Beneficiary Designation Form

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Beneficiary Designation Form

CATASTROPHIC ACCIDENT COVERAGE · PAID IN FULL BY LASPA

Your coverage is already in force and costs you nothing — LASPA pays the entire premium. This form does not enroll you and it is not required for coverage. It tells LASPA who should receive your benefit if you die as the result of a covered accident. If you do not complete this form, benefits are paid to your estate under the terms of the certificate, which can delay payment to your family.

Please complete the following form.

SECTION 1 — MEMBER INFORMATION

All fields required.

Full Legal Name(Required)

First Last

Employee ID Number(Required)

Email(Required)

Phone(Required)

Country Phone Number

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

SECTION 2 — PRIMARY BENEFICIARY

Shares must total 100%.
If you name more than one person, write the percentage each should receive. If you name only one person, write 100%.

Beneficiary 1

Name(Required)

First Last

Relationship(Required)

Date of Birth(Required)

Phone(Required)

Country Phone Number

Share %

Beneficiary 2

Name

First Last

Relationship

Date of Birth

Phone

Country Phone Number

Share %

Beneficiary 3

Name

First Last

Relationship

Date of Birth

Phone

Country Phone Number

Share %

SECTION 3 — CONTINGENT BENEFICIARY

Optional — paid only if no primary beneficiary survives.

Beneficiary 1

Name

First Last

Relationship

Date of Birth

Phone

Country Phone Number

Share %

Beneficiary 2

Name

First Last

Relationship

Date of Birth

Phone

Country Phone Number

Share %

SECTION 4 — MEMBER SIGNATURE

Required

I designate the person or persons named above to receive any benefit payable at my death under the group accident coverage provided to me through the Los Angeles Sheriff’s Professional Association. This designation replaces any prior designation I have made under this coverage. I understand that LASPA maintains this form and provides it to the plan administrator when a claim is filed, and that a later signed form replaces this one.

Electronic Signature (Type Your Full Name)(Required)

First Last

Date(Required)

Employee ID Number(Required)

WHAT YOU SHOULD KNOW BEFORE YOU SIGN

This form does not create or change your coverage. Every LASPA member is covered, and LASPA pays the entire premium. This form only records who receives the benefit.

If you never complete this form, the benefit is still payable. The certificate issued by Federal Life Insurance Company provides:

“Any unassigned benefits that have not been paid at the time of Your death will be paid to Your designated beneficiary, if living, or to the contingent beneficiary. If no such designation is made, or in the event of death of both the beneficiary and contingent beneficiary, benefits will be paid to Your estate.”

Payment through an estate generally takes longer and may require probate or a small-estate affidavit. Naming a person on this form is the faster path for your family.

Do not write Social Security numbers on this form. If a claim is filed, the plan administrator will collect the beneficiary’s Social Security number directly at that time.

Keep it current. Marriage, divorce, a birth, or a death is the time to submit a new form. The most recent signed form on file controls. Verbal changes are not accepted.

This coverage is accident coverage. It pays on a covered accidental death or a covered catastrophic injury. It is not life insurance and does not pay on death from illness. Coverage is for the member only; spouses and children are not covered under this plan. The certificate of coverage, including the full list of exclusions, is available from the LASPA office.