Beneficiary

Print or Type
Underwritten by: (check one)

THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA

PERVEZ AHMAD
Insured’s Name: ______________________________________________________________________________________
KHAN
First Middle Last

Date Employed: _______________________________________________________________________________________

Month Day Year

First Middle
KHANUM
Death Benefits Paid to: _________________________________________________________________________________
SUFIA Last

Relationship: ________________________________________________________________________________________
WIFE

Policyholder: _________________________________________________________________________________________
HILL INTERNATIONAL, Inc.

Name of Employer (if other than Policyholder):______________________________________________________________

Policy Number: _______________________________________________________________________________________

_____________________________________________ _________________________
Insured’s Signature Date

If no beneficiary is designated, benefits will be paid in accordance with the policy provisions. The Company acknowledges receipt
of this form, but does not accept any responsibility for its validity or legal effect.