Employee Retirement Beneficiary Declaration
This form allows you to designate a beneficiary for your retirement account in the event of your death.
Completing this form ensures that the proceeds of your retirement plan are directed according to your wishes and kept on file in compliance with plan policy.
You may update your beneficiary designation at any time by revisiting this page and submitting a new form. If you have any questions or need assistance, please contact Office Management
Your Name:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Hire:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Beneficiary Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to you:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Submit
Should be Empty: