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UHPA Beneficiary Form


University of Hawaii Professional Assembly
Group Term Life Insurance Beneficiary Designation

SIGNATURE REQUIRED:  A printed confirmation, based on what you submit below,  will be mailed to you for your review and signature.  Your beneficiary designation will become effective upon receipt and processing of your hard copy signed confirmation.

The new beneficiary designation cancels all prior designations.  If more than one beneficiary is named, proceeds will be paid in equal shares, unless otherwise indicated.  If no Primary Beneficiary is living, proceeds shall be paid to the surviving Contingent Beneficiary(ies).  All proceeds will be paid in accordance with the terms of the policy.


Your Last Name: *  
Your First Name: *  
Your Middle Name: *  
Your mailing Street Address: *  
Your Social Security Number: *  
Your City, State, Zip Code: *  
Best phone number to reach you at if we have any questions: *
Your e-mail address: *
   
Primary Beneficiary #1's Full Name: *  
Primary Beneficiary #1's Social Security Number: *
Primary Beneficiary #1's Street Address:*
Primary Beneficiary #1's City/State/Zip: *
Primary Beneficiary #1's % of Benefit: *
Primary Beneficiary #1's Relationship to you: *
   
Primary Beneficiary #2's Full Name:
Primary Beneficiary #2's Social Security Number:
Primary Beneficiary #2's Street Address:
Primary Beneficiary #2's City/State/Zip:
Primary Beneficiary #2's % of Benefit:
Primary Beneficiary #2's Relationship to you:
   
Contingent Beneficiary #1's Full Name:
Contingent Beneficiary #1's Social Security Number:
Contingent Beneficiary #1's Street Address:
Contingent Beneficiary #1's City/State/Zip:
Contingent Beneficiary #1's % of Benefit:
Contingent Beneficiary #1's Relationship to you:
   
Contingent Beneficiary #2's Full Name:
Contingent Beneficiary #2's Social Security Number:
Contingent Beneficiary #2's Street Address:
Contingent Beneficiary #2's City/State/Zip:
Contingent Beneficiary #2's % of Benefit:
Contingent Beneficiary #2's Relationship to you:
   Check here to confirm you have read and understand the statements at the top of this page. This box must be checked before your designation form can be processed.
Today's date: *
TYPE YOUR NAME here to represent your signature: *

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