Revised 8/12/2013

REQUIRED DOCUMENTATION To Add Dependents and To Maintain Dependent Child(ren) Coverage

I. For Spouse

A copy of Marriage Certificate, Birth Certificate, Social Security card, AND, if your date of marriage is more than one year old, Your most recent Tax Return – Federal or State (including Puerto Rico Returns)

1. Your most recent tax return showing "married filing jointly" OR "married filing separately.” Your spouse's name must appear on the tax form on the line provided after the "married filing separately" status (or vice versa).

2. Only submit page 1 of the return. This could include the 1040 form, e-File Confirmation Page, Tax Preparer's Summary, or Federal Return Recap.

3. Eliminate all financial information, OR Proof of Joint Ownership Both the enrollee and spouse's name must be listed on the documentation of joint ownership and be dated within the past 90 days. Examples include a copy of:

Homeowners/Renters Insurance Policy Mortgage Statement Credit Card Statement Property Tax Document Loan Obligation Rental/Lease Agreement Bank Account Statement Utility/phone/internet/cable bills Pension/life insurance/will designating spouse as beneficiary

II. For Children For a Natural-Born Child, a copy of: For a Stepchild, or Legally Adopted Child, a copy of:

Birth Certificate showing employee’s name Birth Certificate or Adoption certificate Social Security card Social Security card

III. Dependent Children to age 26 may be eligible for medical benefits under an employee’s family coverage.

IV. Dependent Children Coverage ages 19 and 25 Dependent child age 19 to 25 (or, if applicable: age as specified in your Collective Bargaining Agreement (CBA)) may be eligible for dental and vision care benefits. To enroll or maintain enrollment for your dependent(s) over age 19, and up to age 25 (or per CBA if applicable), for MetLife dental and EyeMed vision care benefits coverage, you must provide verifiable proof of full-time student status for each semester. You may provide proof of full-time status in the form of any of the following: a letter, statement, or documentation from the Bursar or Registrar's office, a printout from the clearinghouse, or a paid receipt that includes the number of classes/credits. V. When Dependents That Are No Longer Eligible Dependents For a dependent to be eligible for COBRA coverage continuation, your dependent must enroll for COBRA coverage within 60 days of losing coverage (the qualifying event date).

You must inform the MTA BSC when your dependent is no longer a full-time student, an eligible dependent. The BSC will update the dependent’s status. COBRA Dental and Vision coverage is administered by P&A. P&A will send you of your notification package.

EMPLOYEE BENEFITS DIVISION HEALTH INSURANCE TRANSACTION FORM

FOR NYS & PE EMPLOYEES

PS-404 (9/17)

INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES.

EMPLOYEE INFORMATION (All employees must complete) 1. Last Name First Name MI 2. Social Security Number 3. Sex

Male Female 4. Permanent Address

StreetCity State Zip

5. Mailing Address (If different)Street

City State Zip

6. Work Location & Address Street

City State Zip

7. Date of Birth 8. Telephone NumbersPrimary Work

9. Marital Status Single Married Widowed Divorced Separated Marital Status Date

10. Covered under Medicare? Self: Yes No Spouse/Domestic Partner: Yes No Child: Yes No

11. ELECT OR DECLINE COVERAGE A. Choose a Pre-Tax election (Only eligible for Pre-Tax deductions if newly eligible or if requested during the PTCP election period, Nov 1-30)

1. Elect Pre-Tax Status for Premium deduction 2. Elect After-Tax Status for Premium deduction

B. Select a NYSHIP Coverage Option (Choose option 1, 2, 3 or 4)

1. Individual EnrollmentMedical (10) (Select Empire Plan or HMO)

Empire Plan HMO Code Name _______________ Dental (11) Vision (14)

2. Family Enrollment(Complete box 13 on page 2)

Medical (10) (Select Empire Plan or HMO) Empire Plan HMO Code Name _______________ Dental (11) Vision (14)

3. Opt-out Program(NYS Medical only)

Individual Opt-out Family Opt-out (Complete Box 13) If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form. Dental (11) Vision (14)

4. Decline Coverage Medical (10) Dental (11) Vision (14)

12. CHANGE OR CANCEL EXISTING COVERAGE

A. Change Coverage: Medical (10) Dental (11) Vision (14) Date of Event: Change to FAMILY (Complete box 13)

Marriage Domestic Partner Newborn Request coverage for dependents not previously covered Previous coverage terminated (proof required) Dependent returned to full-time student status (Dental and Vision only) Other:

Change to INDIVIDUAL Divorce Termination of Domestic Partnership (Attach completed PS-425.4) Only dependent ineligible due to age I voluntarily cancel coverage for my dependents Only dependent died Only dependent married (Dental and Vision only) Only dependent graduated (Dental and Vision only) Other:

NOTE: If you are indicating a change in marital status to Divorced or Separated, please be sure to update the address information for the dependent in Box 13 if applicable.

B. Voluntarily Cancel Coverage: Medical (10) Dental (11) Vision (14) Qualifying Event: NOTE: If you are enrolled in the Pre-Tax Contribution Program, you may make changes during the Annual Option Transfer Period or when experiencing a qualifying event.

NYS Department of Civil Service Health Insurance Transaction Form Albany, NY 12239 Page 2 - PS-404 (9/17)

13. DEPENDENT INFORMATION Must be provided when choosing to enroll or opt-out of NYSHIP family coverage (use additional sheets if necessary) Check One: A (Add), D (Delete) or C (Change) Check all that apply: M (Medical), D (Dental), and V (Vision) Date of Event:

Last Name First Name MI Relationship Date of Birth Sex Address (if different) Social Security Number

A D C

M D V

A D C

M D V

A D C

M D V

A D C

M D V

14. ENTER ANNUAL OPTION TRANSFER REQUEST(S) BELOW

Change NYSHIP Option Change to: Empire Plan HMO Code HMO Name:

Elect Opt-out (NYS Medical only) Individual Opt-out Family Opt-out If choosing Opt-out, you must also complete the

PS-409 Opt-out Attestation Form.

Change Pre-Tax Status Change to: Pre-Tax After-Tax Submit during the Pre-Tax Contribution Selection Period (November 1-30)

Personal Privacy Protection Law Notification

The information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Law for the principal purpose of enabling the Department of Civil Service to process your request concerning health insurance coverage. This information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e) and (f). Failure to provide the information requested may interfere with our ability to comply with your request. This information will be maintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, Albany, NY 12239. For information concerning the Personal Protection Law, call (518) 473-2624. For information related to the Health Insurance Program, contact your Health Benefits Administrator. If, after calling your Health Benefits Administrator, you need more information, please call (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 4:00 p.m. Eastern time.

AUTHORIZATION I have read the Pre-Tax Contribution Program materials and the Opt-out Attestation Form (if applicable), and have made my selection on Page 1 of this document. I understand that if my coverage is declined or canceled, I may subject myself and/or my dependents to waiting periods if I decide to enroll at a later date and may forfeit the right to such coverage after leaving State service (vest, retirement, etc.). I am aware of how to obtain a current Summary of Benefits and Coverage for the NYSHIP option I have selected. I understand that my failure to provide required proof(s) within 30 days may delay the availability of benefits for me or any dependent for whom I fail to provide such proof. Any person who makes a material misstatement of fact or conceals any pertinent information shall be guilty of a crime, conviction of which may lead to substantial monetary penalties and/or imprisonment, as well as an order for reimbursement of claims. I certify that the information I have supplied is true and correct. I hereby authorize deduction from my salary or retirement allowance of the amount required, if any, for the coverage indicated above.

Employee Signature (Required): Date:

AGENCY USE ONLY

Retirement Tier Registration # Sick Leave Information Date Entered on

NYBEAS Effective Date # Hours Hourly Rate of Pay

HBA Signature (Required): Date:

NYS Department of Civil Service Instructions for NYS Health Insurance Transaction Form Albany, NY 12239 PS-404 (9/17)

NYSHIP Program Information Resources

To enroll in benefits or to change your current benefits, you will most likely be required to submit proofs of eligibility for coverage or evidence of a qualifying event with the completed and signed Health Insurance Transaction Form PS-404. Learn more about these additional requirements in the following publications:

• General Information Book (GIB) Eligibility, enrollment, required forms and proofs of eligibility.

• Planning for Option Transfer The Pre-Tax Contribution Program (PTCP) and enrollment dates

• Choices Your plan options under NYSHIP (Empire Plan, NYSHIP HMO or the Opt-out Program) and the benefits included with each one.

In many situations, you will also be required to complete, sign and submit additional forms and proofs. For detailed instructions on what will be required, please refer to your GIB and any additional forms and form instructions for requirements specific to your request.

EMPLOYEE INFORMATION

Boxes 1 – 10 Employee

Information You must complete boxes 1 – 10 with your personal information. Note: Use the Marital Status Date to show the date of marriage, separation or divorce when those marital statuses are selected.

Boxes 11 (A-B) Elect or Decline Coverage

Complete appropriate sections. You are entitled to make separate choices regarding your medical, dental and vision coverage (Exception: If you are an enrollee of the Student Employee Health Plan [SEHP], coverage must be the same). You may enroll in or decline any or all three. You may also enroll in Family coverage for one benefit in Individual coverage for another. Reminder: Enrollees with an Employee Benefit Fund (CSEA, DC-37, UCS and UUP) receive their dental and vision benefits through that fund. If you are a member of one of these groups, you may not enroll for NYSHIP dental or vision benefits.

ELECT OR DECLINE COVERAGE Note: If you choose a NYSHIP HMO, the HMO may require you to complete an additional enrollment form.

11.A.1 11.A.2

Pre-Tax Contribution Program (PTCP) Status

New enrollees must make an election (Pre-Tax or After-Tax) for medical coverage. The PTCP applies to all NYS groups and select Participating Employers (PE). If you work for a PE, contact your HBA to learn if your employer participates in the PTCP and if you are eligible to enroll. If you are enrolling after your waiting period or more than 30 days after a qualifying event, you will need to wait until the annual PTCP Election Period (November 1-30) to enroll. Until then, your deductions will be taken out after taxes.

11.B.1 Individual Enrollment Check box to enroll in Individual coverage. Check Medical, Dental and/or Vision boxes for coverage selected.

11.B.2 Family Enrollment Check box to enroll in Family coverage. Check Medical, Dental and/or Vision boxes for coverage selected.

11.B.3 Elect Opt-out Program Coverage (NYS Medical Only)

Check box to enroll in the Opt-out Program. Also complete PS-409, Opt-out Attestation Form.

11.B.4 Decline NYSHIP Coverage Check box to decline coverage. Be sure to check the appropriate boxes for the coverage type declined.

NYS Department of Civil Service Instructions for NYS Health Insurance Transaction Form Albany, NY 12239 PS-404 (9/17)

CHANGE IN COVERAGE OR VOLUNTARILY CANCEL COVERAGE

Box 12.A Change Coverage Check this box to change from Individual to Family or from Family to Individual

coverage. If you are enrolled in PTCP, you may only change coverage from Family to Individual during the annual PTCP Election Period, or with a PTCP qualifying event (check the qualifying event and enter the Date of Event). Check Medical, Dental, and/or Vision boxes for coverage being changed. In the event that you are indicating a change in your marital status to divorced or separated, please update the dependent’s new address, if applicable, in the Dependent Information section (Box 13).

Box 12.B Voluntarily Cancel Coverage

You are entitled to make separate decisions regarding your medical, dental and vision coverage. You may cancel or change your dental and/or vision coverage(s) at any time during the year. If you are enrolled in PTCP, you may only cancel coverage during the annual PTCP Election Period, or with a qualifying event (enter the qualifying event).

DEPENDENT INFORMATION

Box 13 Dependent Information

Check the box to add or delete dependents or to change dependent information. Check Medical, Dental and/or Vision boxes that apply. Complete all dependent information and provide the dependent’s Social Security Number. Additional documentation is required to add the dependent.

ANNUAL OPTION TRANSFER REQUEST(S)

Box 14 Annual Option Transfer Request(s)

Change NYSHIP Option: Complete during annual Option Transfer Period or with a qualifying event (for example, change of address outside of HMO area). Elect Opt-out: Enrollees in the Opt-out Program must reenroll annually during the Option Transfer Period in order to continue to receive incentive payments. Also complete a PS-409, Opt-out Attestation Form. If you are selecting Family Opt-out, you must have been enrolled in NYSHIP Family coverage beginning April 1 of the current plan year. Change Pre-Tax Status: Existing enrollees can only change PTCP status during the annual PTCP Election Period in November.

AUTHORIZATION You must SIGN and DATE this form.

Business Service Center Last Revised: 04/01/2012 Creation Date: 04/01/2012

MetLife Dental Enrollment Form HR-BEN-061

Section 1 - Information and Instructions

The purpose of this form is to enroll or update coverage in the MetLife Dental Plan for employees or dependents. Please note that appropriate supporting documentation must be submitted with the enrollment form. |

Please fax a signed copy of the form to 212-852-8700 or email a signed copy to bscservice@mtabsc.org.

If you have any questions, please contact the Business Service Center BSC at 646-376-0123 or bscservice@mtabsc.org.

Section 2 - Employee Information

Print Name BSC ID Last First M.I. Suffix

Agency/Dept.(check one)

BSC B&T CC HQ Police

Department SIR LIRR MNR MTA Bus

NYCT

MaBSTOA

Street Address

City State Zip Code

Phone (H) Phone (W) E-mail

Managerial/Non-Rep Yes No Agreement – Represented Yes No (If Yes, union code)

Section 3 – Coverage Type

New Enrollment Reinstatement

Change of Status

Add Dependent/Domestic Partner Delete Dependent/Domestic Partner

Section 4 – List of Eligible Dependents

Please list all of your eligible dependents below.

Eligible Dependents

Full Name Effective Date Date of Birth Social Security No.Relationship to Employee (Spouse, Son, Daughter, Domestic Partner)

Section 5 - Authorizations

Signature of authorized employee

Employee Signature SSN Last 4 Digits Date

Section 6 – Waiver of Coverage

I hereby elect to waive coverage. I understand that if, at a later date, I decide I would like to participate in the plan, I may be required to provide medical evidence of good health satisfactory to the carrier. Further, I understand that my participation in the plan would not be effective until approval is received from the carrier.

Employee Signature Date

Enrollment/Change FormPlease print and complete all sections.

See instructions below.Underwritten by Combined Insurance Company of AmericaNew York Residents only: Combined Life Insurance Company of NewYorkThe Certificate of Insurance is on file with your employer. Contact your employer to review a copy of the Certificate.

EMPLOYER INFORMATION: To be Completed by EmployerGroup Number Employer Name Location Code Division Code Client Co Code Effective Date

EMPLOYEE INFORMATION A: Add (enroll) T: Terminate C: Change (change of name, address or phone)ADDTERMCHG

SexM F

Member ID Last Name (Employee or subscriber)

First Name M.I. Date of Birth

Social SecurityNumber

Home Street Address City/State/Zip Home Phone( )

FAMILY INFORMATION (Only those eligible may be enrolled.) A: Add (enroll) T: TerminateC: Change (change of name)

ATC

SexM F

Last Name (spouse) First Name M.I. Date of Birth Social SecurityNumber

ATC

SexM F

Last Name (dependent) First Name M.I. Date of Birth Social SecurityNumber

ATC

SexM F

Last Name (dependent) First Name M.I. Date of Birth Social SecurityNumber

ATC

SexM F

Last Name (dependent) First Name M.I. Date of Birth Social SecurityNumber

ATC

SexM F

Last Name (dependent) First Name M.I. Date of Birth Social SecurityNumber

Employee Signature: Date:

Instructions:

Employer name: Legal name of the employer. Group Number: Provided by EyeMed or EyeMed representative.Location code: Optional field for employers to track multiple locations.Effective date: Date set by employer in accordance with EyeMed proposal. Employer also sets effective date for new adds during contract period.

Family Information: List only eligible family members who are enrolling. Dependent eligibility is the same as employer’s health plan. (A) Add: Open (group) enrollment or new (individual) enrollment during the contract period. (T) Terminate: To terminate enrollment.(C) Change: A change of name, employee address or employee phone.

HR-BEN-062 BSC ID:

Business Service CenterLast Revised: 04/01/2012 Creation Date: 04/01/2012

Basic Life and Basic Accidental Death & Dismemberment InsuranceHR-BEN-063

Section 1 - Information and Instructions

The purpose of this form is to enroll in the MTA Basic Life and Basic Accidental Death & Dismemberment Insurance or to update or change abeneficiary. Beneficiary information can be changed / updated at any time by completing and resubmitting this form with the requestedchanges.

Please fax a signed copy of the form to 212-852-8700 or email a signed copy to bscservice@mtabsc.org.

If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123 or bscservice@mtabsc.org.

Section 2 - Employee Information

Print Name BSC IDLast First M.I. Suffix

Agency/Dept.(check one)

BSC B&T CC HQ Police

Department SIR LIRR MNR MTA Bus

NYCT

MaBSTOA

Street Address

City State Zip Code

Phone (H) Phone (W) Email

Section 3 – Coverage DetailsManagerial Employees: The Metropolitan Transportation Authority provides Basic Accidental Death & Dismemberment Insurance in the amount of two times annual base salary rounded to the next higher $1,000 (if not already a multiple of $1,000) at no cost to you. Coverage maximum is$750,000. Represented Employees: The Metropolitan Transportation Authority provides Basic Accidental Death & Dismemberment Insurance in the amountoutlined in the Collective Bargaining Agreements (CBAs).

Section 4 – Beneficiary Designation for Basic Life

You may designate more than one person as your primary and/or contingent beneficiary. Use a separate sheet if more space is needed.

Check this box if you are changing or revoking your previous beneficiary designation.

A.) Primary Beneficiary(ies):

Name (First, M.I., Last) Date of Birth SSN # Relationship to Employee

Home Address (Street, City, State, Zip)

B.) Contingent Beneficiary(ies):

Name (First, M.I., Last) Date of Birth SSN # Relationship to Employee

Home Address (Street, City, State, Zip)

Section 5 - Authorization

I hereby request coverage under my employer’s Group Basic Life and Group Basic Accidental Death & Dismemberment Plan, as now or hereafter applicable to me.

Signature Date

Dependent Life InsuranceHR-BEN-064

Business Service CenterLast Revised: 04/01/2012 Creation Date: 04/01/2012

Section 1 - Information and InstructionsThe purpose of this form is to enroll or modify an Employee’s Dependent Life Insurance.

It is important to complete all sections of the form. If any relevant information should change, please resubmit this request, highlighting the changes.

Please fax a signed copy of the form to 212-852-8700 or email a signed copy to bscservice@mtabsc.org.

If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123 or bscservice@mtabsc.org.

Section 2 - Agency Information

Print Name BSC IDLast First M.I. Suffix

Agency/Dept.(check one)

BSC B&T CC HQ Police

DepartmentSIR LIRR MNR MTA Bus

NYCTMaBSTOA

Street Address

City State Zip Code

Phone (W) E-mail

Co

Section 3 – Enrollment or Change in Coverage

The Metropolitan Transportation Authority provides basic Dependent Life Insurance coverage in the amount of $5,000 for your spouse and $1,000for each dependent child at no cost to the employee. You can purchase additional dependent life insurance protection for your eligible dependentsas indicated below.

Option 1: Additional $5,000 spousal and $1,000 per child coverage. Total coverage: $10,000 spouse; $2,000/child

Option 2: Additional $10,000 spousal and $2,000 per child coverage. Total coverage: $15,000 spouse; $3,000/child

Option 3: Additional $15,000 spousal and $3,000 per child coverage. Total coverage: $20,000 spouse; $4,000/child

Option 4: Additional $20,000 spousal and $4,000 per child coverage. Total coverage: $25,000 spouse; $5,000/child

Check this box if you are changing or revoking your previous election.

Section 4 – List Dependent to be Covered

Full Name Relationship Social Security # Birth Date

Dependent Life InsuranceHR-BEN-064

Business Service CenterLast Revised: 04/01/2012 Creation Date: 04/01/2012

Section 5 – Beneficiary Information

You are automatically the beneficiary under the Dependent Life Insurance Plan, unless otherwise indicated below. (You may designate more than one person as your primary and/or contingent beneficiary. (Use a separate sheet if more space is needed)

Check this box if you are changing or revoking your previous beneficiary designation

A) Primary Beneficiary (ies): (In the column entitled “%” indicate the percent of benefits for beneficiary)

Full Name % Date Of Birth Social Security # Relationship to Employee

Home Address(street, City, State, Zip code)

B) Contingent Beneficiary (ies): In the unfortunate circumstance something happens to the Primary Beneficiary, the contingent beneficiary will receivethe benefits. (In the column entitled “%” indicate the percent of benefits for beneficiary)

Full Name % Date Of Birth Social Security # Relationship to Employee

Home Address(street, City, State, Zip code)

Section 6 – Waiver of Coverage

I hereby elect to waive coverage. I understand that if, at a later date, I decide I would like to participate in the plan, I may be required to provide medical evidence of good health satisfactory to the carrier. Further, I understand that my participation in the plan would not be effective until approval is received from the carrier.

Employee Signature Date

Section 7– Authorization

I hereby request Dependent Life Insurance and authorize my employer to make deductions from my earnings of the required contributions to apply toward the premiums for the insurance provided for in the policy issued to my employer by the carrier. Further, I hereby represent and agree that all answers and statements in this request are full, complete and true to the best of my knowledge and understand that said answers and statements form the basis upon which insurance will be made effective.

Additionally, I understand that if at a later date I decide I would like to increase coverage in the plan, I may be required to provide evidence of goodhealth for each eligible dependent satisfactory to the carrier. Furthermore, I understand that my increase in coverage would not be effective until approval is received from the carrier.

Employee Signature Date

For Payroll Use Only:

Effective Date

DESIGNATION OF BENEFICIARY WITH CONTINGENT BENEFICIARIES

MTA DEFINED BENEFIT

PENSION PLAN

First Name MI Last Name

Social Security Number

Address Apt No.

City State Zip Code

( ) Work Phone Number

( ) Home Phone Number

Employee I.D. Gender

E-mail Address

IMPORTANT INFORMATION REGARDING THIS FORM

If you find this form is not suited to the type of designation you prefer please advise the MTA Defined Benefit Pension Office. In the mean time, for your protection and the protection of your beneficiary(ies), you should make an interim designation using this form.

Attachments to your beneficiary form are unacceptable.

New beneficiary forms filed will supersede any previous designation. Therefore, if you want to add or delete a beneficiary, for example a new child, you must include on the new form all beneficiaries you wish to designate.

This form is for designating beneficiaries who will receive ordinary death benefits, if ordinary death benefits become payable on account of your death. You may not designate beneficiaries to receive accidental death benefits. The beneficiaries who are entitled to receive accidental death benefits are mandated by the MTA Defined Benefit Retirement Program.

The same person or persons cannot be designated as both primary and contingent beneficiaries. We can make payment to a contingent beneficiary(ies) only if all primary beneficiary(ies) die before you do.

If you wish to have these benefits distributed through your estate, you should name "my estate" as beneficiary. Your estate can be named as either primary or contingent beneficiary. However, if you name your estate as a primary beneficiary, you may not name any contingent beneficiary.

If a named beneficiary is a minor at the time of your death his or her benefit will be paid to a duly-appointed guardian.

Do not alter this form or make stipulations. The use of correction fluid or other alterations on the beneficiary form will render the designation invalid.

You cannot provide for payment to a trust if you have executed a trust agreement or have provided for a trust in your will. Your designation should include the name and address of the trustee and the date of the trust agreement or will was executed.

IMPORTANT: Please note that in this type of designation, the trust itself is the beneficiary, NOT the person or persons for whose benefit it was established. If the trust expires or is revoked, its designation as beneficiary is no longer effective.

If more than one beneficiary is named they will share equally unless you indicate percentages for each beneficiary. The total must equal 100%. You may not designate dollar amounts

Unborn children may not be designated as beneficiaries.

Make sure that you:

* Complete all required information

* Sign and date the form

* Have the form notarized, making sure the notary has entered his

or her license expiration date

Mail your completed form to:

MTA Consolidated Pensions

2 Broadway, 10th Floor

New York, NY 10004

2 Broadway, 10th Floor New York, NY 10004

BSC I.D.

Signature: __________________________________ Date: / /

STATE OF

COUNTY OF

On this day of , , personally appeared before me the said , to me known to be the individual described in and who executed the foregoing document, and he (she) duly acknowledged to me that he (she) executed the same, and the statements contained therein are true.

Notary Public or Commissioner of Deeds (If you have an official seal, please affix it)

This form must be signed and notarized to be valid

Designation of Primary Beneficiary

I hereby name the following as beneficiary(ies) to receive any death benefit payable on my behalf. If I have named more than one beneficiary, it is my intention that those living at the time of my death should share equally any benefit payable. I reserve the right to change this designation at any time.

1

2

3

4

1

2

Last Name First Name M.I. Date of Birth

Male

FemaleRelationship (Fill in one circle)

Spouse Parent Child OtherAddress: Street Apt. or Unit# City State Zip

Designation of Contingent Beneficiary

Last Name First Name M.I. Date of Birth

Female

MaleRelationship (Fill in one circle)

Spouse Parent Child OtherAddress: Street Apt. or Unit# City State Zip

Last Name First Name M.I. Date of Birth

Male

Female Spouse Parent Child OtherRelationship (Fill in one circle)

Address: Street Apt. or Unit# City State ZipLast Name First Name M.I. Date of Birth

Male

Female Spouse Parent Child OtherRelationship (Fill in one circle)

Address: Street Apt. or Unit# City State Zip

If all of the above named beneficiaries die before I do, any death benefits payable on my behalf shall be paid to the following. If I have named more than one beneficiary, it is my intention that those living at the time of my death should share any benefit equally. Furthermore, if I should out-live all these beneficiaries, any benefit payable should be paid to my estate or any other beneficiary I name hereafter . I reserve the right to change this designation at any time.

Last Name First Name M.I. Date of Birth

Male

Female Spouse ParentRelationship (Fill in one circle)

Child OtherAddress: Street Apt. or Unit# City State Zip

Last Name First Name M.I. Date of Birth

Male

FemaleRelationship (Fill in one circle)

Spouse Parent Child OtherAddress: Street Apt. or Unit# City State Zip