Beneficiary Designation Form - Personnel Kentucky printable pdf download

Nationwide Life

Nationwide Employee Benefits

Group Life and Accidental Death

Insurance Company

Designation of Beneficiary Form

Home Office: Columbus, Ohio

Submit Form to: Personnel Cabinet- Group Life Administration, 501 High Street, 3

Flr, Frankfort,

KY 40601

Section 1: Insured Information (Please complete all appropriate boxes in ink, printing legibly.)

Group Name

Group Number

Commonwealth of Kentucky

90002

Employee Name (First, Middle Initial, Last)

Social Security Number

Subject to the terms and conditions of the above referenced Group Number, I request that any sum becoming payable by reason of my death be payable

to the following beneficiary (ies). It is my understanding that this designation shall operate so as to revoke all designations of beneficiary (ies) previously

made by me under the Group Policy.

Employee Signature (Required)

Date (Required)

Note: Beneficiary designation is not valid unless this form and any separate accompanying sheets are signed and dated.

Section 2: Beneficiary Designation/Change (Please complete all appropriate boxes in ink, printing legibly. If you do not

designate one or more beneficiaries, policy proceeds will be paid to your estate unless otherwise regulated by law.

Basic Life and AD&D

Primary Beneficiary Information (Allocation to all Primary Beneficiaries must equal 100%)

Beneficiary Name and Address

Relationship

Date of birth

SSN (XXX-XX-XXXX)

% of Benefit

Contingent Beneficiary Information (Allocation to Contingent Beneficiaries must equal 100%)

Beneficiary Name and Address

Relationship

Date of birth

SSN (XXX-XX-XXXX)

% of Benefit

Optional Life and AD&D

Primary Beneficiary Information (Allocation to all Primary Beneficiaries must equal 100%)

Beneficiary Name and Address

Relationship

Date of birth

SSN (XXX-XX-XXXX)

% of Benefit

Contingent Beneficiary Information (Allocation to Contingent Beneficiaries must equal 100%)

Beneficiary Name and Address

Relationship

Date of birth

SSN (XXX-XX-XXXX)

% of Benefit

Section 3: General Information

 If more room is needed to indicate additional primary or contingent beneficiaries, please attach a separate sheet and list the information indicated

above for each beneficiary. Please sign and date all additional sheets as well as this original form.

 Your group life coverage is issued by Nationwide Life Insurance Company, One Nationwide Plaza, MR-05-11 Columbus, OH 43215. Please refer to

the Certificate of Insurance and Insurance Contract for all plan details, including any exclusions, limitations and restrictions which may apply.

NSHEB-6009 CWKY(03-2012)

Underwritten by Nationwide Life Insurance Company