Insurance & Risk
Life Insurance Beneficiary Designation
Life insurance beneficiary designation form for policyholders to name or update beneficiaries. 1 signer (policyholder).
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# Life Insurance Beneficiary Designation **Date:** ___________ This Life Insurance Beneficiary Designation Form ("Designation") is submitted by: **Policyholder:** ___________ ("Policyholder") **Policy Number:** ___________ **Insurance Company:** ___________ ## 1. Policyholder Information **Date of Birth:** ___________ **Social Security Number (last 4 digits):** ___________ **Address:** ___________ **Phone:** ___________ **Email:** ___________ ## 2. Primary Beneficiary The Policyholder designates the following as Primary Beneficiary to receive the death benefit proceeds: **Full Legal Name:** ___________ **Relationship:** ___________ **Date of Birth:** ___________ **Address:** ___________ **Percentage of Benefit:** ___________ ## 3. Contingent Beneficiary
Fields (22)
effective date
date 路 required
policyholder name
text 路 required
policy number
text 路 required
insurance company
text 路 required
policyholder dob
date 路 required
policyholder ssn last4
text 路 required
policyholder address
textarea 路 required
policyholder phone
text 路 required
policyholder email
text 路 required
primary beneficiary name
text 路 required
primary beneficiary relationship
select 路 required
primary beneficiary dob
date 路 required
primary beneficiary address
textarea 路 required
primary beneficiary percentage
select 路 required
contingent beneficiary name
text
contingent beneficiary relationship
select
contingent beneficiary dob
date
contingent beneficiary address
textarea
contingent beneficiary percentage
select
special instructions
textarea
governing state
select 路 required
policyholder signer name
text 路 required
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