1. Participant Information

(03/2021) E13737_2 Page 1 of 3 Election of Benefits(For a Participant ) Single Sum Payment, Lump Sum Payment or Rollover Bundled/Full ServicePLEASE PRINTWe will process the withdrawal request on the business day we receive a properly completed form . Failure to properly complete this form will cause a delay in payment. 1. Participant Information First Name, Middle Initial Last Name Social Security NumberAddress (to which payments and/or future mailings are to be sent) City State Zip Code Daytime Telephone Number Mobile Phone Number Email Address Employer s Name Contract ID NumberEmployer s Contact Telephone Number2. Benefit Election & Forms of BenefitThe Election of Benefits is submitted because the Participant is: (To be completed by the Employer/Plan Administrator) (check one) No longer employed by this employer and/or past Normal Retirement Age; (date no longer employed / / ) mm dd yyyy Disabled.

(09/15) E13737_2 Page 1 of 2 Election of Benefits (For a Participant) Single Sum Payment, Lump Sum Payment or Rollover Bundled/Full Fax Number:Service PLEASE PRINT We will process the withdrawal request on the business day we receive a properly completed form.

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