	1375 Virginia Drive, Suite 102 Ft. Washington, PA 19034 Phone 215-542-8211

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 Designation Form - Welfare Only

Use this Form if you only have Welfare Coverage through the Fund. If you have an Annuity or Pension with Local 542, please use Form for All Benefits.

International Union of Operating Engineers Benefit Funds
of Eastern Pennsylvania & Delaware

1375 Virginia Drive, Suite 102, Fort Washington, PA 19034

Phone: (215) 542-8211 www.iuoe542funds.com

Beneficiary Designation Form

Name:
Last		M.I.		First
Social Security No.:			Marital Status:
	(xxx-xx-xxxx)
Address: Street
	City	State		Zip Code

Death Benefit
Regardless of Marital Status, you may elect anyone as beneficiary if eligible

Primary

Full Name(s):			Relationship:

Social Security No.:			Phone Number:
	(xxx-xx-xxxx)
Date of Birth:
	(mm/dd/yyyy)
Address: Street
	City	State		Zip Code

Contingent

Full Name(s):			Relationship:

Social Security No.:			Phone Number:
	(xxx-xx-xxxx)
Date of Birth:
	(mm/dd/yyyy)
Address: Street
	City	State		Zip Code

Signature* _________________________________________________________

Date _______________________

* Please Hand-sign this area and mail the form to the address above

Death Benefit: If you die, a benefit may be paid to your beneficiary
Your beneficiary may receive a death benefit equal to $5,000 if:
1) You were eligible for coverage under the Welfare Fund for 6 out of the; last 12 months; and
2) You are eligible for Welfare benefits on the day you die.

Contact the Funds Office with any questions, 800 - 233 - 2043

This is NOT a census/dependent form.
A separate form needs to be filled out to add/delete a dependent.
Please remember to sign and date this form.

Primary Beneficiary: This is the individual (or individuals) that you would like to receive payment in the event of your death.

Contingent Beneficiary: Will only receive payment if your Primary Beneficiary is no longer alive at the time of your death.

Remember: It's important to review your beneficiary elections annually, or when you experience a "Life-Event Change"

"Life-Event Change" would be a change in marital status, birth of a child, divorce, etc.

7/4/2008