Retirement Enrollment

Personal Information

Please complete this form in its entirety.
Full Name(Required)
MM slash DD slash YYYY
Address(Required)

Employer

Employer Address(Required)

Beneficiaries

Primary Beneficiary

I designate the following as my primary beneficiary: (Must be spouse if legally married unless waiver is filed)

Full Name(Required)
MM slash DD slash YYYY
Address

Contingent Beneficiary(ies)

I designate the following as my contingent beneficiary(ies): (In the event the primary beneficiary is deceased, the contingent beneficiary(ies) will receive the funds in the account)

Full Name
MM slash DD slash YYYY
Address



Full Name
MM slash DD slash YYYY
Address



Full Name
MM slash DD slash YYYY
Address



Full Name
MM slash DD slash YYYY
Address

Term Life Insurance

Group term life insurance is available through Guardian Insurance Company for enrollees who are under 65 years of age. The Basic Term Life Coverage is $25,000 (for as long as you have a retirement plan with the Board of Retirement). The monthly premium of $16.50 is deducted from the contributions to your retirement account. For more information regarding this Group Term Life Insurance, please check out the Life Insurance section or view the Life Benefit Summary.
Term Life Insurance

Investment Selection

You may invest in one (1) or all investment options. Indicate desired percentage to invest in each option (must total 100%). If no choice is made, all funds remain in the Default Strategy.
Investment Options (See Investment Plan Options for a description)
Total must equal 100%
* Preset Plan with set allocations (For more information about Preset Plans, see Investment Plan Options)

Certification

I request the Board of Retirement invest my accumulations/contributions based upon my investment choices above. I have reviewed information provided by the Board of Retirement and make this selection using my own investment judgment. I realize past results are not a guarantee of future performance. If I need additional information, I know I can contact the Board of Retirement.
MM slash DD slash YYYY
Please enter todays date (mm/dd/yyyy)
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Referral

If you were referred to the Board of Retirement or heard about us at an event, please let us know in the box below.
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