Human Resources Truck Driver

Rounds, Calvin

*********Last Name First Name Mid. Initial SSN

Applicant Information

DESIGNATION Name F. I designate the following person(s) to receive my Death benefit under the above-named Plan:

SPOUSE’S CONSENT (ONLY IF PRIMARY BENEFICIARY INCLUDES SOMEONE ELSE) If someone other than your legal spouse is listed as your primary beneficiary you will need to contact Human Resources. Human Resources

1-270-***-**** ext. 316, 322, or 344

*****@***-***.***

*****@***-***.***

LIFE INSURANCE BENEFICIARY FORM

Enrollment Form – Commercial Truck Driver

Paschall Truck Lines, Inc. • P.O. Box 1080 • Murray, KY 42071 Rounds Calvin ***-**-****

Rounds Katina L Wife 100 4731 Percy Rd Memphis TN 381**-**-**-****

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