Designation of Beneficiary Form

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.
Your full name*

First NameLast Name
Your Provider Number*
Your preferred email
example@example.com
Your preferred Phone Number*
Please enter a valid phone number.
Primary Beneficiary
Name of your primary beneficiary*

First NameLast Name
Beneficiary's relationship to you*
Primary beneficiary's mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary beneficiary's email address
example@example.com
Primary beneficiary's phone number*
Please enter a valid phone number.

Would you like to designate a 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.*

YesNo
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.
Name of your contingent beneficiary*

First NameLast Name
Contingent beneficiary's relationship to you*
Contingent beneficiary's mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contingent beneficiary's email address
example@example.com
Contingent beneficiary's phone number*
Please enter a valid phone number.
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.
Signature*

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Use your cursor or, if you are using a touchpad like on a smart phone, your finger to sign in the space above.
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Designation of Beneficiary Form Paid Time Off Benefit

Primary Beneficiary

Contingent Beneficiary