In the event of my death, I designate the following person(s) to receive the proceeds from my Basic Life Insurance (and Accidental Death & Dismemberment Insurance Plan, if applicable). If my beneficiary predeceases me and no new beneficiary is designated, the proceeds from my life/accident insurance plans will be paid to my survivors according to applicable state laws.
PRIMARY BENEFICIARY
_____ %Name / Date of Birth / Soc. Sec. No. / Relationship
_____ %
Name / Date of Birth / Soc. Sec. No. / Relationship
_____ %
Name / Date of Birth / Soc. Sec. No. / Relationship
_____ %
Name / Date of Birth / Soc. Sec. No. / Relationship
_____ %
Name / Date of Birth / Soc. Sec. No. / Relationship
CONTINGENT (SECONDARY) BENEFICIARY (Person(s) to receive benefits if the primary beneficiary(s) is also deceased.)
____ %Name / Soc. Sec. No. / Date of Birth / Relationship
____ %
Name / Soc. Sec. No. / Date of Birth / Relationship
____ %
Name / Soc. Sec. No. / Date of Birth / Relationship
____ %
Name / Soc. Sec. No. / Date of Birth / Relationship
Beneficiaries will receive equal shares unless you indicate differently.
If you want to make other beneficiary designations other than this form will allow, please attach a separate sheet.
Employee’s Printed Name Soc. Sec. No. EMPLOYEE’S SIGNATURE Date
PLEASE RETURN THIS FORM TO:
Kinder Morgan, Inc.
Attn: Benefits
1001 Louisiana Street, Suite 1000
Houston, TX 77002
HR009 Beneficiary Designation Form Revised: 01/13