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How to use or fill out Form must be filled out using blue or black ink only
- Click ‘Get Form’ to open it in the editor.
- Begin with Section 1: Member Information. Fill in your Social Security number, date of birth, and select your gender. Provide your first name, middle initial, last name, mailing address, city, state, zip code, work phone, cell phone, and email address. Indicate your marital status.
- Move to Section 2: Beneficiary Designation. Do not alter this section. List primary beneficiaries by providing their names, relationships to you, genders (M/F), and dates of birth.
- If applicable, fill in secondary beneficiaries under the same format as primary beneficiaries.
- In Section 3: Member’s Signature, sign and date the form. A witness must also sign here.
- Complete Section 4 if married and not naming your spouse as the sole primary beneficiary. Your spouse must sign and date this section along with a witness.
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