Funeral Fund Beneficiary Form

Funeral Fund

Beneficiary Form
I the undersigned here declare that in the event of my death I;

(a) hereby recommend that payment of any benefits from the above fund be made to the following dependants or,

(b) having no dependants, hereby request that payment of any benefits from the above funds be made to the following beneficiaries

in the shares set out hereunder:
Full Name*

First NameLast Name
Employee Number*
List of Beneficiaries
Beneficiary 1
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Member
Share of Benefit
Beneficiary 2
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Member
Share of Benefit
Beneficiary 3
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Member
Share of Benefit
Beneficiary 4
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Member
Share of Benefit
Beneficiary 5
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Member
Share of Benefit
Beneficiary 6
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Member
Number
SIGNATURE OF EMPLOYEE*

Clear
DATE*

MonthDayYear
Date
Should be Empty: