Office of Servicemembers' Group Life Insurance

VGLI Beneficiary Designation/Change

1 VETERAN INFORMATION (please print clearly using capital letters)
All the information in this section is required.
First Name: Last Name: Control #: Address: (See Billing Statement) Social Security #: MI:

City: State: Email: Daytime Phone: Evening Phone: ZIP Code: Check here if your address has changed

By Law – If you do not name a specific beneficiary, your insurance will be paid to your survivors as follows: 1. Widow or widower; if none to 2. Child(ren) in equal shares, with the share of any deceased child distributed among the descendants of that child; if none to 3. Parent(s) in equal shares; if none to 4. A duly appointed executor or administrator of the insured’s estate, and if none, to 5. Other next of kin Check here if you want by law designations, and complete and return only sections 1 and 4.

INSTRUCTIONS FOR COMPLETING THIS FORM
Use this form to designate or make changes to the beneficiary(ies) of your VGLI death proceeds. The information on this form will replace any prior beneficiary designation. You may name anyone or any entity as your beneficiary without anyone knowing or consenting to it. You may change your beneficiary at any time by completing a new VGLI Beneficiary Designation/Change form. This form cannot be used to reinstate your coverage if your insurance is not in force due to failure to pay timely premiums.

INSTRUCTIONS FOR DESIGNATING A PRIMARY OR SECONDARY BENEFICIARY (SECTION 2) • You may name more than one primary and more than one secondary beneficiary. This form allows you to name up to three primary and three • You can name an individual, corporation/organization, trust, or an estate as a beneficiary. The following examples may be helpful in designating beneficiaries: Individual : “Mary A Doe” • Each name should be listed as first name, middle name, last name (“Mary A Doe,” not “Mrs M Doe”). • Include the address, relationship and Social Security number for each individual listed. • Indicate the percentage to be assigned to each individual. Estate: “Estate of the Insured” • Select “Estate” in the box provided. • Indicate the percentage to be assigned to the estate. Charitable Institution: “ABC Charitable Organization” • Select “Charitable Institution” as the Beneficiary Description. • Write the legal name of the Charitable Institution in the space for the First name. • You must provide the address, city and state of operation for each Charitable Institution listed. • Indicate the percentage to be assigned to the Charitable Institution. Trust: See page 4 GL.2006.100B Ed. 09/2012 secondary beneficiaries.

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Control #:

(See Billing Statement)

2 BENEFICIARY DESIGNATION

I hereby revoke any previous designation of primary beneficiary(ies) and secondary beneficiary(ies), if any, and in the event of my death, designate the following: Payment to Beneficiaries If you want the beneficiary(ies) to receive 36 equal monthly payments rather than a lump sum*, you should fill in the corresponding box under Payment Option. If you choose 36 payments, the beneficiary cannot choose to receive a lump sum payment at the time of your death. If you want the beneficiary to have a choice at the time of payment, leave the fields blank.

A. Primary Beneficiaries are the person(s) or entity you choose to receive your life insurance proceeds. Payment will be made in equal shares unless otherwise specified. In the event that a designated primary beneficiary predeceases the Insured, the proceeds will be paid to the remaining primary beneficiaries in equal shares or all to the sole remaining primary beneficiary. The total for all primary beneficiaries must equal 100%. 1. Type (Select One) Gender: First Name: Last Name: Address: Phone: Payment: 2. Type (Select One) Gender: First Name: Last Name: Address: Phone: Payment: 3. Type (Select One) Gender: First Name: Last Name: Address: Phone: Payment: Lump Sum* 36 Equal Monthly Payments SSN: Share: TOTAL: Must equal 100% % Lump Sum* Child Male Parent Female MI: 36 Equal Monthly Payments Spouse Other Family Other Trust Estate SSN: Share: % Charitable Institution Lump Sum* Child Male Parent Female MI: 36 Equal Monthly Payments Spouse Other Family Other Trust Estate SSN: Share: % Charitable Institution Child Male Parent Female MI: Spouse Other Family Other Trust Estate Charitable Institution

* If the insured member elects a lump sum payment, the beneficiary(ies) will be given the option of receiving the lump sum payment through the Prudential Alliance Account® , by check, or Electronic Funds Transfer (EFT). Alliance Account is not available for payments less than $5,000, payments to individuals residing outside the United States and its territories, and certain other payments. These will be paid by check.

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Open Solutions Inc. is the Service Provider of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential Insurance Company of America, located at 751 Broad Street, Newark, NJ 07102-3777. Draft clearing is provided by UMB Bank, N.A. and processing support is provided by First Data Payment Services (FDPS). Alliance Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). Open Solutions Inc., UMB Bank, N.A., and First Data Payment Services are not Prudential Financial companies.

GL.2006.100B Ed. 09/2012

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Control #:

(See Billing Statement)

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B. Secondary Beneficiaries are the person(s) or entity you choose to receive your life insurance proceeds if the primary beneficiary(ies) die (or the entity dissolves) before you die. Payment will be made in equal shares unless otherwise specified. In the event that a designated secondary beneficiary predeceases the insured, the proceeds will be paid to the remaining secondary beneficiaries in equal shares or all to the sole remaining secondary beneficiary. 1. Type (Select One) Gender: First Name: Last Name: Address: Phone: Payment: 2. Type (Select One) Gender: First Name: Last Name: Address: Phone: Payment: 3. Type (Select One) Gender: First Name: Last Name: Address: Phone: Payment: Lump Sum* 36 Equal Monthly Payments SSN: Share: TOTAL: Must equal 100% % Lump Sum* Child Male Parent Female MI: 36 Equal Monthly Payments Spouse Other Family Other Trust Estate SSN: Share: % Charitable Institution Lump Sum* Child Male Parent Female MI: 36 Equal Monthly Payments Spouse Other Family Other Trust Estate SSN: Share: % Charitable Institution Child Male Parent Female MI: Spouse Other Family Other Trust Estate Charitable Institution

Please copy this page to list additional beneficiaries.

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* If the insured member elects a lump sum payment, the beneficiary(ies) will be given the option of receiving the lump sum payment through the Prudential Alliance Account® , by check, or Electronic Funds Transfer (EFT). Alliance Account is not available for payments less than $5,000, payments to individuals residing outside the United States and its territories, and certain other payments. These will be paid by check.
Open Solutions Inc. is the Service Provider of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential Insurance Company of America, located at 751 Broad Street, Newark, NJ 07102-3777. Draft clearing is provided by UMB Bank, N.A. and processing support is provided by First Data Payment Services (FDPS). Alliance Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). Open Solutions Inc., UMB Bank, N.A., and First Data Payment Services are not Prudential Financial companies.

GL.2006.100B Ed. 09/2012

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Control #:

(See Billing Statement)

3

TRUST DESIGNATION – COMPLETE IF A TRUST HAS BEEN NAMED AS A BENEFICIARY IN SECTION 2
Complete this section if you have named a trust as a primary or secondary beneficiary in Section 2. Fill in the name and address for each trustee. Fill in the title and date of the Trust Agreement in the space provided. Trust: “The John Doe Trust. A Trust with a trust agreement dated 1/1/2010 whose Trustee is Jane Smith.” • Select “Trust” as the Type in section 2. • Indicate the percentage to be assigned to the trust in section 2. • Complete the section below, Trust Designation.

1. Trustee Name: (First, MI, Last) Address:

2. Trustee Name: (First, MI, Last)

Address:

And successor(s) in trust, as Trustee(s) under:

Title of Agreement Dated as amended and executed by me and said Trustee.

M M

D D

Y

Y

Y

Y

Date of Agreement

4

AUTHORIZATION / SIGNATURE
I authorize OSGLI to record and consider the individuals/institutions that I have named on this form as beneficiaries for VGLI benefits. If designating a trust as beneficiary, I understand OSGLI assumes no obligation as to the validity or sufficiency of any executed Trust Agreement and does not pass on its legality. In making payment to any Trustee(s), OSGLI has the right to assume that the Trustee(s) is acting in a fiduciary capacity until notice to the contrary is received by OSGLI. I agree that if OSGLI makes any payment(s) to the Trustee(s) before notice is received, OSGLI will not make payment(s) again. Veteran’s Signature: The Veteran must sign and date this form. The signature date must be the date the Veteran actually signed the form. Submit the completed form to: The Prudential Insurance Company of America Office of Servicemembers’ Group Life Insurance P O BOX 41618 Philadelphia, PA 19176-9913 Keep a copy for your records.

Date: M M

D D

Y

Y

Y

Y

GL.2006.100B Ed. 09/2012

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