Beneficiary Designation Election and QPSA Notice

Pension plans are required to offer at least a QPSA death benefit to spouses of vested participants in the event the participant dies before beginning retirement benefits. This QPSA is by default a joint and survivor annuity assumed to commence the day before death where the surviving spouse receives the surviving portion of annuity. A plan may offer additional death benefit called non-QPSA benefits that may be provided to spouses or designated Beneficiaries. This Beneficiary Designation Election and QPSA Notice may be used for these requirements and elections. Review with your counsel to determine if they are appropriate to use.

Related Guidence:

401(a)(11) 417 1.401(a)-20 1.417(a)(3)-1 1.417(e)-1

Plan Name

Plan Number

Plan Administrator

Admin Phone

Admin Email

Admin's Street, City & State with Zip

Employer

EIN on 5500

Select Non-QPSA Death Benefit Option

None, other than the qualified preretirement survivor annuity.

The excess (if any) of the Present Value of the Participant's vested Accrued Benefit minus the Present Value of the QPSA benefit.

The proceeds of any insurance policies purchases on the Participant's life, including the QPSA benefit, not to exceed 100 times the Anticipated Monthly Retirement Benefit.

The proceeds of any life insurance policies purchased on the Participant's life plus the theoretical ILP Reserve minus the Present Value of the QPSA benefit and the cash balance of any life insurance contracts.

Other (Specify):

Beneficiary Designation Election and QPSA Notice

Related Guidence:

Notice Inputs

Select Non-QPSA Death Benefit Option