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Beneficiary Designation Summary Catherin Curry On 7/28/2009 you indicated that you are not married. If your marital status has changed, please carefully review and update your beneficiary designations.
Today is: 7/28/2009 10:03:05 AM
The beneficiaries shown below are designated to ALL of the following benefits: Group Life Insurance Group Accidental Death and Dismemberment (AD & D) • Payroll Due After Death • One Month's Pay Death Benefit • Employees' Retirement Plan * • Short Term Disability • •
Beneficiaries: Subject to the terms and conditions of each of the benefits listed on this form, I request that any su my death be payable to the named beneficiary(ies). I understand and intend that this designation s previous designations of beneficiary made by me for these benefits. If percent is blank, equal percents will be payable to each Primary Beneficiary totaling 100% and eq Contingent Beneficiary totaling 100%. Beneficiary Name Edit William R. Puckett
Address 16701 NE 9th Avenue
*Important: • If you are not married at the time you execute this form, please be aware that this form will automatically cease to apply
on the date you marry and your spouse will be entitled to your entire Employees' Retirement Plan benefit upon your death
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