Salary Replacement Plan/ Beneficiary Form
 
  -   -  
 Social Security Number
E-mail (No work email addresses please)
 
First Name
Middle Initial		  
 Last Name
 
Mailing Address
 
City		  
County		  
State		  
Zip

PRIMARY BENEFICIARY
  -   -  
 Social Security Number		  
Date of Birth
 
 Current Relationship
 
First Name
Middle Initial		  
Last Name
 
Mailing Address
 
City		  
County		  
State
Zip

Home Phone
Other Phone

SECONDARY BENEFICIARY
  -   -  
 Social Security Number		  
Date of Birth
 
 Current Relationship
 
First Name
Middle Initial		  
Last Name
 
Mailing Address

City		  
County		  
State		  
Zip
 
Home Phone		  
Other Phone
 

Member's Signature:  Date:

*Claims are paid to the listed beneficiary regardless if the status of the relationship changes.
**Secondary beneficiary is eligible for benefits if primary beneficiary is unavailable.
If no beneficiary is named or if beneficiary is unavailable, benefits will be paid to the member's estate.

Please complete this form,  print it, sign it, and then mail to:  
Southern States PBA
2155 Hwy 42 South
McDonough, GA  30252

Phone: 800-233-3506

THIS BENEFIT IS AT NO ADDITIONAL COST TO YOU!