Death Benefit Claim Request 401(a) Plan

Death Benefit Claim Request 401(a) plan CERF savings plan - 401(a) plan 98993-02. When would this form be used? When the Claimant is making a Claim on this account due to the Death of the Participant (Decedent). Additional Information If there are multiple Claimants, each named Claimant must complete a separate Death Benefit Claim Request form for their portion of the proceeds. Death Benefit Claim Request forms received in good order by market close will be processed using that business day's effective date. I understand that an original or certified copy of the final issued Death certificate is required for processing a Death Benefit . See the attached Death Benefit Claim Guide ("Guide") for additional details. For purposes of this form, the terminology 'Withdrawal' is the same as 'Distribution'. For questions regarding this form, refer to the Guide, visit the website at or contact Service Provider at 1-800-701-8255. Return Instructions for this form are in Section H. Use black or blue ink when completing this form.

Death Benefit Claim Request 401(a) Plan STD FDEATH ][05/11/17)(98993-02 WITHDRAWALNO_GRPG 58091/][GU22][GP22DOC ID: 483027910 Page 1 of 16 CERF Savings Plan - 401(a) Plan 98993-02 When would this form be used?

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  Benefits, Plan, Request, Claim, Death, Savings, Savings plan, Death benefit claim request 401

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