APPLICATION TO APPEND COVERAGE FOR
INCIDENTAL DEATH BENEFIT; ACCIDENTAL DEATH
PROGRAM AND/OR FIREFIGHTERS COVERAGE
SC Public Employee Benefit Authority
Police Officers Retirement System
202 Arbor Lake Drive, Columbia, SC 29223
EmployerServices@peba.sc.gov
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
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
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 6/15/2021
and the South Carolina Retirement Systems.
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.