1375 Virginia Drive, Suite 102
Ft. Washington, PA 19034
Phone 215-542-8211
 
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Don't Forget!

It's Your responsibility to update the Funds Office with any dependent changes - Birth of a child, Change in Marital Status, etc.
 
 

Beneficiary Form - Pension, Annuity and Welfare

 
International Union of Operating Engineers Benefit Funds
of Eastern Pennsylvania & Delaware
1375 Virginia Drive, Suite 102, Fort Washington, PA 19034
Phone: (215) 542-821        www.iuoe542funds.com
Last Name
 First Name
 M.I.
Social Security Number
 Marital Status
Street Address
 City
 State
 Zip Code
1. Pension Plan
* - If Eligible
 If you are vested and married, your spouse is automatically your primary beneficiary under the Pension plan. You may elect anyone as your contingent Beneficiary.
Primary
Name(s)
 Relationship
SSN (xxx-xx-xxxx)
 Phone Number
 Date of Birth (mm/dd/yyyy)
Address
City
 State
 Zip Code
Contingent
Name(s)
 Relationship
Social Security (xxx-xx-xxxx)
 Phone Number
 Date of Birth (mm/dd/yyyy)
Address
City
 State
 Zip Code
2. Annuity Plan
* - If Eligible
 If you are married your spouse is automatically your primary beneficiary under the Annuity plan. You may elect anyone as your contingent Beneficiary.
Primary
Name(s)
 Relationship
Social Security (xxx-xx-xxxx)
 Phone Number
 Date of Birth (mm/dd/yyyy)
Address
City
 State
 Zip Code
Contingent
Name(s)
 Relationship
Social Security (xxx-xx-xxxx)
 Phone Number
 Date of Birth (mm/dd/yyyy)
Address
City
 State
 Zip Code
3. $5000 Death Benefit
* - If Eligible
 Regardless of Marital Status, you may elect anyone as beneficiary(s).
Primary
Name(s)
 Relationship
Social Security (xxx-xx-xxxx)
 Phone Number
 Date of Birth (mm/dd/yyyy)
Address
City
 State
 Zip Code
Contingent
Name(s)
 Relationship
Social Security (xxx-xx-xxxx)
 Phone Number
 Date of Birth (mm/dd/yyyy)
Address
City
 State
 Zip Code
Signature* _________________________________________________________

Date _______________________

* Please Hand-sign this area and mail the form to the address above
7/4/2008