Form 717 Benefit Inquiry Questionnaire

PBGC Form 717
Approval OMB 1212-0055
Expires XX/XX.2027

Benefit Inquiry Questionnaire

For assistance, call 1-800-400-7242

Full name

Relationship to worker

Address

Mobile phone

Other phone

Email address

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

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

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Position held by worker

First day of worker's employment

Last day of worker’s employment

_________________________________
Union Name

_________________________________________
Local Number

Was the worker hourly, salaried or part-time?

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

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

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