Page 58 - LGB Group

Appendix 3

NOMINATION OF BENEFICIARY FORM

To:

Attention: Human Resource Department.

Dear Sir,

I hereby nominate the following person(s) as my beneficiary to receive the Group
Insurance benefits in the event of my death. I confirm that this nomination supersedes
all previous nominations made by me.

Name IC Number Relationship % share of
(where applicable) benefits

TOTAL 100%

Name of Employee :

IC Number :

Date :

Signature :

Witnessed by :

Name :

53