Unum Beneficiary Designation Form – Human Resources

Unum Life Insurance Company of America
Provident Life and Accident Insurance Company
The Paul Revere Life Insurance Company

Instructions: Please complete, sign and date this form to designate your beneficiary(ies). This form cancels all prior designations. If more than one beneficiary is named and no percentages are indicated, payment will be made to them in equal shares. If there are more than two (2) primary an/or contingent beneficiaries, please make a note in the field below labeled “Other Beneficiary Information”.

Unum Beneficiary Form

Employee Name * Required
First Middle Last Suffix
Employer Name
Check the coverages listed below to which this beneficiary designation applies:
- Basic Life
- Voluntary Life
- Accidental Death & Dismemberment
- Retiree Life
- All
Primary Beneficiary (ies)
Primary Beneficiary Name * Required
First Middle Last
Additional Primary Beneficiary Name
First Middle Last
Contingent Beneficiary Name
First Middle Last
Additional Contingent Beneficiary Name
First Middle Last
Primary Beneficiary Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Primary Beneficiary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contingent Beneficiary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Contingent Beneficiary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Beneficiary Relationship * Required
Additional Primary Beneficiary Relationship
Contingent Beneficiary Relationship
Additional Contingent Beneficiary Relationship
Primary Beneficiary Birth Date * Required
Month
Day
Year
Additional Primary Beneficiary Birth Date
Month
Day
Year
Contingent Beneficiary Birth Date
Month
Day
Year
Additional Contingent Beneficiary Birth Date
Month
Day
Year
Primary Beneficiary Percentage * Required
Please enter a number from 1 to 100.
Additional Primary Beneficiary Percentage
Please enter a number from 1 to 100.
Contingent Beneficiary Percentage
Please enter a number from 1 to 100.
Additional Contingent Beneficiary Percentage
Please enter a number from 1 to 100.
Other Beneficiary Information
Please list any additional information about your beneficiary(ies) here. Example: If you have more more than 2 primary and/or contingent beneficiaries.
Employee Signature * Required
Date
MM slash DD slash YYYY

Important Information About Designation of Beneficiaries

Beneficiary Information

Primary Beneficiary(ies) means the person(s) you choose to receive your life insurance benefits. Please specify the percentage of the benefit you want paid to each beneficiary; these percentages should total 100%. If any primary beneficiary is disqualified or dies before you, his/her percentage of the benefit will be paid to the remaining primary beneficiary(ies).
Contingent Beneficiary(ies) means the person(s) you choose to receive your life insurance benefits only if all primary beneficiaries are disqualified or die before you. Please specify the percentage of the benefit you want paid to each beneficiary; these percentages should total 100%. If any contingent beneficiary is disqualified or dies before you, his/her percentage of the benefit will be paid to the remaining contingent beneficiary(ies).
Minor Beneficiary(ies) – When your designate minors a beneficiaries, it is important to understand that insurance benefits may not be released to a minor child. They may, however, be paid to a court appointed guardian of the child’s estate. The regulations governing minor beneficiaries vary by state.
Trust – You may designate a valid trust as beneficiary.

Types of Coverage Information

Basic Life is life insurance provided by your employer for which they pay the premiums.
Additional Life aka Voluntary Life is life insurance elected by you for which you pay the premiums.
AD&D is Accidental Death & Dismemberment coverage.
If you wish to designate different beneficiaries for each of the above coverages, please complete a separate form.

General Information

Updates to Your Beneficiary Designation – You can change your beneficiary designation at any time. You may wish to review your designation periodically.
Consult an Attorney – This information is not intended to be relied on as legal advice. You may wish to get the assistance of an attorney to help ensure your beneficiary designation correctly reflects your intentions.

If you have questions please email Human Resources.