313 Beneficiary Form

Beneficiary Designation Form
IMPORTANT INFORMATION ABOUT BENEFICIARY DESIGNATIONS

The Beneficiary Designation Form allows you to designate one or more beneficiaries to receive applicable benefits in the event of your death. If we do not have a designated beneficiary on file in the Fund Office, or if you do not name a beneficiary, payment may not be made to the person(s) you intend to receive the benefit. For further information regarding payment of death benefits, please refer to your Summary Plan Description. No change in beneficiary designation shall be effective or binding on the Plan or the Trustees unless it is received by the Fund Office prior to the time any payments are made to the beneficiary(ies) whose designation is on file.

It is also important that you keep the Plan informed of your current address. Address changes must be submitted in writing to the Fund Office.

DEFINITIONS

You may find the following definitions helpful in completing this form:

Primary Beneficiary(ies): the person(s) or entity you designate as the first in line to receive your benefit. You may name more than one Primary Beneficiary. Payment will be made in equal shares unless otherwise specified. The percentages you list for all beneficiaries should total 100%. In the event that a designated primary beneficiary predeceases you, the benefit will be paid to remaining primary beneficiaries in equal share or all to the sole remaining primary beneficiary.

Contingent Beneficiary(ies): the person(s) or entity you designate to receive your benefit in the event your primary beneficiary predeceases you. You may name more than one Contingent Beneficiary. Payment will be made in equal shares unless otherwise specified. The percentages you list for all beneficiaries should total 100%. In the event that a designated contingent beneficiary predeceases you, the benefit will be paid to remaining contingent beneficiaries in equal share or all to the sole remaining contingent beneficiary.

Health/Welfare: a package of hospitalization, medical, and other benefits.

Pension: a multiemployer defined benefit pension fund. The Pension Plan provides several kinds of pension benefits with varying eligibility requirements and benefit amounts. Please refer to your most current annual statement or contact the Fund office for a summary of your hours.

Annuity: a defined contribution profit-sharing plan. For annuity balances, please refer to your most current annual statement. Balances will not be disclosed over the phone.

INSTRUCTIONS
- Complete this form to designate one or more beneficiaries to receive applicable benefits in the event of your death for EACH Fund indicated.
- For Pension and Annuity benefits, a married participant must obtain his/her spouse's consent to the designation of someone other than the spouse as a primary beneficiary. You may fill this form out again in the future if you desire to change your beneficiary designation, but for Pension or Annuity benefits, your spouse must consent to any such change.
- Please note that in cases of divorce, a former spouse will no longer be considered an approved beneficiary unless he/she has been added after the divorce. In such instances, a new beneficiary form must be completed, signed and dated after the divorce has been filed.
- The Participant must read, sign and date the authorization.
- Submit the completed form and keep a copy for your records.
Do you plan to name someone other than your spouse as a primary beneficiary to receive some or all of your Pension or Annuity benefits?

YesNo

Participant Information
Name*

First NameLast Name
Last 4 of Social Security Number*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email Address*
Marital Status*

SingleMarriedSeparatedDivorced (provide copy of divorce decree(s))Widowed (provide copy of death certificate)
Please indicate the Funds you would like to designate beneficiaries for*

Health FundPension PlanAnnuity Fund
N.E.C.A. Local 313 I.B.E.W. Health Fund
Primary Beneficiaries
(1) Name

First NameLast Name
(1) Social Security Number
(1) Date of Birth

MonthDayYear
Date
(1) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(1) Phone Number
(1) Relationship
(1) Beneficiary %
(2) Name

First NameLast Name
(2) Social Security Number
(2) Date of Birth

MonthDayYear
Date
(2) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(2) Phone Number
(2) Relationship
(2) Beneficiary %
Contingent Beneficiaries
(1) Name

First NameLast Name
(1) Social Security Number
(1) Date of Birth

MonthDayYear
Date
(1) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(1) Phone Number
(1) Relationship
(1) Beneficiary %
(2) Name

First NameLast Name
(2) Social Security Number
(2) Date of Birth

MonthDayYear
Date
(2) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(2) Phone Number
(2) Relationship
(2) Beneficiary %
N.E.C.A. Local 313 I.B.E.W. Pension Plan
Primary Beneficiaries
(1) Name

First NameLast Name
(1) Social Security Number
(1) Date of Birth

MonthDayYear
Date
(1) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(1) Phone Number
(1) Relationship
(1) Beneficiary %
(2) Name

First NameLast Name
(2) Social Security Number
(2) Date of Birth

MonthDayYear
Date
(2) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(2) Phone Number
(2) Relationship
(2) Beneficiary %
Contingent Beneficiaries
(1) Name

First NameLast Name
(1) Social Security Number
(1) Date of Birth

MonthDayYear
Date
(1) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(1) Phone Number
(1) Relationship
(1) Beneficiary %
(2) Name

First NameLast Name
(2) Social Security Number
(2) Date of Birth

MonthDayYear
Date
(2) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(2) Phone Number
(2) Relationship
(2) Beneficiary %
N.E.C.A. Local 313 I.B.E.W. Annuity Fund
Primary Beneficiaries
(1) Name

First NameLast Name
(1) Social Security Number
(1) Date of Birth

MonthDayYear
Date
(1) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(1) Phone Number
(1) Relationship
(1) Beneficiary %
(2) Name

First NameLast Name
(2) Social Security Number
(2) Date of Birth

MonthDayYear
Date
(2) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(2) Phone Number
(2) Relationship
(2) Beneficiary %
Contingent Beneficiaries
(1) Name

First NameLast Name
(1) Social Security Number
(1) Date of Birth

MonthDayYear
Date
(1) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(1) Phone Number
(1) Relationship
(1) Beneficiary %
(2) Name

First NameLast Name
(2) Social Security Number
(2) Date of Birth

MonthDayYear
Date
(2) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(2) Phone Number
(2) Relationship
(2) Beneficiary %
Employee Signature
I certify that all information furnished in this form is true to the best of my knowledge. I understand and agree that any misrepresentation may constitute grounds for the denial of benefits to me or on my behalf or for the cancellation or recovery of benefit payments made in reliance thereon.
Please sign

Clear
Today's Date

MonthDayYear
If you have supporting documentation, please upload it here.

Browse Files

Cancelof

Please print and complete a hard copy of this form, which can be found here. You will need to obtain your spouse's consent and it must be acknowledged by a Notary Public.
Should be Empty:

Beneficiary Designation Form

Participant Information

N.E.C.A. Local 313 I.B.E.W. Health Fund

N.E.C.A. Local 313 I.B.E.W. Pension Plan

N.E.C.A. Local 313 I.B.E.W. Annuity Fund

Employee Signature