Beneficiary Information Form

BENEFICIARY INFORMATION FORM

This Beneficiary Information Form is executed on the Effective Date: by and between Account Holder Name: (hereinafter "Account Holder") and Plan Administrator Name: (hereinafter "Administrator").

RECITALS

WHEREAS, Account Holder maintains an account, plan, or policy administered by Administrator for which Account Holder may designate one or more beneficiaries to receive benefits upon the Account Holder's death; and

WHEREAS, Account Holder desires to designate or update the persons or entities entitled to receive such benefits and to provide the Administrator with the information and certifications necessary for proper administration; and

WHEREAS, Administrator requires a written beneficiary designation in the form provided to ensure that benefits are distributed in accordance with Account Holder's intent and applicable plan or policy provisions;

NOW, THEREFORE

In consideration of the mutual covenants set forth herein and other good and valuable consideration, the parties agree as follows:

1. DESIGNATION OF BENEFICIARIES

Account Holder hereby designates the following Primary Beneficiaries to receive the specified percentage of benefits upon Account Holder's death. Unless otherwise indicated, percentages must total 100% for Primary Beneficiaries.

Primary Beneficiary 1

Primary Beneficiary 2 (Optional)

Contingent Beneficiaries

If all Primary Beneficiaries predecease the Account Holder, the following Contingent Beneficiaries shall receive the benefits in the percentages set forth below.

2. SPECIAL DESIGNATIONS AND TRUSTS

If any beneficiary is a trust, indicate below. For trust designations, provide the complete trust name, date of trust, and trustee information. Administrator shall rely on the trust document and trustee certification to effectuate distributions.

3. CERTIFICATIONS, REPRESENTATIONS AND AUTHORIZATION

Account Holder certifies that the information provided herein is accurate and complete to the best of Account Holder's knowledge. Account Holder further certifies that this designation supersedes any prior beneficiary designation for the same account unless otherwise expressly stated in writing.

Account Holder authorizes Administrator to rely on the beneficiaries and instructions provided in this form. Administrator may request additional documentation, including but not limited to death certificates, trust instruments, or court orders, prior to making any distribution. Administrator shall have no liability for reliance on the representations contained herein so long as Administrator acts in good faith and in accordance with applicable plan or policy terms.

4. REVOCATION OF PRIOR DESIGNATIONS

By executing this form, Account Holder expressly revokes all prior beneficiary designations related to the same account or policy unless Account Holder indicates otherwise in writing below. Any conflicting earlier designations shall be void to the extent they conflict with this designation as of the Effective Date.

5. NOTICES

All notices required or permitted under this form shall be in writing and delivered to the addresses provided below. Delivery by mail, courier, or personal delivery shall be sufficient. Notices are effective upon receipt.

6. AMENDMENT; WAIVER

This form may be amended only by a written instrument signed by the Account Holder and accepted by the Administrator in accordance with the Administrator's procedures. No failure or delay by either party in exercising any right under this form shall operate as a waiver of that right, and no single or partial exercise of any right shall preclude other or further exercise of that right or the exercise of any other right.

7. GOVERNING LAW

This form shall be governed by and construed in accordance with the laws of the jurisdiction in which the Administrator maintains the account or otherwise as required by the governing plan or policy documents. Account Holder and Administrator submit to the exclusive jurisdiction of competent courts in that jurisdiction for disputes arising under this form.

8. ENTIRE AGREEMENT; SEVERABILITY

This form, together with any incorporated plan or policy provisions and any attachments specifically referenced herein, constitutes the entire agreement between the parties with respect to the subject matter hereof. If any provision of this form is held to be invalid, illegal, or unenforceable, such provision shall be severed and the remaining provisions shall continue in full force and effect.

9. COUNTERPARTS; EXECUTION

This form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Electronic or facsimile signatures shall be treated as original signatures for all purposes.

ACKNOWLEDGMENT

By signing below, Account Holder confirms understanding of the legal effect of this designation and that the information provided is accurate. Administrator acknowledges receipt of this form and its obligation to record and follow the designation as permitted by the governing account, plan, or policy documents.

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