UA 392 Beneficiary Designation Form

Universal Beneficiary Designation Form
If eligible, beneficiary(ies) listed below shall receive participant's death benefits from the Health & Welfare Fund and/or Pension Fund.

The designation of a spouse as beneficiary is void upon divorce, and a new designation form will be required in order to name a new beneficiary(ies) or to re-name your former spouse as beneficiary.
Lump Sum Death Benefit If Applicable - Health & Welfare Fund
Beneficiary 1
Name

First NameLast Name
Relationship to Member
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Percentage
%
PrimaryContingent
Beneficiary 2
Name

First NameLast Name
Relationship to Member
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Percentage
%
PrimaryContingent
Beneficiary 3
Name

First NameLast Name
Relationship to Member
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Percentage
%
PrimaryContingent
Return Of Contributions Death Benefit If Applicable - Pension Fund
Beneficiary 1
Name

First NameLast Name
Relationship to Member
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Percentage
PrimaryContingent
Beneficiary 2
Name

First NameLast Name
Relationship to Member
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Percentage
PrimaryContingent
Beneficiary 3
Name

First NameLast Name
Relationship to Member
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Percentage
PrimaryContingent
Primary Beneficiary: The primary beneficiary is the person(s) you name to receive death benefits. You may name more than one beneficiary. If you specify benefit percentages, the total must equal 100%. If you do not specify benefit percentages, proceeds will be paid in equal shares to the primary beneficiaries who survive you.

Contingent Beneficiary: The contingent beneficiary is the person(s) you name to receive death benefits if no primary beneficiary survives you or is void because of divorce. If you specify benefit percentages, the total must equal 100%.

No Beneficiary: If you do not name a beneficiary, or if no beneficiary survives you, we will pay death benefits in the order of survivorship shown in the Summary Plan Description.
This Designation revokes any prior beneficiary designations, made by me, for my benefit.
Participant Name*

First NameLast Name
Participant Social Security # (not working)
Participant Social Security #*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date*

MonthDayYear
Date
Signature

Clear
Plumbers, Pipe Fitters & Mechanical Equipment Service Local Union No. 392
1228 Central Parkway, Suite 100 Cincinnati, Ohio 45202-7500

Review of Death Benefits Payable from the Pension & Welfare Plans

Lump Sum Death Benefits

1. Welfare Fund Death Benefit.

The type of death benefit you are eligible for under the Welfare Plan depends on whether you are eligible for Class A(Active) benefits at the time of your death or if you are eligible for Class C or F (Retiree) benefits at the time of death.The details of both death benefits are as follows.
1. Active Participant
  
  You are eligible for a $10,000 death benefit if you are eligible for Class A (Active) benefits at the time of death.
2. Retired Participant
  
  You are eligible for a $10,000 death benefit if you are eligible for Class C or Class F (Retiree) benefits time of death. A $2,000 death benefit applies to Local 59 Retirees. There is no death benefit for Local 113 retirees who participate because of their union's merger with Local 392 on or after May 1, 1988.
2. Pension Fund Death Benefit.

You are eligible for a $5,000 death benefit from the Pension Fund if a death benefit is not payable from the Welfare Plan and you retired on or after October 1, 1999 from the active service of an employer.

Return of Contribution Death Benefit Under the Pension Plan

The Return of Contribution Benefit is paid to the beneficiary of a participant in situation where the participant and their qualified spouse(s) (if applicable) die before receiving total payments which equal or exceed a guaranteed amount. The guaranteed amount is the total of all contributions received on your behalf.

If you are married and your qualified spouse is eligible to receive a Survivor Annuity upon your death, you may want to name someone other than your spouse as the beneficiary for the benefit because the UBD would only determine benefits in the event your qualified spouse either died before you or at the same time as you. If you don't know whether your spouse is qualified for a Survivor Annuity, you should contact the Fund Office.

If you have any questions, please contact the Fund Office.

Summary of Materials Modifications
Welfare Fund EIN: 31-0561070, PN: 501; Pension Fund EIN: 31-0655223, PN: 001
Should be Empty:

Universal Beneficiary Designation Form

Lump Sum Death Benefit If Applicable - Health & Welfare Fund

Return Of Contributions Death Benefit If Applicable - Pension Fund

This Designation revokes any prior beneficiary designations, made by me, for my benefit.