Please follow these instructions carefully when submitting this form to prevent any delays caused by unclear or omitted information. Be sure to read and fill out the form completely when submitting. 

1. Death proceeds shall be paid as shown on the acknowledged and recorded Beneficiary Designation form. If the terms of the contract conflict with the items listed in the form, the terms of the contract prevail.

2. Use percentages in your designation. All proceeds must total 100 percent (%) in each category (Primary, Contingent, Tertiary). If no percentages are listed, proceeds will be paid equally.

3. If you are adding beneficiaries but not changing existing beneficiaries, you must restate all existing beneficiaries.

4. When children are beneficiaries and not named individually, all living and future children born to or adopted by the insured are included unless otherwise designated. Unless named individually, stepchildren are not included. This designation should be listed as “all children of the insured.”

5. An irrevocable beneficiary is a designation that cannot be changed without the irrevocable beneficiaries’ written consent. If you designate an irrevocable beneficiary, the Company will require the irrevocable beneficiary to consent in writing to requests for other policy changes (i.e., assignment, contract changes, loan or surrender requests, annuity withdrawals, etc. If you are naming an irrevocable beneficiary, state “irrevocable” after the named beneficiary.

6. If the owner is a company, provide a corporate resolution or similar document that lists all of the officers and/or individuals authorized to sign on behalf of the company.

7. If this form is signed by a power of attorney, guardian or conservator, a copy of the appropriate documentation is required.

 

PRIMARY or the first person(s)/entity(ies) in line to receive the death proceeds after the insured is deceased. Funds are paid to all primary beneficiaries who are living/existing when the insured dies. If no primary beneficiaries are living/existing when the insured dies, then funds are paid to contingent beneficiaries who are living/existing. CONTINGENT or the second or subsequent person(s)/ entity(ies) in line to receive the death proceeds after the insured is deceased and there are no surviving primary beneficiaries. If no contingent beneficiaries are living/existing when the insured dies, then funds are paid to tertiary beneficiaries. TERTIARY or the third or subsequent person(s)/ entity(ies) in line to receive the death proceeds after the insured is deceased and there are no surviving primary or contingent beneficiaries. NOTE: If no beneficiaries are living/existing when the Insured dies, funds are paid to the owner or the owner’s estate.

• By signing below:
• I acknowledge this request is subject to the provisions and conditions of my policy/contract(s) and Assurity may request additional information in order for my request to be processed.
• I understand by submitting this document, I revoke any existing beneficiary designations with respect to any proceeds payable at the death of the insured.
• I acknowledge that payment to any designated trust as directed by this beneficiary designation ends the company’s responsibility in full. If a trust is named as beneficiary but does not exist when the insured dies, or no trustee qualifies or makes claim within six (6) months after the insured dies, or the company receives proof that no trustee will qualify or make claim, then the funds shall be paid as if that trust ceased to exist before the insured died.