Please read the instructions below before completing this form. If you have any questions, please call the Unisys Benefits Service Center at 1-800-600-4015, business days (excluding holidays recognized by the New York Stock Exchange) from 8:30 A.M. to Midnight Eastern time, to speak with a Service Representative.
Beneficiary Designation InstructionsSeparate and different beneficiaries may be designated for each plan by specifying the coverage for which each designation applies. If you do name different beneficiaries by plan, and leave any plan blank, the Standard Beneficiary Designation as indicated below is assumed for any plans that have no beneficiary designated.
You have the right to change beneficiaries at any time. If you are only changing one designation, you must fill in all your previous designations, or the Standard Beneficiary Designations will apply. Your spouse must consent, however, to any designation of primary beneficiary for the Unisys Savings Plan or the Retirement Accumulation Account of the Unisys Pension Plan if your spouse is not the sole primary beneficiary for that Plan. To change beneficiaries, complete a new Beneficiary Designation form.
Under the laws of several states, your spouse may be entitled to a portion of the life insurance proceeds payable upon your death, regardless of any non-spouse beneficiary designation. If you designate a person other than your spouse as the beneficiary under your Company-Provided Life Insurance, consult with an attorney to determine what effect, if any, state law may have upon such designation.
Standard Beneficiary Designation
Unisys endorses the Standard Beneficiary Designation, which provides the convenience of automatically updating your beneficiaries as your family composition changes without the need to change your designation(s) whenever you gain or lose an immediate family member. The Standard Beneficiary Designation is…
- Spouse, if living at my death;
- If my spouse is not living, surviving children equally, including any legally adopted children;
- If no children survive, surviving parents equally;
- If neither parent survives, surviving brothers and sisters equally;
- If no brothers or sisters survive, estate.
If you do not want to use the Standard Beneficiary Designation, you may name anyone you like as your beneficiary, including any corporation except Unisys. If more than one beneficiary is named, you must indicate the percentage of the benefit payable to each beneficiary. These percentages must total 100%. If more than one beneficiary is named and you do not indicate the percentage of the benefit payable to each beneficiary, payment will be made in equal shares to each named beneficiary. Below are some common alternate designations:
Beneficiary / Examples of Non-Standard Beneficiary Designations
(replace the Smith family names with your beneficiary’s name):
1. One primary beneficiary
2. Two primary beneficiaries
3. Three or more primary
beneficiaries
4. One primary beneficiary and
one secondary beneficiary
5. One primary beneficiary and
two secondary beneficiaries
6. One primary beneficiary and three
or more secondary beneficiaries
7. One primary beneficiary and
unnamed children
8. Two primary beneficiaries and
one secondary beneficiary
9. Two beneficiaries in unequal
portions
10. Trustee
11. Member’s estate / Dorothy Smith, wife.
Peter Smith, father, and Joan Smith, mother, equally, or the survivor.
Peter Smith, father, Joan Smith, mother, Tom Smith, son, or the survivors, equally, or the survivor.
Dorothy Smith, wife, if living; otherwise, Tom Smith, son.
Dorothy Smith, wife, if living; otherwise, Tom Smith, son, and Carol Smith, daughter, equally, or the survivor.
Dorothy Smith, wife, if living; otherwise, Tom Smith, Carol Smith and
Mary Smith, children, or the survivors, equally, or the survivor.
Dorothy Smith, wife, if living; otherwise the children born of the marriage of
the member and said wife, or the survivors, equally, or the survivor.
Peter Smith, father, and Joan Smith, mother, equally, or the survivor;
otherwise, Dorothy Smith, wife.
40% to Peter Smith, father, and 60% to Joan Smith, mother, if both survive; otherwise, all to survivor.
(Name and complete address) Trustee, under a trust agreement with the member dated ______, or to the successor in said trust.
Executor or administrator of my estate.
Notes:
Please provide name, address, telephone number, date of birth, Social Security number and relationship to you for each beneficiary you designated. If you need additional space, please use a new sheet of paper and include your signature and the date.
If your beneficiary is a married woman, her given name must be used; for example: “Mary A. Doe” and not
“Mrs. John C. Doe.”
If your beneficiary is not related to you, use the term “no relation” and enter the beneficiary’s address.
Under No. 1 through No. 9, you may choose to add “otherwise, the executor or administrator of the member.” Do not use No. 10 unless there is an executed Trust Agreement in existence.
Your Signature — Without your signature and date, the Beneficiary Designation form will be invalid.
Please make a copy of this form for your files and return the original to: / Unisys Benefits Service CenterPO Box 770003
Cincinnati, OH 45277-0072
The information contained herein has been provided by Unisys and is the sole responsibility of Unisys.
3.UN-B-596C.102UNISYSBeneficiary Designation
Unisys Savings Plan
Unisys Pension Plan (Retirement Accumulation Account)
Company-Provided Life Insurance
Business Travel Accident & Seat Belt Insurance
About You – Please print the information below in blue or black ballpoint pen.
Last name / First name / Middle initial / Social Security number
Street address / City or Town / State / ZIP code
Home telephone number / Daytime telephone number / Date of birth
( ) / ( ) / /
Marital status / Spouse date of birth
/
Spouse last name / First name / Middle initial / Spouse Social Security number
Beneficiary Designation (See Instructions for information regarding Beneficiary Designations.)
By completing this section, I designate the following person(s) to receive, in the event of my death, the total amount of benefits available under the specific plan(s) below. I understand that the Standard Beneficiary Designation, as explained in the instructions for this form, will be assumed for plans which have no beneficiary designated below.Unisys Savings Plan (Spouse’s consent below may be required.)
Spouse’s Consent for Non-Standard Beneficiary Designation
If you do not name your spouse as your sole primary beneficiary under the Unisys Savings Plan, this form must be signed by your spouse and notarized to validate that election.
I, (print spouse’s name) / , recognize that my spouse has designatedsomeone other than me as the sole beneficiary to receive benefits payable under the Unisys Savings Plan. I understand that such designation means that I will not be entitled to receive surviving spouse benefits otherwise required to be paid to me if my spouse should die before I do. I also understand that this consent is limited to my spouse’s designation of a beneficiary specified above.
Spouse’s signature
/ DateNotarized
/ Signed and subscribed to before me this / day of / , YearWitness
to Spousal / Notary’s signatureWaiver / Notary’s commission expiration date
Beneficiary Designation (Cont.) (See Instructions for Information on Beneficiary Designations.)
Unisys Pension Plan – Retirement Accumulation Account (Spouse’s consent below may be required.)
Spouse’s Consent for Non-Standard Beneficiary Designation
If you do not name your spouse as your sole primary beneficiary under the Unisys Pension Plan (RetirementAccumulation Account), this form must be signed by your spouse and notarized to validate that election.
I, (print spouse’s name) / , recognize that my spouse has designatedsomeone other than me as the sole beneficiary to receive benefits payable from theRetirement Accumulation Accountof the Unisys Pension Plan. I understand that such designation means that I will not be entitled to receive surviving spouse benefits otherwise required to be paid to me if my spouse should die before I do. I also understand that this consent is limited to my spouse’s designation of a beneficiary specified above.
Spouse’s signature
/ DateNotarized
/ Signed and subscribed to before me this / day of / , YearWitness
to Spousal / Notary’s signatureWaiver / Notary’s commission expiration date
Company-Provided Life Insurance
Business Travel Accident and Seat Belt InsuranceAuthorization and Signature
The above designations cancel and supersede any and all previous beneficiary designations I have made with respect to all these plans and will remain in effect unless I change them by written designation.Your signature / Date
Administration Use Only
Received by / Date receivedReturn original form to: Unisys Benefits Service Center, PO Box 770003, Cincinnati, OH 45277-0072.
Retain a copy for your records.
Did You Remember To:
DESIGNATE BENEFICIARY INFORMATION ACCURATELY:
- Use only whole-number percentages totaling 100%. For example, designations such as
33-1/3 or 33.3 are not acceptable. - Fill out required information. For example, the form will be returned if there is missing information such as date of birth and address.
- Avoid using wording such as “either/or” or “and/or”.
- If you are married, federal law generally requires that all benefits from the retirement plans be paid to your spouse unless your spouse consents in writing to another beneficiary designation and this consent is witnessed by a Notary Public.
3.UN-B-596C.102