Form Eb-0791-0812 - Designation Of Beneficiary

INSTRUCTIONS FOR COMPLETING THE DESIGNATION OF BENEFICIARY FORM

Indicate Your Contribution Program — Check the appropriate box of the contribution program of which you are

a member.

Indicate Your Employment Status — Check the box to indicate if you are an active employee or retired member.

3 - 5. Member Information — PRINT your full name, date of birth, and full Social Security number.

Location Name — PRINT the name of your active or retired location.

Nominate Your Group Life Insurance Beneﬁ ciary — PRINT the name of your primary beneﬁ ciary(ies) and

contingent beneﬁ ciary(ies). If this section is not completed, this beneﬁ t will automatically default to your estate.

All members must complete the following – Make sure to sign, date and provide your address

and daytime telephone number on the form. On any additional sheets used to specify beneﬁ ciary information,

please be sure to include your signature and date on the sheet, and print your name, address, daytime telephone

number, and your full Social Security number.

Alternate Beneﬁ t Program/DCRP

Division of Pensions & Beneﬁ ts

P.O. Box 295

Trenton, NJ 08625-0295

If you have any questions on how to complete your Designation of Beneﬁ ciary form, send an e-mail to

pensions.nj@treas.nj.gov or visit

DOS AND DON’TS OF BENEFICIARY DESIGNATION

Do complete this form in ink. Completing this form in pencil makes the form unacceptable.

Do use proper names. Nicknames are not acceptable. When naming a married female as beneﬁ ciary, be certain the

proper name is given, e.g. Mary J. Jones, not Mrs. John R. Jones.

Do use speciﬁ c names. The phrase “my children” or “my grandchildren” will not be accepted. You must list each child

using his or her speciﬁ c name.

Do make a copy of your completed Designation of Beneﬁ ciary form before submitting it to the Division and pe-

riodically review it to make sure all beneﬁ ciary information is correct. It is especially important to update this information

after a life event such as a birth, marriage, divorce, or death.

Don’t use a Designation of Beneﬁ ciary form to update a beneﬁ ciary’s address. A signed letter notifying us of your

beneﬁ ciary’s address change will sufﬁ ce. Your letter will be added to your ﬁ le so your beneﬁ ciary information remains

current.

Don’t use “white out” or cross out names to make changes in designation. This makes the form unacceptable and a

new form will be mailed to you.

Don’t name the same person or persons in both the “primary” and “contingent” beneﬁ ciary sections. This makes

the form unacceptable and a new form will be mailed to you.

Before submitting the Designation of Beneﬁ ciary form, be sure to complete all the items indicated above. Failure to

complete this form totally and accurately may jeopardize the payment of your beneﬁ ts. For any designation not naming

a speciﬁ c person or a share and share alike distribution, please refer to Fact Sheet #68, Designating a Beneﬁ ciary.

Form Eb-0791-0812 - Designation Of Beneficiary - 2012 Page 3