Change of Beneficiary Form

Please print this form and complete to change the beneficiary to your life policy. This designation revokes all previous designations.

section 1:
Name: _____________________________________________________________

Social Security Number: _______________________________________________

Address: __________________________________________________________________

City: ________________________________ State: ___________ Zip: _____________

Home Phone: _________________ Birth Date: _____________ Gender: __________

Section 2:
Primary Beneficiary

Full Name % of Benefit Address SSN Relationship

_________________ _________ ____________________ _________ __________

Contingent Beneficiary (Contingent beneficiaries will only be paid if there are not surviving primary beneficiaries.)

Full Name % of Benefit Address SSN Relationship

_________________ __________ __________________ __________ __________

_________________ __________ __________________ ___________ __________

Section 3:
Life Insurance provided by Hartford Life.

Printed Name: __________________________________________

Signature: ____________________________________________

Date: ___________________

Return to:     Southeast Missouri State University
                        Human Resources, MS 3150
                        One University Plaza
                        Cape Girardeau, MO 63701