Preretirement Survivor Benefit Beneficiary Designation Form For Unmarried Participants

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Preretirement Survivor Benefit
New York State Nurses Association
PO Box 12430
N
Y
S
N
A
Beneficiary Designation Form
Albany, NY 12212-2430
Pension Plan
PHONE (877) RN BENEFITS
For Unmarried Participants
FAX (518) 456-3954
E-MAIL
If you’re not married and would like to name one or two beneficiary(ies) for your Preretirement Survivor Benefit, please complete Section
IV of this form and return it to the Plan office.
Name ____________________________________________
Date ________________________________
Social Security Number _____________________________
Marital Status _________________________
Present Employer __________________________________________________________________________
I. Eligibility
The unmarried participant may change her/his beneficiary
designation at any time.
Effective January 1, 2002, NYSNA Pension Plan
participants who were not married could designate one
III. Preretirement Survivor Benefit
individual to receive their Preretirement Survivor Benefit.
Your beneficiary will receive a monthly Preretirement
The NYSNA Pension Plan (also referred to on this form
Survivor Benefit payable for his/her life, based on 50% of
as “the Plan” or “the Pension Plan”) covers the cost for
your vested pension payable at your age 65 or your date
this Preretirement Survivor Benefit; the benefit costs
of death, if later, reduced by:
you nothing. The Plan will pay a Preretirement Survivor
• The Plan’s 50% Joint and Survivor annuity reduction
Benefit to the beneficiary you name on this form if you are
(based on your beneficiary’s age and your age, and
vested and die:
had you survived to the date benefits commenced) if
• While you are in active, covered employment; or
payments commence after your 55
birthday; and
th
• After you’ve terminated service, but before you’ve
• The Plan’s early commencement reduction factor
started receiving your pension benefit; or
if payments commence between your 55
and 65
th
th
• While you’re receiving a disability benefit under the
birthdays; or
Plan.
• An actuarial equivalent reduction factor applied to
Effective August 1, 2013, eligible participants who are
the benefit otherwise payable at your 55
birthday if
th
not married may designate up to two individuals to
payments commence before your 55
birthday.
th
receive this Preretirement Survivor Benefit.
If you have two beneficiaries on your date of death,
the Preretirement Survivor Benefit will be based on 50%
II. Designated Beneficiary(ies)
of your vested pension payable at your age 65 or your
If you are not married, effective August 1, 2013, you may
date of death, if later; each beneficiary will receive 50%
name up to two individual persons as your beneficiary(ies)
of the Preretirement Survivor Benefit and the reductions
(trusts, estates and successor beneficiaries are not permitted
described above would be applied separately to each
under the Plan).
beneficiary’s benefit.
If you do not designate a beneficiary, or if your
Preretirement Survivor Benefit payments will begin
beneficiary(ies) dies before you and you do not name
on the first day of the month immediately following or
another beneficiary by filing a new beneficiary designation
coincident with the date of your death and cannot be
form with the Plan office, no death benefit will be paid.
deferred. If the present value of the benefit is $5,000 or
If you designate two beneficiaries and one predeceases
less, the present value of benefit will be distributed to
you, the entire Preretirement Survivor Benefit will be
your beneficiary as an immediate lump sum payment.
payable to the surviving beneficiary.
If the present value of the benefit is more than $5,000,
If you are not married now, but later get married,
the Preretirement Survivor Benefit will be paid monthly
the beneficiary designation you have made on this form
during your beneficiary’s lifetime. If there are two
automatically will be revoked as of the date of your
beneficiaries and the present value of the benefit payable
marriage. Your spouse automatically will become your
to one of them is $5,000 or less, both beneficiaries will
beneficiary and will receive the Preretirement Survivor
receive immediate lump sum payments.
Benefit unless you file a new beneficiary election form with
the Plan office with your spouse’s consent.

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