BENEFICIARY NOMINATION FORM

Please complete the details below

This form must be completed when nominating a beneficiary for your Triarc Group Risk Policy

MEMBER DETAILS

Full Names *

Surname *

Passport/ID Number *

Company Name *

Email *

Contact Number *

Address *

Apt, suite, etc.

Country

City

State

Zip code

BENEFICIARY NOMINATION DETAILS FOR MEMBER

Beneficiary to whom the money will be paid on the death of the Policyholder. Please complete the details of the Beneficiary you nominate. If any of the other Insured Lives die, you will be the beneficiary and we will pay the Benefits to you.

If you do not nominate a Beneficiary to receive the money in the event of your death, you agree that the Claimant will be your Beneficiary.

PRIMARY BENEFICIARY

Beneficiary Name

Beneficiary Surname

Beneficiary Passport/ID Number

Beneficiary Date of Birth

Relationship to Member

Percentage

*Percentage of benefit up to 100%

Beneficiary Contact Number

If a Trust is the beneficiary please complete this section

Trust Name

Trust Registration Number

Percentage

*Percentage of benefit up to 100%

Trust Contact Number

A secondary nominated Beneficiary is advisable in the case that the Policyholder and primary Beneficiary die together.

SECONDARY BENEFICIARY

Beneficiary Name

Beneficiary Surname

Beneficiary Passport/ID Number

Beneficiary Date of Birth

Relationship to Member

Percentage

*Percentage of benefit up to 100%

Beneficiary Contact Number

If a Trust is the beneficiary please complete this section

Trust Name

Trust Registration Number

Percentage

*Percentage of benefit up to 100%

Trust Contact Number

SIGNATURE

Signed at *

Date *

Signature *

Reset Signature

Signature is required.

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Contact Us

Contact us directly using the details below, or complete our contact form and one of our professional, friendly consultants will get back to you.

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087 231 0222

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086 235 5238

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BENEFICIARY NOMINATION FORM

Please complete the details below

MEMBER DETAILS

BENEFICIARY NOMINATION DETAILS FOR MEMBER

PRIMARY BENEFICIARY

SECONDARY BENEFICIARY

SIGNATURE

Contact Us

087 231 0222

086 235 5238

Unit 122 The Quays, Park Lane Century City, 7441

Complete Our Contact Form