Statement of Claimant Form

Statement of Claimant Form


After the Plan Member has died, the Member’s beneficiary should complete the Statement of Claimant form to notify the Plan Administrator of the Member’s death and select how he/she wishes to receive the Member’s Pension benefit that has accumulated in the Plan.

Please contact the Plan Administrator for a copy of your form.

Information Needed to Complete the Form

To complete the form, the beneficiary must provide:

  • Member’s personal information
  • Beneficiary’s personal information, and
  • Method of payment of Pension funds.

The original death certificate (or a notarized copy) must be submitted with this form.

Depending on the method of payment selected by the beneficiary, additional forms may need to be submitted as outlined on the form or advised by the Plan Administrator.


Completed forms should be forwarded to the Plan Administrator.