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  • Designation of Beneficiary Form Paid Time Off Benefit 

  • Securely manage your benefits online with MyCarewell503. Starting July 1, 2024, the English version of this form will be available exclusively on MyCarewell503. Learn more.

  • Please complete this form to designate a beneficiary who you would like to receive your PTO benefits in the event that you pass away before receiving the benefits. You may designate one primary beneficiary, as well as one contingent beneficiary, who will receive any available benefit in the event that your primary beneficiary dies before you. Please provide the full name of your designated beneficiaries, as well as their addresses and their relationships to you.

  • Primary Beneficiary

  • Contingent Beneficiary

    A contingent beneficiary would receive any of your Carewell SEIU 503 PTO benefits in the event of your death if your primary beneficiary named above is also deceased.
  • By my signature below, I hereby designate the above individual as my Primary Beneficiary for the purpose of receiving any Carewell SEIU 503 Paid Time Off benefit payable on my behalf in the event of my death. Further, I hereby revoke any prior designation of Primary Beneficiary. I understand that this beneficiary designation will become effective only upon its receipt by Carewell SEIU 503 Benefits.

  • By my signature below, I hereby designate the above individuals as my Primary and Contingent Beneficiaries for the purpose of receiving any Carewell SEIU 503 Paid Time Off benefit payable on my behalf in the event of my death. Further, I hereby revoke any prior designation of Primary or Contingent Beneficiaries. I understand that these beneficiary designations will become effective only upon receipt by Carewell SEIU 503 Benefits.

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