|EMPLOYERS AND LABORERS LOCALS 100 & 397
DESIGNATION OF BENEFICIARY
SECTION I – PARTICIPANT INFORMATION
Name: Social Security Number: - -
Married – Check this box if you are married, complete Section II and sign below. Have your spouse complete the Spousal Consent section if your spouse is not the sole primary beneficiary.
Unmarried – Check this box if you are unmarried, complete Section II and sign below.
SECTION III – SPOUSAL CONSENT
THIS SECTION TO BE COMPLETED ONLY IF PARTICIPANT IS MARRIED AND DOES NOT DESIGNATE HIS/HER SPOUSE AS SOLE PRIMARY BENEFICIARY
I understand that if the Primary Beneficiary is someone other than myself, I am giving up any death benefit due me by
giving my consent to the above Designation of Beneficiary.
I understand that without my consent to the Beneficiary Designation, I am entitled to the death benefit payable to a
spouse under Plan provision in the absence of a Beneficiary Designation Form. The remaining death benefits, if any,
not payable to me, will be payable to the beneficiaries designated by the participant.
I DO consent to the Beneficiary selection.
I DO NOT consent to the Beneficiary selection.
Signature of Spouse Date
The person signing above appeared before a notary public and made the election as a voluntary act and deed.
Signature of Notary Date (REQUIRED)
SECTION IV – PARTICIPANT’S SIGNATURE
I reserve the right to change the beneficiary(ies) at any time by giving notice to the Trustees in writing. This designation revokes any previous designation of beneficiary(ies).
Participant’s Signature Date
Witness’ Signature Date 5/98
Please return this completed form
(with Notary signature and seal, if appropriate)
Ekon Benefits, Inc.
4940 Washington Blvd.
St. Louis, MO 63108
in the enclosed, self-addressed envelope.
If you have any questions please call
Cheryl Holtmann at 314-367-6555.