Beneficiary Nomination Form

We are delighted that you are now a member of the company’s Group Life Scheme insured with Atlas Life.

As a member of the scheme it is important to nominate a beneficiary so that in the event of anything happening to
you, the policy proceeds can be paid out immediately following the approval of the claim by the insurer.

For many people the decision is straightforward and usually they will choose either their spouse, children, parents or
siblings.

If you do not nominate a beneficiary the policy proceeds will be paid into your estate which may mean the funds will
not be available for distribution to anyone until the legal process of settling your estate is complete. In addition, it
could mean that anyone you owe money to could make a claim against the policy proceeds.

Some countries have specific laws governing the distribution of the estate of a deceased person and if you are
concerned about the probate laws in your country of residence you should consider consulting a legal adviser before
completing this section.

To ensure we can pay your beneficiary(ies), please complete their details in the space provided below.

Declaration
Please pay the primary beneficiary(ies) who survives me in the percentage specified against their names:

PERCENTAGE OF
PRIMARY BENEFICIARY DATE OF BIRTH RELATIONSHIP DEATH BENEFIT

Alicia Fernandez Nina 20/04/1964 Mother 100 %

If the primary beneficiary named above does not survive me, then please pay the first contingent beneficiary(ies) in
the percentage specified against their names:

FIRST CONTINGENT PERCENTAGE OF

DATE OF BIRTH RELATIONSHIP
BENEFICIARY DEATH BENEFIT

I fully understand that my circumstances and those of my beneficiaries may change and that this nomination is
revocable by me at any time. I accept the responsibility of updating my beneficiary details should any changes need to
be made.

Italo
Firmado digitalmente por Italo
SIGNATURE OF MEMBER
AND LIFE ASSURED
Fecha: 2022.08.23 08:58:02
-05'00'

NAME Ítalo José Gutiérrez Fernández DATE 1

D D0 / 1
M 1
M / 1
Y 9
Y 8
Y 7
Y