State of Michigan

Civil Service Commission

EMPLOYEE BENEFITS DIVISION

Life Insurance and Accidental Duty Death Beneficiary Designation or Change Form

EMPLOYEE DATA	INSU	FOR HUMAN RESOURCES USE ONLY
Employee I.D. Number

Social Security Number

Deduction Code	Effective Date	Unit Code	Department/Agency
Employee Name (Last, First, M.I.)

Date of Birth

Male

Female
Street Address

City

State

Zip Code

LIFE INSURANCE BENEFICIARY DESIGNATION – Subject to the terms of the Group Policy, I request the following as my designated beneficiary(ies).
Name of Beneficiary

Last	First	M.I.	Related To Me As	Address of Beneficiary	Percent Share If

Not Equal
Contingent Beneficiary (See definition on reverse)

ACCIDENTAL DUTY DEATH BENEFICIARY DESIGNATION – Subject to the terms of the Group Policy, I request the following as my designated beneficiary(ies).
Name of Beneficiary

Last	First	M.I.	Related To Me As	Address of Beneficiary	Percent Share If

Not Equal
Contingent Beneficiary

FOR BOTH LIFE INSURANCE AND ACCIDENTAL DUTY DEATH BENEFICIARY DESIGNATIONS, IF MORE THAN ONE BENEFICIARY IS NAMED, THE BENEFICIARIES SHALL SHARE EQUALLY UNLESS OTHERWISE STATED ABOVE. If any named beneficiary dies before me, the share which that beneficiary would have received shall be payable equally to the remaining designated beneficiary(ies) who survive me unless otherwise stated above. But, if no designated beneficiary survives me, the beneficiary shall be determined as described on the reverse side of this form. This Designation of Beneficiary is subject to change as provided in said Group contract(s).

I have read and agree to the applicable terms and conditions stated on the reverse side of this beneficiary form.
Employee’s Signature	Date
Federal privacy laws and/or state confidentiality requirements protect a portion of this information.

Distribution:	Original to Human Resources

Copy to Employee

INSTRUCTIONS

(PLEASE READ VERY CAREFULLY)

USE THIS FORM IF

You want to designate a different beneficiary from any previous beneficiaries.

Any or all of your previously designated beneficiaries have died.

You get a divorce, and wish to change your beneficiary.

NOTE: Divorce automatically cancels a spouse’s beneficiary designation. If you want to keep your ex-spouse as a beneficiary, you must file a new form with “ex-spouse” or “friend” in the “Related To Me As” column in the designation section.

WHO CAN BE NAMED AS A BENEFICIARY

Any person or institution – except a funeral home.

HOW TO LIST A BENEFICIARY ON THIS FORM

If a married woman is to be named as a beneficiary for Employee Coverage benefits, her full given name should be shown – for example, Mary J. Smith, not Mrs. John H. Smith. Likewise, if the employee is a married woman, she should sign her full given name.

When two or more beneficiaries are named for Employee Coverage benefits and they are not to share equally, the percentage each beneficiary is to receive should be shown. Dollars and cents should not be specified.

IF YOU WANT TO NAME A CONTINGENT BENEFICIARY

An employee may designate a “contingent beneficiary” who should receive Employee Coverage benefits in the event the named beneficiary(ies) die(s) before the employee. Otherwise, if the named beneficiary dies before the employee and no “contingent beneficiary” is named, Employee Coverage benefit amounts will be paid as follows:

First, to the employee’s spouse, if living;

Otherwise, equally to the employee’s natural and adopted child(ren);

Otherwise, equally to the employee’s surviving parents;

Otherwise, equally to the employee’s brother(s) and sister(s);

Otherwise, to the employee’s estate.

ACCIDENTAL DUTY DEATH INSURANCE

Accidental Duty Death Insurance is a benefit for all employees who are eligible for life insurance. The insurance pays $100,000, in addition to the employee’s regular group life insurance, if an employee’s death results from accidental personal injuries arising out of or in the course of state service, and the employee’s death occurs within 180 days of the accident.

Direct any questions and the completed form to your Office of Human Resources.

OFFICE OF HUMAN RESOURCES

When an employee transfers, send this form to the new department.

When an employee retires, send this form to the Retirement System.

Final Compensation Beneficiary Designation

Employee Name:

Employee ID:

Page 2

CS-1781

REV 5/2010

CS-1781 Beneficiary Designation Change.dot

Beneficiary Designation Change

CS-1781

Questions regarding the use of this template may be directed to Janet Keesler, at (517) 335-5584. Questions regarding the beneficiary designation should be directed to your Personnel Office.

Janet Keesler

2012-03-13

Kathy Gilliland

CS_Forms

Susan Kant

Civil Service Commission