Designation of Beneficiary Form

Member Information



   Please enter your legal name as it appears on your driver's license or birth certificate.

   Optionally enter a preferred name if different from your legal first name.




Please use mm/dd/yyyy format.


Once approved, the beneficiaries on this form will completely and fully replace any prior beneficiaries that LAFRA had on file for you.
Member Address





Member Contact Information

Use ###-###-#### format for domestic numbers.

Use ###-###-#### format for domestic numbers.


Spouse Information



   Please enter spouse's legal name as it appears on their driver's license or birth certificate.


   Optionally enter a preferred name if different from your spouse's legal first name.


Use ###-###-#### format for domestic numbers.

Please use mm/dd/yyyy format.


Please use mm/dd/yyyy format.






Domestic Partner Information



   Please enter domestic partner's legal name as it appears on their driver's license or birth certificate.

   Optionally enter a preferred name if different from your domestic partner's legal first name.


Use ###-###-#### format for domestic numbers.

Please use mm/dd/yyyy format.


Please use mm/dd/yyyy format. Enter date legally official.







In Case of Accident or Death, I Wish You to Notify




Use ###-###-#### format for domestic numbers.






Primary Beneficiaries (must be at least 18 years of age)
Your primary beneficiary is first in line to receive your death benefit. 



Enter a whole number, without % symbol.





Use ###-###-#### format for domestic numbers.

Please use mm/dd/yyyy format.




Use ###-###-#### format for domestic numbers.

Use ###-###-#### format for domestic numbers.














Secondary Beneficiaries (must be at least 18 years of age)
If all your primary beneficiaries die before you, a secondary or contingent beneficiary is the next in line.



Enter a whole number, without % symbol.





Use ###-###-#### format for domestic numbers.

Please use mm/dd/yyyy format.




Use ###-###-#### format for domestic numbers.

Use ###-###-#### format for domestic numbers.














Tertiary Beneficiaries (must be at least 18 years of age)
If all your secondary beneficiaries die before you, a tertiary or contingent beneficiary is the next in line.



Enter a whole number, without % symbol.





Use ###-###-#### format for domestic numbers.

Please use mm/dd/yyyy format.




Use ###-###-#### format for domestic numbers.

Use ###-###-#### format for domestic numbers.













Signatures
TO THE BOARD OF TRUSTEES, OFFICERS, AND MEMBERS OF THE LOS ANGELES FIREMEN’S RELIEF ASSOCIATION

I agree to conform to and abide by all laws, rules and regulations of said Association now in force or which hereafter may be adopted.

The statements herein contained are true to the best of my knowledge and I hereby agree that any misrepresentation or concealment of facts herein shall disqualify me to receive or participate in any of the benefits or privileges or membership.


Please use mm/dd/yyyy format.
Hidden Fields








Your Social Security Number must be filled in and match the confirmation before you may submit.