Member Name *

Member Address *

SSN *

Employer *

If more than one beneficiary is named check one of the two boxes

Mailing Address

Mailing Address

Executor / Administrator

Executor / Administrator Address

Signature *

Info

If you designate your spouse as beneficiary but become divorced, the designation as to that spouse only shall be void. You may redesignate that former spouse as beneficiary, relationship - "other". Any death benefits payable to a minor beneficiary shall be paid to the court appointed guardian/conservator of the minor's estate or to a custodial account for the benefit of the minor beneficiary. If you fail ( or are unable ) to make a valid designation of a beneficiary, or if no designated beneficiary survives you, your beneficiary will be the survivor(s) in the first surviving class among the following: (1) surviving spouse, (2) children, (3) parents, (4) brother and sisters (5) estate. You may change, or revoke the designation of your beneficiary at any time. To be effective, designation, change , or revocation must be made in writing on an accepted from and must be received by your local union office before your death .This beneficiary designation cancels any previous designation you have made. In all instances, the terms and conditions of the Group Policy and the Plan Document will determine your insured benefits and how they are paid, insofar as permitted by law.