CO-OP Retirement Plan - Request An Estimate of Your Benefits

Request An Estimate of Your Benefits

Are you thinking about retiring in the near future? Or, are you contemplating a change of jobs that will take you outside of the Co-op Retirement Plan network? Either way, we invite you to ask for a detailed estimate of your benefits. Your estimate will be processed and mailed to the address that shows in our database.

All fields with an * are required

*First Name:

M.I:

*Last Name:

*Last Four Digits of your SS Number:

*Date of Birth (mm/dd/yyyy):

*Mailing Address: (To cross-check the address in our database)
*Street:
*City:	*State:	*Zip:

*Your Employer:

*Employer's City:

*Employer's State:

*Your last day on the payroll (This is your official termination of employment date, the date you are removed from the payroll of your employer. If you're not sure about your exact date of termination of employment, enter a hypothetical date): (mm/dd/yyyy)

Is the date entered above in the next calendar year? If so, please enter your expected gross wages for the current calendar year:

Retirement Date: (Complete this only if you are at least 55 years old and vested) Benefit payments will begin effective:

If you are married, please provide Spouse's Date of Birth:

*Daytime Phone Number (In case we need to ask you a question):

*Your Email Address:

*Your Comments:

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	Date Last Updated 02/09/2010
	CO-OP Retirement Plan - P.O. Box 169005, Kansas City, MO 64116-9005 1-800-816-5535 Copyright 2007 United Benefits Group