Primary Beneficiary Designation
Primary beneficiary designations must total 100%. Percentage can be made out to two decimal places.
First Primary Beneficiary
Contingent Beneficiary Designation
Contingent beneficiary designations must total 100%. Percentage can be made out to two decimal places.
First Contingent Beneficiary
I have completed, understand and agree to all pages of the Beneficiary Designation form. Subject to and in accordance with the terms of the Plan, I am making the above beneficiary designations for my vested account in the event of my death with no surviving spouse or with the consent of my surviving spouse. If I have more than one primary beneficiary, the account will be divided as specified. If a primary beneficiary predeceases me, his or her benefit will be allocated to the surviving primary beneficiaries. Contingent beneficiaries will receive a benefit only if there is no surviving primary beneficiary, as specified. If a contingent beneficiary predeceases me, his or her benefit will be allocated to the surviving contingent beneficiaries. If I fail to designate beneficiaries, amounts will be paid pursuant to the terms of the Plan or applicable law. This designation is effective upon execution and delivery to Service Provider. If any information is missing, additional information may be required prior to recording my designation.
This designation supersedes all prior designations. Beneficiaries will share equally if percentages are not provided and any amounts unpaid upon death will be divided equally. Primary and contingent beneficiaries must separately total 100%. The percentage can be divided up to two decimal points (Example: 33.33%).
I understand that Service Provider is required to comply with the regulations and requirements of the Office of Foreign Assets Control, Department of the Treasury (“OFAC”). As a result, Service Provider cannot conduct business with persons in a blocked country or any person designated by OFAC as a specially designated national or blocked person. For more information, please access the OFAC website at: http://www.treasury.gov/aboutorganizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx.
Important notice: In accordance with ERISA and/or Plan Document, if I am married and I elect a primary beneficiary other than my spouse or in addition to my spouse, my spouse must consent by signing the Spousal Consent for Beneficiary Designation section of this form.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.