|
STATE OF MARYLAND AIR TRAVEL ACCIDENT INSURANCE
BENEFICIARY DESIGNATION FORM
**See Note Below
Employee:____________________________________ Bus. Phone:
_________________
State Agency:
__________________________________________________________________
Dates of Travel: Depart: _________________________
Return:________________________
Destination:
___________________________________________________________________
PRIMARY BENEFICIARIES:
_________________________________ RELATIONSHIP
__________________________
_________________________________ RELATIONSHIP
__________________________
_________________________________ RELATIONSHIP
__________________________
CONTINGENT BENEFICIARIES:
_________________________________ RELATIONSHIP
__________________________
_________________________________ RELATIONSHIP
__________________________
| _________________________________________ |
_____________________ |
| EMPLOYEE SIGNATURE |
DATE |
**Please Note:
Submission of this form is required only if you wish to designate a different
beneficiary than is named on your State pension plan. | 
