CSS2HTML: WEB1106.XDP

STATE ORP ACTIVE INCIDENTAL DEATH BENEFIT

BENEFICIARY DESIGNATION

SC Public Employee Benefit Authority

Attention:  Enrollment

202 Arbor Lake Drive

Columbia, SC 29223

Form 1106

Revised 7/1/2025

 

Print or type in black ink

1. Last Name & Suffix

3. Social Security Number

2. First/Middle Name

4. Date of Birth

5. Address

Section I*

2. Name of Beneficiary (ONE PERSON)

3. Name of Beneficiary (ONE PERSON)

1. Name of Beneficiary (ONE PERSON)

Social Security #

Social Security #

Social Security #

Sex

Sex

Relationship

Relationship

Relationship

Date of Birth

Date of Birth

Date of Birth

Sex

PAGE ____ OF ____

4. Name of Trustee(s)

    Name of Trust Beneficiary (ONE PERSON)

Trust ID, if applicable

Address of Trustee(s)

Social Security #

Date of Birth

Relationship

    Name of Trust Beneficiary (ONE PERSON)

Social Security #

Sex

Date of Birth

Relationship

Section II*

Section III

IMPORTANT:

Please read the Certification and Conditions section of the instructions on Page 2 before signing this form. I hereby certify I have read and understand the information on Page 2, including the certification and conditions, and I agree to the provisions stated.

6. City

7. State

8. ZIP+4

Please read the instructions on Page 2  before completing this form.

CHECK ONE:

PERSONAL INFORMATION

                    BENEFICIARY(IES) FOR ACTIVE INCIDENTAL DEATH BENEFIT
I designate the following beneficiary(ies) to receive the State ORP Incidental Death Benefit:

CERTIFICATION AND CONDITIONS

Sex

* YOUR BENEFICIARY DESIGNATIONS WILL NOT BE REVOKED UNDER SECTION 62-2-507 OF THE SOUTH CAROLINA CODE OF LAWS BY

  DIVORCE, ANNULMENT, OR ORDER TERMINATING MARITAL PROPERTY RIGHTS.

Please contact PEBA's Customer Contact Center with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.

THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS AND DOES NOT CREATE A CONTRACT BETWEEN THE MEMBER AND THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY.  THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT. 

(Certified copy of legal authorization required with signature other than applicant's)  

 (Please print)

 (Required only when signed by a mark) 

DATE

DATE

MM/DD/YYYY

MEMBER'S OR ALTERNATE PAYEE'S SIGNATURE

WITNESS

STATE OF

COUNTY OF

ACKNOWLEDGED BEFORE ME THIS DATE

NOTARY NAME 

MY COMMISSION EXPIRES 

NOTARY SIGNATURE

NOTARY BUSINESS PHONE