Name of Insured (please print): ______________________________________
Social Security Number of Insured: ___________________________________
INTER VIVOS TRUSTEE DESIGNATION
TO BE ATTACHED TO AND MADE PART OF DESIGNATION OF BENEFICIARY DATED______________________________________
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 (Name of Trust Agreement) __________________________________ bearing the date of
______________ executed by me.
I further request that in the case of the failure of said Trustee(s) to be appointed as such or to qualify as such for any reason, or the termination for any reason of the trust prior to my death that the Proceeds shall be paid to:
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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.
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| Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.)
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Date of execution (Month, day, year)
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Two Witnesses to Signature (A witness is not eligible to receive payment as a beneficiary):
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________________________ |
________________________ |
| Signature of witness
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Number and street
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City, state and ZIP code
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| __________________ |
________________________ |
________________________ |
| Signature of witness
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Number and street
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City, state and ZIP code
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U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 | (202) 606-1800 | TTY (202) 606-2532