Life Insurance Designation Card Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.LOCAL 3090 GROUP LIFE INSURANCE BENEFICIARY DESIGNATION CARD $10,000 LIFE $5,000 AD&D Please complete the form below to dictate your life insurance beneficiaries Click the links below for helpful information on completing your beneficiary card. Beneficiary Basics Term Life Highlights Employee Name *FirstLastEmployee Identification Number *Date of Birth *Home Phone *Work Phone *Email *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary Beneficiaries Please complete the information below for each beneficiary. 1 Beneficiary Name *FirstLastRelationship *Date of Birth *Social Security Number *Percentage *Email *Phone *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code2 Beneficiary NameFirstLastRelationshipDate of BirthSocial Security NumberPercentageEmailPhone of Layout Date AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code3 Beneficiary NameFirstLastRelationshipDate of BirthSocial Security NumberPercentageEmailPhoneAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code4 Beneficiary NameFirstLastRelationshipDate of BirthSocial Security NumberPercentageEmailPhoneAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmployee Signature * Clear Signature Date *Lack of Notice of Community Property Interest: If AUL has not previously written notice of a community property interest and if the space for consent below is not signed by person having such an interest, then AUL shall be entitled to rely upon its good faith that no such interest exists. AUL assumes no reponsibility of inquiry regarding such interest and, in the consideration of acknowledgment of this designation, the insured person listed above, for himself/herself and his/her estate, heirs, successors and assigns, agrees to indemnify AUL and hold it harmless from the consequences of acknowledging this beneficiary designation. 1) Total percentage must equal 100% if percentage does not equal 100% the benefits will be paid on a pro-rated basis according to the percentages shown, if no percentages are shown, benefits will be distributed equally. 2) Total percentage must equal 100% if percentage does not equal 100% the benefits will be paid on a pro-rated basis according to the percentages shown, benefits will be distributed equally. Spouse’s signature is needed only if Insured/Beneficiary lives in a community property state which currently includes AZ, CA, ID, LA, NM, TX, WA and WI. Spouse's Signature Clear Signature DateSubmit
