Life Insurance Beneficiary Designation

The purpose of this form is to allow you to designate a beneficiary or beneficiaries for any death benefit which may be payable from the RCCL Life Insurance Plan while you are signed on the ship. If you would like to change your beneficiary or if the dependant (under age 21) status should change you must complete and sign a new form.

Unique I.D. # ________________

Insured Person (Employee) First Name: Last Name: Date of Birth:

Street Address:

Postal Code: State: Country:

Telephone Number: E-Mail Address:

Primary Beneficiary: __________% First Name: Last Name: Date of Birth:

Street Address:

Postal Code: State: Country:

Telephone Number: E-Mail Address:

Contingent Beneficiary: __________% First Name: Last Name: Date of Birth:

Street Address:

Postal Code: State: Country:

Telephone Number: E-mail Address:

Please list below dependent children under 21 years of age: Full Name: Date of Birth:

Full Name: Date of Birth:

Full Name: Date of Birth:

Full Name: Date of Birth:

Insured person’s signature:

Date Signed:

Witness:

Date Signed:

Original should be signed in blue ink: Hiring Partner – to send to RCCL Invoicing Clerk 2 signed copies: 1 for Hiring Partner – for File; 1 for Employee.