Election Of Contingent Annuitant Benefit Upon Retirement Form
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1Teamsters Joint Council No. 83 of Virginia
Health & Welfare and Pension Funds
8814 Fargo Road ∙ Suite 200 ∙ Richmond, VA 23229
Phone (804) 282-3131 ∙ 800-852-0806 ∙ Fax (804) 288-3530
Election of Contingent Annuitant Benefit upon Retirement
You have a right to take 30 days to consider the form of benefit.
Retiree’s name ____________________________________________________ SSN_____________________
Contingent Annuitant’s name _________________________________________ SSN_____________________
Contingent Annuitant’s date of birth______________________
I elect to have my Contingent Annuitant receive
50% or
66.7% or
75% or
100% of my pension
benefits in the event of my death. (Check one %)
I hereby swear that I am not married and will not be married as of my retirement effective date of_____________.
I UNDERSTAND THE FOLLOWING CONDITIONS:
1)
If I elect the Contingent Annuitant Benefit, my pension benefits will be adjusted accordingly, to a lesser
amount, on the basis of actuarial equivalence in order to provide the lifetime benefit to my Contingent
Annuitant after my death.
2)
My election of the Contingent Annuitant Benefit cannot be cancelled or changed once I retire under this
benefit unless my Contingent Annuitant dies before me as noted below.
3)
My Contingent Annuitant must be at least 18 years of age upon my retirement effective date and the
Adjusted Age Differential between the Contingent Annuitant and myself cannot be
(a)
more than 25 years if I elect the 66.7% Contingent Annuitant Benefit,
(b)
more than 19 years if I elect the 75% Contingent Annuitant Benefit, or
(c)
more than 10 years if I elect the 100% Contingent Annuitant Benefit.
4)
If my Contingent Annuitant dies before my pension benefits commence, this election is cancelled and
no adjustment will be made in my pension benefits for the Contingent Annuitant Benefit.
5)
If my Contingent Annuitant dies after my pension benefits commence, I will continue to receive the
reduced benefit amount until I submit a certified copy of the Contingent Annuitant’s death certificate to
the Fund Office.
6)
If I elect the Contingent Annuitant Benefit, the 5-year and Lump Sum Death Benefit provisions of the
Plan described in Article IV, Sections 4.9 and 4.10 do not apply.
Signature_____________________________________________________Date__________________________
Submit a copy of your Contingent Annuitant’s birth certificate with this election.
Upd. 7/10/12
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