Designation Of Beneficiary For Ktrs Life Insurance Benefit
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1479 Versailles Road, Frankfort, KY 40601
K
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Designation of Beneficiary for KTRS Life Insurance Benefit
Full-time members of the Kentucky Teachers' Retirement System (KTRS) are covered by a life insurance benefit provided by KRS
161.655. KTRS statutes permit an active or retired member to designate a beneficiary to receive the life insurance payment. If a beneficiary
is not designated, the life insurance benefit will be made to the member's estate.
You may name only ONE person, funeral home, a trust pre-approved by KTRS or your estate as your PRIMARY BENEFICIARY.
Additionally, you may name only ONE person, funeral home, a trust pre-approved by KTRS or your estate as a CONTINGENT BENEFICIARY
to receive this benefit in the event your Primary Beneficiary predeceases you.
This section may be used to designate a beneficiary for only the life insurance benefit and is not affected by or contingent upon the
beneficiary/beneficiaries named for your retirement account. If you are a retired member of KTRS and selected an option that includes a
monthly payment to a beneficiary in the event of your death, this designation does not change that beneficiary.
Upon receipt, the completed form will be placed in your KTRS file. Please complete legibly and in ink, retaining a copy for your records.
State statute requires that if you have a living spouse and you designate someone else as your primary beneficiary, the spouse must
sign below to acknowledge he or she is not named as the primary beneficiary.
Beneficiary Designation For the KTRS Life Insurance Benefit
In the event of my death, I direct the Board of Trustees of the Kentucky Teachers’ Retirement System
to pay my life insurance benefit to:
#1: PRIMARY BENEFICIARY
(One person only)
First Name
Last Name
Relationship
Gender
Address/City/State/ZIP
Date of Birth
Social Security Number
The Contingent Beneficiary becomes entitled to this benefit in the event your Primary Beneficiary predeceases you.
#2: CONTINGENT BENEFICIARY
(One person only)
First Name
Last Name
Relationship
Gender
Address/City/State/ZIP
Date of Birth
Social Security Number
This
has been executed on the __________ day of ________________, 20_____,
and is to remain in full force and effect until changed by me.
Designation of Beneficiary
:
Single
Married
Divorced
Widowed
(ONE MUST BE CHECKED)
Marital Status
Signature of Member
Member ID Number
Current Phone Number
Email Address
Printed Name
Address/City/State/ZIP
APPLICABLE: I acknowledge, as the spouse of the above named KTRS member, that I am not the named primary
beneficiary of this benefit and I am not entitled to any life insurance benefit from Kentucky Teachers' Retirement System upon the death
COMPLETE IF
of my spouse. Required by state law (KRS 65.154).
Signature of Spouse _______________________________________________________ Printed Name __________________________________________
Date __________________________
NOTE TO MEMBER: TWO ADULTS OTHER THAN YOUR BENEFICIARIES OR SPOUSE MUST SIGN AS WITNESSES TO YOUR SIGNATURE.
NOTE TO WITNESSES: We, the undersigned, of lawful age, certify that we are acquainted with the member (and spouse of member if
applicable) signing this Designation of Beneficiary form and that such member (and spouse of member if applicable) has requested us to
witness his or her signature as his or her free act and deed.
Witness #1
*MS-AM-15B*
Address/City/State/Zip
Witness #2
Address/City/State/Zip
FORM DB-1 . JAN2013
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