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.
Signatures of Governing Body (a majority must sign):
IN WITNESS WHEREOF, we have hereunto set our hands and authority this day of
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,
It is further agreed to comply with the requirements of the South Carolina Retirement Act and its Rules and Regulationsof the Board as amended from time to time.
Form 6502Revised 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.
Scripting must be enabled for this form to work correctly.