Group Insurance Beneficiary Designation/Change

IMPORTANT INFORMATION ABOUT BENEFICIARY DESIGNATIONS

Use this form to designate or make changes to the beneficiary(ies) of your Group Insurance death proceeds. evenly among those named. Payment will be made to the named beneficiary. If there is no named
The information on this form will replace any prior beneficiary designation. You may name anyone or any beneficiary, or the named beneficiary predeceased the insured, settlement will be made in accordance
entity as your beneficiary and you may change your beneficiary at any time by completing a new Group with the terms of your Group Contract. If designating percentages for contingent beneficiaries,
Insurance Beneficiary Designation/Change form. Common designations include individuals, estates, the percentage for all contingent beneficiaries must also equal 100%.
corporation/organizations and trusts. Payment will be made to the named beneficiary. If there is no You can name an individual, corporation/organization, trust, or an estate as a beneficiary.
named beneficiary, or the named beneficiary predeceased the insured, settlement will be made The following examples may be helpful in designating beneficiaries:
in accordance with the terms of your Group Contract. Individual: Mary A. Doe
DEFINITIONS Each name should be listed as first name, middle initial, last name (Mary A. Doe, not
Mrs. M. Doe)
You may find the following definitions helpful in completing this form: Include the address, relationship and date of birth for each individual listed.
Primary Beneficiary(ies) the person(s) or entity you choose to receive your life insurance proceeds. Indicate the percentage to be assigned to each individual.
Payment will be made in equal shares unless otherwise specified. In the event that a designated primary
beneficiary predeceases the insured, the proceeds will be paid to the remaining primary beneficiaries in Estate: Estate of the Insured
equal shares or all to the sole remaining primary beneficiary. Select Other as the beneficiary description and write estate in the blank space provided.
Contingent Beneficiary(ies) the person(s) or entity you choose to receive your life insurance proceeds Indicate the percentage to be assigned to the estate of the insured.
if the primary beneficiary(ies) die (or the entity dissolves) before you die. Payment will be made in equal Corporation/Organization: ABC Charitable Organization
shares unless otherwise specified. In the event that a designated contingent beneficiary predeceases the Select Corporation/Organization as the beneficiary description.
insured, the proceeds will be paid to the remaining contingent beneficiaries in equal shares or all to the Write the legal name of the corporation or organization in the space for the beneficiarys first name.
sole remaining contingent beneficiary. You must provide the address, city, and state of operation for each organization or corporation listed.
Indicate the percentage to be assigned to the corporation or organization.
INSTRUCTIONS FOR DESIGNATING A PRIMARY OR CONTINGENT BENEFICIARY
Trust: The John Doe Trust. A Trust with a trust agreement dated 1/1/99 whose Trustee is Jane Smith.
1. EMPLOYEE INFORMATION Select Trust as the Beneficiary Description.
All information in this section is required. Indicate the percentage to be assigned to the trust.
Unless otherwise indicated in Section 1, the information supplied on the form will apply to ALL Complete Section 3, Trust Designation.
coverages offered under the employers group plan.
Unless otherwise indicated in Section 2, the information supplied on the form will apply to all 3. TRUST DESIGNATION
the Group Life coverage(s) issued by The Prudential Insurance Company of America (Prudential) Complete this section if you have named a trust as a primary or contingent beneficiary in
to the group contract holder. Section 2. Fill in the name and address for each trustee.
Fill in the title and date of the Trust Agreement in the space provided.
2. BENEFICIARY DESIGNATION
You may name more than one primary and more than one contingent beneficiary. This form allows you 4. AUTHORIZATION/SIGNATURE
to name up to three primary and three contingent beneficiaries. If you need additional space, please The employee must read, sign, and date the authorization.
attach a separate sheet of paper. Submit the completed form to your benefits administrator or Human Resources (as directed
Please indicate the percentage share designated to each primary beneficiary. The total for all by your employer) and keep a copy for your records.
primary beneficiaries must equal 100%. If no percentages are specified, the proceeds will be split

1. EMPLOYEE INFORMATION (please print)

Last Name First Name MI Employee ID # (if applicable) Marital Status Married Widowed Gender (check one) Has this insurance been assigned?
Melwin J
Poovakottu 11097 (check one) Single Divorced Male Female Yes No
Address City State ZIP Code Daytime Phone Home Phone Date of Birth Date of Hire Date of Retirement (if applicable)
2545 W Hillcrest Dr, Thousand Oaks CA 91320 949247114 12/aug/1989 10/Aug/2015
Name of Employer/Group Policyholder Group Policy No  nless otherwise indicated below, this Beneficiary Designation/Change form applies to ALL coverages offered under my employers group plan.
U
ZS Associates This form applies only to my ______________________________________________________________________ coverage(s).

GL.2001.169 Ed. 01/2015 Page 1 of 2

 Group Insurance Beneficiary Designation/Change

2. BENEFICIARY DESIGNATION: I hereby revoke any previous designations of primary beneficiary(ies) and contingent beneficiary(ies), if any, and in the event of my death, designate the following:
A. Primary Beneficiaries
Beneficiary Description (check one) First Name MI Last Name Address (include city, state, ZIP) Relationship Date of Birth SSN/Tax ID Number Phone % Share
Individual Other___________ T. J. James Poovakottu House, Father 5/Jan/ 1954 +919946513371 50
Trust Corporation/Organization Koodathai, Kerala, India
Individual Other___________ Mary James Poovakottu House, Mother 25/Aug/1954 +918281900670 50
Trust Corporation/Organization Koodathai, Kerala, India
Individual Other___________
Trust Corporation/Organization
TOTAL:
(must equal 100)
B. Contingent Beneficiaries
Beneficiary Description (check one) First Name MI Last Name Address (include city, state, ZIP) Relationship Date of Birth SSN/Tax ID Number Phone % Share
Individual Other___________ Bebil Poovakottu Yeovil, UK Brother +447778472474 100
Trust Corporation/Organization
Individual Other___________
Trust Corporation/Organization
Individual Other___________
Trust Corporation/Organization
TOTAL:
(must equal 100)
3. TRUST DESIGNATION COMPLETE IF A TRUST HAS BEEN NAMED AS A BENEFICIARY IN SECTION 2
Trustees Name (First, MI, Last) Address (include city, state, ZIP)

And successor(s) in trust, as Trustee(s) under _____________________________________________________ dated _______________________________ as amended and executed by me and said Trustee.
Title of Agreement Date of Agreement
4. AUTHORIZATION/SIGNATURE
I authorize my plan administrator to record and consider the individuals/institutions that I have named on this form as beneficiaries for benefits under the applicable employee benefit plans. If designating a trust as a
beneficiary, I understand Prudential assumes no obligation as to the validity or sufficiency of any executed Trust Agreement and does not pass on its legality. In making payment to any Trustee(s), Prudential has the right
to assume that the Trustee(s) is acting in a fiduciary capacity until notice to the contrary is received by Prudential at its Group Life Claim office. I agree that if Prudential makes any payment(s) to the Trustee(s) before
notice is received, Prudential will not make payment(s) again.

Employees Signature X __________________________________________________________________________________________ Date ____________________

The employee must sign and date this form. The signature date must be the date the employee actually signed the form.

Group Life Insurance coverages are issued by The Prudential Insurance Company of America, a Prudential Financial company, 751 Broad Street, Newark, NJ 07102. Group Variable Universal Life Insurance coverage is distributed by Prudential
Investment Management Services LLC, Three Gateway Center, 14th Floor, Newark, NJ 07102-4077, a registered broker/dealer and a Prudential Financial company. Please refer to the Booklet-Certificate, which is made a part of the Group
Contract, for all plan details, including any exclusions, limitations, and restrictions, which may apply. Contract provisions may vary by state. Contract series: 83500 (Term Life), 89579 (Group Variable Universal Life), 96945 (Group Universal Life).
2015 Prudential Financial, Inc. and its related entities.
Prudential, the Prudential logo and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide.
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