Form 02-1841 - Supplemental Benefits System Beneficiary (Life, Ad&d, Survivor)

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Supplemental Benefits System Beneficiary Instructions
This form names the people you want to receive Supplemental Life, Accidental Death and Dismemberment, or Survivor insurances
you may have elected in the event of your death. It may also be used to change those names at any time. You are responsible for
this form being received by the Division of Retirement and Benefits. Bring or mail this completed form directly to this office.
Please Note—To designate beneficiaries for your Alaska Supplemental Annuity Plan (SBS-AP) account, you must complete
separately from this form the Alaska Supplemental Annuity Plan Beneficiary Designation form (sbs006).
SECTION ONE: PERSONAL DATA
Complete this section each time you use this form.
SECTION TWO: BENEFICIARY DESIGNATION
This section has space for up to five beneficiaries. If necessary, attach additional forms. This section must be completed listing all
intended beneficiaries each time this form is used.
8. - 15. Enter the beneficiary's name, relationship to you, social security number, and address.
16.
Indicate which benefits this beneficiary should receive if you die. Only check those programs in which you
have enrolled.
17.
Indicate whether this beneficiary is primary or contingent. Primary beneficiaries receive the benefit first if
you die. Contingent beneficiaries receive the benefit if the primary beneficiary has died.
18.
Indicate the percentage of the benefits that you would like this beneficiary to receive. The total percentage
given to primary beneficiaries must equal 100%. The total percentage given to contingent beneficiaries
must equal 100%.
19. - 62. List as many beneficiaries as you like, following the instructions for the first beneficiary in #8 through #18
above.
EXAMPLES
Jane Doe is married with no children. She wishes her husband to receive this benefit if she dies:
.
.
BENEFICIARY LAST NAME
FIRST NAME
M
I
RELATIONSHIP
SOCIAL SECURITY NUMBER
Doe
John
K.
Husband
123-45-6789
MAILING ADDRESS
CITY AND STATE
ZIP CODE
1000 Any Street
Anytown, AK
99999
:
:
I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
I WANT THIS BENEFICIARY TO BE
I WANT THIS BENEFICIARY TO
:
RECEIVE
100
%
&
LIFE
AD
D
SURVIVOR
PRIMARY
CONTINGENT
Fred Smith is not married and has two children. He has enrolled in life insurance and Accidental Death and Dismemberment
(AD&D). He wishes his children to share equally if he dies:
.
.
BENEFICIARY LAST NAME
FIRST NAME
M
I
RELATIONSHIP
SOCIAL SECURITY NUMBER
Smith
Jane
Daughter
123-45-6789
R.
MAILING ADDRESS
CITY AND STATE
ZIP CODE
1000 "E" Street
Anytown, AK
99999
:
:
I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
I WANT THIS BENEFICIARY TO BE
I WANT THIS BENEFICIARY TO
:
RECEIVE
50
%
&
LIFE
AD
D
SURVIVOR
PRIMARY
CONTINGENT
.
.
BENEFICIARY LAST NAME
FIRST NAME
M
I
RELATIONSHIP
SOCIAL SECURITY NUMBER
Smith
John
Son
123-45-6789
F.
MAILING ADDRESS
CITY AND STATE
ZIP CODE
1000 Any Street
Anytown, AK
99999
:
:
I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
I WANT THIS BENEFICIARY TO BE
I WANT THIS BENEFICIARY TO
:
RECEIVE
%
&
50
LIFE
AD
D
SURVIVOR
PRIMARY
CONTINGENT
SECTION THREE: SIGNATURE
This form must be signed
G:/publications/forms/benefits/02-1841.pmd/1
(Rev. 1/06)

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