Form 02-1841 - Sbs/select Beneficiary Form

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1. 1. 1. 1. 1.
SBS/SELECT BENEFICIAR
SBS/SELECT BENEFICIAR
SBS/SELECT BENEFICIARY FORM
Y FORM
Y FORM
Y FORM
SBS/SELECT BENEFICIAR
SBS/SELECT BENEFICIAR
Y FORM
Division of Retirement and Benefits
P.O. Box 110203
550 West 7
th
Avenue, Suite 1020
Juneau, AK 99811-0203
Anchorage, AK 99501-3562
Phone: (907) 465-4460
Phone: (907) 269-0333
Employer Code:
FOR SBS/SELECT USE ONLY
FOR SBS/SELECT USE ONLY
FOR SBS/SELECT USE ONLY
FOR SBS/SELECT USE ONLY
FOR SBS/SELECT USE ONLY
Fax: (907) 465-3086
Fax: (907) 269-0280
0 0 0 1
TDD: 465-2805
Health Benefits Phone: (907) 465-8600 / Fax: (907) 465-4668
SECTION ONE: PERSONAL DATA
SECTION ONE: PERSONAL DATA
SECTION ONE: PERSONAL DATA
SECTION ONE: PERSONAL DATA
SECTION ONE: PERSONAL DATA
EMPLOYEE LAST NAME
EMPLOYEE LAST NAME
EMPLOYEE LAST NAME
EMPLOYEE LAST NAME
EMPLOYEE LAST NAME
FIRST NAME
FIRST NAME
FIRST NAME
FIRST NAME
FIRST NAME
M.I.
M.I.
M.I.
M.I.
M.I.
2. 2. 2. 2. 2.
3. 3. 3. 3. 3.
4. 4. 4. 4. 4.
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
HOME PHONE
HOME PHONE
HOME PHONE
HOME PHONE
HOME PHONE
WORK PHONE
WORK PHONE
WORK PHONE
WORK PHONE
WORK PHONE
5. 5. 5. 5. 5.
6. 6. 6. 6. 6.
7. 7. 7. 7. 7.
( ( ( ( (
) ) ) ) )
( ( ( ( (
) ) ) ) )
SECTION TWO: BENEFICIARY DESIGNATION
SECTION TWO: BENEFICIARY DESIGNATION
SECTION TWO: BENEFICIARY DESIGNATION
SECTION TWO: BENEFICIARY DESIGNATION
SECTION TWO: BENEFICIARY DESIGNATION
.
.
9. 9. 9. 9. 9.
FIRST NAME
10.
10.
10.
10.
10.
M
I
11.
11.
11.
11.
11. RELATIONSHIP
8. 8. 8. 8. 8.
BENEFICIARY LAST NAME
12.
12.
12.
12.
12.
MAILING ADDRESS
13.
13.
13.
13.
13.
CITY AND STATE
14.
14.
14.
14.
14.
ZIP CODE
0
:
:
15.
15.
15.
15.
15.
16.
16.
16.
16.
16. I WANT THIS BENEFICIARY TO BE
17.
17.
17.
17.
17. I WANT THIS BENEFICIARY TO
I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
:
RECEIVE
% % % % %
& & & & &
CONTINGENT
CONTINGENT
CONTINGENT
CONTINGENT
CONTINGENT
PRIMARY
PRIMARY
PRIMARY
PRIMARY
PRIMARY
LIFE
LIFE
LIFE
AD
AD
AD
D D D D D
SURVIVOR
SURVIVOR
SURVIVOR
ANNUITY
ANNUITY
ANNUITY
LIFE
LIFE
AD
AD
SURVIVOR
SURVIVOR
ANNUITY
ANNUITY
.
.
18.
18.
BENEFICIARY LAST NAME
18.
18.
18.
19.
19.
20.
20.
M
I
21.
21.
RELATIONSHIP
19.
19.
19.
FIRST NAME
20.
20.
20.
21.
21.
21.
MAILING ADDRESS
22.
22.
22.
22.
22.
23.
23.
CITY AND STATE
24.
24.
23.
23.
23.
24.
24.
24.
ZIP CODE
1
:
:
25.
25.
25.
25.
25.
I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
26.
26.
26.
26.
26. I WANT THIS BENEFICIARY TO BE
27.
27.
27.
27.
27.
I WANT THIS BENEFICIARY TO
:
RECEIVE
% % % % %
& & & & &
PRIMARY
PRIMARY
CONTINGENT
CONTINGENT
CONTINGENT
CONTINGENT
CONTINGENT
LIFE
LIFE
LIFE
AD
AD
AD
D D D D D
SURVIVOR
SURVIVOR
SURVIVOR
ANNUITY
ANNUITY
ANNUITY
PRIMARY
PRIMARY
PRIMARY
LIFE
LIFE
AD
AD
SURVIVOR
SURVIVOR
ANNUITY
ANNUITY
.
.
29.
29.
28.
28.
BENEFICIARY LAST NAME
29.
29.
29.
FIRST NAME
30.
30.
31.
31.
31. RELATIONSHIP
28.
28.
28.
30.
30.
30.
M
I
31.
31.
32.
32.
32.
32.
32.
MAILING ADDRESS
33.
33.
33.
33.
33.
34. ZIP CODE
CITY AND STATE
34.
34.
34.
34.
2
:
:
35.
35.
35.
35.
35.
I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
36.
36.
36.
36.
36.
I WANT THIS BENEFICIARY TO BE
37.
37.
37.
37.
37.
I WANT THIS BENEFICIARY TO
:
RECEIVE
% % % % %
& & & & &
CONTINGENT
CONTINGENT
PRIMARY
PRIMARY
PRIMARY
CONTINGENT
CONTINGENT
CONTINGENT
LIFE
LIFE
LIFE
LIFE
LIFE
AD
AD
AD
AD
AD
D D D D D
SURVIVOR
SURVIVOR
SURVIVOR
SURVIVOR
SURVIVOR
ANNUITY
ANNUITY
ANNUITY
ANNUITY
ANNUITY
PRIMARY
PRIMARY
.
.
39.
39.
39.
40.
40.
40.
M
I
41.
41.
41.
RELATIONSHIP
38.
38.
38.
38.
38.
BENEFICIARY LAST NAME
39.
39.
FIRST NAME
40.
40.
41.
41.
43.
43.
43.
43.
43.
42.
42.
CITY AND STATE
44.
44.
44.
44.
44.
ZIP CODE
42.
42.
42.
MAILING ADDRESS
3
:
:
45.
45.
45.
45.
45.
I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
46.
46.
46.
46.
46.
I WANT THIS BENEFICIARY TO BE
47.
47.
I WANT THIS BENEFICIARY TO
47.
47.
47.
:
RECEIVE
% % % % %
& & & & &
CONTINGENT
CONTINGENT
PRIMARY
PRIMARY
PRIMARY
PRIMARY
PRIMARY
CONTINGENT
CONTINGENT
CONTINGENT
LIFE
LIFE
LIFE
LIFE
LIFE
AD
AD
AD
AD
AD
D D D D D
SURVIVOR
SURVIVOR
SURVIVOR
SURVIVOR
SURVIVOR
ANNUITY
ANNUITY
ANNUITY
ANNUITY
ANNUITY
.
.
48.
48.
48.
48.
48.
49.
49.
49.
49.
49.
BENEFICIARY LAST NAME
FIRST NAME
50.
50.
50.
50.
50.
M
I
51.
51.
51.
51.
51. RELATIONSHIP
52.
52.
53.
53.
54.
54.
52.
52.
52.
MAILING ADDRESS
53.
53.
53.
CITY AND STATE
54.
54.
54.
ZIP CODE
4
:
:
56.
56.
56. I WANT THIS BENEFICIARY TO BE
57.
57.
57.
I WANT THIS BENEFICIARY TO
55.
55.
55.
I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
56.
56.
57.
57.
55.
55.
:
RECEIVE
% % % % %
& & & & &
LIFE
LIFE
LIFE
AD
AD
AD
D D D D D
SURVIVOR
SURVIVOR
SURVIVOR
ANNUITY
ANNUITY
ANNUITY
CONTINGENT
CONTINGENT
CONTINGENT
CONTINGENT
CONTINGENT
LIFE
LIFE
AD
AD
SURVIVOR
SURVIVOR
ANNUITY
ANNUITY
PRIMARY
PRIMARY
PRIMARY
PRIMARY
PRIMARY
.
.
58.
58.
BENEFICIARY LAST NAME
59.
59.
59.
59.
59.
FIRST NAME
60.
60.
60.
60.
60.
M
I
61.
61.
61.
61.
61.
RELATIONSHIP
58.
58.
58.
62.
62.
62.
63.
63.
63.
64.
64.
64.
62.
62.
MAILING ADDRESS
63.
63.
CITY AND STATE
64.
64.
ZIP CODE
5
:
:
I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
66.
66.
66. I WANT THIS BENEFICIARY TO BE
67.
67.
67.
I WANT THIS BENEFICIARY TO
65.
65.
65.
66.
66.
67.
67.
65.
65.
:
RECEIVE
% % % % %
&
PRIMARY
PRIMARY
CONTINGENT
CONTINGENT
CONTINGENT
CONTINGENT
CONTINGENT
LIFE
AD
D
SURVIVOR
ANNUITY
ANNUITY
ANNUITY
PRIMARY
PRIMARY
PRIMARY
ANNUITY
ANNUITY
SECTION THREE: SIGNATURE
SECTION THREE: SIGNATURE
SECTION THREE: SIGNATURE
SECTION THREE: SIGNATURE
SECTION THREE: SIGNATURE
DATE
DATE
EMPLOYEE
EMPLOYEE
EMPLOYEE SIGNATURE
SIGNATURE
SIGNATURE
SIGNATURE
DATE
DATE
DATE
EMPLOYEE
EMPLOYEE
SIGNATURE
02-1841
G:/forms/benefits/02-1841.p65/2
(Rev. 10/00)

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