Form Gg-17 - Beneficiary Designation Change Form
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1Beneficiary Designation/
P.O. Box 14334
Change Form
Lexington, KY 40512
PLEASE TYPE or PRINT CLEARLY.
(The entire form, properly completed, signed and dated by the Insured, must be submitted or the changes cannot be processed.)
EMPLOYER/PLANHOLDER NAME:
GROUP NUMBER
EMPLOYEE NAME (LAST, FIRST, M.)
SOCIAL SECURITY #
EMPLOYEE HOME ADDRESS (STREET, CITY, STATE, ZIP)
I AUTHORIZE Guardian or my employer to record and consider the individuals/instructions that I have named on this form as
beneficiaries for benefits under the applicable employee benefits plan.
(PLEASE COMPLETE THE APPROPRIATE SECTIONS ONLY.)
BENEFICIARY INFORMATION:
(Complete to designate a beneficiary or change the beneficiary designation); Include full proper name, relationship and
social security number of proposed beneficiary(s) - i.e. Mary A. Doe, and relationship - i.e. husband, wife, friend, son, daughter.
Primary:
Relationship
%
Social Security #
Date of Birth
1)
Name
Phone#
Email
Address
Relationship
%
Social Security #
Date of Birth
2)
Name
Phone#
Email
Address
Contingent:
Relationship
%
Social Security #
Date of Birth
1)
Name
Phone#
Email
Address
Relationship
%
Social Security #
Date of Birth
2)
Name
Phone#
Email
Address
If more than one primary and/or contingent Beneficiary is designated and no percentage has been designated, settlement will be made in
equal shares to such of the designated beneficiaries as survive the Insured, unless otherwise provided herein. If no designated beneficiary
survives the Insured, settlement will be made to the estate of the Insured, unless otherwise provided in the Group Plan.
SIGNATURE OF INSURED
SIGNATURE OF WITNESS (SOMEONE OTHER THAN BENEFICIARY)
DATE
Community Property State Consent for Residents of Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas,
Washington, or Wisconsin. If you are married and live in a community property state your spouse may have a legal claim for a portion of
the life insurance benefit under state law. If you
name someone other than your spouse as beneficiary, you may have your spouse sign
below to waive his or her rights to any community property interest in the benefit.
As the insured Employee’s spouse, I am aware that my spouse, the Employee named above, has designated someone other than me to be
the beneficiary of group life insurance under the above policy. I hereby consent to such designation and waive any rights I may have to the
proceeds of such life insurance under applicable community property laws. I understand that this consent and waiver supersedes any prior
spousal consent or waiver under this plan.
Signature of Employee’s Spouse __________________________________________________________________
ALL SIGNATURES MUST BE IN INK
CHANGE IN BENEFICIARY’S NAME (Complete only if the name has been legally changed.)
FROM (WAS)
TO (NOW IS)
SOCIAL SECURITY #
DATE
CHANGE IN INSURED’S NAME (Complete only if the name has been legally changed.)
FROM (WAS)
TO (NOW IS)
SOCIAL SECURITY #
DATE
SIGNATURE OF INSURED
DATE
ANY CHANGES IN DEPENDENT STATUS AND/OR NAME OF INSURED SHOULD BE REPORTED TO THE GROUP FIELD
SUPPORT DEPARTMENT ON THE APPROPRIATE FORM
THIS SECTION TO BE COMPLETED BY GUARDIAN/or THE PLANHOLDER ONLY.
This is to certify that the following changes have been recorded in connection with the insurance for the above named insured.
The BENEFICIARY has been changed
The NAME of the BENEFICIARY has been changed
New Employee
Recorded by __________________________________________________________________________ Date ____________________
GG-17
(1/15)
FORWARD FORM TO THE PLANHOLDER OR GUARDIAN LIFE INSURANCE FOR RECORDING
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