Life Insurance | The NewsGuild of Greater Philadelphia

Name*

First

Middle

Last

Date of Birth*

Email Address*

Phone*

Phone Type*

Employer*

Date of Hire*

Department/Job Title*

Beneficiary Information

In accordance with the conditions of the Group Policy listed above, I designate as primary beneficiary and/or secondary beneficiary in the event of my death, the following:

Primary Beneficiary

Name of Primary Beneficiary*

First

Last

Relationship to Primary Beneficiary*

Address of Primary Beneficiary*

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number of Primary Beneficiary*

Add Another Primary Beneficiary?*

No
Yes

Name of Additional Primary Beneficiary

First

Last

Relationship to Additional Primary Beneficiary

Address of Additional Primary Beneficiary

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number of Additional Primary Beneficiary

Percentages to Primary Beneficiaries

The values must total 100%

Percentage to First Primary Beneficiary

Please enter a number from 1 to 99.

Percentage to Additional Primary Beneficiary

Please enter a number from 1 to 99.

Secondary Beneficiary

Policy benefits are only distributed to secondary beneficiary(ies) if primary beneficiary(ies) are not alive.

Add A Secondary Beneficiary?*

No
Yes

Name of Secondary Beneficiary*

First

Last

Relationship to Secondary Beneficiary*

Address of Secondary Beneficiary*

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number of Secondary Beneficiary*

Add Another Secondary Beneficiary?*

No
Yes

Name of Additional Secondary Beneficiary

First

Last

Relationship to Additional Secondary Beneficiary

Address of Additional Secondary Beneficiary

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number of Additional Secondary Beneficiary

Add A Third Secondary Beneficiary?

No
Yes

Name of Third Secondary Beneficiary

First

Last

Relationship to Third Secondary Beneficiary

Address of Third Secondary Beneficiary

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Add A Fourth Secondary Beneficiary?

No
Yes

Name of Fourth Secondary Beneficiary

First

Last

Relationship to Fourth Secondary Beneficiary

Address of Fourth Secondary Beneficiary

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Percentages to Secondary Beneficiaries

The values must total 100%

Percentage to First Secondary Beneficiary

Please enter a number from 1 to 99.

Percentage to Additional Secondary Beneficiary

Please enter a number from 1 to 99.

Percentage to Third Secondary Beneficiary

Please enter a number from 1 to 99.

Percentage to Fourth Secondary Beneficiary

Please enter a number from 1 to 99.

Signature

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