[104-10291-10000.pdf — page 254]
IMPORTANT. - The filing of this form will completely cancel any Designation of Beneficiary under the FederalEmployers' Group Life Insurance Art you may have previously filed. Be sure to name in this form all persons you wishto designate as beneficiaries of any group life and accidental death Insurance payable under that act at your death.## EXAMPLES OF DESIGNATIONS### 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 | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || Mary E. Brewn                                                               | 214 Central Avenue, Muncie, Ind.          | Niece        | All                                  |### 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 | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || Alice M. Long                                                               | 509 Canal Street, Red Bank, N. J.         | Aunt         | One-fourth                           || Joseph P. Brady                                                             | 360 Williams Street, Red Bank, N. J.      | Nophow       | One-fourth                           || Catherine L. Rowe                                                           | 792 Broadway, Whiting, Ind.               | Mother       | One-half                             |### How To DESIGNATE A CONTINGENT BENEFICIARY| Type or print first name, middle initial, and last name of each beneficiary | Type or print address of each beneficiary | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || John M. Parrish, if living                                                  | 810 West 180th Street, New York, N. Y.    | Father       | All                                  || Otherwise to: Susan A. Farrish                                              | 810 West 180th Street, New York, N. Y.    | Sister       | All                                  |### How To CANCEL A DESIGNATION OF BENEFICIARY SO THAT AMOUNT DUE WILL BE PAYABLE AS PROVIDED IN THE LAW| Type or print first name, middle initial, and last name of each beneficiary | Type or print address of each beneficiary | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || Cancel prior designations                                                   |                                           |              |                                      |Also and write name as M. Brown or as Mrs. John H. BrownBe sure that the shares to be paid to the several beneficiaries add up to 100 percent.