UCI

SF 4400-VTL (110-2006) Supersedes (11-05) issue

Instructions for Beneficiary Designation Change Form (SF 4400-VTL)

###### ON ROLL EMPLOYEES

**IMPORTANT: Beneficiary changes will NOT go into effect until signed
and dated by the employee with the original returned to the Benefits
office (MS-1021) or mail to the address at the bottom of the form.**

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

2.  This form applies ONLY to the Voluntary Term Life Insurance. To
    apply for an increase you will also need a Statement of Insurability
    form, which can be obtained from Benefits at 845-2363.

3.  You may have other insurance coverages (e.g. Basic Group Term Life
    and Supplemental Group Life Insurance) and/or VGA (Voluntary Group
    Accident) please check the internal web under \"Your Benefits\" for
    a list of your current coverages.

4.  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.

5.  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.

###### RETIREES

1.  Retirees can cancel their VTL by sending this completed form to the
    Retirement Counselor 1021.

2.  Complete the form with your name, social security number,
    beneficiary(ies) and check the appropriate options.

3.  Retirees are not eligible to increase coverage.

4.  This form applies ONLY to the Voluntary Term Life Insurance.

5.  Coverage for VTL for Retirees terminates at age 65,

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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.

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```
6.  Retirees may contact Benefits Customer Service at 845-2363 to check
    other insurance coverages (e.g., Basic).

**UCI**

**UCI**

SF 4400-VTL (3-2004) Supersedes (7-2003) issue **VOLUNTARY TERM LIFE
INSURANCE PROGRAM**

# FOR EMPLOYEES OF SANDIA CORPORATION

Please contact the Voluntary Term Life Administration Unit at
1-800-843-7724 with questions regarding this form.

<table>
<colgroup>
<col style="width: 5%" />
<col style="width: 14%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 11%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="4"><h3 id="a.-employee-information">A. EMPLOYEE
INFORMATION</h3></td>
<td colspan="9"><h2 id="employee-social">Employee Social </h2>
<p><strong>Security No.      </strong></p></td>
<td colspan="7"><h3 id="policy-no.-96020"> POLICY NO. 96020</h3></td>
</tr>
<tr class="even">
<td colspan="8"><h3 id="employee-name-last">EMPLOYEE NAME LAST</h3>
<p><strong>     </strong></p></td>
<td colspan="7"><h3 id="first">FIRST</h3>
<p><strong>     </strong></p></td>
<td colspan="5"><h3 id="middle">MIDDLE</h3>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="11"><h3 id="street-address">STREET ADDRESS</h3>
<p><strong>     </strong></p></td>
<td colspan="4"><h3 id="apt.">APT.</h3>
<p><strong>     </strong></p></td>
<td colspan="5"><h3 id="date-hired">DATE HIRED</h3>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="5"><p>CITY</p>
<p><strong>     </strong></p></td>
<td colspan="4"><p>STATE</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>ZIP</p>
<p><strong>     </strong></p></td>
<td colspan="5"><p>WORK PHONE</p>
<p>(<strong>     </strong>) <strong>     </strong></p></td>
<td colspan="3"><p>HOME PHONE</p>
<p>(<strong>     </strong>) <strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="15"><strong>B. ACTION</strong></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td rowspan="2"><p>(1) </p>
<p>(2) </p></td>
<td colspan="3"><p>Enroll</p>
<p>(Complete Sections A, B, C, D, &amp; E)</p></td>
<td colspan="4" rowspan="2"><p>(3) </p>
<p>(4) </p></td>
<td colspan="6"><p>Cancel</p>
<p>(Complete Sections A, B, &amp; E)</p></td>
<td colspan="2" rowspan="2"><p>(5) </p>
<p>(6) </p></td>
<td colspan="4"><p>Beneficiary Change</p>
<p>(Complete Sections A, B, D, &amp; E)</p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>Change Coverage Option</p>
<p>(Complete Sections A, B, C, &amp; E)</p></td>
<td colspan="6"><p>Name Change</p>
<p>(Complete Sections A, B, &amp; E)</p></td>
<td colspan="4"><p>Decline Coverage (Waiver)</p>
<p>(Complete Sections A, B, &amp; F)</p></td>
</tr>
<tr class="even">
<td colspan="20"><strong>C. COVERAGE OPTION (Check One)</strong></td>
</tr>
<tr class="odd">
<td colspan="2"> <strong>1 Time Annual Base Pay*</strong></td>
<td colspan="5"> <strong>2 Time Annual Base Pay*</strong></td>
<td colspan="5"> <strong>3 Time Annual Base Pay*</strong></td>
<td colspan="6"> <strong>4 Time Annual Base Pay*</strong></td>
<td colspan="2"> <strong>5 Time Annual Base Pay*</strong></td>
</tr>
<tr class="even">
<td colspan="2"> <strong>6 Time Annual Base Pay*</strong></td>
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="20"><strong>*rounded to the next higher one thousand
dollars</strong></td>
</tr>
<tr class="even">
<td colspan="20"><p>The Voluntary Term Life Insurance Program booklet
contains specific details regarding the Program provisions, including
the effective date of changes in coverage.</p>
<p>I hereby request to be insured under the Voluntary Term Life
Insurance Program as indicated above. I authorize Sandia to deduct the
monthly premium from my pay or benefits.</p>
<p>I understand that if my requested level of coverage is more than
$1,250,000, evidence of my insurability will be required. I also
understand that I may change my coverage option at any time. However, in
order to become insured for a new option, which increases coverage,
evidence of good health, satisfactory to Prudential, must be
provided.</p>
<h4 id="beneficiary-designations">BENEFICIARY DESIGNATIONS</h4>
<p>In accordance with the conditions of the Group Policy issued to
Sandia Corporation for the Voluntary Term Life Insurance Program by
Prudential Life Insurance Company of America, I hereby revoke any
previous designations of primary beneficiary(ies) and designate as
primary beneficiary(ies) and contingent beneficiary(ies) in the event of
my death, the following:</p></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Name (Legal Name)</strong></td>
<td colspan="3"><strong>Relationship</strong></td>
<td colspan="4"><strong>Date of Birth</strong></td>
<td colspan="9"><strong>Address</strong></td>
<td><strong>Share</strong></td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="9"><strong>     </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="9"><strong>     </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="9"><strong>     </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="9"><strong>     </strong></td>
<td><strong>     </strong></td>
</tr>
</tbody>
</table>

In the event all primary beneficiaries predecease me, I designate as
contingent beneficiaries:

CONTINGENT BENEFICIARY DESIGNATION

  ------------------ ----------- ----------- --------------------------- -----------
  **     **          **     **   **     **   **     **                   **     **

  **     **          **     **   **     **   **     **                   **     **

  **     **          **     **   **     **   **     **                   **     **
  ------------------ ----------- ----------- --------------------------- -----------

If additional space is required, please continue on separate sheet,
sign, date and attach to this from.

+---+-----------+-----------+----------------------------------------+---+
| * |           |           |                                        |   |
| * |           |           |                                        |   |
| E |           |           |                                        |   |
| . |           |           |                                        |   |
| * |           |           |                                        |   |
| * |           |           |                                        |   |
+---+-----------+-----------+----------------------------------------+---+
|   | **Date**  |           | **Employee's Full Signature**          |   |
+---+-----------+-----------+----------------------------------------+---+
| * | ##### WAI |           |                                        |   |
| * | VER OF VO |           |                                        |   |
| F | LUNTARY T |           |                                        |   |
| . | ERM LIFE  |           |                                        |   |
| * | INSURANCE |           |                                        |   |
| * |  COVERAGE |           |                                        |   |
+---+-----------+-----------+----------------------------------------+---+

I have received the booklet explaining the Voluntary Term Life Insurance
Program. I elect not to participate at this time. I understand that I
will be required to furnish evidence of good health should I wish to
enroll at a later date.

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

      **Date**                  **Employee's Full Signature**            
  --- ------------ ------------ ---------------------------------------- --

**DO NOT ATTEMPT TO ERASE OR MAKE ANY CORRECTION; USE A NEW FORM** (If
you have any questions call your local

Benefits office or the Voluntary Term Life Administration Unit at
1-800-843-7724.) SHPS

  ---------------------------------- ----------- ------------------------
                                                 Life Insurance
                                                 Administration Unit

                                                 PO Box 32800

                                     **UCI**     Louisville, KY
                                                 40232-2800
  ---------------------------------- ----------- ------------------------