Get the free editable beneficiary dessignation form

Yes No How many people do you employ? Are you a sole proprietor? Yes No Name of person who is in charge of your account: Yes No Name of the person who is in charge of your account: (Please print name) (Please note names cannot be changed) Are your employer(s) insured against catastrophic loss? Yes No Have you ever been in an accident? Yes No Did you have medical expenses after the accident? Yes No Did you file an insurance claim from the accident? Yes No Are you enrolled in Medicare? Yes No Does any of your insurance cover disability? Yes No Are you covered by medical insurance? Yes No Are your employer's insurance policies or coverage at fault? Yes No. Do you have any other insurance policy’s, if any)? Yes No Did your employer pay your claim(s) for medical expenses? Yes No Did you file your own claim, if so, please provide: Yes No Name of your insurer? (Please print name & address, if applicable) Insurance agent (for insurance claims filed by you) No Yes How many types of health insurance are you covered under? Are you covered under the following types of health insurance? Medical/Dental Home Employee Benefit Plan Employer sponsored (not employer) Health Insurance Other insurance Coverage of Your Premises Is this house or building owner/operator (or building manager) or landlord (or management company) liable if there was any property damage due to an act of God (for example, hurricane, fire, earthquake, etc.)? Yes No (if “No” please provide a more specific description) Will the person renting this house/barn/apartment (if applicable) be liable for any such liability? Yes No Is the landlord responsible or liable for any damages caused directly or indirectly by tenants (for example, landlord's own negligence, bad tenant or other tenant behavior, etc.)? (If yes for any of the above, please indicate who is at fault) Yes No Is the property insured under the policy name that is printed directly below your employer's name in this section? Yes No Name of insurance company/s involved? Yes No Name of policy or program. (if applicable) (e.g.