THE PERMANENTE MEDICAL GROUP, INC.

TRAVEL ACCIDENT INSURANCE

BENEFICIARY DESIGNATION

Name of Insured: (Please Print): First Name, Middle Initial, Last Name ID Number / Last 4 digits of Social Security No.:

Marital Status: Facility:

Address: Street City State / Zip Code

I hereby revoke all beneficiary designations previously made by me under the Travel Accident Insurance Policy and
hereby request the following beneficiary designation to apply to any death benefits payable under the provisions of said
Policy upon my death.

Please review the Beneficiary Designation Guide on the reverse side of this form prior to completion.
Incomplete designations or designations that are not clear will be returned.

PLEASE PRINT. Provide full name, relationship, date of birth, and address of all designated beneficiaries and their
share or percentage amount.
REMEMBER: LIST A PRIMARY BENEFICIARY(S) AND, IF APPLICABLE, ANY SECONDARY BENEFICIARY(S)
INDICATING THEIR DESIGNATED PORTION(S). SEE EXAMPLES ON THE REVERSE SIDE.

For additional beneficiaries, attach sheet and initial here: _______

__________________________________________________________ _____________________________________________
SIGNATURE OF PARTICIPANT DATE
(PLEASE SIGN IN BLUE INK)
IMPORTANT: The signature of your spouse is required if you designate a person other than your spouse as your
primary beneficiary. Absent the signed consent of your spouse, your beneficiary designation will be considered invalid
and will be returned to you.

CONSENT OF SPOUSE
I hereby consent to the above beneficiary designation, relating to benefits payable under said Policy upon the death of
my spouse. I understand that; (1) the effect of such consent is that benefits which may otherwise to payable to me
upon the death of my spouse, will be paid to the designated beneficiary; (2) absent my consent, such beneficiary
designation may not be valid; and (3) my consent is irrevocable.

This consent is voluntary given and no undue influence or coercion has been exercised in connection with such
consent.
_____________________________________________ _______________________________________
SIGNATURE OF SPOUSE DATE
_____________________________________________ _______________________________________
SIGNATURE OF WITNESS DATE

FRONT
Rev 03/2006
 BENEFICIARY DESIGNATION GUIDE
IMPORTANT:
• If you are married and designate a beneficiary who is not your spouse, the beneficiary designation is invalid unless the spouse consents to the
designation in the manner required by the Plan. If you are not married at the time you designate a beneficiary and later become married (or if
you are married, become divorced and remarry) any designation of a beneficiary who is not your spouse at the time of your death is invalid
unless your spouse at the time of your death has consented to such beneficiary designation in the manner required by the Plan.
• If you do not designate a beneficiary or if the named beneficiary does not survive you and there is no contingent beneficiary, any payment will
be made in accordance with the terms of the Plan.

NAMING BENEFICIARIES: VERY IMPORTANT SECTION

• Provide the beneficiary’s first name, middle initial, last name, relationship, date of birth, address, and their share or
percentage amount.
• Use the following terminology to show the relationship of the beneficiary to you:
1. “Spouse” rather than “Wife/Husband”
2. “Former Spouse” rather than “Divorced Wife/Husband”
3. “The Executors or Administrators” rather than “Estate”
4. “No Relation” rather than “Friend”
5. “Fiancée / Fiancé” rather than “Intended Wife/Husband”
6. “Mother and Father” rather than “Parents”
• If a married woman is the named beneficiary, show her maiden name, in parenthesis, following her last name, for example, “Helen P. Jones
(Smith)”, rather than Mrs. John P. Jones.
EXAMPLES OF POPULAR BENEFICIARY DESIGNATIONS
Neither the Plan Administrator, the Trustee nor TPMG assume any responsibility for any errors, mistakes, or omissions in the preparation
or form of any beneficiary designation and does not assume any responsibility for the accuracy or effectiveness of the following illustrative
designations which are merely shown as examples only. Designing a beneficiary designation is an important legal decision and competent
and professional legal assistance is recommended. Please note: the examples do not show the date of birth or address of the beneficiary, which is
requested on the beneficiary designation form, and has only been omitted here for ease of illustration.

1. One Beneficiary Only: “Mary J. Smith (Doe), Spouse”

2. Two or more beneficiaries, equal share: “William F. Smith, father, Alice C. Smith, sister, and Richard B. Smith, brother, share alike or
to the survivors or survivor in equal shares”
3. Unequal share: “50% to Robert P. Doe, son, 25% to Mary J. Doe, daughter, 25% to John P. Doe, son; the share of any deceased
beneficiary to be paid to the survivor or survivors in equal shares”
4. One primary and two or more contingent beneficiaries: “Mary J. Smith (Doe), spouse, if living; otherwise to Thomas F. Smith, son,
and Linda M. Smith, daughter, share alike or to the survivor”
5. Two primary and one contingent beneficiary: “William F. Smith, father, Lynn K. Smith (Jones), mother, share alike or to the survivor,
but if neither survives, to Alice S. Smith, sister”
6. Primary and two classes of contingent beneficiaries: “Mary J. Smith (Doe), spouse, if living; otherwise to Linda M. Smith, daughter, if
living; otherwise to Lynn K. Smith (Jones), mother”
7. Primary and two classes of contingent beneficiaries (including the children of a contingent beneficiary): “Mary J. Smith (Doe),
spouse, if living; otherwise to Alice C. Smith, sister, if living; otherwise to the children of Alice C. Smith, sister, or to the survivors or
survivor, in equal shares” *
8. Primary and two classes of contingent beneficiaries (including the children of the marriage of the Participant and Spouse): “Mary J.
Smith (Doe), spouse, if living; otherwise to Lynn K. Smith (Jones), mother, if living; otherwise to the children born of the marriage of the
Participant and Mary J. Smith (Doe), spouse, or to the survivors or survivor, in equal shares” *
9. Primary and contingent (unnamed class) beneficiary: “Mary J. Smith (Doe), spouse, if living; otherwise to the children born of the
marriage of the Participant and Mary J. Smith (Doe), spouse, or to the survivors or survivor, in equal shares” *
10. Primary and contingent beneficiaries (the interest of any deceased contingent beneficiary to pass to any surviving children): “Mary
J. Smith (Doe), spouse, if living; otherwise to Thomas F. Smith, son, and Linda M. Smith, daughter; but if said son or said daughter, or
both shall predecease me, any interest which that person would, if living, have had shall be share equally by any living children of that
person”
11. Trustee beneficiary (under trust instrument): “The Trust Company of Smith, Illinois, as trustee under a Trust Instrument dated
December 29, 1980”
12. Trust for minor or incompetent (in absence of trust instrument): “Thomas F. Smith, son, provided that any payment becoming due to
that son during his minority will be paid to Richard B. Smith, trustee, otherwise the legal guardian of said son” **
13. Charitable, religious or educational institution: “American Red Cross, Smith County Chapter, Smithville, Colorado” ***
14. Death in a common accident: “Mary J. Smith (Doe), spouse, if living; otherwise to William F. Smith, father; if Mary J. Smith does not
survive me by fifteen days, following a common accident with me”
15. Estate: “The Executors, Administrators or the assigns of the Participant”

* If the designation in #7, #8 or #9 above is to include adopted children as contingent beneficiaries, insert “and any children legally adopted by the
Participant” after “children born of the marriage of the Participant and Mary J. Smith (Doe)”
** Substitute incompetence if this is the reason for trustee.
*** The institution should be fully identified by complete name, including number and location where applicable.

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Rev 03/2006