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APPLICATION TO APPEND COVERAGE FOR

INCIDENTAL DEATH BENEFIT; ACCIDENTAL DEATH

PROGRAM AND/OR FIREFIGHTERS COVERAGE

SC Public Employee Benefit Authority

Police Officers Retirement System

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

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

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.

 

FIREFIGHTERS COVERAGE UNDER THE POLICE OFFICERS RETIREMENT SYSTEM wherein firefighters in service of this employer shall be covered under the terms and conditions of ?9-1-660 of the 1976 Code of Laws of South Carolina.

 

The ACCIDENTAL DEATH PROGRAM of the Police Officers Retirement System under the terms and conditions of  ?9-11-140 of the 1976 Code of Laws of South Carolina.

This coverage is to become effective July 1, 

This coverage is to become effective July 1, 

This coverage is to become effective July 1, 

The INCIDENTAL DEATH BENEFIT of the Police Officers Retirement System under the terms and conditions of ?9-11-120 of the 1976 Code of Laws of South Carolina.

It is hereby agreed that the members in service of this employer shall be covered under (check all that apply):

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

Form 6502P
Revised 7/10/2012

and the South Carolina Retirement Systems.

Certification

Number

Name

Number

Year

Month

Day

Year

Year

Year

Legal Name of Entity

Title

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. 

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