Carpet & Fabricare Institute

Insured Information

Name
Name
First
Middle
Last
Sex assigned at birth:
Home Address
Home Address
City
State/Province
Zip/Postal
Business Address
Business Address
City
State/Province
Zip/Postal
$.00
Do you file a K-1 or W-2?
Would you like to enroll in Life, AD&D, and LTD insurance?
Please check all of the primary beneficiaries:

First Beneficiary

Name
Name
First
Middle
Last
Sex assigned at birth:
Is this beneficiary’s address the same as the insured (above)?
Address
Address
City
State/Province
Zip/Postal
Relationship to Insured
%

Second Beneficiary

Name
Name
First
Middle
Last
Sex assigned at birth:
Is this beneficiary’s address the same as the insured (above)?
Address
Address
City
State/Province
Zip/Postal
Relationship to Insured
%

Third Beneficiary

Name
Name
First
Middle
Last
Sex assigned at birth:
Is this beneficiary’s address the same as the insured (above)?
Address
Address
City
State/Province
Zip/Postal
Relationship to Insured
%

Your Estate

%

Testamentary Trust created in your Will

%

Living (Inter Vivos) Trust

Trustee’s Name
Trustee's Name
First
Middle
Last
Address
Address
City
State/Province
Zip/Postal
%

Charity or Organization

Address
Address
City
State/Province
Zip/Postal
%
%
This must add to 100% before you can submit this form.