LIFE INSURANCE / ACCIDENTAL DEATH

BENEFICIARY DESIGNATION
Policy Holder Name HTC Global Services
This form is valid for all company
Employee Name sponsored life insurance and
Date of Birth accidental death policies,
whether provided or voluntary.
Social Security Number

HTC Global Services' life insurance/accidental death policy requires that you name a beneficiary to receive the proceeds of the policy should
death occur. Life insurance proceeds will be payable to named beneficiary below.

Beneficiary 1 Date of Birth

Relationship Social Security Number
Address Percent of Benefit

Beneficiary 2 Date of Birth

Relationship Social Security Number
Address Percent of Benefit

Beneficiary 3 Date of Birth

Relationship Social Security Number
Address Percent of Benefit

Contingent beneficiary is an individual who is entitled to receive proceeds of the life insurance/accidental death policy if the primary beneficiary
dies before or simultaneously with you.

Contingent 1 Date of Birth

Relationship Social Security Number
Address Percent of Benefit

Contingent 2 Date of Birth

Relationship Social Security Number
Address Percent of Benefit

Contingent 3 Date of Birth

Relationship Social Security Number
Address Percent of Benefit

Please Note -
This document is not valid without an authentic signature and date on the form. You must print and sign the form for it to be valid. Once
signed, you should email the completed form to benefits@htcinc.com.

Signature Date
SUBMIT
PRINT
(only if electronically signed)