F200054 Designation of Life Insurance Beneficiary for Retirees


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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 G2-202, 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 F200054. 

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

F200054 Designation of Life Insurance Beneficiary for Retirees

Retiree 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 Life Insurance 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

MANDATORY - Indicate Primary Beneficiary Name(s),  Relationship(s),  Address(es) and Contact #

First Name*

Middle Name

Last Name*





Postal/Zip Code*

Country Telephone Code*

Contact Number*

Contingent Beneficiary

RECOMMENDED - Indicate Contingent Beneficiary Name(s),  Relationship(s),  Address(es) and Contact #

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

First Name

Middle Name

Last Name





Postal/Zip Code

Country Telephone Code

Contact Number

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.*

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. 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. 



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.