Ironworkers 118 - Active Participant Designation of Beneficiary Form (All benefits except Annuity Trust)

CALIFORNIA FIELD IRONWORKERS TRUST FUNDS

Pension Trust • Welfare Plan • Vacation Trust • Apprenticeship Training & Journeyman Retraining Fund
Active Participant Designation of Beneficiary Form

(All Benefits Except Annuity Trust)

Complete this form to designate beneficiaries for benefits from the SRB, Vacation Trust, the Welfare Fund, and the Pension Fund.
I. Participant Information:
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last 4 SSN:*
MaleFemale
Telephone Number*
Date of Birth*

MonthDayYear
Date
Local Union:*
SingleMarriedDivorcedLegally Separated
Name of Spouse (if married)
Date (if divorced)

MonthDayYear
Date
Date (if legally separated)

MonthDayYear
Date
II. Beneficiary Designations

I hereby designate the following as my beneficiary(ies) for the benefits listed below. If you name more than one beneficiary for each Fund, benefits will be divided equally among your surviving beneficiaries unless a specific percentage is provided.

Rows	Beneficiary's Name	Address	Relationship
SRB
Vacation
Welfare Fund Death Benefit (Including AD&D)
Pension Fund (Pre-Retirement Death Benefit)

I understand that my beneficiary designations specified above remain in effect until I notify the Trust Fund Office in writing that I revoke one or more of the designations, specifying which designations are revoked, or until I file a new designation of beneficiary form with the Trust Fund Office. I further understand that if, as a result of my death, my surviving spouse is entitled to a pre‐retirement surviving spouse benefit from the Pension Fund, no other benefits will be payable from the Pension Fund, and my designation of beneficiary(ies) for the Pension Fund will be void.
Participant's Signature*

Clear
Date*

MonthDayYear
Date
131 N. El Molino Avenue, Suite 330 • Pasadena, CA 91101‐1878

(626) 792‐7337 • 1 (800) 527‐4613

Visit us on the web at www.ironworkerbenny.com

ENR001A April 2013
Should be Empty:

CALIFORNIA FIELD IRONWORKERS TRUST FUNDS

Active Participant Designation of Beneficiary Form

I. Participant Information:

II. Beneficiary Designations