Aides & Assistants Beneficiary Designation Form

HARRISON CENTRAL SCHOOL DISTRICT

Teacher/School Aide & Teaching Assistant Beneficiary Designation Form
Article VI, section 5 and Article XI, section 6 of the Aides/Assistants collective bargaining agreement provides a death benefit to unit members and requires unit members to designate a beneficiary. Please complete the form to designate a beneficiary.

Any future change to the beneficiary designation must be made in writing to the Office of Human Resources.
Employee Name*

First NameLast Name
Employee Email*
example@example.com
School Assignment*

Harrison High SchoolLouis M. Klein Middle SchoolHarrison Avenue Elementary SchoolParsons Memorial Elementary SchoolSamuel J. Preston Elementary SchoolPurchase Elementary School
Assignment*

Teaching AssistantTeacher AideSchool Aide
Beneficiary Name*

First NameLast Name
Beneficiary Relationship to Employee*
Beneficiary Phone Number*

Area CodePhone Number
Beneficiary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Beneficiary Name (optional - in the event the primary beneficiary cannot be reached)

First NameLast Name
Alternate Beneficiary Relationship to Employee
Alternate Beneficiary Phone Number

Area CodePhone Number
Alternate Beneficiary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

HARRISON CENTRAL SCHOOL DISTRICT