Print Form
UNI Life Insurance Beneficiary Designation Change
Group Number 10962-1
A. Employee Information
Name (Last, First, MI): ______________________________________________________________________________________
University ID: ______________________________________________________________
Date of Employment at UNI (mm/dd/yy): _________________________________________
Effective Date (mm/dd/yy): ____________________________________________________
B. Beneficiaries
Name
Gender
(M/F)
Date of
Birth
Soc.
Security
Number
Primary/
Contingent
Percent
of
Benefits*
Relationship
UNI
Employee
(Y/N)
*Unless provided, proceeds will be paid in equal shares to those named in each class (primary and contingent).
I declare that I am eligible to enroll for this coverage and request to be covered. If the group policy would provide, at some
point, that contributions be made by me, I authorize my employer to deduct them from my pay. I hereby declare that, to
the best of my knowledge and belief, the information given here is correctly recorded, complete and true. I understand that
an agent cannot guarantee coverage or revise rates, benefits or policy provisions without written approval of Principal
Insurance, Co.
Employee Signature: ___________________________________________
Date: ____________________________
Witness Signature: _____________________________________________
The University of Northern Iowa is required by federal law to report income along with Social Security Numbers (SSNs) for all employees to whom compensation is paid.
Employee SSNs are maintained and used by the University for payroll, reporting and benefits purposes, and are reported to federal and state agencies in formats required by
law or for benefits purposes. The University will not disclose an employee’s SSN without the consent of the employee to anyone outside the University except as mandated by
law or required for benefit purposes. Responses to items marked “optional” are options; responses to all other items are required.
Revised 11/2012
BENEFITS
027 Gilchrist  Cedar Falls, IA 50614-0034  Phone: 319-273-2422  Fax: 319-273-2927  http://www.uni.edu/hrs