Form 02-1841 - Supplemental Benefits System Beneficiary (Life, Ad&d, Survivor) Page 2
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1
21.
Employer Code:
Supplemental Benefits System Beneficiary
0 0 0 1
FOR OFFICE USE ONLY
(Life, AD&D, Survivor)
Division of Retirement and Benefits
Juneau: 465-4460
Toll-Free: 1-800-821-2251
PO Box 110203
TDD: (907) 465-2805
Fax: (907) 465-4668
Juneau, Alaska 99811-0203
SECTION ONE: PERSONAL DATA
PLEASE TYPE OR PRINT CLEARLY
EMPLOYEE LAST NAME
FIRST NAME
M.I.
2.
3.
4.
SOCIAL SECURITY NUMBER
HOME PHONE
WORK PHONE
5.
6.
7.
(
)
(
)
SECTION TWO: BENEFICIARY DESIGNATION
.
.
8. BENEFICIARY LAST NAME
9. FIRST NAME
10. M
I
11. RELATIONSHIP
12. SOCIAL SECURITY NUMBER
13. MAILING ADDRESS
14. CITY AND STATE
15. ZIP CODE
0
:
:
:
16. I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
17. I WANT THIS BENEFICIARY TO BE
18. I WANT THIS BENEFICIARY TO RECEIVE
❒
❒
❒
❒
❒
%
&
LIFE
AD
D
SURVIVOR
PRIMARY
CONTINGENT
.
.
19. BENEFICIARY LAST NAME
20. FIRST NAME
21. M
I
22. RELATIONSHIP
23. SOCIAL SECURITY NUMBER
24. MAILING ADDRESS
25. CITY AND STATE
26. ZIP CODE
1
:
:
:
27. I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
28. I WANT THIS BENEFICIARY TO BE
29. I WANT THIS BENEFICIARY TO RECEIVE
❒
❒
❒
❒
❒
%
&
LIFE
AD
D
SURVIVOR
PRIMARY
CONTINGENT
.
.
30. BENEFICIARY LAST NAME
31. FIRST NAME
32. M
I
33. RELATIONSHIP
34. SOCIAL SECURITY NUMBER
35. MAILING ADDRESS
36. CITY AND STATE
37. ZIP CODE
2
:
:
:
38. I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
39. I WANT THIS BENEFICIARY TO BE
40. I WANT THIS BENEFICIARY TO RECEIVE
❒
❒
❒
❒
❒
%
&
LIFE
AD
D
SURVIVOR
PRIMARY
CONTINGENT
.
.
41. BENEFICIARY LAST NAME
42. FIRST NAME
43. M
I
44. RELATIONSHIP
45. SOCIAL SECURITY NUMBER
46. MAILING ADDRESS
47. CITY AND STATE
48. ZIP CODE
3
:
:
:
49. I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
50. I WANT THIS BENEFICIARY TO BE
51. I WANT THIS BENEFICIARY TO RECEIVE
❒
❒
❒
❒
❒
%
&
LIFE
AD
D
SURVIVOR
PRIMARY
CONTINGENT
.
.
52. BENEFICIARY LAST NAME
53. FIRST NAME
54. M
I
55. RELATIONSHIP
56. SOCIAL SECURITY NUMBER
57. MAILING ADDRESS
58. CITY AND STATE
59. ZIP CODE
4
:
:
:
60. I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
61. I WANT THIS BENEFICIARY TO BE
62. I WANT THIS BENEFICIARY TO RECEIVE
❒
❒
❒
❒
❒
%
&
LIFE
AD
D
SURVIVOR
PRIMARY
CONTINGENT
.
.
63. BENEFICIARY LAST NAME
64. FIRST NAME
65. M
I
66. RELATIONSHIP
67. SOCIAL SECURITY NUMBER
68. MAILING ADDRESS
69. CITY AND STATE
70. ZIP CODE
5
:
:
:
71. I WANT THIS BENEFICIARY TO RECEIVE THE FOLLOWING BENEFITS IF I DIE
72. I WANT THIS BENEFICIARY TO BE
73. I WANT THIS BENEFICIARY TO RECEIVE
❒
❒
❒
❒
❒
%
&
LIFE
AD
D
SURVIVOR
PRIMARY
CONTINGENT
SECTION THREE: SIGNATURE
EMPLOYEE SIGNATURE
DATE
02-1841
G:/publications/forms/benefits/02-1841.pmd/2
(Rev. 1/06)
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