Form Rs 6046 - Application For Accidental Death Benefit
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1
2Please return this application to the Retirement System in an envelope marked “Personal and Confidential, Mail Drop 7-1”
RECEIVED
Application for
Office of the New York State Comptroller
Accidental Death Benefit
New York State and Local Retirement System
110 State Street, Albany, New York 12244-0001
RS 6046
(Rev. 12/13)
INSTRUCTIONS: Please print plainly or type. The application must be signed and notarized on reverse side.
Please call our Call Center at 1-866-805-0990 if you need help completing this application.
1. NAME OF DECEASED MEMBER:
2. SEX:
3. SOCIAL SECURITY NUMBER*:
M
F
4. ADDRESS:
5. REGISTRATION NUMBER:
6. DATE OF BIRTH
/
/
7. TELEPHONE NUMBERS:
HOME
(
)
8. EMPLOYER:
WORK
(
)
CELL
(
)
9. PAYROLL TITLE
10. DATE OF DEATH
11. FOR UNITED STATES TAX WITHHOLDING AND REPORTING PURPOSES (PLEASE CHECK ONE),
I AM A:
U.S. CITIZEN
RESIDENT ALIEN
NONRESIDENT ALIEN
12. LIST BELOW ALL DOCTORS WHO TREATED
(The last box to name doctor who performed autopsy.)
Primary Care Physician
Doctor
Doctor
Internal Med/Family Practitioner
Medical Speciality
Medical Speciality
Street
Street
Street
City, State and Zip Code
City, State and Zip Code
City, State and Zip Code
Doctor
Doctor
Autopsy Doctor
Medical Speciality
Medical Speciality
Medical Speciality
Street
Street
Street
City, State and Zip Code
City, State and Zip Code
City, State and Zip Code
13. LIST BELOW ALL HOSPITALS WHERE DECEASED WAS TREATED, IF ANY. (Use additional sheets if required)
Hospital
Dates of Admission
Hospital
Dates of Admission
Street
Street
City, State and Zip Code
City, State and Zip Code
Dates of Admission
Dates of Admission
Hospital
Hospital
Street
Street
City, State and Zip Code
City, State and Zip Code
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