PSERS Retirement State College Area School District 2013

Psers. state. pa.us PSERS Health Insurance Program Nomination of Beneficiaries PSRS-187 08/2012 Complete this form to indicate how you want your benefit with the Public School Employees Retirement System PSERS distributed in the event of your death. Commonwealth of Pennsylvania - Public School Employees Retirement System 5 N 5th Street Harrisburg PA 17101-1905 Toll-free 1-888-773-7748 Web Address www. In all cases the nominated individual must survive you by 30 days. If all individuals named as primary and secondary beneficiaries predecease you the benefits are paid to your estate. If you wish to change beneficiaries at a later date a new form must be filed with PSERS* The form with the most recent date is the only one used to distribute benefits regardless of your membership status at the time of your death. Earlier forms are considered void* This Form Provides Sufficient Space To Nominate up to six individual primary beneficiaries your estate as primary or secondary beneficiary up to three trusts and/or charities as primary and/or secondary beneficiaries up to two guardians If you are naming more beneficiaries and/or guardians than space allows provide the additional information on a separate sheet of paper and attach it to your form* Remember to provide all information as indicated on the form* Details To Remember When Completing Your Beneficiary Nomination This form is a legal document that may not be altered in any way. If you make a mistake during completion contact PSERS to request a new form* You must name at least one primary beneficiary. You may divide the distribution of your benefit between individuals trusts charities and/or your estate. Benefits will be paid in accordance with this nomination provided that the nominated person or persons survive you by 30 days. If any named primary beneficiary predeceases you their share percentage will be distributed among any remaining primary beneficiaries. For a secondary beneficiary to receive a benefit all named primary beneficiaries must be deceased* If all named beneficiaries predecease you the benefit will be paid to your estate. If you name a minor primary and/or secondary beneficiary you must name a guardian for each. You may change your nomination at any time by submitting a new form* Your signature and date you signed this form are required* What If I Need Assistance Call our toll-free number 1-888-773-7748 1-888-PSERS4U Harrisburg local callers 787-8540 between the hours of 7 30 a*m* and 5 00 p*m* to speak with a service representative. Where Should I Send My Completed Application Send PSERS What Will PSERS Do After My Application Is Processed After receipt and acceptance of your Nomination of Beneficiaries form PSERS will return an acknowledgment of your beneficiary nomination for your records. Page 1 of 3 IMPORTANT Read all instructions carefully. Forms not properly completed will not be accepted by PSERS* A Member Information Member Name. If incorrect you may make the change directly on this form* If your last name changed for any reason other than marriage or divorce a photocopy of the legal document regarding your name change is required as proof* If your first name changed through a legal process a photocopy of the legal document regarding your name change is required as proof* C Primary Beneficiary Naming An Estate Trust Or Charity Complete this section to designate your estate and/or one or more trusts or charities as primary beneficiary to receive any outstanding amount due left in your account in the event of your death.