UCI

SA 4805-GA (3-2004) Supersedes (7-2003) issue

Instructions for Beneficiary Designation Change Form (SA4805-GA)

*SCROLL DOWN FOR FORM.*

**IMPORTANT: Beneficiary changes will NOT go into effect until signed by
the employee and a witness (non-family/ non-beneficiary), and with the
original returned to the Benefits office (MS-1021).**

1.  Complete the form with your name, social security number,
    beneficiary(ies) and check the appropriate Plan(s).

2.  See the examples below, which may help you in completing the
    beneficiary section.

3.  The witness must be a Non-Family member and also someone who will
    not be receiving any of the benefit.

4.  The Plan called "Retirement Income/Pension Security Plan" applies
    only to those employees who were employed prior to 7/1/75 and
    contributed to the pension plan.

  ---------- -------------------------------------------------------------
  For        The beneficiary designation on your Basic Group Life
  Retirees   Insurance **G-90373** is a "Qualified Family Member" defined
  Only:      as a spouse that you have been married to for one year or
             more; a [dependent]{.underline} child; or a
             [dependent]{.underline} parent. If there is no "Qualified
             Family Member," then \$500 is paid to your estate. **THIS
             DESIGNATION CANNOT BE CHANGED.**

  ---------- -------------------------------------------------------------

5.  Please check the internal web under **"Your Benefits"** for a list
    of your current coverages.

```{=html}
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```
A.  This form applies ONLY to the Company paid Basic Group Life
    insurance and Basic Supplemental Group Life insurance.

B.  If you have VTL (Voluntary Term Life), a beneficiary change form (SF
    4400-VTL) is available on the web.

C.  If you have VGA (Voluntary Group Accident), please contact Benefits
    Customer Service at 845-2363 for a beneficiary change card.

```{=html}
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```
6.  To change beneficiaries on your Saving Plan (401K) see the form on
    the web or contact Courtney Woods at 284-5830, Dave Medina at
    844-0997, or Benefits Customer Service at 845-2363 for a beneficiary
    change form (SF 4400-PBD).

7.  Be sure to make a copy of the beneficiary change forms (and don't
    forget to file them with your other legal documents) before you
    return them to Benefits MS-1021.

**Examples:**

+---+---+-------------------------+---+---+--------------------+------+
| 1 | U |                         |   |   |                    |      |
| \ | s |                         |   |   |                    |      |
| . | e |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | w |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | " |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | " |                         |   |   |                    |      |
|   | b |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | m |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | p |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | w |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | b |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | w |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | p |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | c |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | g |                         |   |   |                    |      |
|   | b |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | c |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | y |                         |   |   |                    |      |
|   | . |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | John Doe                | M |   | > son              |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | and Mary Doe            | M |   | > daughter         |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | and Sue Smith           | M |   | > daughter         |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
| 2 | U |                         |   |   |                    |      |
| \ | s |                         |   |   |                    |      |
| . | e |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | w |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | " |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | w |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | " |                         |   |   |                    |      |
|   | b |                         |   |   |                    |      |
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|   | f |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
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|   | n |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | m |                         |   |   |                    |      |
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|   | o |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
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|   | h |                         |   |   |                    |      |
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|   | c |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
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|   | g |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | b |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | c |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | y |                         |   |   |                    |      |
|   | , |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | . |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | . |                         |   |   |                    |      |
|   | , |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | p |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | w |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | c |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | v |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | b |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | l |                         |   |   |                    |      |
|   | y |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | p |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | c |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | g |                         |   |   |                    |      |
|   | b |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | c |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | y |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | c |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | . |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | Mary Doe                | M |   | > wife             |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | otherwise John Doe      | M |   | > son              |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | and Jane Doe            | M |   | > daughter         |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | otherwise Robert Doe    | M |   | > cousin           |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
| 3 | C |                         |   |   |                    |      |
| \ | h |                         |   |   |                    |      |
| . | i |                         |   |   |                    |      |
|   | l |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | u |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | 1 |                         |   |   |                    |      |
|   | 8 |                         |   |   |                    |      |
|   | c |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | b |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | p |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | b |                         |   |   |                    |      |
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|   | n |                         |   |   |                    |      |
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|   | y |                         |   |   |                    |      |
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|   | n |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | l |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | c |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | u |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | p |                         |   |   |                    |      |
|   | p |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
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|   | d |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
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|   | r |                         |   |   |                    |      |
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|   | a |                         |   |   |                    |      |
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|   | a |                         |   |   |                    |      |
|   | l |                         |   |   |                    |      |
|   | m |                         |   |   |                    |      |
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|   | u |                         |   |   |                    |      |
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|   | t |                         |   |   |                    |      |
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|   | h |                         |   |   |                    |      |
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|   | d |                         |   |   |                    |      |
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|   | c |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | 1 |                         |   |   |                    |      |
|   | 8 |                         |   |   |                    |      |
|   | . |                         |   |   |                    |      |
|   | I |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
|   | y |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | u |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
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|   | d |                         |   |   |                    |      |
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|   | u |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | c |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | l |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | , |                         |   |   |                    |      |
|   | p |                         |   |   |                    |      |
|   | l |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | l |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | v |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | u |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | l |                         |   |   |                    |      |
|   | l |                         |   |   |                    |      |
|   | y |                         |   |   |                    |      |
|   | . |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | John Doe                | M |   | > Son              |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | Mary Doe                | M |   | > Daughter         |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | Sue Doe                 | M |   | > Daughter         |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
| 4 | S |                         |   |   |                    |      |
| \ | h |                         |   |   |                    |      |
| . | o |                         |   |   |                    |      |
|   | w |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
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|   | f |                         |   |   |                    |      |
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|   | h |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
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|   | u |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | g |                         |   |   |                    |      |
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|   | m |                         |   |   |                    |      |
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|   | n |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | w |                         |   |   |                    |      |
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|   | l |                         |   |   |                    |      |
|   | l |                         |   |   |                    |      |
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|   | s |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
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|   | n |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
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|   | e |                         |   |   |                    |      |
|   | ( |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | ) |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
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|   | t |                         |   |   |                    |      |
|   | h |                         |   |   |                    |      |
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|   | T |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | u |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
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|   | e |                         |   |   |                    |      |
|   | ( |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | ) |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | f |                         |   |   |                    |      |
|   | y |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | u |                         |   |   |                    |      |
|   | w |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | d |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | g |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | e |                         |   |   |                    |      |
|   | y |                         |   |   |                    |      |
|   | o |                         |   |   |                    |      |
|   | u |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | * |                         |   |   |                    |      |
|   | L |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | v |                         |   |   |                    |      |
|   | i |                         |   |   |                    |      |
|   | n |                         |   |   |                    |      |
|   | g |                         |   |   |                    |      |
|   | T |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
|   | u |                         |   |   |                    |      |
|   | s |                         |   |   |                    |      |
|   | t |                         |   |   |                    |      |
|   | . |                         |   |   |                    |      |
|   | * |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | First Bank, Town,       | M |   | > living trust     |      |
|   |   | State,                  | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | Trustee under Trust     | M |   | > living children  |      |
|   |   | Agreement               | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | dated Month Day Year    | M |   | > mother           |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   | o |                         |   |   |                    |      |
|   | r |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | John Doe and Mary       | M |   | > living trust     |      |
|   |   | Jones,                  | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | Trustee under Trust     |   |   |                    |      |
|   |   | Agreement               |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   | dated Month Day Year    |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
| 5 | S |                         |   |   |                    |      |
| \ | h |                         |   |   |                    |      |
| . | o |                         |   |   |                    |      |
|   | w |                         |   |   |                    |      |
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|   | . |                         |   |   |                    |      |
|   | * |                         |   |   |                    |      |
|   | D |                         |   |   |                    |      |
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|   | n |                         |   |   |                    |      |
|   | a |                         |   |   |                    |      |
|   | m |                         |   |   |                    |      |
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|   | . |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         | M |   | > testamentary     |      |
|   |   |                         | y |   | > trust            |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
| 6 | W |                         |   |   |                    |      |
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+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         | M |   | > estate           |      |
|   |   |                         | y |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
|   |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+
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| i |   |                         |   |   |                    |      |
| n |   |                         |   |   |                    |      |
| d |   |                         |   |   |                    |      |
| t |   |                         |   |   |                    |      |
| o |   |                         |   |   |                    |      |
| t |   |                         |   |   |                    |      |
| h |   |                         |   |   |                    |      |
| e |   |                         |   |   |                    |      |
| p |   |                         |   |   |                    |      |
| l |   |                         |   |   |                    |      |
| a |   |                         |   |   |                    |      |
| n |   |                         |   |   |                    |      |
| a |   |                         |   |   |                    |      |
| d |   |                         |   |   |                    |      |
| m |   |                         |   |   |                    |      |
| i |   |                         |   |   |                    |      |
| n |   |                         |   |   |                    |      |
| i |   |                         |   |   |                    |      |
| s |   |                         |   |   |                    |      |
| t |   |                         |   |   |                    |      |
| r |   |                         |   |   |                    |      |
| a |   |                         |   |   |                    |      |
| t |   |                         |   |   |                    |      |
| o |   |                         |   |   |                    |      |
| r |   |                         |   |   |                    |      |
| . |   |                         |   |   |                    |      |
+---+---+-------------------------+---+---+--------------------+------+

**UCI**

**UCI**

SA 4805-GA (3-2004) Supersedes (7-2003) issue

![](media/image1.png){width="2.7506944444444446in"
height="0.42986111111111114in"} **BENEFICIARY DESIGNATION CHANGE FORM**

**BENEFITS ADMINISTRATION AND SERVICES ORG.**

  ---------- ------------ ----------- --------- -- --------------- ---------------- ----------- --------- ----------- --
                                                   **NAME CHANGE                                                      
                                                   ONLY**                                                             

  NAME       **     **    **     **   **   **      **If you have                                                      
                                                   changed your                                                       
                                                   name, list                                                         
                                                   below the name                                                     
                                                   you used                                                           
                                                   previously:**                                                      

             (Last Name,                                                                                              
             First Name,                                                                                              
             Middle                                                                                                   
             Initial)                                                                                                 

                                                                                                                      

  Social                  **     **                                **     **        **     **             **     **   
  Security                                                                                                            
  Number                                                                                                              

                                                                   Last Name        First Name  Middle                
                                                                                                Initial               
  ---------- ------------ ----------- --------- -- --------------- ---------------- ----------- --------- ----------- --

  ---------------- -------------------------------------------------------------------
  When changing    
  beneficiaries,   
  please note the  
  following:       

                   

  1\.              Write the beneficiary's name like this -- Mary A. Doe -- not like
                   this -- Mrs. John Doe

                   

  2\.              **If you name a beneficiary who is not a member of your family,
                   please indicate the person's social security number and address.**

                   

  3\.              Remember that if you name several people as primary (or contingent)
                   beneficiaries, they will share equally unless you specifically
                   indicate differently in the percentage column. Please indicate the
                   percentage you wish to go to each beneficiary.
  ---------------- -------------------------------------------------------------------

+---+-------------+-----------+---+--------------------------+---+---------+---+
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| o |             |           |   |                          |   |         |   |
| w |             |           |   |                          |   |         |   |
| i |             |           |   |                          |   |         |   |
| n |             |           |   |                          |   |         |   |
| g |             |           |   |                          |   |         |   |
| n |             |           |   |                          |   |         |   |
| a |             |           |   |                          |   |         |   |
| m |             |           |   |                          |   |         |   |
| e |             |           |   |                          |   |         |   |
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| i |             |           |   |                          |   |         |   |
| n |             |           |   |                          |   |         |   |
| d |             |           |   |                          |   |         |   |
| i |             |           |   |                          |   |         |   |
| v |             |           |   |                          |   |         |   |
| i |             |           |   |                          |   |         |   |
| d |             |           |   |                          |   |         |   |
| u |             |           |   |                          |   |         |   |
| a |             |           |   |                          |   |         |   |
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| : |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   | **Primary   |           |   | **Relationship to me**   |   | **%**   |   |
|   | Benefic     |           |   |                          |   |         |   |
|   | iary(ies)** |           |   | **     **                |   | **   ** |   |
|   |             |           |   |                          |   |         |   |
|   | **     **   |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   | **     **   |           |   | **     **                |   | **   ** |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   | **     **   |           |   | **     **                |   | **   ** |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   | **     **   |           |   | **     **                |   | **   ** |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   | **     **   |           |   | **     **                |   | **   ** |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   | *           |           |   | **Relationship to me**   |   | **%**   |   |
|   | *Contingent |           |   |                          |   |         |   |
|   | Benefic     |           |   | **     **                |   | **   ** |   |
|   | iary(ies)** |           |   |                          |   |         |   |
|   |             |           |   |                          |   |         |   |
|   | **     **   |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   | **     **   |           |   | **     **                |   | **   ** |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   | **     **   |           |   | **     **                |   | **   ** |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   | **     **   |           |   | **     **                |   | **   ** |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   | **     **   |           |   | **     **                |   | **   ** |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
| P |             |           |   |                          |   |         |   |
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| p |             |           |   |                          |   |         |   |
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| e |             |           |   |                          |   |         |   |
| q |             |           |   |                          |   |         |   |
| u |             |           |   |                          |   |         |   |
| e |             |           |   |                          |   |         |   |
| s |             |           |   |                          |   |         |   |
| t |             |           |   |                          |   |         |   |
| a |             |           |   |                          |   |         |   |
| d |             |           |   |                          |   |         |   |
| d |             |           |   |                          |   |         |   |
| i |             |           |   |                          |   |         |   |
| t |             |           |   |                          |   |         |   |
| i |             |           |   |                          |   |         |   |
| o |             |           |   |                          |   |         |   |
| n |             |           |   |                          |   |         |   |
| a |             |           |   |                          |   |         |   |
| l |             |           |   |                          |   |         |   |
| f |             |           |   |                          |   |         |   |
| o |             |           |   |                          |   |         |   |
| r |             |           |   |                          |   |         |   |
| m |             |           |   |                          |   |         |   |
| s |             |           |   |                          |   |         |   |
| . |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             | Basic     |   |                          |   |         |   |
|   |             | Group     |   |                          |   |         |   |
|   |             | Life      |   |                          |   |         |   |
|   |             | Insurance |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
|   |             | Basic     |   |                          |   |         |   |
|   |             | Sup       |   |                          |   |         |   |
|   |             | plemental |   |                          |   |         |   |
|   |             | Group     |   |                          |   |         |   |
|   |             | Life      |   |                          |   |         |   |
|   |             | Insurance |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+
| I |             |           |   |                          |   |         |   |
| f |             | Cont      |   |                          |   |         |   |
| e |             | ributions |   |                          |   |         |   |
| m |             | from the  |   |                          |   |         |   |
| p |             | R         |   |                          |   |         |   |
| l |             | etirement |   |                          |   |         |   |
| o |             | Income    |   |                          |   |         |   |
| y |             | Plan or   |   |                          |   |         |   |
| e |             | Pension   |   |                          |   |         |   |
| d |             | Security  |   |                          |   |         |   |
| p |             | Plan      |   |                          |   |         |   |
| r |             |           |   |                          |   |         |   |
| i |             |           |   |                          |   |         |   |
| o |             |           |   |                          |   |         |   |
| r |             |           |   |                          |   |         |   |
| t |             |           |   |                          |   |         |   |
| o |             |           |   |                          |   |         |   |
| 7 |             |           |   |                          |   |         |   |
| / |             |           |   |                          |   |         |   |
| 1 |             |           |   |                          |   |         |   |
| / |             |           |   |                          |   |         |   |
| 7 |             |           |   |                          |   |         |   |
| 5 |             |           |   |                          |   |         |   |
+---+-------------+-----------+---+--------------------------+---+---------+---+

<table style="width:100%;">
<colgroup>
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 35%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 18%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Dated at</td>
<td colspan="2"><strong>     </strong></td>
<td>this</td>
<td><strong>     </strong></td>
<td>day of</td>
<td><strong>     </strong></td>
<td>,</td>
<td><strong>     </strong></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">(City, State)</td>
<td></td>
<td>(Day)</td>
<td></td>
<td>(Month)</td>
<td></td>
<td>(Year)</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td><p>Full Signature of Witness</p>
<p>(Non-Relative or Non-Beneficiary)</p></td>
<td></td>
<td colspan="6">Full Signature of Employee</td>
</tr>
</tbody>
</table>

**Return the original to Benefits Organization, Mail Stop 1021**

# UCI