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Beneficiary Designation Under Group Life Insurance Policy Submit our com leted form to our Employer *Reminder to kee this form updated Products and financial services provided by American United Life Insurance Company® a ONEAMERICA® company One American Square, P.O. Box 6123 Indianapolis, IN 46206-6123 1-[PHONE REDACTED] Fax: 1-[PHONE REDACTED] www.employeebenefits.aul.com IMPORTANT: PLEASE READ INSTRUCTIONS AND SAMPLE DESIGNATIONS ON REVERSE SIDE BEFORE COMPLETING FORM. CHECK IF BENEFICIARY FOR: □ All Policies or □ Basic Life □ Supplemental □ Voluntary Term Life □ AD&D D List Other Group Policv/Particioatinq Unit Number Name of Group Policvholder/Participatinq Unit Name of Insured Person Insured Person's SSN I I insured Person's Date of Birth I 0NEAMERICA° ,fli Shared Strength• Trusted Care Subject to the provisions of the policy, applicable laws, and the rights of any valid assignee of record with American United Life Insurance Company® (AUL), it is requested the beneficiary of any policy proceeds payable at the death of the Insured Person be as follows: PRIMARY BENEFICIARY(S) Name Relationship Address DOB SSN Percentage Total1 0 CONTINGENT BENEFICIARY(S) IF THE PRIMARY BENEFICIARY(S) PREDECEASES YOU Name Relationship Address DOB SSN Percentage Tota12 0 It is understood and agreed upon receipt of this beneficiary designation by AUL at its principal office, such beneficiary designation will become effective and shall relate back to the date this beneficiary designation is signed, but without prejudice to AUL on account of any payment made prior to the receipt of and acknowledgement of the validity of the beneficiary designation by AUL. AUL shall not be obligated to honor this beneficiary designation unless and until it has been received by AUL, acknowledged by the appropriate officer of AUL, and determined by AUL to comply with applicable law at the time a claim is made. This beneficiary designation supersedes and cancels all prior beneficiary designations by the Insured Person for the policy(s) indicated. If no beneficiary designation is named on any additional AUL coverage, the undersigned understands that this beneficiary designation will be used by AUL for any additional coverage. The undersigned hereby declares that he/she has not been declared incompetent and no court order or laws prevent naming the above designee(s). It is agreed that AUL assumes no responsibility for the validity or effect of any purported beneficiary designation or transfer of rights under the policy. The undersigned represents and warrants any information or documents provided to AUL by the undersigned prior to and after the date of the application for insurance and the facts and other matters contained in the foregoing are true and accurate to the best of the undersigned's knowledge and belief. The undersigned understands and agrees: 1) any insurance coverage or benefits is contingent upon any statements made to AUL as being complete and correct and 2) benefits under any policy will be paid only if AUL decides the applicant is entitled to them under the policy. Signature of Witness Sionature of Insured (The Witness must have no interest in the po/icy/contract or be a named beneficiary) Printed Name Printed Name Date Date Lack of Notice of Community Property Interest: If AUL has not previously received written notice of a community property interest and if the space for consent below is not signed by a person having such an interest, then AUL shall be entitled to rely upon its good faith that no such interest exists. AUL assumes no responsibility of inquiry regarding such interest and, in consideration of acknowledgement of this designation, the insured person listed above, for himself/herself and his/her estate, heirs, successors and assigns, agrees to indemnify AUL and hold it harmless from the consequences of acknowledging this beneficiary designation. Spouse's signature and consent (if applicable}:3 _ Date 1 Total percentage must equal 100%. If percentages do not equal 100%, then oonefits will be paid on a pro-rata basis, according to the percentages shown. If no percentages are shown, benefits will be distributed equally. 2 Total percentage must equal 100%. If percentages do not equal 100%, then benefits will be paid on a pro-rata basis, according to the percentages shown. If no percentages are shown, benefits will be distributed equally. 3 Spouse's signature is needed only if Insured/Beneficiary lives in a community property state which currently include AZ, CA, ID, LA NM, NV, TX, WA and WI. G-13117 8/19/14 G-620377 III-A ---PAGE BREAK---