Lifetime Income Security Accrual Fund

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*

MonthDayYear
Employee Gender*

MaleFemale
Employee Email Address*
example@example.com
Employee Home Phone No.*
Employee Mobile Phone No.*
Employee Mailing Street Address*
City*
State*
ZIP code*
Name of Employer*
Hire Date*

MonthDayYear
Union and Local No.*
Marital Status*

SingleMarriedDivorcedWidowedRemarried
Current Spouse Name
Spouse Birthdate

MonthDayYear
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*
Email Address*
example@example.com
Birthdate*

MonthDayYear
Date
Relation to Employee*
Signature*

Clear
Date

MonthDayYear
Fund ID
Should be Empty:

EMPLOYEE INFORMATION FORM