Vital Information - Survivor'S Benefit Checklist
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SURVIVOR’S BENEFIT CHECKLIST
DO YOU HAVE A CURRENT:
1. “Employee Action Request” (State Form 686) designating the person authorized to receive
warrants in the event of death (or a State Form 243) on file with your Department of Forestry
and Fire Protection personnel office? Is the address correct?
2. “State Employees’ Retirement System Change of Beneficiary” (State Form 241) on file with
PERS designating the correct beneficiary for “Basic Death Benefit” and “Group Term Life
Insurance Benefit?”
3. “Will” and Living Trust giving disposition of your “estate” (real property, autos, stocks and
bonds, credit union, savings and loan and bank/savings accounts, etc.)?
4. Listing of possessions and assets prepared for reference?
5. Correct beneficiary designation on private life insurance policies, deferred compensation plans,
etc.?
NOTE: The following checklists identify the information and documentation needed by
survivors following the death of an employee or a retiree. They do not constitute a complete
listing for all individuals. They are solely intended to be a representative “guide” to the
survivor’s benefits which will most likely be applicable.
I.
Death of an active employee
II.
Additional requirements in the event of an accidental death
III.
Death of a retired member
Also, extreme care must always be utilized to ensure that all potential survivor’s benefit sources
are contacted so survivors receive everything to which they are entitled, i.e., military, service
clubs, fraternal organizations, CSFA, CSEA, travel clubs, etc.
DEATH OF AN ACTIVE EMPLOYEE
A.
(the following must be obtained or done):
IN THE EVENT OF ACCIDENTAL DEATH
1. If on the job, en route to or from work, or if there is a possibility, however remote, of
a job-related death or cause thereof, notify Workers Compensation and submit
SCIF Form 3067 (REV 2-93). (Also, forward a copy of the Form 3067 to PERS
upon their request.)
2. Promptly consult a recognized and knowledgeable attorney (or firm) to obtain legal
advice on the appropriate action to follow.
3. This is particularly true when in doubt as to whether or not the death could be job-
related or IF there is a possibility of a third party liability.
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