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Membership & Life Insurance

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

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, as detailed in my form submission.

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:

Address of Primary Beneficiary:

Add Another Primary Beneficiary?

Address of Additional Primary Beneficiary:

Percentages to Primary Beneficiaries (only applicable if additional beneficiary added)

SECONDARY BENEFICIARY:

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

Address of Secondary Beneficiary:

Add Another Secondary Beneficiary?

Address of Additional Secondary Beneficiary:

Percentages to Primary Beneficiaries (only applicable if additional beneficiary added)

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

July 26, 2022 1:00 am EDT

Membership & Life Insurance Uploaded by Bill Ross - local10@notify.bicyclecreative.com IP 136.58.80.249