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UHRS[removed]Personal Accident Insurance Plan Beneficiary Designation Form Complete and return form to: Personal Accident Insurance Plan, University Human Resource Services, 400 E. 7th Street, Poplars E165, Bloomington,
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Document Date: 2011-01-31 14:52:24

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File Size: 109,58 KB

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City

Other Town / Employee / Any Town / /

Facility

University Human Resource Services / Indiana University / /

Organization

Indiana University / Division of Benefits / /

Person

Mary L. Doe / MARY E. SMITH / John K. Doe / Martha B. Doe / Hazel B. Gray / JOHN J. SMITH / Robert C. Black / Jane B. Smith / /

Position

testamentary trustee / Trustee / /

ProvinceOrState

Indiana / Ohio / /

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