ENROLLMENT FORM

LRS-2 (Rev 8-2012)
For Office Use Only, Leave Blank
Employer #
Missouri Local Government Employees Retirement System
P.O. Box 1665, Jefferson City, MO 65102
P: 1-800-447-4334
F: 1-573-636-9671
Dept #
ENROLLMENT FORM
Employee #
st
1 Appeared on Stmt
PERSONAL INFORMATION (PLEASE PRINT)
Name of Employee
Social
Security #:
First
Employer
Mailing Address
Dept. ID (General, Police, Fire)
City
Job Title
Birth Date
Gender
Male

Female

Middle
Last
Street
State
Month
Day
Year
Date Employed
Full Time:
Have you previously been a member of LAGERS?
If yes, please list the previous employer(s) & date(s) of employment below:
Previous Employer(s):
Zip
Month
Yes

Day
No
Year

Dates of Employment:
DESIGNATION OF BENEFICIARY OR BENEFICIARIES (PLEASE PRINT)
I hereby direct the Board of Trustees of the Missouri Local Government Employees Retirement System (LAGERS) to divide my accumulated
contributions (if any) between as many of the primary beneficiaries listed below as may be living at the time of my death. The contingent
beneficiary(ies) will receive a payment only if the primary beneficiary(ies) do not survive me. Statutes may supersede a beneficiary designation.
My accumulated contributions will only be distributed if I do not have a spouse and/or dependent child(ren) whom are eligible for monthly survivor
benefits. This beneficiary designation supersedes and revokes prior beneficiary designations for all of my non-retired accounts.
Beneficiary Name
Relationship to You Birth Date
Month Day Year
Primary
Contingent

Mailing Address
City
State
Beneficiary Name
Relationship to You
Birth Date
Mailing Address
City
State
Beneficiary Name
Relationship to You
Birth Date
Mailing Address
City
State
Beneficiary Name
Relationship to You
Birth Date
Mailing Address
City
State
Beneficiary Name
Relationship to You
Birth Date
Mailing Address
City
State
Zip
Month Day Year
Primary

Zip
Month Day Year
Month Day Year
Primary
Month Day Year
Primary
I declare the above statements to be correct and true to the best of my knowledge and belief.
Signature of Employee
Date
Signature of Employer
Contingent

Contingent

Your date of marriage (if spouse)
Primary

Zip

Your date of marriage (if spouse)

Zip
Contingent
Your date of marriage (if spouse)

Zip

Your date of marriage (if spouse)
Contingent

Your date of marriage (if spouse)
Date
DESIGNATING BENEFICIARIES PRIOR TO RETIREMENT
What Benefits are Payable if I Die? If an active LAGERS member were to pass away before retirement, LAGERS will look first to pay a monthly survivor benefit to any eligible spouse or dependent children. If no monthly survivor benefit is payable, LAGERS will pay a refund of any accumulated member contributions to the designated beneficiary of record. Who is Eligible for a Monthly Survivor Benefit? Regardless of any beneficiary designation you make with the LAGERS office, Missouri state law decides who the eligible recipient will be on a LAGERS monthly survivor benefit. A spouse of at least two years* will be considered the first eligible recipient. If there is no eligible spouse, the recipient will automatically be any dependent child, see definition below. If there is no eligible spouse or dependent children, there is no monthly survivor benefit payable. What if No Monthly Survivor Benefit is Payable? If no monthly survivor benefit is payable, LAGERS will refund any employee contributions, plus interest, to your beneficiary of record. Who May I List as a Beneficiary for a Refund of My Contributions? You may designate an individual, legal entity (such as a charity), trust, or your estate as a beneficiary. You may designate more than one primary and/or contingent beneficiary to share equally in your accumulated contributions. Why Should I List a Contingent Beneficiary? A contingent beneficiary will only be eligible to receive your accumulated contributions should all your primary beneficiaries predecease your contingent beneficiaries. Without a contingent beneficiary, your estate would determine how your contributions are disbursed should your primary beneficiary predecease you. My Employer is Currently Non‐Contributory, Do I Still Need to Designate Beneficiaries? It is always a best practice to keep current beneficiaries on file with the LAGERS office. LAGERS employers have the option to change their ‘Contributory Status’ once every two years. This means that even if you are not contributing toward your LAGERS retirement today, there is always the possibility that you may in the future. Likewise, if you at any time worked for a LAGERS employer who was contributory, or you made contributions in the past with your current employer (and you have not taken a refund of those contributions), they will still be accumulating interest in your LAGERS account and would be payable to your beneficiaries should no monthly survivor benefit be payable at the time of your death. Where Can I View my Current Designations and Account Balances? You can view your current beneficiary designations by logging on to the myLAGERS member page. There, you may view your account information as well as make updates to your beneficiary designations. You may also refer to your most recent annual statement or contact the LAGERS office to obtain this information. What Does My Eligible Beneficiary Need to Do in the Event of My Death? In the event of your death, it is solely the beneficiary’s responsibility to notify the LAGERS system and submit the required Application for Survivor’s Benefit Form or Request for Refund of Employee’s Contributions by Beneficiary Form to the LAGERS office. These forms may be obtained at www.molagers.org or by contacting our office. *The two year requirement for a spousal survivor benefit will be waived if the cause of the death is determined to be accidental or duty related. Missouri Revised Statutes define a child as a ‘dependent’ “until the child's death or marriage or attainment of age eighteen, whichever occurs first; provided, the age eighteen maximum shall be extended as long as the child continues uninterruptedly being a full‐time student at an accredited secondary school or college or university… [AND] the age eighteen maximum shall be extended for any child who has been found totally incapacitated by a court of competent jurisdiction for as long as such incapacity exists.”