Employee Benefits Insurance Beneficiary Change Form
Employee Information
Full Name
Employee ID
Department
Phone Number
Email Address
Current Insurance Plan(s)
Select Plan(s)
Life Insurance
Accident Insurance
Critical Illness Insurance
Primary Beneficiary(ies)
Name
Relationship
Date of Birth
Share (%)
Address
Contingent Beneficiary(ies)
Name
Relationship
Date of Birth
Share (%)
Address
Authorization
Employee Signature
Date
Remarks