UnitedHealthCare
LIFE/AD&D
Beneficiary Designation

LIFE INSURANCE

Please provide beneficiary information for your current Basic Life and, if you have elected it, Supplemental Life benefit.

Enter YOUR information on our Secure Site
*Required fields

First Name

Last Name

Gender

Male

Female

Email

Social Security #

Date of Birth

Enter BENEFICIARY Information

Life Beneficiary 1

Beneficiary 1 Social Security

Percentage to Beneficiary 1

Relationship 1

Life Beneficiary 2

Beneficiary 2 Social Security

Percentage to Beneficiary 2

Relationship 2

Life Beneficiary 3

Beneficiary 3 Social Security

Percentage to Beneficiary 3

Relationship 3

Life Beneficiary 4

Beneficiary 4 Social Security

Percentage to Beneficiary 4

Relationship 4

TOTAL = 100%

If you wish to add additional beneficiaries, please contact Amanda Garcia at (210) 283-5571.

Which organization employs you?

TACO

MAD

CFR

RJC

ORI

YADAV

I'M NOT SURE

None of the above, I work for:

Your Signature

Thank you for submitting your beneficiary information.
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UnitedHealthCare LIFE/AD&D Beneficiary Designation