Beacon Benefits, Inc.

Rollover/Distribution Request

In general you may request to either rollover your account or take a distribution of your account when you stop working for your employer.

For specific rules governing rollovers and distribution, please request an SPD.

Rollover/Distribution Request


Plan Name :
Participant Name :
Participant Address :
City :
State :
Zip Code :
Last Day Worked :
Date Of Birth :
Pay-Order Instructions :
Cash :	Make Check Payable To:
Direct Rollover :	Name of Financial Institution Name of Trustee Account Number
Split Distribution : (Complete Cash & Direct Rollover Section)	Cash Amount ($) Direct Rollover Amount ($)

Please remember your former employer must authorize all plan distributions.

Beacon Benefits, Inc. Willowdale
205B Willow Street South Hamilton, MA 01982
phone 978.468.1555 fax 978.468.2221 email: info@beacon-benefits.com