Life Insurance Company of North America
Group Insurance
Life Accident Disability
Employer Name _____________________________________________
Employee Name_____________________________________________ Employee Social Security #_________________
Current Address__________________________________________ City__________________State______ Zip _______
Home Phone____________________Work Phone____________________
please enter all dates in mm//dd/yyyy format.
Primary and Contingent Beneficiaries – Unless you designate a percentage, proceeds are paid to primary surviving
beneficiaries in equal shares. Proceeds are paid to contingent beneficiaries only when there are no surviving primary
beneficiaries. If you designate contingent beneficiaries and do not designate percentages, proceeds are paid to the
surviving contingent beneficiaries in equal shares. Unless otherwise provided, the share of a beneficiary who dies before
the insured will be divided proportionately among the surviving beneficiaries in the respective category (primary or
Voluntary Term Life Insurance, Life Insurance Company of North America - Policy No. ________________
Employee’s Primary Beneficiary(ies):
Relationship to Employee
Social Security Number
of Birth
% (total must
equal 100%)
Employee’s Contingent Beneficiary(ies):
Relationship to Employee
Social Security Number
of Birth
% (total must
equal 100%)
If you need additional space, using the above format, please attach a separate piece of paper with the appropriate
policy number, the date and your signature.
Community Property Laws - If you are married, reside in a community property state (Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin), and name someone other than your spouse as
beneficiary, payment of benefits may be delayed or disputed unless your spouse also signs the beneficiary designation.
Spouse Signature________________________________________________________________Date____/____/____
Owner Signature___________________________________________________________________Date____/____/____
General - Please be sure to include the beneficiary’s full name, social security number and relationship to you. Providing this
information can help expedite the claim process by making it easier to locate and verify beneficiaries.
Minors - While you may designate minors as beneficiaries, please note that claim payments may be delayed due to special
issues raised by these designations. In the event of a claim and the beneficiary is a minor child, the insurance proceeds will
not be released to the minor child. The insurance proceeds may be paid to a duly appointed guardian of the child’s estate.
You may want to obtain the assistance of an attorney in drafting your beneficiary designation.
Trust as Beneficiary - You may designate a trust as beneficiary, using the following form: “To [name of trustee], trustee of the
[name of trust], under a trust agreement dated [date of trust].”
If you wish to designate a testamentary trust as beneficiary (i.e., one created by will), you should recognize the possibility that
your will which was intended to create this trust may not be admitted to probate (because it is lost, contested, or superseded
by a later will). Claim payment delays can result if the beneficiary designation doesn’t provide for this situation.
Life Status Changes - We recommend that you review your beneficiary designation when significant life status events
occur, such as marriage, divorce, or birth of a child.
See an Attorney! The above guidelines are general and are not intended to be relied on as legal advice. Unless your
designation is a simple one, we recommend that you obtain the assistance of an attorney in drafting your beneficiary designation.
A qualified attorney can help assure that your beneficiary designation correctly reflects your intentions, is clear and
unambiguous, and meets legal requirements.
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