RELIANCE STANDARD BENEFICIARY
Life Insurance Beneficiary Form for Clackamas Fire Employees
Policyholder
Policy Number
Employee Name
Social Security Number
I hereby designate the following as my PRIMARY beneficiary(ies) for my life insurance policy (must equal 100%) If no percentages are indicated, benefits will be divided equally between all primary beneficiaries.
Rows
Full Name and Address
Percentage
Date of Birth
Relationship
SSN
#1
#2
#3
I hereby designate the following as my CONTINGENT beneficiary(ies) for my life insurance policy. This is ONLY APPLICABLE if you are not survived by one or more primary beneficiaries. You do NOT need to list anyone here. If no percentages are indicated, any benefits payable to contingent beneficiaries will be divided equally between all contingent beneficiaries.
Rows
Full Name and Address
Percentage
Date of Birth
Relationship
SSN
#1
#2
#3
PLEASE NOTE
This beneficiary designation revokes ALL revocable prior beneficiary designations.
Unless you indicate otherwise, if any beneficiary predeceases you, that beneficiary's share will be divided pro-rata among
the surviving beneficiaries of the same class (primary or contingent).
If no beneficiary (primary or contingent) survives you, payment will be made pursuant to the terms of the applicable
policy.
Signature of Insured
Date
/
Month
/
Day
Year
Date
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