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Get Bene Des. And Change Request - PU - Purdue University

Ompany Group Insurance Department Employer Policy number 33727/33759/33728 Insured Insured's date of birth PUID number Policyowner (if different than the insured) Policyowner's telephone number ( ) Print policyowner's name and address below. New address INSTRUCTIONS: 1. Print or type in the space below, the full name, address, relationship to the insured, and share % of each beneficiary to be named. 2. Sign and date the completed form. 3. Return to Minnesota Life using the address abov.

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