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Lifetime Income Security Accrual Fund
Physical Address 7525 SE 24th Street, Suite 200, Mercer Island, WA 98040 - Mailing Address PO Box 34203, Seattle, WA 98124
EMPLOYEE INFORMATION FORM
Employee Last Name
*
Employee First Name
*
Employee Middle Initial
Employee Social Security No.
*
Employee Birthdate
*
/
Month
/
Day
Year
Employee Gender
*
Male
Female
Employee Email Address
*
example@example.com
Employee Home Phone No.
*
Format: (000) 000-0000.
Employee Mobile Phone No.
*
Format: (000) 000-0000.
Employee Mailing Street Address
*
City
*
State
*
Please Select
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Texas
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ZIP code
*
Name of Employer
*
Hire Date
*
/
Month
/
Day
Year
Union and Local No.
*
Marital Status
*
Single
Married
Divorced
Widowed
Remarried
Current Spouse Name
Spouse Birthdate
/
Month
/
Day
Year
Spouse Social Security No.
BENEFICIARY
IF
UNMARRIED
(FOR
RECEIPT
OF
ANY
PAYABLE
DEATH BENEFITS)
Beneficiary Last Name
*
Beneficiary First Name
*
Beneficiary Middle Initial
Mailing Address
*
Street, City, State, ZIP
Phone
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Birthdate
*
/
Month
/
Day
Year
Date
Relation to Employee
*
Signature
*
Date
/
Month
/
Day
Year
Fund ID
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