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Administered by: GROUP INSURANCE PLAN BENEFICIARY DESIGNATION FORM NEW CHANGE First Name Last Name Member No. MEMBER INFORMATION BENEFICIARY DESIGNATION Complete each section for any benefits for

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2. Read the instructions provided with the form to understand the requirements.
3. Begin with the first section of the form and enter the requested information.
4. Ensure that all mandatory fields are filled out accurately.
5. Move on to the next section and repeat the same process until all sections are completed.
6. Double-check the filled-out sections for any errors or missing information.
7. If necessary, gather any supporting documents or attachments required.
8. Review the entire form once again to make sure all sections are properly filled out.
9. Sign and date the form, if required.
10. Submit the completed form by following the specified submission method.

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