Great West Form 598 – Fill Out and Use This PDF

BENEFICIARY DESIGNATION FORM

Policy Number

Name of Policy Owner

The policy owner revokes any previous beneficiary designations and instructions. The policy owner designates revocably the following beneficiaries to receive any policy proceeds payable on and after the death of the life insured:

Policy Owner Marital Status:	Married	Single	Divorced	Widowed
	(If Married, Divorced or Widowed, see Instructions - page 2, section 2D)

PRIMARY BENEFICIARY(IES) - in equal shares, unless otherwise provided below: (Indicate % for each beneficiary = 100%)

Full Name

Address

Relationship

Social Security Number

Date of Birth

Phone Number

Percentage

Full Name

Address

Relationship

Social Security Number

Date of Birth

Phone Number

Percentage

Full Name

Address

Relationship

Social Security Number

Date of Birth

Phone Number

Percentage

If no Primary Benefi ciary survives the life insured, then the proceeds will be paid to:

CONTINGENT BENEFICIARY(IES) - in equal shares, unless otherwise provided below: (Indicate % for each benefi ciary = 100%)

Full Name

Address

Relationship

Social Security Number

Date of Birth

Phone Number

Percentage

Full Name

Address

Relationship

Social Security Number

Date of Birth

Phone Number

Percentage

Full Name

Address

Relationship

Social Security Number

Date of Birth

Phone Number

Percentage

MINOR CLAUSE - TRUSTEE FOR CHILDREN:

Full Name

Address

Relationship

Social Security Number

Date of Birth

Phone Number

Percentage

is hereby appointed as Trustee to receive any payment due on or after the life insured’s death to any beneficiary designated in this form who is a minor child on the date such payment falls due.

If the undersigned is signing in a representative capacity, the undersigned warrants that he or she has the authority to bind the entity on whose behalf this document is being executed.

Policy Owner(s)			Date			Policy Owner(s)		Date
Irrevocable or Preferred Benefi ciary (if any)			Date			Other Required Signature (if any)		Date
	GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
	THE GREAT-WEST LIFE ASSURANCE COMPANY
				PO Box 85056
				Lincoln, NE 68501-5056
This designation is subject to the provisions on Page 2. The Company assumes no responsibility for the validity or effect of this designation.
Form 598 (02/01/2014) REG	Designation is not valid until received and recorded by the Company.							1 of 2

PROVISIONS

1.DECEASED BENEFICIARIES - Unless otherwise provided in this form, the interest of any deceased beneficiary shall be shared by the surviving beneficiaries then entitled, in equal shares, or shall fall to the last surviving beneficiary. All payments which fall due on and after the death of the last survivor of the beneficiaries shall be payable to the estate of that last survivor, except that if no beneficiary survives the life insured, such payments shall be payable to the policy owner, if living, otherwise to the policy owner’s estate.

2.OPTIONAL SETTLEMENT ELECTION BY BENEFICIARY - If any beneficiary appointed herein becomes entitled to any policy proceeds and elects to have such proceeds paid under one of the Optional Settlements in the policy, then any benefits payable under the Optional Settlement so elected shall be payable to that benefi ciary, if living, otherwise to the beneficiary’s estate.

3.ASSIGNEE - Payment of policy proceeds to any benefi ciary is subject to the interest of any assignee.

4.CHILD OR CHILDREN - The terms “child” or “children” used in this form shall include any legally adopted child or children unless otherwise indicated in this form by the policy owner.

5.TRUST AGREEMENT IN EFFECT - If the Trustee(s) under a written Trust Agreement (other than the “Minor Clause” in this form) are appointed as beneficiary, The Company reserves the right to require proof satisfactory to it of the existence of the Trust, prior to payment of any policy proceeds to such Trustee(s). If the trust is not in effect at the time such payment falls due, then payment shall be made to the succeeding entitled beneficiary(ies) as provided in this form.

6.TRUSTEE DISCHARGE - The Company shall not be responsible for the application, disposition or use of any policy proceeds paid to any Trustee(s) designated herein. The receipt of the Trustee(s) shall be a full discharge to the Company for the amount of the payment.

INSTRUCTIONS

1.USE THIS FORM for a change of beneficiary under an individual policy issued in the United States. The form should be dated and signed by the current owner(s) of the policy with the signatures witnessed as indicated. A separate form should be used for each policy.

2.SIGNATURES - when this form is signed by:

(A)A Corporation - The full name of the Corporation must be signed, with the signatures of two signing officers and a corporate resolution or one signing offi cer under corporate seal. The titles of the offi cers signing the form should also be shown.

(B)A Firm or Partnership - The full name of the Firm or Partnership must be signed, with the signatures of all the partners.

(C)A Trustee - The Trustee is signing in a representative capacity and warrants that he or she has the legal authority to bind the entity on whose behalf this document is being executed. The name of the entity must also appear above the signature.

(D)If state residence is covered under the Community Property provision, the signature of the owner’s spouse is required under ‘Other Required Signature’. If the owner is divorced or widowed, please provide a copy of the divorce decree or death certificate.

Community Property laws are applicable in: AZ, CA, ID, LA, NV, NM, TX, WA, WI.

Note - If the policy has a total death benefit of $1,000,000.00 or more, signatures on the form(s) must be notarized. The Company reserves the right to require that a notarial declaration be completed to certify the validity and authority of any signatures. Any forms which require a notarial declaration cannot be sent in via facsimile; the originals must be received at the offi ce of the Company.

We have the right to ask for additional information or documentation.

3.RELATIONSHIP - The relationship of the beneficiary to the life insured is requested for the purposes of identification. If no relationship to the life insured exists, indicate “no relation” and show any other information which would help to identify the beneficiary.

4.ABSOLUTE ASSIGNMENT FOR IRREVOCABLE OR “PREFERRED” BENEFICIARIES - This form can also be used by an irrevocable or “preferred” beneficiary to release their interest in the policy. This form should be signed by the irrevocable or “preferred” beneficiary if they wish to release their interest in the policy.

5.If this form is to be used to change the benefi cary in a Family Plan Policy, or a policy with a Spousal and/or Child Term Rider, please indicate that the Designation of Benefi ciary is for the Rider.

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY

THE GREAT-WEST LIFE ASSURANCE COMPANY

PO Box 85056

Lincoln, NE 68501-5056

Form 598 (02/01/2014) REG

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