F83345SA Rev 10-2021
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Securian Financial is the marketing name for Securian Life Insurance Company and Minnesota Life Insurance Company. Insurance products are
issued by Minnesota Life Insurance Company or Securian Life Insurance Company, a New York authorized insurer. Minnesota Life is not an authorized
New York insurer and does not do insurance business in New York. Both companies are headquartered in Saint Paul, MN. Product availability and
features may vary by state. Each insurer is solely responsible for the nancial obligations under the policies or contracts it issues.
Beneficiary Designation
Securian Life Insurance Company
Minnesota Life Insurance Company
Group Customer Service • 400 Robert Street North, St. Paul, MN 55101-2098
Fax 651-665-4827
• Completing this Beneficiary Designation form will revoke all current beneficiary designations.
• The same person(s) cannot be named as both a primary and contingent beneficiary.
• If you need more space, attach an additional sheet of paper with all of the information required. Be
sure to sign and date this additional information page.
• To receive a death benefit, a beneficiary must survive the insured. If the named beneficiary does not
survive the insured, that beneficiary’s portion shall be equally distributed to the remaining beneficiaries
within that category.
• When the signed and completed beneficiary form has been accepted, you will be mailed a
confirmation.
• Primary Beneficiary: This is the individual(s), trust, charity, or estate that you want to receive the
insurance benefit. You can divide the insurance proceeds between primary beneficiaries. The total
shares must equal 100%.
• Contingent Beneficiary: If all the primary beneficiary(ies) are no longer living, eligible, or able to
receive the benefits, it will be paid to the contingent beneficiary(ies) designated. You can divide the
insurance proceeds between your named contingent beneficiaries. The total shares must equal 100%.
• Naming Minor Children: You may name your children (by name) directly, or to a trust. Minors cannot
directly receive life insurance proceeds; however, they may be paid to a court-appointed guardian or
held until the minor child is legal age.
• Trust: Provide the trust name, effective date and tax ID or Social Security number (if applicable) - i.e.,
“John Smith Trust dated 01/01/20xx.”
• Charity: Provide the full name, address, tax ID number.
1. Clearly print or type the information.
2. Sign and date the completed form.
3.
INSTRUCTIONS
GENERAL BENEFICIARY INFORMATION
Return to:
Securian Financial
PO Box 259708
Madison, WI 53725-9708
F83345SA Rev 10-2021
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Beneficiary Designation
Securian Life Insurance Company • Minnesota Life Insurance Company
SIGNATURE REQUIRED - This beneficiary form revokes all prior designations.
Insured’s name (first, middle initial, last)
Address (street, city, state, zip)
Insured’s date of birth Policyowner (if different than insured)
ID (or last four of SSN)
Policyowner’s phone number
Employer name Policy number
This designation applies to all coverages.
Beneficiary full name/trust name
Address (street, city, state, zip) and phone number
Date of birth/trust date Tax ID (SSN or EIN) Share %
Relationship to insured
Beneficiary full name
Address (street, city, state, zip) and phone number
Date of birth Tax ID (SSN) Share %
Relationship to insured
Beneficiary full name
Address (street, city, state, zip) and phone number
Date of birth Tax ID (SSN) Share %
Relationship to insured
Beneficiary full name
Address (street, city, state, zip) and phone number
Date of birth Tax ID (SSN) Share %
Relationship to insured
Beneficiary full name/trust name
Address (street, city, state, zip) and phone number
Date of birth/trust date Tax ID (SSN or EIN) Share %
Relationship to insured
Beneficiary full name
Address (street, city, state, zip) and phone number
Date of birth Tax ID (SSN) Share %
Relationship to insured
Insured or policyowner’s penned signature
Signature of spouse
Date
X
X
Beneficiary full name
Address (street, city, state, zip) and phone number
Date of birth Tax ID (SSN) Share %
Relationship to insured
Email address
Total Primary Shares Must Equal 100%
Total Contingent Shares Must Equal 100%
PRIMARY BENEFICIARY(IES)
- The person or persons named will receive the benefit.
CONTINGENT BENEFICIARY(IES)
- Receives a benefit ONLY if all primary beneficiaries are no longer living.
Community Property State Consent for current and former residents of Arizona, California, Idaho, Louisiana,
Nevada, New Mexico, Texas, Washington, or Wisconsin. If you are married and live in, or previously lived in, a
community property state and name someone other than your spouse as beneciary, you may have your spouse sign
below to waive his or her rights to any community property interest in the benet. You should consult with a qualied
tax advisor and/or seek legal advice if you have any questions in connection with the Beneciary Designation.
As the Insured’s spouse, I do hereby consent to the beneciary designation(s) indicated on this form and waive any
right that I may have to the proceeds of such insurance under applicable community property laws. My spouse may
withdraw this designation at any time but may not designate a dierent primary beneciary without my consent.
Date signedPlease print spouse name clearly
32872-G
