Acknowledgement of Group Life and AD&D Coverage under Student Plan 19
Appointing a beneficiary is an important part of being a member of Student
Plan 19. In the event of your accidental death or dismemberment, having an
appointed beneficiary ensures that your benefits go to the appropriate person(s).
With this form, you also acknowledge that Group Life and Accidental Death and
Dismemberment Coverage are benefits of this plan.
Please print and fill out this form. Mail it to HMSA at the address below.
To avoid delays, please make sure your information is complete.
- Designate a beneficiary. Fill in their name, date of birth, and relationship to
you. If designating more than one beneficiary, divide the benefits into percentages.
Please ensure that percentages add up to 100 percent at each beneficiary level (primary,
- Sign and date the form, and print your name and HMSA number.
- Attach this to your application for HMSA’s Student
Plan 19 and proof of full-time student status.
Mail all application materials to:
P.O. Box 860
Honolulu, HI 96808-0860