CSS2HTML: WEB6502.XDP

APPLICATION TO APPEND COVERAGE FOR

INCIDENTAL DEATH BENEFIT

SC Public Employee Benefit Authority

South Carolina Retirement System

P.O. Box 11960, Columbia SC 29211-1960  

APPENDIX   to   Application   and   Resolution   entered   into   between   the   Governing   Body   of

and the South Carolina Retirement Systems.

Legal Name of Entity

above,                 members voted in favor of the above APPENDIX.

entity, do hereby certify that the aforesaid body consists of                  duly elected/appointed members and that, as stated

I,                                                                                                                                              of the aforesaid

IN WITNESS WHEREOF, I have hereunto set my hand and the authority of the aforesaid entity.

 

Date (MM-DD-YYYY)

Signature

Signatures of Governing Body (a majority must sign):

IN WITNESS WHEREOF, we have hereunto set our hands and authority this                        day of

Certification

Number

Name

Number

Year

Month

Day

Title

It is hereby agreed that the members in service of this employer under the Incidental Death Benefit Program of the
South Carolina Retirement System under terms and conditions of ?9-1-1770 of the 1976 Code of Laws of South Carolina.



This coverage is to become effective July 1, 

Year

It is further agreed to comply with the requirements of the South Carolina Retirement Act and its Rules and Regulations
of the Board as amended from time to time.

 

Form 6502
Revised 7/10/2012

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 RETIREMENT SYSTEMS.  THE SOUTH CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.