
SAMPLESOFBENEFICIARYDESIGNATIONS:Belowareexamplesofsomecommonbeneficiarydesignationsthatmaybehelpfulas
youcompletethisform.
1. Specificunequalshares
(NOTE:Insert“PerStirpes”after%tohaveanyBenefitsdueanydeceasedbeneficiarypayableto
his/herdescendents)
Class/Share
BeneficiaryName
JohnJ.Smith
Relationship
toInsured
Brother
(First) (Middle) (Last)
Address
15BayRidgeBoulevardSmithvilleAK99999‐1111
(Street) (City)(State) (Zip)
DateofBirth
11/15/1974 SocialSecurityNumber 123–45–6789 PhoneNumber (111)234‐5678
Primary
Contingent
__60%___
Perstirpes
(MM/DD/YYYY)(AreaCode)(Number)
□Address/PhonesameasInsuredMember
BeneficiaryName
AntoinetteDuboisJones
Relationship
toInsured
Sister
(First) (Middle) (Last)
Address
2201‐1870SouthwestThirdAvenue OceanCity KS 11111‐2222
(Street) (City)(State) (Zip)
DateofBirth
5/7/1979 SocialSecurityNumber 987–65–4321 PhoneNumbe
(999)876‐5432
Primary
Contingent
__40%___
Perstirpes
(MM/DD/YYYY)(AreaCode)(Number)
□Address/PhonesameasInsuredMember
2. TrustasBeneficiary:
“John Smith and Mary Jones as Trustees of the Jones Family Trust under the Trust document dated December 1, 2012.”
[PleaseprovideIdentifyingInformationforallTrustees.]
3. MinorBeneficiary‐UniformTransfers/GiftstoMinorsAct(UTMA/UGMA)Designation:
“[Name of Adult] as Custodian for [Name of Minor] under [Insured Member’s or Minor’s State of Residence] Uniform
Transfers/GiftstoMinorsAct.”[PleaseprovideIdentifyingInformationfortheminorandadultCustodian.]
NOTICEREGARDINGDESIGNATINGAMINORBENEFICIARY
Unless a UTMA/UGMA designation is used, or there is an existing court appointed guardian of the minor’s estate who can make
financialdecisionsfortheminor,aclaimspaymenttoaminormaybedelayeduntilasurvivingparent,relative,orotherinterested
partyobtainsacourtappointmentasfinancialguardianoftheminor’sestate,forthepurposeofreceivingtheproceedsonbehalfof
thechild.
NOTICEREGARDINGTESTAMENTARYTRUSTUNDERLASTWILLANDTESTAMENTASBENEFICIARY
ThefollowingisunderstoodandagreedwhennamingaTestamentaryTrustundertheLastWillandTestamentasbeneficiary ofa
specifieddecedent(InsuredMemberornon‐insuredowner).
Proceedsshall be paid tothe named contingentbeneficiaryifthe decedentdies intestate (withouta Last Will and Testament), or
withaLastWillandTestamentbut(1)itdoesnotcreateaTrustandnameaTrusteeor(2)nocourtproceedinghasbeenstartedto
probatetheLastWillandTestamentornoTrusteequalifiesandclaimstheproceedswithin12months(18inMississippi,NewYork,
Texas;6monthsinFloridaandNorthCarolina)afterthedecedent’sdeath.Ifthenamedcontingentbeneficiaryisnotliving,andno
furtherbeneficiaryisnamed,paymentshallbemadeinaccordancewiththeGroupPolicy.
New York Life is not obligated to inquire about the terms of any Trust affecting this policy or its proceeds, and shall not be held
responsibleforknowingthetermsofanysuchTrust.
PaymenttoandreceiptbysaidTrustee(s)oranysuccessorTrustee(s),orpaymenttoand receiptbythecontingentbeneficiary or
insured’sestateshallconstituteafulldischargeandreleasestheNewYorkLifeInsuranceCompanytotheextentofsuchpayment.
ThefulldischargeandreleaseoftheNewYorkLifeInsuranceCompany’sobligationforpaymentappliestoallpersonsandfiduciaries
havinganyinterestinsuchproceeds.
NOTICEREGARDINGNON‐INSUREDOWNER
Anon‐insuredownerwhowishestonameapersonotherthanthemselvesasbeneficiaryshoulddosoonlyafterreceivingadvice
fromtheirCounselastothepossibletaxconsequencesinlightofexisting decisionallawtotheeffectthat,whentheproceedsare
paidtosomeoneotherthanthenon‐insuredowner,theproceedsconstituteataxablegiftfromtheownertothebeneficiaryatthe
timeoftheinsured’sdeath.
*PerStirpes
meansthatanyinterestinalifeinsurancepolicythatadeceasedbeneficiarywouldhave,ifliving,willbesharedequally
byalllivingchildrenofthatdeceasedbeneficiary.
GMADCOBForm200‐2(12/12)