Name of Insured (please print):______________________________________
Social Security Number of Insured: __________________________________
TESTAMENTARY TRUSTEE DESIGNATION
I request that the amount payable under the FEDERAL EMPLOYEES' GROUP LIFE INSURANCE PROGRAM (Proceeds) be paid to the Trustee(s) or Successor Trustee(s) as provided under my Last Will and Testament, and I further request that in the case of the failure of said Trustee to be appointed as such or to qualify as such by reason of non-probate of any Will to that effect or for any other reason whatsoever, the Proceeds shall be paid to:
| Name | Address | Relationship | Share |
| _________________ | __________________ | _________________ | ______________ |
| _________________ | __________________ | _________________ | ______________ |
| _________________ | __________________ | _________________ | ______________ |
The Office of Federal Employees' Group Life Insurance (OFEGLI) shall not be responsible for the application or disposition of the proceeds by said Trustee and the receipt by said Trustee shall fully discharge OFEGLI's liability under the FEDERAL EMPLOYEES' GROUP LIFE INSURANCE PROGRAM.
| ____________________________________ | ______________________________ |
| Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) | Date of execution (Month, day, year) |
Two Witnesses to Signature (A witness is not eligible to receive payment as a beneficiary):
| __________________ | ________________________ | _______________________________ |
| Signature of witness | Number and street | City, state and ZIP code |
| __________________ | ________________________ | _______________________________ |
| Signature of witness | Number and street | City, state and ZIP code |