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APPLICATION FOR DEATH BENEFITS Before completing application on reverse side, please read all instructions carefully. NOTE: The Government Employees Retirement System furnishes this form solely upon request, neither admitting the validity of a claim nor the liability of the System, nor waiving any rights in the premises, and without indication of what action it may take upon this application. CLAIMANT'S STATEMENT must be made by the person or persons to whom the benefit is payable. If there is more than one beneficiary, a separate application will be furnished for each. When the benefit is payable to the estate or executors or administrators of the deceased, the application must be made by an executor or administrator, a certificate of whose appointment must be furnished. When the benefit is payable to a minor, the application must be made by a guardian, an official certificate of whose appointment must be furnished. A birth certificate must be provided for each beneficiary. When the benefit is payable to a named beneficiary or two or more beneficiaries and by death of any beneficiary has become otherwise payable, a death certificate must be furnished, giving the place and date of death of the deceased beneficiary. When the benefit, or any part of it, is payable to "children" or others of a class, a sworn statement must be furnished by the Claimant giving the names and dates of birth and a copy of a birth certificate of each. If any have died, the sworn statement must give the place and date of death, and must also state whether they died unmarried, intestate, and without issue. If an official inquiry as to cause of death has been made, a copy of the verdict, or finding duly certified, must be furnished with this application. A certified copy of the CERTIFICATE OF DEATH must be furnished with this statement. A CERTIFICATE OF DEATH may be obtained from the local Department of Health, Division of Vital Statistics. Any such certificate must bear the official seal of the agent issuing it or be properly notarized. When completing the application, each question must be distinctly and fully answered. The System reserves the right to require or to obtain further information should it be deemed necessary. _________________ Claimant’s Initials GERS-BEN108 REV 06 GOVERNMENT EMPLOYEES RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex - STE 1, St. Thomas, VI 00802-5750 • (340) 776-7703 • Fax (340) 776-4499 3005 Orange Grove, Lot #5, Christiansted, St. Croix, VI 00820-4313 • (340) 773-5480 • Fax (340) 773-5497 APPLICATION FOR DEATH BENEFITS SSN of Member: ___________________________________ Member’s Employee No.:_____________________________ Beneficiary Phone No.:_______________________________ I, ____________________________________ , the undersigned, residing at ____________________________________ do hereby make application for the death benefit provided by the Retirement System for employees of the Government of the Virgin Islands, on account of the death of ___________________________________________________________ who was a member of the Employees Retirement System and who was employed in the department of ____________ ____________________ in the capacity of _________________________ on the island of _________________________ DECEASED INFORMATION Deceased date of birth _______–_______–__________ Deceased place of birth _______________________________ Date and place of death ______________________________________________________________________________ Residence of deceased at death _______________________________________________________________________ Cause of death ______________________________________________________________________________________ Was the death directly connected with the specific occupational duties of the deceased? J Yes J No On what date did deceased last attend work? _____________________________________________________________ Name and address of last attending physician ___________________________________________________________ In what capacity or by what title do you claim this benefit? __________________________________________________ How long have you known the deceased? _____________ What is your relationship to the deceased? _____________ What is your date of birth?_______–_______–__________ Claimant’s SSN ___________________________________ Dated _______–_______–__________ Signature ______________________________________________________ Claimant's mailing address: ____________________________________________________________________________ ____________________________________________________________________________ Territory of the U.S. Virgin Islands } District of } ss: On this ___________day of___________________________ , before me personally appeared ________________________________, known to be the individual whose named is subscribed in the foregoing instrument and acknowledge that ________________________ executed the same as __________________________ free and voluntary act. ______________________________________________________ Notary Public Commission Expires _____________________________________ GERS-BEN108 REV 06 (Name) (Physical Address) (Full Name of Deceased) (Department or Agency) (State whether Beneficiary, Executor, Adminstrator, Guardian or Trustee) mm dd yyyy mm dd yyyy mm dd yyyy (No. of Years) (Select a value)