Change Beneficiary(ies) for Retiree/Surviving Dependent Life Policy(ies)

Retiree Information

Effective Date

Primary Beneficiaries

I wish to change my life insurance beneficiary(ies); following is a new list of ALL my beneficiaries. Any previously named beneficiary not listed on this form will be considered to have been removed. Complete all fields for each named beneficiary and indicate the percentage of your life insurance you wish the beneficiary to receive.

Jane Doe (Beneficiary One) - 25% Remove

First Name

Last Name

Address

City

State

Zip Code

Phone

Social Security Number

Relationship

Percent of Benefit
%
Steve Doe (Beneficiary One) - 25% Remove

First Name

Last Name

Address

City

State

Zip Code

Phone

Social Security Number

Relationship

Percent of Benefit
%

Total for primary beneficiary(ies) = 50%

Contingent Beneficiaries

Jane Doe (Beneficiary One) - 30% Remove

First Name

Last Name

Address

City

State

Zip Code

Phone

Social Security Number

Relationship

Percent of Benefit
%
Steve Doe (Beneficiary One) - 30% Remove

First Name

Last Name

Address

City

State

Zip Code

Phone

Social Security Number

Relationship

Percent of Benefit
%

Total for contingent beneficiary(ies) = 50%

A power of attorney must grant specific authority, by the terms of the document or applicable law, to make or change a Beneficiary designation. If you have any questions, please call 1 (800)233-2576.

Declaration and Signature

By selecting the boxes below, I acknowledge that:

Participation in the New Mexico Retiree Health Care Act is subject to specific eligibility requirements and that benefits offered through the New Mexico Retiree Health Care Authority are subject to legal limitations. Ineligible individuals cannot receive benefits through this program and will benefits or services will not exceed legal limitations. Submitting information on this page is only an application for benefits and does not create any contractual relationship or impose any duties on the part of the New Mexico Retiree Health Care Authority. I must comply with all program requirements, including making timely payments, to enroll and participate. I agree that the New Mexico Retiree Health Care Authority may terminate my participation in this program for noncompliance. I have carefully read and understood all statements on this page and included with this submission, approve all indicated changes, and elect the coverages and benefits selected. I am the actual person applying for benefits whose signature appears below or I am signing on another's behalf under a power of attorney. (If I am signing on another's behalf under a power of attorney, I have attached current authorizing documents or ensured that the New Mexico Retiree Health Care Authority has current authorizing documents on file.)

By typing my name in the space provided below, I hereby declare that all the information I have provided in connection with this application is true and complete to the best of my knowledge.

Type full name in the box below

Today's Date

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