UUP Benefit Trust Fund Group Term Life Beneficiary Form

Please fill out the form below to electronically submit a Beneficiary form for your UUP Benefit Trust Fund Group Term Life Insurance.

To enroll and complete a paper enrollment form HERE and you may email, fax or mail to the UUP Benefit Trust Fund.

Fax: 1-866-559-0516 Mail: Benefit Trust Fund , PO Box 15143, Albany, NY 12212-9954 Email: Benefits@uupmail.org

Unum Life Insurance Company Group Policy

Number: 118668-36

Amount of Group Term Life Insurance: $6,000

Employee Information:

*First name:  


*Last name:  

*Date of Birth:  

NYS Employee ID:  




*Zip Code:  



*Non-SUNY Email:  


Beneficiary Information:

First name:  


Last name:  

Date of Birth:  





Zip Code:  

Add more beneficiaries:   minus (HERE)

*Acceptance of Terms

YES! I Agree that Submission of this form constitutes my consent to online beneficiary designation. You will receive an e-mail confirming receipt of this beneficiary form. Please retain a copy of that e-mail for your records.

* Required

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