Benefit Information Request Page 2
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1
2Request Other Information:
Check applicable box(es)
Beneficiary Designation (ET-2320) form
Elect participation in the Variable Trust (active WRS members only)
Duplicate Statement of Benefits. This
Cost of purchasing six-month qualifying service (active WRS members only)
document provides an annual account
Non-teachers only, if WRS service began before Jan. 1, 1973.
summary for divorce and/or mortgage
Cost of purchasing forfeited service (service forfeited if you previously closed
verification purposes.
your account by taking a separation benefit) (active members only)
Cancel participation in the Variable Trust
Approx. begin/end dates of service forfeited: _____________________
Other _____________________________
Other name(s) used: ________________________________________
Name of former employer(s): _________________________________
Complete the following sections to report the death of a WRS member and to request information about
potential death benefits. This is not an application for death benefits. A Death Benefit Estimates & Application (ET-
6309) will be sent to eligible beneficiary(ies) after ETF reviews this request.
Necessary Documentation:
ETF requires a copy of the member’s death certificate. If the deceased member was enrolled in the Wisconsin
Public Employers' Group Life insurance program, a certified copy of the death certificate is required. ETF will
forward the certified copy of the death certificate to the life insurance carrier with notification of the amount of
coverage in force at the time of death.
If the deceased member had active military service prior to January 1, 1974, ETF may be able to add a military
service credit to his/her account which may increase the amount of the death benefit payable. If the deceased
member was age 55 or older (age 50 for protective category employees) and was still actively employed in a
covered WRS position at the time of death, send a copy of their military service discharge papers (i.e., DD-214).
These papers must show the date of entry into active service, the discharge date and type of discharge (must be
other than “Dishonorable”).
Information About the Deceased Member:
Name (First, middle, last, previous/maiden)
Social Security number or Member ID
Birth date
Date of death
Last WRS Employer
(MM/DD/CCYY)
(MM/DD/CCYY)
Your Contact Information:
Name (First, middle, last, previous/maiden)
Address
City
State
ZIP code
Telephone
Relationship to deceased
(
)
(
)
Home:
Work:
Birth date (MM/DD/CCYY) (complete only if you may be a beneficiary)
Social Security number (complete only if you may be a beneficiary)
Survivor’s name if other than yourself (i.e., spouse or domestic partner, if no spouse or domestic partner, list child(ren) or next of kin)
Survivor’s birth date (MM/DD/CCYY) (if available)
Survivor’s Social Security number (if available)
Survivor’s relationship to deceased
Survivor’s telephone
(
)
(
)
Home:
Work:
ET-7301 (REV 1/20/2016)
Page 2 of 2
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