Beneficiary/ies
Maximum number of beneficiaries is four (4) with total allocation of 100%.
Insured Name*
First Name Last Name
1. Beneficiary Name*
First Name Middle Name Last Name Suffix
Date of Birth*
Month Day Year
Date
Gender*
Male Female
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Relationship to the Insured*
Allocation*
Total Allocation 100%
Add Beneficiary 2?
YES NO
2. Beneficiary Name*
First Name Middle Name Last Name Suffix
Date of Birth*
Month Day Year
Date
Gender*
Male Female
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Relationship to the Insured*
Allocation*
Total Allocation 100%
Add Beneficiary 3?
YES NO
3. Beneficiary Name*
First Name Middle Name Last Name Suffix
Date of Birth*
Month Day Year
Date
Gender*
Male Female
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Relationship to the Insured*
Allocation*
Total Allocation 100%
Add Beneficiary 4?
YES NO
4. Beneficiary Name*
First Name Middle Name Last Name Suffix
Date of Birth*
Month Day Year
Date
Gender*
Male Female
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Relationship to the Insured*
Allocation*
Total Allocation 100%
TOTAL
Should be Empty:

Beneficiary/ies