Designation Of Beneficiary And Waiver Of Pre-Retirement Survivor Annuity Page 2
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3DESIGNATION OF BENEFICIARY and
WAIVER OF PRE-RETIREMENT SURVIVOR ANNUITY
Plan Name:
Participant’s Name:
Social Security No.:
Date of Birth:
Designation of Beneficiary (to be completed by all participants)
Primary Beneficiary (attach additional sheets if necessary):
(a) Name:
Relationship:
Date of Birth:
% of benefits:
(b) Name:
Relationship:
Date of Birth:
% of benefits:
(c) Name:
Relationship:
Date of Birth:
% of benefits:
(d) Name:
Relationship:
Date of Birth:
% of benefits:
Contingent Beneficiary - in the event my Primary Beneficiary predeceases me (attach additional sheets if necessary):
(a) Name:
Relationship:
Date of Birth:
% of benefits:
(b) Name:
Relationship:
Date of Birth:
% of benefits:
(c) Name:
Relationship:
Date of Birth:
% of benefits:
(d) Name:
Relationship:
Date of Birth:
% of benefits:
Election to Waive Pre-Retirement Survivor Annuity (to be completed by married participants only)
I hereby acknowledge that I have been informed by the Plan Administrator that:
(1) if I should die before my benefit payments begin, the death benefit under the Plan will be paid to my spouse in the form of
a life annuity;
(2) I have the right to waive the designation of my spouse as beneficiary of such death benefit only if my spouse duly
consents in writing to the waiver;
(3) I have the right to revoke such waiver at any time without my spouse's consent.
I hereby elect to have my death benefit paid in the form of a lump sum rather than as a survivor annuity. My spouse shall
remain as beneficiary.
I hereby elect to have my death benefit paid in the form of a lump sum rather than as a survivor annuity. In addition, I
have designated a primary beneficiary other than my spouse as indicated in the Designation of Beneficiary Form.
I hereby elect to have my death benefit paid in the form of a survivor annuity to a beneficiary other than my spouse as
indicated in the Designation of Beneficiary Form.
(If none of the boxes above is checked, the death benefit will be paid as a survivor annuity to your spouse.)
Execution and Certification of Marital Status (check the appropriate box and sign below)
I certify that all information provided on this form is complete and accurate. I agree to furnish evidence of my date of birth as
may be requested at any time by the Plan Administrator, and to immediately inform the Plan Administrator of any change in
my marital status.
Unmarried Participants. I certify that I am not married, I have no spouse, or my spouse cannot be located. I
designate as beneficiary the person(s) named above. However, if I hereafter marry, this will revoke the designation
and my spouse shall be my beneficiary. I will immediately inform the Plan Administrator of any change in my
marital status.
Married Participants. I designate as beneficiary the person(s) above, and make the election regarding my pre-
retirement survivor annuity as indicated above. I understand that any designation of a beneficiary other than my
spouse and any election to waive the pre-retirement survivor annuity will not be effective unless the Spouse's Consent
is completed below. I will immediately inform the Plan Administrator of any change in my marital status.
Date
Participant
Page 1
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