CHUBB TRAVEL ACCIDENT INSURANCE
BENEFICIARY DESIGNATION REQUEST
FEDERAL INSURANCE COMPANY (the "Company")
INSTRUCTIONS: Complete this form and retain a copy with your important papers.
Indicate: ________ Original Designation
________ Change of Beneficiary
Policyholder: ________________________________
CHEIBA/Colorado School of Mines
Policy Number: _____________________
9906-91-71
_______________________________________________________________________________________
Name of Insured
Social Security Number
_______________________________________________________________________________________
Address
City
State
Zip Code
Hereby revoking any and all previous designations, I designate the person(s) on this form as my
Beneficiary(ies) to receive any payment from the policy or certificate number shown above. I fully
understand that this designation of Beneficiary(ies) only applies to the full Accidental Loss of Life Benefit
Amount that is in force.
Date:_____________________
Insured's Signature:_______________________________
__________% _______________________________________________________________________
Name of Beneficiary
Relationship
______________________________________________________________________
Address
City
State
Zip Code
__________%
______________________________________________________________________
Name of Beneficiary
Relationship
______________________________________________________________________
Address
City
State
Zip Code
__________%
______________________________________________________________________
Name of Beneficiary
Relationship
______________________________________________________________________
Address
City
State
Zip Code
__________%
______________________________________________________________________
Name of Beneficiary
Relationship
______________________________________________________________________
Address
City
State
Zip Code
44-10-0345 (Ed. 9/97)
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Original - Policyholder
Copy - Insured Person