Beneficiary Change Form – Fill Out and Use This PDF

The Beneficiary Change Form is a document that allows you to change who will receive the proceeds of your insurance policy if you pass away.

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Beneficiary Change Form PDF Details

If you have a change in your beneficiary designations after you have already completed your retirement plan paperwork, it is important to file a Beneficiary Change Form (often called a " beneficiaries designation form ") with the appropriate retirement plan administrator. This will ensure that your money goes to the right people when the time comes. The process for doing this may vary depending on the type of retirement plan you have, so be sure to check with your administrator for specific instructions. In most cases, however, you will need to provide the following information: name of beneficiary, relationship to account holder, and mailing address or other contact information for beneficiary.

You may find information regarding the type of form you need to complete in the table. It will show you how much time you will require to fill out beneficiary change form, exactly what fields you need to fill in and a few further specific facts.

Question	Answer
Form Name	Beneficiary Change Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	42
Avg. time to fill out	8 min 58 sec
Other names	banner life insurance change of beneficiary form, beneficiary change form, teacher retirement system of texas change of beneficiary form, banner life insurance beneficiary change form

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Form Preview Example

Name • Address • Beneficiary Change Form

Personal Information

Name:

Date of Birth:

SSN or Account Number:

Street Address:

City:

State:

ZIP:

Home Phone:

Work Phone:

Email:

Type of Request & Paperless Delivery Option

c Beneficiary Change

c Address Change

c Name Change*

*Proof of name change must be attached; i.e. copy of your driver’s license, Social Security card, or marriage certificate.

Paperless Delivery: By providing your email address you are consenting to receive statements, confirmations, terms, agreements and other information provided in connection with your retirement plan electronically. Unless you choose to have statements, account documents and other documents sent in connection with your retirement plan delivered via US Mail to the mailing address of record by checking the box below, these documents will be made available to you electronically

cI wish to receive my statements and account documents via US Mail.

Beneficiary Designation

This beneficiary designation applies to all funding options (including life insurance) unless otherwise noted. For payout purposes, the Plan Administrator will establish sub-accounts and not separate accounts for beneficiaries, which in the case of multiple beneficiaries may require that required minimum distributions be based on the life expectancy of the oldest beneficiary.

PLEASE NOTE: Percentage split must total 100% for each category of beneficiary.

If you select “Equal Percentage” for your beneficiaries, there may be some minor variance based upon the number of beneficiaries you have listed. For example: if you list three beneficiaries, the oldest beneficiary will be designated 33.34% and the other two will be 33.33%.

If additional space for beneficiaries is required, attach additional sheets and mark this box: c

Primary Beneficiary(ies) (must total 100%): c Equal Percentage

1. Full Name:

Date of Birth:

Relationship:

SSN:

Phone:

Split:

%

2. Full Name:

Date of Birth:

Relationship:

SSN:

Phone:

Split:

%

Contingent Beneficiary(ies) (must total 100%): c Equal Percentage

1. Full Name:

Date of Birth:

Relationship:

SSN:

Phone:

Split:

%

2. Full Name:

Date of Birth:

Relationship:

SSN:

Phone:

Split:

%

Authorization

This designation supersedes any prior beneficiary designation and shall become effective on the date accepted by the Plan as listed below prior to my death. My death benefits will be paid first to my Primary Beneficiaries. If some of my Primary Beneficiaries predecease me, then my death benefit will be paid to the remaining Primary Beneficiaries.

Contingent Beneficiaries will only receive benefits if no Primary Beneficiary survives me. If no beneficiary designation is on file, benefits will be paid pursuant to the sequence set forth in the Plan Document.

Signature:			Date:
	DC-770 (07/2019)	For help, please call 877-NRS-FORU		nrsforu.com	1

Model Beneficiary Designations

Indicate the full names of the beneficiaries, their Social Security numbers, date of birth, relationship to you, address, phone number, and split you’d like each one of them to receive. Please use the following designations as a guide when completing this form.

	Name	Split%	Relationship	SSN	Date Of Birth
1.	Primary: Joan Nation	100%	spouse	123-45-6789	01/02/1962
2.	Primary: Joan Nation	100%	spouse	123-45-6789	01/02/1962
	Contingent: Henry Nation	100%	son	987-65-4321	06/26/1984
3.	Primary: Joan Nation	100%	spouse	123-45-6789	01/02/1962
	Contingent: Henry Nation	50%	son	987-65-4321	06/26/1984
	Contingent: Betty Nation	50%	daughter	305-24-9731	02/12/1980
4.	Primary: Henry Nation	50%	son	987-65-4321	06/26/1984
	Primary: Betty Nation	50%	daughter	305-24-9731	02/12/1980
5.	Primary: Henry Nation	34%	son	987-65-4321	06/26/1984
	Primary: Betty Nation	33%	daughter	305-24-9731	02/12/1980
	Primary: John Nation	33%	son	876-91-3416	09/31/1986
6.	Primary: Sara Nation	60%	mother	811-61-1781	10/14/1950
	Primary: George Nation	40%	father	916-18-1781	12/30/1945
	Contingent: Jean Nation	100%	sister	913-19-3319	03/29/1971

7.Primary: My Estate

8.First National Bank of Canton, Ohio, as Trustee under Trust Agreement with Robert E. Nation dated January 1, 2002. (Attach a copy of the title and signature page of the Trust).

Generic beneficiary designations will not be accepted. Examples of generic designations include:

1.My spouse, parent(s), sister(s), brother(s), son(s), daughter(s).

2.My children.

3.Children of this marriage or any past marriage.

4.As designated in my will.

Form Return

By mail:	Nationwide Retirement Solutions	Email:	rpublic@nationwide.com
	PO Box 182797	By fax:	877-677-4329
	Columbus, OH 43218-2797

2

DC-770 (07/2019)

For help, please call 877-NRS-FORU

nrsforu.com

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