348 W. Hospitality Lane, Suite 100 San Bernardino, CA 92408
P: 909.885.7980 E: memberservices@sbcera.org
BENEFICIARY DESIGNATION / CHANGE This form cancels and replaces all prior designations on file. You must rewrite all your beneficiary designations below.
MEMBER INFORMATION (Please print or type)
NEW
CHANGE
Last Four Digits of SSN
Employee ID
Status
Last Name
First Name
Middle Name
Date of Marriage
Daytime Telephone
Evening Telephone
Address
City
State
Zip Code
BENEFICIARY INFORMATION Primary 1 Beneficiary Name Date of Birth
Relationship Social Security Number
Address
Phone Number City
% of Benefit Email Address State
Zip Code
Primary 2 Beneficiary Name Date of Birth
Relationship Social Security Number
Address
Phone Number City
% of Benefit Email Address State
Zip Code
Alternate 1 Beneficiary Name Date of Birth
Relationship Social Security Number
Address
Phone Number City
% of Benefit Email Address State
Zip Code
Alternate 2 Beneficiary Name Date of Birth Address
CRT220 Revised 7-13-20
Relationship Social Security Number
Phone Number City
% of Benefit Email Address State
Zip Code