Life Insurance Beneficiary Designation

The purpose of this form is to allow you to designate a beneficiary or beneficiaries for any death benefit
which may be payable from the RCCL Life Insurance Plan while you are signed on the ship. If you
would like to change your beneficiary or if the dependant (under age 21) status should change you must
complete and sign a new form.

928569
Unique I.D. # ________________

Insured Person (Employee)

First Name: JOHANN LEONARDO Last Name: COTRINO DIAZ
Street Address: CRA 56 NO. 57B 34 BLOQ 40 APT 202 PABLO VI

Date of Birth:

Postal Code:

Country: COLOMBIA

State: CUNDINAMARCA

Telephone Number: (+57)3222913317

E-Mail Address:

29/08/1980

johleo04@hotmail.com

Primary Beneficiary: __________%

85
First Name:
Street Address:

VIOLA MARIE

Last Name: GUCE BERNARDINO Date of Birth:

19/04/1989

CRA 56 NO 57B 34 BLOQ 40 APT 202 PABLO VI

Postal Code:

State:

Country:

CUNDINAMARCA

Telephone Number: 1- 443-9737129

COLOMBIA
bernardino_viola@yahoo.co

E-Mail Address:

15
Contingent Beneficiary: __________%
First Name:
Street Address:

YOLANDA

Last Name:

DIAZ LOPEZ

Date of Birth:

19/09/1958

CRA 56 NO 57B 34 BLOQ 40 APT 202 PABLO VI

Postal Code:
Telephone Number:

State: CUNDINAMARCA
E-mail Address:
(+57)3013162718

Country: COLOMBIA

yoliwanda@yahoo.com

Please list below dependent children under 21 years of age:

Full Name:

Date of Birth:

Full Name:

Date of Birth:

Full Name:

Date of Birth:

Full Name:

Date of Birth:

Insured persons signature:

Date Signed:

Witness:

Date Signed:

Original should be signed in blue ink: Hiring Partner to send to RCCL Invoicing Clerk
2 signed copies: 1 for Hiring Partner for File; 1 for Employee.