Form 717 Benefit Inquiry Questionnaire

PBGC Form 717
Approval OMB 1212-0055
Expires __________

Benefit Inquiry Questionnaire

For assistance, call 1-800-400-7242

Inquirer Info
Full name

Relationship to worker

Address

Mobile phone

Other phone

Email address

Worker Info

Full name

Social Security Number (SSN)

Other last name(s) used

Worker evening phone

Worker (or beneficiary) daytime phone

Worker address

Worker email address

Worker's date of birth

If deceased, worker's date of death

Employer Info
Employer

Current Plan Sponsor

Previous Plan Sponsor or other name

Location of Employer

Company tax identification number (EIN)

If company was bankrupt or closed, when?

Company location when worker was employed

Employment Info

Position held by worker

First day of worker's employment

Was the worker hourly, salaried or part-time?

Last day of worker’s employment

Hourly

Salaried

Part-Time

Were there changes in work status (e.g. part to full time, hourly to salary, union to non-union)? If so, give dates.
_________________________________________________________________________________________________________________
Name of one or two co-workers

Any additional info that might help determine worker's eligibility for a PBGC benefit

Pension Info
If there are documents from the former employer that describe the pension benefits earned, please complete the information below and mail
a copy of all relevant documents to PBGC:

Did worker receive a distribution, lump sum, or cash-out from the company? If so, amount

Pension Plan Name
___________________________________________________________________________________________________________
Pension Plan
Terminated – Standard Termination
Terminated – PBGC Trusteed
Ongoing
non-defined benefit plan
_________________________________
Normal Retirement Date

__________________________
Monthly benefit amount

_____________________________________
Benefit Form (Straight life, J&S, etc.)

Was the worker notified that an annuity was purchased on their behalf? If so, provide contact information

SSA L99-C1 Info
If you received a Potential Private Pension Benefit Information Form L-99-C1 from the Social Security Administration, please complete the
information below and mail a copy to PBGC: (New fields are highlighted)

Plan Name

Plan Number

Identification Number

Plan Administrator and Address

Year Reported

Estimated Amount

Type of Annuity

Payment Frequency

Units or Shares

Value of Account

PBGC Use Only

Date of call

CRM service request number

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