Employee Beneficiary Form for Life Insurance

Employee Information

Note: the accompanying instructions are an integral part of this form and you should use them to assist you

Emp #: ______________ Name: ____________________ Designation ___________________________

School: ___________________________________Campus:___________________________________

Region:_________________Area:______________________D.O.J_____________________________

Marital Status:  Single  Married

Primary Beneficiary

Name of beneficiary: ___________________________________________________________________

Relationship: _________________________________________________________________________

CNIC Number: _____________________________ Contact No.: ______________________________

Address: __________________________________________________________________________

Contingent Beneficiary

In the event that there is no living primary beneficiary at my death, I hereby designate the following person as
contingent beneficiary:

Name of beneficiary: ___________________________________________________________________

Relationship: __________________________________________________________________________

CNIC Number: _________________________________Contact No.: ______________________________

Address: __________________________________________________________________________

Signature

I hereby nominate the person mentioned above who are members of my family to receive the assured sum in the
event of my death under group term life insurance.
I also declare that the above information is correct to my knowledge and I agree to the terms and conditions of
the organization:

Employee: __________________________________ Date: ______________

Note: Please attach one copy of CNIC for each beneficiary