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INSURED INFORMATION
Insured Name *
Birth Date *
SSN *
Phone *
Employer/Plan Administrator Name
Policy Number(s)
BENEFICIARY INFORMATION
I request that the beneficiaries under this policy/certificate be changed as indicated below. Unless otherwise provided in this request, if two or more primary beneficiaries are named, the proceeds shall be paid in equal shares to the named primary beneficiaries if surviving the insured. If no primary beneficiaries survive, the proceeds shall be paid in equal shares to the named contingent beneficiaries, if any. If no beneficiary survives, payment shall be made according to the terms of the policy. The right of the owner to change the beneficiary hereafter is reserved.

Primary Beneficiary: The person designated to receive insurance proceeds when they become due.
Contingent Beneficiary: (Also referred to as a secondary beneficiary.) An alternate beneficiary designated to receive insurance proceeds if there is no eligible primary beneficiary.
Spousal Consent: ReliaStar Life Insurance Company does not require spousal consent for a beneficiary designation and will not refuse a beneficiary designation based on lack of spousal consent. However, if the insured resides in a community property state and changes the beneficiary from the spouse to another person or entity, it is suggested that spousal consent be obtained to protect the claim proceeds of the named beneficiary.

For each Beneficiary give Full Name, Address (street, city, state and zip code), Phone, Birth Date, Social Security Number and Relationship to Insured.
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Full Name *
Address *
Phone Number *
Birth Date *
SSN/TIN *
Relationship *
Percent(%) *
Beneficiary Type *
Primary
Contingent
Beneficiary Designation change is requested for: *
All Life / AD&D Insurance
Basic Life / AD&D Insurance
Supplemental Life / AD&D Insurance
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Full Name
Address
Phone Number
Birth Date
SSN/TIN
Relationship
Percent(%)
Beneficiary Type
Primary
Contingent
Beneficiary Designation change is requested for:
All Life / AD&D Insurance
Basic Life / AD&D Insurance
Supplemental Life / AD&D Insurance
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Full Name
Address
Phone Number
Birth Date
SSN/TIN
Relationship
Percent(%)
Beneficiary Type
Primary
Contingent
Beneficiary Designation change is requested for:
All Life / AD&D Insurance
Basic Life / AD&D Insurance
Supplemental Life / AD&D Insurance
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Note: Coverage may not be offered through your Employer/Plan Administrator.
AUTHORIZATION AND ACKNOWLEDGMENT
This designation is revocable as to each beneficiary except when otherwise stated, and beneficiaries of like class shall share equally with right of survivorship. Please refer to the Suggested Beneficiary Designations on page 2 of this form. Any designation of an individual shall mean an individual living at the insured's death.
Owner/Insured Signature *

Use your mouse, finger, or touch device to write your signature.
Date
Owner/Insured Address *
City *
State *
Zip *
Irrevocable Beneficiary(ies) Signature(s) (if any)
Date
Spousal Consent Signature (optional)
Date
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INSTRUCTIONS
Insured/Owner: Type or print legibly in ink. Sign and date form. Return original and retain a copy for your records.
Plan Administrator: Send the completed form to the Company for approval if any of the following apply: 1) The wording used in the request differs
from the examples given below; 2) The policy/certificate has been assigned; 3) The previous beneficiary is irrevocable; or 4) The coverage is under an
individual policy. Also send copies of all previous beneficiary changes, assignment forms, and a copy of the insured's enrollment form or application. The
Company will return a copy of the approved change request form.

For change request forms that do not require the Company approval, retain a copy of the approved change request form with the insured's records.
INSTRUCTIONS

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SUGGESTED BENEFICIARY DESIGNATIONS
Personal Beneficiaries
1. If one individual is to be designated, use full legal name thus – “Anna May Smith,” not “Mrs. John Smith.”
2. If two individuals are to be named, designate as follows: “Anna May Smith, wife and Dorothy Smith Andrews, daughter, in equal shares, or the survivor.”
3. If three or more individuals are to be named, designate as follows: “Anna May Smith, wife, Dorothy Smith Andrews, daughter, and William Smith, son, or the survivors, in equal shares, or the survivor.”
4. If one or more secondary beneficiaries are to be named, they may be designated individually as follows: “Anna May Smith, wife, if living, otherwise Joseph Smith, father, and Elizabeth Smith, mother, in equal shares, or the survivor;” or
(a) If all children of the marriage are to be named secondary beneficiaries, designate them collectively rather than individually as follows: “Anna May Smith, wife, if living, otherwise the then surviving children, if any, born of insured’s marriage with said wife, in equal shares.” (This designation will include children born later without the necessity of changing the designation.)
(b) If all children of the marriage are to be named secondary beneficiaries and a second alternate beneficiary is to be named, designate as follows: “Anna Smith, wife, if living, otherwise the then surviving children, if any, born of insured’s marriage with said wife, in equal shares, or if said wife is not living and there is no such child, James Smith, father.”
(c) If children not of the present marriage are to be included, designate as follows: “Anna May Smith, wife, if living, otherwise John Smith and Mary Smith, children, and any other child or children born of insured’s marriage with said wife, or the survivors, in equal shares, or the survivor.”
(d) If a “Clean Up Fund” of a stated amount is desired and there are secondary beneficiaries who are minors, the designation may be as follows: “The proceeds up to $___________ to Anna Smith, wife, if living, otherwise the executors or administrators of the estate of the insured, and the remainder to said wife, if living, otherwise John Smith and Mary Smith, children, in equal shares, or the survivor.” Minor children should not be named beneficiaries of proceeds intended for “Clean Up Fund” because the guardian of the children probably could not use the proceeds for the purpose.
Estate
5. If an estate is named, specify whose estate, such as: “Estate of the Insured.”
Trustee
6. Trustee under the last will and testament of the insured, or his successors in trust, PROVIDED, HOWEVER, that if no claim is made by said Trustee within one year from the date of death of the insured or if the insured shall die leaving no last will and testament containing a trust covering this policy, the proceeds shall be payable to the estate of the insured. Payment of the proceeds of this policy to said Trustee or successors in trust shall fully and finally discharge the Company from all liability.
7. “The ______________________________ Trust Company, trustee under written trust agreement date ______________, or its successor or successors in trust, and payment of the proceeds of this policy to said Trustee or successor or successors shall fully and finally discharge the Company from all liability.”
Business Partners
8. Under a cross ownership plan, designate the surviving partners as beneficiaries. For example, for insurance on the life of John Jones, designate “Henry Smith and William Brown, partners, in equal shares, or the survivor.” Similar designation may be made for the other partners. Just as a corporation may be the owner and beneficiary of a policy, a partnership may, in the partnership name, own and be the beneficiary of a policy. The firm name should be used together with the words, “a partnership.” For example, “Jones, Smith and Brown, a partnership presently consisting of John Jones, Henry Smith and William Brown.”
Per Stirpes
9. “____________________, wife, if living, otherwise the then surviving children, if any, born of insured’s marriage with said wife and the then surviving legally adopted child or children of the insured, if any, in equal shares, except in case of death of any child or children of said marriage or any legally adopted child or children of the insured, leaving lawful surviving child or children (including legally adopted children but not including grandchildren or other remote descendants), such child or children of the deceased child shall receive, in equal shares, the share which such deceased child would have received if he or she had survived.”
Irrevocable Beneficiary
10. If you want to name a beneficiary that you can not change without his/her consent, designate him/her as irrevocable beneficiary, such as: “Frank Jones, as irrevocable beneficiary.” Then if you change the designation in the future, both you and the irrevocable beneficiary must sign the front of the form.






  • Stanislaus County DSA

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