issue per stirpes?  Yes  No
1d. Class (Select one):  Primary  Secondary  Tertiary
Type (Select one):  Named Individual  Trust  Trust under Insured’s Will  Estate of Insured  Other Entity
Class of children (If selected, name living children below):
 Any lawful children of the Insured  Any children born of the marriage of and/or legally adopted by the Insured and (list other
parent full legal name): ____________________________________________________________________________________
Full legal name: ________________________________________________________________________________________________
Mailing address: _______________________________________________________________________________________________
Phone number: ( __________ ) ____________ – ______________
Extension: ________  Home  Work  Mobile  Unknown
Date of birth/Trust (mm/dd/yyyy): __________________________
TIN: ________________________  SSN  EIN  Unknown
Relationship to Insured: __________________________________
Distribution (If not equal shares): %/$ ______________________
Issue per stirpes?  Yes  No
1e. Class (Select one):  Primary  Secondary  Tertiary
Type (Select one):  Named Individual  Trust  Trust under Insured’s Will  Estate of Insured  Other Entity
Class of children (If selected, name living children below):
 Any lawful children of the Insured  Any children born of the marriage of and/or legally adopted by the Insured and (list other
parent full legal name): ____________________________________________________________________________________
Full legal name: ________________________________________________________________________________________________
Mailing address: _______________________________________________________________________________________________
Phone number: ( __________ ) ____________ – ______________
Extension: ________  Home  Work  Mobile  Unknown
Date of birth/Trust (mm/dd/yyyy): __________________________
TIN: ________________________  SSN  EIN  Unknown
Relationship to Insured: __________________________________
Distribution (If not equal shares): %/$ ______________________
Issue per stirpes?  Yes  No
C UTMA/UGMA : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
1. UTMA/UGMA refer to a state’s law that governs the transfer of title to life insurance proceeds to a Custodian to manage for a minor until
the minor reaches an age permitted by law. Under the UTMA/UGMA of the state designated in 1b, the person designated in 1a will be
Custodian for the child(ren) named in Section B. These custodial arrangements may only be used in states where permitted by applicable
law. This is not applicable to the Issue per stirpes, if selected.
a. Custodian’s full legal name (First, MI, Last, Suffix): _________________________________________________________________
b. Custodial state: ____________________________________________________
page 2 of 4
Beneficiary Designation Form – 0413
F5159 US
D Disclosures : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
Beneficiary. Unless otherwise requested, proceeds shall be paid
equally and in one sum as follows:
 If there is no living or existing beneficiary, the proceeds will
be paid to the owner or the owner’s estate.
 If there is no living or existing beneficiary, and the owner is an
entity, the proceeds will be paid to the entity.
 For survivorship policies, if both insureds are owners and
there is no living or existing beneficiary, the proceeds will be
paid to the estate of the last to die of the insureds.
 If Distribution Amounts/Percentages are designated, and a
beneficiary predeceases the Insured, no longer exists or is no
longer entitled to payment, that amount/percentage will be
distributed to the surviving beneficiaries in that class as per
the ratio designated.
 If dollar amounts are designated, and the proceeds at the
death of the Insured are greater or less than the total amount
designated, then the proceeds payable to each beneficiary
will be adjusted so that the relative ratio between and among
the beneficiaries remains the same.
 If a revocable trust is the owner, and the trust is not in effect
at the death of the Insured, and there is no living or existing
beneficiary, the proceeds shall be paid to the designated
grantor(s) equally, otherwise to the estate of whichever said
grantors is the last to die.
 If a Trust under the Insured’s Will is designated, then
proceeds will be paid only if the Will is probated and if there is
a trust in effect.

For Other Entities, it includes the successors or assigns of
the designated Entity.
Definitions:
 “Lawful child(ren)”, “issue” and “children” of a person mean
only the lawful children born to or adopted by that person.
 “Issue per stirpes” means that if a beneficiary dies before the
Insured, any amount that would have been paid to that
beneficiary, will be paid in one sum and in equal shares to the
surviving children of that beneficiary, if any, before any other
contingent beneficiary.
General Provisions:
 The Company is only responsible to perform according to the
terms of the policy, and is not responsible for carrying out the
terms of any trust or any trust agreement outside of this policy.
 If no custodian is designated, any money payable to a minor
will be paid to the court appointed guardian of the estate of
the minor. Only the legal guardian of the minor can exercise
any rights given to a minor.
 When the Owner of the contract is not the Insured and the
Owner is not the beneficiary, there may be unintended
income and gift tax consequences. The Owner should seek
advice from personal legal or tax advisors.
E Signatures : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A
CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
At time of Application. I, the undersigned, have read the Application including all supplements and all statements and answers, and affirm that
these statements and answers are true, complete and correctly recorded to the best of my knowledge and belief. To the best of my knowledge
and belief, all statements made in the Part 1 are true, complete and correctly recorded. I hereby adopt all statements made in the Application
and agree to be bound by them.
After issue. I, the undersigned, agree the information provided on this form is true, complete and correctly recorded to the best of my
knowledge and belief.

Signature of Owner: _____________________________________________________________________________________________
Printed name: ___________________________________________________________________
Date: ______________________
Title (Required when applicable): _____________________________________________________________________  Sole Officer
Printed name of Corporation/Partnership/Trust (If applicable): ____________________________________________________________

Signature of Owner 2 (If applicable): ________________________________________________________________________________
Printed name: ___________________________________________________________________ Date: ______________________
Title (Required when applicable): __________________________________________________________________________________
Printed name of Corporation/Partnership/Trust (If applicable): ____________________________________________________________
Witness Signature Section
A witness is a disinterested party (anyone other than the Owner, Insured or Beneficiary). Not for use with new applications. Use only for
change of beneficiaries post issue. See instructions for requirements.

Signature of Witness: ___________________________________________________________________________________________
Printed name: _____________________________________________________________________ Date: ____________________
page 3 of 4
Beneficiary Designation Form – 0413
F5159 US
E Customer Service Information : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
Once you have reviewed and completed the Beneficiary Designation Form, please return pages 1 - 3 for processing.
We will only accept responsibility for forms that are faxed or mailed to the number or address indicated.
A copy of this document transmitted by facsimile shall have the same effect as an original.
To submit your request, please mail or fax it to:
Life
Phone:
1-800-272-2216
Monday through Friday, 8 a.m. – 8 p.m.
Eastern Time
Mail:
MassMutual Financial Group
Attention: Life Hub
1295 State Street
Springfield MA 01111
Fax:
Attention: Life Hub
1-866-329-4527
Retain this original and the fax machine
confirmation statement for your files.
Mail:
MassMutual Financial Group
Attention: EB Hub
1295 State Street
Springfield MA 01111
Fax:
Attention: Client Services
1-860-562-6154
Retain this original and the fax machine
confirmation statement for your files.
Executive Benefits
Phone:
1-800-548-0073
Monday through Friday, 8 a.m. – 5 p.m.
Eastern Time
For additional information regarding your policy, please use the following resource
Internet Service Connection:
www.massmutual.com
page 4 of 4
Beneficiary Designation Form - 0413
F5159 US