[104-10291-10000.pdf — page 204]
IMPORTANT. The filing of this form will completely cancel any Designation of Beneficiary under the Federal Employees Group Life Insurance Program you may have previously filed. Be sure to name in this form all persons you wish to designate as beneficiaries of any insurance payable under that program at your death.# EXAMPLES OF DESIGNATIONS1.  How To DESIGNATE ONE BENEFICIARY| Type or print first name, middle initial, and last name of each beneficiary | Type or print address of each beneficiary (Including ZIP Code) | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | -------------------------------------------------------------- | ------------ | ------------------------------------ || Mary E. Brown                                                               | 214 Central AvenueMuncie, Ind. 47303                           | Niece        | All                                  |2.  How To DESIGNATE MORE THAN ONE BENEFICIARY| Type or print first name, middle Initial, and last name of each beneficiary | Type or print address of each beneficiary(Including ZIP Code) | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ------------------------------------------------------------- | ------------ | ------------------------------------ || Alice M. Long                                                               | 509 Canal StreetRed Bank, N.J. 07701                          | Aunt         | 25%                                  || Joseph P. Brady                                                             | 360 Williams StreetRed Bank, N.J. 07701                       | Nephew       | 25%                                  || Catherine L. Rowe                                                           | 792 BroadwayWhiting. Ind. 46394                               | Mother       | 50%                                  |3.  How To DESIGNATE A CONTINGENT BENEFICIARY| Type of print first name, middle Initial, and last name of each beneficiary | Type or print address of each beneficiaryIncluding ZIP Codes | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ------------------------------------------------------------ | ------------ | ------------------------------------ || John M. Parrish, if living                                                  | 810 West 180th StreetNew York, N.Y. 10033                    | Father       | All                                  || Otherwise to: Susan A. Parrish                                              | 810 West 180th StreetNew York, N.Y. 10033                    | Sister       | All                                  |4.  HOW TO DESIGNATE DIFFERENT BENEFICIARIES FOR REGULAR AND OPTIONAL INSURANCE| Type print first name, middle Initial, and last Dame of each. beneficiary | Type or print address of each beneficiary(Including ZIP Coder) | Relationship | Share to be paid to each beneficiary || ------------------------------------------------------------------------- | -------------------------------------------------------------- | ------------ | ------------------------------------ || John D. Jones                                                             | 124 Elm StreetDayton, Ohio 45420                               | Son          | All RegularInsurance                 || Jane H. Smith                                                             | 421 Spring Avenue-Portland, Maine 04101                        | Niece        | All OptionalInsurance                |5.  HOW TO CANCEL A DESIGNATION OF BENEFICIARY AND EFFECT PAYMENT UNDER ORDER OF PRECEDENCE (see back of duplicate)| Type of print first name, middle Initial and last haine of rach beneficiary | Type or print strces of each-beneficiaryIP Conte | Relationship | Share to paid to cach, benefciary || --------------------------------------------------------------------------- | ------------------------------------------------ | ------------ | --------------------------------- || Cancel prior designations                                                   |                                                  |              |                                   |"Do net write name as M. E. Brown or as Mrs. John H. Browe If wew want to designate pour estate as beneficiary, enter "My estate" in the beneficiary column.*Be wary that the sharre to be paid to the beneficiaries all up to 100 percent.ce!!! eementary for reritar or notmal insurance predecess decreaalie and there is no rurviving i tary or contingent breeficiary for that type of insurance. payment for that ty of nrurance wil he made in order of precedence :see back of duplicate).