Form R414 PDF Details

Form R414 is an important document for Rhode Island employers. This form must be completed and filed with the Rhode Island Department of Labor and Training within 10 days of any new hire. The purpose of this form is to report information about the new employee, including their name, social security number, date of birth, and occupation. Failing to file this form can result in fines and other penalties. So make sure you are familiar with all the requirements for filing Form R414 if you have new employees in your workplace.

You can definitely find it helpful to understand how much time you'll need to fill in this form r414 and how lengthy this document is.

Form NameForm R414
Form Length4 pages
Fillable fields0
Avg. time to fill out1 min
Other namesUniversal Change Form afba insurance beneficiary form

Form Preview Example

Administrative Ofice: 909 North Washington Street, Alexandria, VA 22314 • 800-776-2322 •



Date Received

Only complete the section you wish to change. Complete a separate form for each life insurance account except for sections 2 & 3.

Account Number

Product Type


Owner (If other than insured)

1. CHANGE OF BENEFICIARY (Please see instructions on pages 3 and 4)

I hereby revoke any previous designation of beneiciaries and request that the life insurance beneit payable at my death be paid in accordance with the designations below. If more than one beneiciary is designated in the same beneiciary class, payment shall be made in equal shares to the designated beneiciaries unless otherwise provided herein. We must be informed of any legal restrictions affecting your beneiciary designation(s). Note: To comply with the laws of your state, beneiciary changes on 5Star Life Insurance Company (“5Star Life”) forms, and not those changes contained in an insured’s will or trust shall govern in cases of change. Benei- ciary changes arising from a divorce are not binding on 5Star Life unless made in the above prescribed manner or referenced in a court order iled with 5Star Life prior to the death of the insured.




I designate as my primary beneiciary class:



Full given name


Relationship Date of Birth Sex Address & Phone

(First, Middle, Last)




I designate as my secondary beneiciary class:




Full given name



Date of Birth Sex

Address & Phone

(First, Middle, Last)


p I elect to change the name of the p Insured p Owner p Payor to the following:

Name before change ___________________________________________________________________________________________

Name after change ____________________________________________________________________________________________

Date of change _______________________________________________________________________________________________

Reason for change: p Marriage p Divorce

p Adoption p Other:________________________



Page 1 of 4


Universal Request for Change Form R414

SIGNATURES required on page 2 - - >


Account Number

Product Type


Owner (If other than insured)


p Insured p Owner p Payor

Complete Address (including Zip Code)___________________________________________________________________________

Phone Numbers (including Area Code): Daytime _________________ Cell _________________ Evening ___________________

Email Address____________________________________________________________________________________________


pI elect to change the owner of this certiicate/policy to the following individual and understand that all beneits, rights, and privi- leges incident to ownership of this certiicate/policy will be vested in the new owner.

New Owner (First, Middle, Last) __________________________________________________ Relationship ______________________

New Owner’s Date of Birth (MM/DD/YYYY) _____________________ SSN __________________

Phone Numbers (including Area Code): Daytime _________________ Cell __________________ Evening _______________________

New Owner’s Complete Address (including Zip Code) ___________________________________________________________________


(Not applicable for Group, Individual, or Executive Select Term. Please contact us with questions.)

pI ____________________________, owner of this certiicate/policy would like to decrease my coverage amount to $ ________


pPlease send Statement of Insurance Coverage.

pPlease send complete duplicate certiicate/policy.

Reason for request p Cannot locate p Never received p Other ___________________________


Sign and date this form and forward to 5Star Life. We will acknowledge receipt by returning a date stamped copy to you.

Signature of Insured _________________________________________________________ Date ____________________________

(Parent or guardian, if insured is a minor)

Signature of Owner _________________________________________________________ Date ____________________________

(Required if other than Primary Insured)

Owner’s Name (Please Print) ____________________________________________________________________________________

Signature of New Owner _______________________________________________________________________________________

Contingent Owner (in the event owner predeceases insured)____________________________________

Please Note: The CURRENT owner MUST sign above to request this ownership change.

The current owner’s spouse must also sign if current owner lives in a community property state (AZ, CA, ID, LA, NV, NM, TX, WA, & WI).

Spouse’s Signature __________________________________

Phone Numbers (including Area Code): Daytime _________________ Cell__________________ Evening _______________________

Owner’s Complete Mailing Address ______________________________________________________________________________

Universal Request for Change Form R414

Page 2 of 4

Administrative Ofice: 909 North Washington Street, Alexandria, VA 22314 • 800-776-2322 •

Instructions for Beneiciary Designation

Only the owner of the life insurance coverage may change the beneiciary(ies).

Naming A Beneiciary

The complete name (including middle name), Social Security number, date of birth, current residential address, and telephone number must be included for all beneiciaries. Always use full names, for example: “Susan Ann Smith” not “Mrs. John Smith.”

If more than one person or entity is named in the same beneiciary class, use percentages or fractions to denote the pro- ceeds to be designated to each person (such as 50%) so that the proportion remains consistent in the event the insurance amount changes.

Do not use words such as “or,” and the terms “and/or,” “by law,” “descendents,” “heirs.”

Secondary (or Contingent Beneiciary)

After the primary beneiciary is named, a secondary (or contingent) beneiciary may also be designated. The secondary beneiciary will receive the beneit if no beneiciary in the primary class survives the insured.


In order to determine the true and appropriate beneiciary in the event of a divorce between the insured and a spouse ben- eiciary, 5Star Life requires a copy of the divorce decree and property settlement agreement since many state divorce laws automatically void the designation of a spouse as beneiciary, unless the divorce decree expressly retains the designation.


Minor children may be named as beneiciaries. Guardians for the children should not be named because most states will not recognize a guardian unless appointed by a court. In the event that a beneiciary is a minor when he/she is entitled to insurance beneits, payment will not be made until the court appoints a guardian or conservator. Exceptions:

a.State laws where the minor lives may allow the minor to give a discharge for the proceeds (some states deine age of majority as age 21; others age 18; and others if the child is married).

b.A Trust established for the beneit of the minor beneiciary(ies).

For people who want all of their children or grandchildren to have an equal share in the proceeds, there is a way to desig- nate the children as beneiciaries without actually naming each child.

• Children of the insured.

This designation includes all born, adopted, and step-children of the insured.

Children of the insured’s marriage with ______________________(name of spouse). This designation would include any born, adopted, and step-children from this marriage.

For people who want to split the proceeds unevenly among their children, it is necessary to include each child’s name and, using percentages or fractions, indicate the designated proceeds that each child is to receive. Use this designation when completing the primary or secondary beneiciary class sections of the form.

Universal Request for Change Form R414

Page 3 of 4



If an Estate is named, specify whose Estate, such as “Estate of Susan Ann Smith.” Please be aware that at time of claim, “Letters Testamentary”, that is, a document issued by the court of proper jurisdiction indicating what person, bank, or or- ganization has been appointed as Executor, Administrator, or Personal Representative of a deceased insured’s estate, will be required in order to release proceeds.


A Trustee under a Trust Agreement or Living Trust may be named as beneiciary by use of the following wording: “To

__________ (person, bank, or trust company) as Trustee under Trust Agreement dated _____.

If proceeds are paid to a Trustee beneiciary, 5Star Life and/or the Master Policyholder of any group coverage is not bound by the terms of a Will.


If a Will is named, use the following wording: “To the Executor or Personal Representative named in my Last Will and Testament dated ________.”

Please be aware, designations of proceeds by a Will can cause delays in processing a claim.

Absolute Assignment

If an assignment of ownership of the life insurance coverage has been made, only the assignee (the person or group the insurance proceeds were assigned to) may designate a new beneiciary(ies).

Instructions for Changing Ownership

Only the current owner of the life insurance coverage may change ownership.


In order to accept a change of ownership, the Ownership Change section of the Universal Request for Change Form must be completed in full and the current owner, as well as the new owner, must sign the form. If the current owner lives in a community property state, the current owner’s spouse must also sign the Universal Request for Change Form. (Commu- nity property states are AZ, CA, ID, LA, NV, NM, TX, WA, & WI.)

Change Due to Death of Owner

In the event of death of the owner, ownership of the life insurance coverage may be changed by a court-appointed Per- sonal Representative (Executor) of the estate of the deceased owner.

Ownership change can also be accomplished through a fully executed and notarized Power of Attorney (POA). The change must be performed by the grantor’s representative (Attorney-in-Fact) named in the POA during the lifetime of the grantor of the POA. The POA must cover the requested transaction.

Contingent Owner

The owner of the life insurance coverage may name a contingent owner who will be granted all the rights of ownership in the event the owner predeceases the insured.

Beneiciary Checklist

rDid you sign and date your designation?

rDid you provide all demographic information requested on the form for your beneiciary(ies)?

rDid you sign and date all attachments that require signatures?

rHave you re-married? Your current designation could be revoked if your divorce decree contains a provision for insurance coverage. In order to determine proper disbursement of claim proceeds, please submit a copy of the inal Divorce Decree and Property Settlement Agreement. These documents are required before a claim can be processed.

Universal Request for Change Form R414

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