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Last Day Planner_NEW_PIC_2018

Benefits Available Upon

Benefits Available Upon My Death Available Death Benefits, Present Employer My employer is (name, address, telephone number):__________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ My family may be eligible for the following benefits from my employer upon my death. (Yes No) if yes check all that apply: Group life insurance Deferred compensation Group health insurance (death benefit) Credit union deposits COBRA continuation coverage Pension (survivors benefits) Profit-sharing plan (survivors benefits) Unpaid salary Other If I am killed on the job, additional benefits may be payable to my family from: Workmen’s compensation Accident travel insurance, common carrier insurance, tickets purchased by credit card Other Past Employer(s) (Yes No) Because of my previous employment there, I have a vested interest in the pension plan or other benefits at:___________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Papers needed to apply for benefits are located at:____________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 18

Benefits Available Upon My Spouse’s Death Available Death Benefits, Present Employer My employer is (name, address, telephone number):__________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ My family may be eligible for the following benefits from my employer upon my death. (Yes No) if yes check all that apply: Group life insurance Deferred compensation Group health insurance (death benefit) Credit union deposits COBRA continuation coverage Pension (survivors benefits) Profit-sharing plan (survivors benefits) Unpaid salary Other If I am killed on the job, additional benefits may be payable to my family from: Workmen’s compensation Accident travel insurance, common carrier insurance, tickets purchased by credit card Other Past Employer(s) (Yes No) Because of my previous employment there, I have a vested interest in the pension plan or other benefits at:___________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Papers needed to apply for benefits are located at:____________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 19

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