Life Insurance Beneficiary Election Form

Employer / Group Information

Employer:

Delta Advanced Trucking, Inc.

Group:

Delta Advanced Trucking Benefits Plan

Policy Reference:

DAT-2025-LIFE

Employee / Insured Information

Employee Name:

Maria Lopez

Employee ID:

DRV-002

Address:

450 N Michigan Ave, Chicago, IL 60611

Phone:

707-773-6386

Email:

maria.lopez@boftransport.com

Basic Life Insurance Election

Basic Life — Active / Included

Basic Life — Declined

Supplemental Life Insurance Election

Supplemental Life — Elected

Waived / No payroll deduction on file

Primary Beneficiary

Beneficiary Name	Relationship	Address	Allocation %	Allocation Total
Demo Beneficiary A	Spouse	50.0	$50,000.00
Total Allocation:		100.0%		$100,000.00

Contingent Beneficiary

Beneficiary Name	Relationship	Address	Allocation %	Allocation Total
Total Allocation:		100.0%		$50,000.00

Employee Certification

I hereby certify that the beneficiary designations made are in accordance with my wishes and that I have provided all required information to the best of my knowledge. I understand that I may change these designations at any time by submitting a written request to Human Resources.

Employee Signature

Maria Lopez

Date:

2025-11-09

Employee Name (Print): Maria Lopez

HR/Benefits Review

M. Torres

Date:

2025-11-10

HR Representative: M. Torres

Relationship Note: This form connects to benefits administration and life insurance policy management where applicable.