Page 95 - C:\Users\jsalazar145\Documents\Flip PDF Professional\new-employees-benefits-guide-2019 030619\

Human Resources
201 W. Sheridan, Bldg A
San Antonio, Texas 78204
Phone: (210) 485-0200 Fax: (210) 486-9074
_____ _____________________________________

LIFE INSURANCE BENEFICIARY DESIGNATION (ACTIVE AND RETIREE)

__________________________________________ _____________________ _____________ __________
Member Name ( First, Middle, Last) Social Security Number Date of Birth Gender
(mm-dd-yyyy)
___________________________________________________________ ___________________ ________ ___________
Address City State Zip Code
__________________________________ _________________________________________________________
Phone Email
PLEASE CHECK RETIREMENT ACCOUNT TYPE THAT APPLIES
Active Hi-Ed Retiree
PRIMARY BENEFICIARY (Read Reverse Side Before Completing)

_____________________________________ P E Spouse Son Daughter Other _______ __________
Beneficiary Name (First, Middle, Last & Check P=Person or E=Estate) Relationship (Check One) (specify) Date of Birth
(mm-dd-yyyy)
Social Security Number --- - --- (Required) Gender: M F
___________________________________________________ ______________________ ___________ _________
Address City State Zip Code
ALTERNATE BENEFICIARIES (Read Reverse Side Before Completing)
_____________________________________ P E Spouse Son Daughter Other _______ ___________
Beneficiary Name (First, Middle, Last & Check P=Person or E=Estate) Relationship (Check One) (specify) Date of Birth
(mm-dd-yyyy)
Social Security Number --- - --- (Required) Gender: M F

___________________________________________________ ______________________ ___________ _________
Address City State Zip Code
MULTIPLE BENEFICIARIES (Read Reverse Side Before Completing)
1.____________________________________ P E Spouse Son Daughter Other _________ ___________

Beneficiary Name (First, Middle, Last & Check P=Person or E=Estate) Relationship (Check One) (specify) Date of Birth
(mm-dd-yyyy)
Social Security Number --- --- (Required) Gender: M F
___________________________________________________ ______________________ ___________ _________
Address City State Zip Code
2.___________________________________ P E Spouse Son Daughter Other __________ __________
Beneficiary Name (First, Middle, Last & Check P=Person or E=Estate) Relationship (Check One) (specify) Date of Birth
(mm-dd-yyyy)
Social Security Number --- - --- (Required) Gender: M F
___________________________________________________ ______________________ ___________ _________
Address City State Zip Code
3.___________________________________ P E Spouse Son Daughter Other __________ ___________
Beneficiary Name (First, Middle, Last & Check P=Person or E=Estate) Relationship (Check One) (specify) Date of Birth
(mm-dd-yyyy)
Social Security Number --- --- (Required) Gender: M F
___________________________________________________ ______________________ ___________ _________
Address City State Zip Code
MEMBER SIGNATURE REQUIRED WITNESS SIGNATURE REQUIRED
This document revokes all prior designations for the account(s) indicated above. WITNESS CANNOT BE A BENEFICICIARY OR RELATED TO MEMBER
Member Signature:__________________________________ Witness Signature:__________________________________________
Date:_____________________________________________ Address:____________________________________________________
Phone: Home:_________________ Work:_______________ City__________________________ State___________ Zip Code________

95