Pbgc Form 709 - Plan Participation Information
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2Plan Participation Information
PBGC Form 709
Approved OMB 1212-0055
Expires 04/30/06
Pension Benefit Guaranty Corporation.
For assistance, call 1-800-400-7242
P.O. Box 151750 Alexandria Virginia 22315-1750
Plan Name:
Plan Number:
Participant Name / SSN:
Date Printed:
Date of Plan Termination:
INSTRUCTIONS: Complete this form if you believe you are eligible for a pension. Use dark ink and be sure to
print clearly. If you have questions, call our Customer Contact Center at 1-800-400-7242 for information.
1. General information about you
Last Name
First Name
Middle Name
Other Name(s) Used
Social Security Number
Date of Birth
Gender
MALE
-
-
/
/
FEMALE
Mailing Address
Apartment / Route Number
City
State
Zip Code
Country
Email (optional)
Daytime Phone
Evening Phone
E
XTENSION
(
)
-
x
(
)
-
Name of plan participant, if different
Social Security Number
-
-
2. Participant employment information -
Related to the claim for benefits.
Employer Name
City and State
Title
Location of Employment
Date of Hire
Date of Birth
Reason for Termination
/
/
/
/
CONTINUE
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