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Lbany, NY 12244; telephone number 518-474-3524. This form is for designating beneficiaries to receive ordinary death benefits, if ordinary death benefits become payable on account of your death. You may not designate beneficiaries to receive accidental death benefits. The beneficiaries entitled to receive accidental death benefits are mandated by statute. Please go to the reverse side of this form to designate beneficiaries, sign and date the form, and have the form notarized. RS 5127.

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