F01603 Designation of Insurance Beneficiary for CO Staff

Instructions:

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Information on Completing the Form

Please return this signed form to your Country Office Administrator who will fax it to HR Operations at +1-202-522-7025. The original is kept in your staff file in the Country Office.

CAUTION: Please do not use this form to name a Pension Beneficiary. To name a Pension Beneficiary, please contact 1pension@worldbank.org or call +1-202-458-2977.

Click here to check common mistakes on Form F01603. 

Click here to view examples of beneficiary designations.

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 25 Apr 2023

Staff Member's Information

World Bank Group UPI*

First Name*

Last Name*

I, the above-named, hereby designate the following as my beneficiary(ies) to receive, in the event of my death, amounts which may be payable for the Benefits Program(s) I indicate below, and for which I am eligible. This designation expressly revokes all designations of beneficiary, if any, made by me prior to this date, for the Benefits Program(s) I designate.

Beneficiaries - Check all Benefits Programs that apply for one beneficiary designation

Primary Beneficiary

If you wish to designate different beneficiaries for different Benefits Programs, complete one form for each designation. 

First Name*

Middle Name

Last Name*

Relationship*

Country*

City*

Address*

Postal/Zip Code*

Country Telephone Code*

Contact Number*

Distribution Percentage*

Contingent Beneficiary

Contingent beneficiaries receive benefits only if the primary beneficiaries above are unable to receive benefits

First Name

Middle Name

Last Name

Relationship

Country

City

Address

Postal/Zip Code

Country Telephone Code

Contact Number

Distribution Percentage

Beneficiary Clarification      

Is a beneficiary named above aged 17 or younger? *

If you answered YES: Please click here below to certify that you are aware of the consequences of naming minor children as beneficiaries, as described on the accompanying documentation to this form.*

Authorization and Signature

I hereby authorize the World Bank Group or the World Bank Group's insurers, to pay amounts to the beneficiary(ies) designated on this form. I also agree on behalf of myself and my heirs, administrators and representatives and all persons claiming by, through or under me, that payment of any amounts to the above beneficiary(ies) shall be a complete discharge and release of the World Bank Group for and to the extent of the amounts so paid. I acknowledge that the beneficiary(ies) named for the Benefits Programs I indicated on this form apply only to Benefits Programs to which I have enrolled, and that in the event of any conflicts between enrollment and designation of beneficiaries for a particular Benefits Program, the World Bank Group shall use my enrollment decision and not my beneficiary(ies) designation to determine benefits that shall be paid. If any individual beneficiary designated on this form is not living when any of such amounts would otherwise become owing to him or her, and if no beneficiary shall have been designated hereby or pursuant hereto to receive the same in such circumstances, then such part of all of such amounts not so provided for shall be paid to my estate. I reserve the right to change or revoke the above designation of beneficiary(ies), at any time. 

Signature

Date

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.