Form Beneficiaries PDF Details

In the realm of preparing for the future, the task of allocating benefits after one’s departure is both crucial and sensitive. The Commonwealth of Pennsylvania provides a structured avenue for public school employees to articulate their wishes through the Beneficiaries form, furnished by the Public School Employees' Retirement System located at 5 N 5th Street, Harrisburg PA 17101-1905. This form, explicitly designed for members of the retirement system, allows for the meticulous planning of the distribution of benefits associated with the PSERS Health Insurance Program. With provisions to appoint up to six individual primary beneficiaries, six secondary beneficiaries, and the option to include estates, trusts, charities, and guardianships, the form ensures that an employee’s assets are distributed according to their precise intentions. The obligatory 30-day survival period for beneficiaries, the necessity for updates through filing a new form, and the strict invalidation of prior designations unless most recent, emphasize the form’s legal binding and the importance of thoughtful completion. Moreover, the provision for assistance through toll-free and local Harrisburg numbers underlines the support system in place for navigating this crucial exercise. With every detailed specification, the form not only encapsulates the legal complexities surrounding the distribution of benefits posthumously but also embodies a compassionate approach towards planning for the welfare of loved ones.

QuestionAnswer
Form NameForm Beneficiaries
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namespsers state pa us forms, pa retirement state retirement member beneficiary nomination form, psrs 187, psers change of beneficiary form

Form Preview Example

Commonwealth of Pennsylvania - Public School Employees' Retirement System

5 N 5th Street

Harrisburg PA 17101-1905 Toll-free: 1.888.773.7748 www.psers.state.pa.us

PSRS-187 (10/2013)

PSERSNominationHeal h I suranceof BeneficiariesProgram

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. 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

Up to six individual secondary 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 717.787.8540, between the hours of 8:00 a.m. and 5:00 p.m. to speak with a service representative.

Where Should I Send My Completed Application?

Send To:

PSERS

 

5 N 5th Street

 

Harrisburg PA 17101-1905

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.

Nomination of Beneficiaries - Guidelines

Page 1 of 3

A

IMPORTANT: Read all instructions carefully.

Forms not properly completed will not be accepted by PSERS.

 

Member Information

 

C

 

Primary Beneficiary

 

 

 

Naming an Estate, Trust, or Charity

 

 

 

 

 

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.

Social Security Number. Your form cannot be processed without your social security number. If incorrect, you may make the change directly on this form.

A photocopy of your social security card is required as proof of the change.

Gender. If incorrect, you may make the change directly on this form. Written verification explaining the reason for the change is required.

Date of Birth. If incorrect, you may make the change directly on this form. Enter your correct birth month, day, and year including century (e.g., 08-08-1965). A photocopy of one of the following is required as proof:

Birth certificate

Baptismal record

Passport

Elementary/secondary school records

Life insurance policy listing your full date of birth PA driver's license

Naturalization card

Alien registration card

B

Primary Beneficiary

Naming One or More Individuals

Complete this section to designate one or more individuals as a primary beneficiary to receive any outstanding amount due left in your account in the event of your death.

Percent. Enter the percentage (e.g., 25%, 33 1/3%, 50%, etc.) of your benefit that should be distributed to each named primary beneficiary. The total percentage of Sections B and C must equal 100%.

Name. Enter the name (first, middle, last) of each primary beneficiary you wish to nominate.

Social Security Number. Enter the social security number for each named primary beneficiary.

Date of Birth. Enter the birth month, day, and year including century (e.g., 08-08-1965) for each named primary beneficiary.

Gender. Enter "M" for male or "F" for female for each named primary beneficiary.

Relationship. Enter the relationship between you and each named primary beneficiary (e.g., spouse, son, daughter, friend, etc.)

Address. Enter the address for each named primary beneficiary.

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.

Percent. Enter the percentage (e.g., 25%, 33 1/3%, 50%, etc.) of your benefit that should be distributed to each named estate or trust. The total percentage of Sections B and C must equal 100%.

Estate, Trust, or Charity Indicator. Indicate whether you are designating your estate, trust, or charity as a primary beneficiary by checking the appropriate box. For an "Estate" or "Trust", no other information is required.

When your "Estate" is named, the courts must appoint an administrator or an executor before benefits can be paid upon your death.

When naming a "Trust," do not submit a copy of your Trust Agreement. Upon your death, PSERS will send a Trustee Certification. This certification, if properly completed by the Trustee, will allow PSERS to make payment in accordance with the Nomination of Beneficiaries. If the Trust is not valid or is no longer operative, PSERS will not make payment to the Trust, but will pay the named secondary beneficiary or if none, the estate. You should ensure that your attorney has determined that the Trust Agreement meets all legal requirements.

Charity Name. If you indicated "charity" as a primary beneficiary, enter the name of the designated charity.

Contact Name. Enter the name (first, middle, last) of the contact person for each named estate, trust, or charity. A minor may not be named as an executor or trustee.

Address. Enter the address for each contact person listed.

Nomination of Beneficiaries - Guidelines

Page 2 of 3

D

Secondary Beneficiary

Naming One or More Individuals

 

Complete this section to designate one or more individuals as a secondary beneficiary to receive any outstanding amount due left in your account in the event of your death and the deaths of all named primary beneficiaries.

Percent. If you wish to designate your secondary beneficiaries using percentages, indicate what percentage (e.g., 25%, 33 1/3%, 50%, etc.) of your benefit that should be distributed to each named secondary beneficiary. The total percentage of Sections D and E must equal 100%.

Order. If you wish to designate your secondary beneficiaries using preferential order, indicate the order of preference in the Percent/Order columns (e.g., 1, 2, 3, etc.) between Sections D and E. If all primary beneficiaries predecease you, full payment will be made to the first secondary beneficiary. If that individual also predeceased you, full payment wil be made to the second secondary beneficiary, and so on in preferential order.

Name. Enter the name (first, middle, last) of each secondary beneficiary you wish to nominate.

Social Security Number. Enter the social security number for each named secondary beneficiary.

Date of Birth. Enter the birth month, day, and year including century (e.g., 08-08-1965) for each named secondary beneficiary.

Gender. Enter "M" for male or "F" for female for each named secondary beneficiary.

Relationship. Enter the relationship between you and each named secondary beneficiary (e.g., spouse, son, daughter, friend, etc.).

Address. Enter the address for each named secondary beneficiary.

E

Secondary Beneficiary

Naming an Estate or Trust

Complete this section to designate your estate and/or one or more trusts or charities as a secondary beneficiary. As in Section D, you may designate the distribution of a benefit to secondary beneficiaries using percentages or preferential order. If you use percentages, the total percentage of Sections D and E must equal 100%.

If you wish to designate your secondary beneficiaries using preferential order, indicate the order of preference in the Percent/Order columns (e.g., 1, 2, 3, etc.) between Sections D and E.

Estate, Trust, or Charity Indicator. Indicate whether you are designating your estate, trust, or charity as a secondary beneficiary by checking the appropriate box. For an "Estate" or "Trust", no other information is required.

When your "Estate" is named, the courts must appoint an administrator or an executor before benefits can be paid upon your death.

When naming a "Trust," do not submit a copy of your Trust Agreement. Upon your death, PSERS will send a Trustee Certification. This certification, if properly completed by the Trustee, will allow PSERS to make payment in accordance with the Nomination of Beneficiaries . If the Trust is not valid or is no longer operative, PSERS will not make payment to the Trust, but will pay the named secondary beneficiary or if none, the estate. You should ensure that your attorney has determined that the Trust Agreement meets all legal requirements.

Charity Name. If you indicated "charity" as a secondary beneficiary, enter the name of the designated charity.

Contact Name. Enter the name (first, middle, last) of the contact person for each named estate, trust, or charity. A minor may not be named as an executor or trustee.

Address. Enter the address for each contact person listed.

F Guardian Information

Complete this section to name a guardian for any named primary and/or secondary beneficiary less than 18 years of age.

If you name more than one person as a guardian for an individual minor primary or secondary beneficiary, the guardian names must be connected with "and" (e.g., John and Mary Smith); do not use "or" or "and/or" (e.g., John and/or Mary Smith, John Smith or James Jones).

Guardian Name(s). Enter the name (first, middle, last) of each guardian you wish to designate for each named minor.

Address. Enter the address for each named guardian.

Minor Name(s). Enter the name (first, middle, last) of each minor primary and/or secondary beneficiary nominated.

G Member Certification

Your signature and date you signed this form are required. By signing this form, you are certifying that all information provided is correct.

Nomination of Beneficiaries - Guidelines

Page 3 of 3

 

 

Commonwealth of Pennsylvania - Public School Employees' Retirement System

5 N 5th Street

Harrisburg PA 17101-1905 Toll-free: 1.888.773.7748 www.psers.state.pa.us

PSRS-187 (10/2013)

PSERSNominationHeal h I suranceof BeneficiariesProgram

A

Member Information

Member Name

Social Security

Number

Gender

Date of Birth

Former Last Name (only if used in this System)

Check here if you do not want your beneficiary to appear on your annual Statement of Account.

Member Address Change

 

 

Check here if

 

 

 

 

 

new address

 

 

 

Apt# or Suite

 

 

 

Street Address

City

State & Zip Code

Daytime Phone

Evening Phone

B

Primary Beneficiary - Naming One or More Individuals

Complete this section to designate one or more individuals as a primary beneficiary. Indicate what percentage (e.g., 25%, 33 1/3%, 50%, etc.) of your benefit should be distributed to each named primary beneficiary in the event of your death. The total percentage of Sections B and C must equal 100%.

Percent

Name

Social Security

Date of Birth

(first, middle, last)

Number

(month/day/year)

Gender

Relationship

Address

(street, city, state, zip code)

 

 

Nomination of Beneficiaries

Page 1 of 3

 

 

SS#

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 a primary beneficiary. Indicate what percentage (e.g., 25%, 33 1/3%, 50%, etc.) of your benefit should be distributed to each named estate, trust, or charity in the event of your death. The total percentage of Sections B and C must equal 100%.

Percent

Indicate

Charity Name

Contact Name

Contact Address

Estate, Trust, or Charity

(if applicable)

(street, city, state, zip code)

 

 

Estate

Trust

Charity

Estate

Trust

Charity

Estate

Trust

Charity

D

Secondary Beneficiary - Naming One or More Individuals

Complete this section to designate one or more individuals as a secondary beneficiary. You may designate the distribution of a benefit to secondary beneficiaries in one of two ways: using percentages or preferential order.

If you wish to designate your secondary beneficiaries using percentages, indicate in the Percent/Order column what percentage (e.g., 25%, 33 1/3%, 50%, etc.) of your benefit should be distributed to each named secondary beneficiary in the event of your death and the deaths of all named primary beneficiaries. The total percentage of Sections D and E must equal 100%.

If you wish to designate your secondary beneficiaries using preferential order, indicate the order of preference in the Percent/Order column (e.g., 1, 2, 3, etc.) between Sections D and E. If all primary beneficiaries predecease you and you choose preferential order, full payment will be made to the first secondary beneficiary. If that individual also predeceases you, full payment will be made to the second secondary beneficiary, and so on in preferential order.

Percent/

Name

Social Security

Order

(first, middle, last)

Number

Date of Birth

(month/day/year)

Gender

Relationship

Address

(street, city, state, zip code)

 

Nomination of Beneficiaries

Page 2 of 3

 

 

SS#

E

Secondary Beneficiary - Naming an Estate, Trust, or Charity

Complete this section to designate your estate and/or one or more trusts or charities as a secondary beneficiary. You may designate the distribution of a benefit to secondary beneficiaries in one of two ways: using percentages or preferential order.

If you wish to designate your secondary beneficiaries using percentages, indicate in the Percent/Order column what percentage (e.g., 25%, 33 1/3%, 50%, etc.) of your benefit should be distributed to each named secondary beneficiary in the event of your death and the deaths of all named primary beneficiaries. The total percentage of Sections D and E must equal 100%.

If you wish to designate your secondary beneficiaries using preferential order, indicate the order of preference in the Percent/Order column (e.g., 1, 2, 3, etc.) between Sections D and E. If all primary beneficiaries predecease you and you choose preferential order, full payment will be made to the first secondary beneficiary. If that individual also predeceases you, full payment will be made to the second secondary beneficiary, and so on in preferential order.

Percent/

Indicate Estate, Trust, or

Charity Name

Contact Name

Contact Address

Order

Charity

(if applicable)

(street, city, state, zip code)

 

Estate

Trust

Charity

Estate

Trust

Charity

Estate

Trust

Charity

F

Guardian Information

Complete this section to name a guardian for any named primary and/or secondary beneficiary less than 18 years of age.

You may not list yourself as a guardian.

Guardian Name(s)

Address

Minor Name(s)

(street, city, state, zip code)

 

 

 

 

 

 

 

 

G

Member Certification

I certify that all statements provided on this form are accurate. I agree that any deliberate misrepresentation for the purpose of obtaining benefits is an offense punishable by law. I also agree that it is important to keep my nomination current.

Member Signature

Date Signed

Nomination of Beneficiaries

Page 3 of 3

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Charity Name if applicable, Estate Trust Charity Estate Trust, and Charity of nomination beneficiaries

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