BENEFICIARY AFFIDAVIT
AND INDEMNIFICATION AGREEMENT
The purpose of this form is to designate a beneficiary who has an interest in
property rights with respect to certain property, referred to herein as “Unearned
Premium,” which shall be distributed by UnitedHealthcare Insurance Company
(the ”Administrator”) to the beneficiary upon execution of this form. This form
shall be used for no other purpose.
I Affidavit
The undersigned, ______________________ (the “Beneficiary”), being duly
sworn, under oath does depose and say:
1. That the Beneficiary is a surviving _________________
(natural or legally adopted child, parent, sibling, other relative) of
_________________________ (the “Decedent”), or a duly appointed fiduciary of
the estate of the Decedent. (In the case of a duly appointed fiduciary of the
estate of the Decedent, a copy of the Letters Testamentary, Probate
Certificate, or similar document is required to be attached to this form.)
2. That the Beneficiary represents that he/she is the closest
surviving relative or the Decedent, or the duly appointed fiduciary of the
estate of the Decedent.
3. That the Beneficiary is over eighteen years of age, or is a
guardian of a child of the Decedent who is under eighteen years of age, or is
the duly appointed fiduciary of the estate of the Decedent.
4. That the Beneficiary has a legal claim to the Unearned
Premium.
II Indemnification Agreement
The Beneficiary shall, in consideration for the receipt of the Unearned
Premium, indemnify and reimburse the Administrator for all amounts required to be
paid by the Administrator. The Beneficiary understands that this means that if, after
the Beneficiary receives the Unearned Premium, it is determined that the
Administrator is required to pay all or part of the value of the Unearned Premium to
someone else, or that the Administrator must pay cost and/or damages as a result of
the distribution of the Unearned Premium to the Beneficiary, the Beneficiary will be
responsible to reimburse the Administer for any such payments, costs and/or
damages.
______________________________________________
Signature of Beneficiary
Dated this __________ day of _____________, 20__.
Please print the required information:
Name of Beneficiary Address
City State Zip
Social Security No. Date of Birth Telephone No.
Please return completed form along with the original check to:
UnitedHealthcare
Railroad Accounts
185 Asylum St
CT039-03B
Hartford, CT 06103
STATE OF )
: ss.
COUNTY OF )
On this ________________ day of _________________, 20___, before me,
a notary public, personally appeared _________________________ who acknowledged
himself/herself to be the person whose name is signed to the foregoing instrument and that
he/she executed the foregoing instrument for the purposes set forth therein.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
[Notary Seal] Notary Public
My Commission expires:
