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Benefits

Life Insurance

The Hartford Life Insurance Company – Group Policy #GL-881398
$10,000 Coverage (Active Member)
Beneficiary Designation

"*" indicates required fields

Name*

First Middle Last

Date of Birth*

Month

Day

Year

Email Address*

Phone*

Phone Type*

Employer*

Date of Hire*

Department/Job Title*

Beneficiary Information

In accordance with the conditions of the Group Policy listed above, I designate as primary beneficiary and/or secondary beneficiary in the event of my death, the following:

Primary Beneficiary

Name of Primary Beneficiary*

First Last

Your Relationship to Primary Beneficiary*

Address of Primary Beneficiary*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number of Primary Beneficiary*

Add Another Primary Beneficiary?*

No

Yes

Name of Additional Primary Beneficiary

First Last

Your Relationship to Additional Primary Beneficiary

Address of Additional Primary Beneficiary

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number of Additional Primary Beneficiary

Add A Third Primary Beneficiary?*

No

Yes

Name of Third Primary Beneficiary

First Last

Your Relationship to Third Primary Beneficiary

Address of Third Primary Beneficiary

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number of Third Primary Beneficiary

Add A Fourth Primary Beneficiary?*

No

Yes

Name of Fourth Primary Beneficiary

First Last

Your Relationship to Fourth Primary Beneficiary

Address of Fourth Primary Beneficiary

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number of Fourth Primary Beneficiary

Percentages to Primary Beneficiaries

The values must total 100%

Percentage to First Primary Beneficiary

Please enter a number from 1 to 99.

Percentage to Additional Primary Beneficiary

Please enter a number from 1 to 99.

Percentage to Third Primary Beneficiary

Please enter a number from 1 to 99.

Percentage to Fourth Primary Beneficiary

Please enter a number from 1 to 99.

Secondary Beneficiary

Policy benefits are only distributed to secondary beneficiary(ies) if primary beneficiary(ies) are not alive.

Add A Secondary Beneficiary?*

No

Yes

Name of Secondary Beneficiary*

First Last

Your Relationship to Secondary Beneficiary*

Address of Secondary Beneficiary*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number of Secondary Beneficiary*

Add Another Secondary Beneficiary?*

No

Yes

Name of Additional Secondary Beneficiary

First Last

Your Relationship to Additional Secondary Beneficiary

Address of Additional Secondary Beneficiary

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number of Additional Secondary Beneficiary

Add A Third Secondary Beneficiary?

No

Yes

Name of Third Secondary Beneficiary

First Last

Relationship to Third Secondary Beneficiary

Address of Third Secondary Beneficiary

Street Address City State / Province / Region ZIP / Postal Code Country

Add A Fourth Secondary Beneficiary?

No

Yes

Name of Fourth Secondary Beneficiary

First Last

Relationship to Fourth Secondary Beneficiary

Address of Fourth Secondary Beneficiary

Street Address City State / Province / Region ZIP / Postal Code Country

Percentages to Secondary Beneficiaries

The values must total 100%

Percentage to First Secondary Beneficiary

Please enter a number from 1 to 99.

Percentage to Additional Secondary Beneficiary

Please enter a number from 1 to 99.

Percentage to Third Secondary Beneficiary

Please enter a number from 1 to 99.

Percentage to Fourth Secondary Beneficiary

Please enter a number from 1 to 99.

Signature

After submitting this form please be sure to submit your signature on the next page that loads.

Agreement*

I have read and agree to the terms and conditions, confirm the accuracy of the information provided, and consent to the processing of my data for the purpose stated. By checking this box, I acknowledge that I am the person completing and signing this form.

Full Name:*

Type your full name here then sign below.

Signature*

Your Name
Your Name
Your Name

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