Please Complete the Following Information (PLEASE PRINT OR TYPE)

Change of Beneficiary Form

Please complete the following information (PLEASE PRINT OR TYPE):

Name: / TUID:
Group Term Life Insurance Accidental Death and Dismemberment
Effective date of change:

I designate the beneficiary/beneficiaries shown below to receive all sums due on account of my death under the Group Term Life Insurance policy and/or Accidental Death and Dismemberment policy provided by Temple University (Please note: you must select at least one primary designation. If you designate more than one primary beneficiary, all sums due will be divided equally among surviving primary beneficiaries unless otherwise specified below):

Name / Relationship
Primary designation:
Contingent designation:

Signature Date Signed

Forms should be scanned and emailed to , faxed to 215-926-2288, or returned to:

Revised 2/18/2010

Mailing Address:

Temple University Human Resources

Benefits Department

TASB (083-39)

1852 N. 10th Street

Philadelphia, PA 19122

Physical Address:

Temple University Human Resources

Benefits Department

1st Floor

2450 W Hunting Park Avenue

Philadelphia, PA 19129

Revised 2/18/2010