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    Nomination of Beneficiaries

    Uploaded by

    On'na Shikyō

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Nomination of Beneficiaries

    Uploaded by

    On'na Shikyō
    3 views1 page

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3 views1 page

    Nomination of Beneficiaries

    Uploaded by

    On'na Shikyō

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    NOMINATION OF BENEFICIARIES

    This form supercedes all previous nominations and should be completed and signed by the insured employee. For your convenience
    you can save data typed into this form before printing and signing it. If you choose to complete this form in handwriting please use
    BLOCK CAPITALS.

    THE LIST OF BENEFICIARIES MAY BE AMENDED AT ANY TIME. ANY CHANGE MUST BE NOTIFIED TO US IN WRITING AS SOON AS POSSIBLE.

    Unless otherwise specified in this form, the beneficiary/beneficiaries of an insured employee’s Life/Accidental Death policy shall be:
    (i) His/her spouse or legally declared civil partner at the time of death. Failing him/her,
    (ii) His/her legally declared children, including adopted children, in equal shares. Failing them,
    (iii) His/her estate.
    If you are unsure about the status of your nomination please complete and return this form.

    INSURED EMPLOYEE DETAILS


    First name
    Surname
    Address

    Date of birth
    D D / M M / Y Y Y Y Policy number (if known)
    Telephone number (incl. country code)
    Email
    Company name

    BENEFICIARY DETAILS
    Beneficiary 1 Beneficiary 2 Beneficiary 3 Beneficiary 4
    First name
    Maiden Name (if applicable)
    Surname
    Address

    Email address
    Date of birth (dd/mm/yy)
    Place of birth
    Percentage share allocated * % % % %
    * Please note the percentage share allocated to all beneficiaries should not exceed 100%. If you wish to nominate more than four beneficiaries please use an
    additional form. In the event that a named beneficiary dies first, their share will be transferred to the remaining surviving beneficiaries in accordance with the
    percentage share allocated. If no beneficiaries survive, the life benefit shall be paid to your estate according to the policy wording.
    Benefits paid may be subject to tax and the beneficiaries are advised to contact their relevant authority to settle any appropriate taxes.

    I hereby designate the aforementioned beneficiary/beneficiaries to receive any applicable benefits payable under my Life/Accidental Death policy upon my death.

    Signature of insured employee


    Date D D / M M / Y Y Y Y

    Please complete, sign and return this form to:


    Email: [email protected] or
    Fax: +353 1 517 6985 or
    Post: Life, Accident & Disability Team, Allianz Care, 15 Joyce Way,
    Park West Business Campus, Nangor Road, Dublin 12, Ireland
    FRM-LDADD-NB-EN-1018

    AWP Health & Life SA, acting through its Irish Branch, is a limited company governed by the French Insurance Code.
    Registered in France No. 401 154 679 RCS Bobigny. Irish Branch registered in the Irish Companies Registration Office,
    registered No.: 907619, address: 15 Joyce Way, Park West Business Campus, Nangor Road, Dublin 12, Ireland. Allianz Care
    and Allianz Partners are registered business names of AWP Health & Life SA.

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