F01604 Designation of Insurance Beneficiary for HQ-based Staff

F01604 Designation of Insurance Beneficiary for HQ-based Staff

Instructions:

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Information on Completing the Form

 Please return this signed form to HR Operations  (Select one transmittal format, and submit only once):

a.  E-mail at hroperations@worldbank.org         

b.  Mail to: HR Operations, World Bank MSN MC3-300, P.O.Box:1420, Landover MD 20785, USA

c.  Fax +1 (202) 522-7026

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 F01604. 

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 16 Oct 2024

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.

If no boxes are checked, in the event of a loss the beneficiary(ies) named below will be the beneficiary(ies) of any program for which the deceased is enrolled.

Primary Beneficiary Details (Mandatory)

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 Details (Recommended)

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 Certification        

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.

Staff Member 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.

Completing the Form for Designation of Beneficiary for HQ-Based Staff

Common mistakes on Form F01604

ü         Boxes not checked in Section 2

If you do not check a box and a beneficiary is named, in the event of a loss the named beneficiary will be the beneficiary of any program for which the deceased is enrolled. If you would like to designate different beneficiaries for each Benefit Program, please complete a separate form F01604 for each Benefit Program.

•  All Regular, Open,  Term staff and Executive staff  have basic life and accident insurance coverage,

    and may have elected optional life or accident coverage.

•  Some retirees elected optional retiree life insurance coverage.

•  All ETC/ETT appointments have basic group term life insurance equivalent to one times their net annual

   salary (for staff paid on a gross basis, the net equivalent is 75% of the gross amount).

•  All STC/STT and ETC/ETT appointments (including retirees on those appointments) have basic

   accidental death insurance coverage while on business of the World Bank.

ü          Minor child listed as beneficiary

Minor child(ren) should not be designated as beneficiary because of minors' general legal incapacity. When a guardianship or trust for such children is or has been established by will or other appropriate legally bind instrument, we recommend obtaining legal advice concerning designation of beneficiaries so as to ensure that the use and benefit of the proceeds go for the children.

ü          Bank/lender listed as beneficiary to use insurance as loan collateral

Insurance proceeds can not directly pay off loans. You should either create a trust as your beneficiary with instructions to pay off your debts, or name your estate as beneficiary and create a will to divide your assets.

ü          Too many contingent beneficiaries listed

 You should name a contingent beneficiary in the event your primary beneficiary predeceases you, but keep it simple! Use the samples provided below.

ü          No contingent beneficiary listed

Make sure you specify your wishes if your primary beneficiary pre-deceases or co-deceases you.

ü         Charity or institution listed as beneficiary

Full name, address, phone, fax and e-mail address of the beneficiary must be provided.

REMINDER

If you need legal advice, you should contact the Bank Group's legal advisor for a free consultation and referral to a competent attorney in your resident state to draw up a trust, create a will,  and designate beneficiaries so that your needs are best served. Contact Jeffrey Silverstein on x81609 and indicate that you are a Bank Group staff member, seeking legal advice and referral.

Examples of Beneficiary Designations

Overview

The following examples have been prepared for your guidance in completing the designation of beneficiary form(s).  State your beneficiary's name and relationship to you.  Please note:

ü         A married woman should be designated by her first name, middle initial, and last name (for example Mary J. Smith, not Mrs. Thomas A Smith).

ü         If your beneficiary is not related to you by blood or marriage, “business associate,” “partner” or other economic relationship should be inserted; otherwise, insert “non-relative.”  Please include the current home address.

ü         Minor children cannot receive insurance proceeds.

Examples

1.         Single beneficiary

“Mary J. Smith, wife, 123 Oregon Street, Chicago, IL 30333”

2.         Primary and contingent beneficiary

“Mary J. Smith, wife, if living, 227 Oak Terrace, Los Angeles, CA 90226; otherwise the children born of the insured to Mary J. Smith, equally or equally to the survivors, or to the survivor.”

3.         Joint beneficiaries

“In equal shares to Mary J. Smith, 1301 Wyandotte Avenue, Kansas City, MO (wife) and James Arthur Smith, 1222 New York Avenue, New York, NY (father) but if one of them shall predecease me then in their entirety to the survivor of them.”

4.         Unequal amounts:

“50% to Mary J. Smith, wife, 6 Pine Loop, Toronto, Ontario, Canada; and

25% to Alice C. Smith, sister, 900 James Blvd, Richmond, VA 23205; and

25% to Richard B. Smith, brother, 49 rue Picolo, Paris, France;

with the share of any deceased beneficiary to be paid in equal shares to the survivors or to the survivor.”

5.         Trustee beneficiary:

“The Trust Company of Smith, Illinois as trustee under a Trust Instrument dated April 1, 1999.”