Officer’s Beneficiary Designation Form

2026 Officer's Beneficiary Designation Form

Society Number *

Society Name *

City / State / Zip *

Name of Officer *

Office Held *0 / 150

I acknowledge that I have $1500.00 of life insurance coverage while serving as an office of my Society. My designation of beneficiary is:

Primary *0 / 150

Relationship *0 / 200

Contingent0 / 150

Relationship0 / 200

Signature of Insured *

Please type your name *

Email Address *

THE SOCIETY PRESIDENT, VICE PRESIDENT, SECRETARY AND TREASURER MUST COMPLETE THIS FORM EACH YEAR AND RETURN IT TO THE STATE OFFICE BY JANUARY 16TH OF EACH YEAR.

IF THE SOCIETY HAS AN ACTIVE REGISTERED JUNIOR DIVISION, THE JUNIOR DIRECTOR SHOULD ALSO COMPLETE THIS FORM.

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2026 Officer's Beneficiary Designation Form

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