Location Number and Membership
Number
The location number and the
membership number spaces in the box at the top of the
application are to be completed by the Division of Pensions and
Benefits.
Pension Fund
Check the box indicating that the
employee is a member of the Public Employees' Retirement System,
or PERS.
Part I: Applicant Information
Item
1: Name
Enter the employee's full legal name
(last, first, and middle initial). Nicknames should not be used.
If applicable, please indicate the member's maiden name or name
used during a previous membership in the space provided.
Item 2: Address
Enter the employee's current
mailing address.
Item 3: Social Security Number
Enter the employee's Social Security
number (numbers only).
Item 4: Gender
Please check the appropriate box
indicating the employee's gender.
Item
5: Date of Birth
Enter the employee's month, day,
and year of birth, using the format mm/dd/yyyy. Since the employee's
proof of age is required at the
time of retirement, a copy of the employee's birth certificate,
baptismal certificate, or any other acceptable form of proof
of age should be submitted at the same time this application
is filed. (Please do not send the original.)
Do not delay filing the Enrollment
Application if the proof of age is not available.
Item
6: Daytime Phone Number
Provide the applicant's daytime phone
number, with area code (and extension, if applicable).
Item
7: Is member receiving retirement benefits from a New Jersey
State-administered or local New Jersey retirement system?
Check "Yes" or "No".
When checking "Yes", enter also the name of the New
Jersey State-administered retirement system or a local New Jersey
retirement system from which applicant is receiving retirement
benefit.
There are many rules and laws governing
the return to public employment and reenrollment following retirement
from a NJ State-administered retirement system. For further
information, please see the "Employment
after Retirement" section provided in the Manual.
Employer Information
Item
8: Name of the Employer
Please list the complete name of
the employing location.
For Boards of
Education
Most school teachers
and staff are employees of the presiding board of education,
not the school in which they work. The board of education would
then be the "employing agency" and must be listed
as the employer on record, on the Enrollment Application,
rather than the name of the school.
Item 9: County
Please list the county in which the
employer is located.
Item 10: Location Number, Bureau
Number, and Payroll Number
Location Number: This is the
number assigned to your employing location by the Division of
Pensions and Benefits. The number you include on this line is
specific to the retirement system into which the employee will
be enrolled. It is very important that the Location Number be
included.
Bureau Number: Please
include the Bureau Number if one has been assigned to your location.
Payroll Number: The Payroll
Number is required for State agencies paid through Centralized
Payroll only.
The Location Number, Bureau Number
(if applicable), and Payroll Number (State locations paid through
Centalized Payroll only) should be entered as appearing on your
location's quarterly Report of Contributions (ROC).
Item 11: Title/Position of Applicant
Please indicate the title/position
under which the employee was hired.
On-call Employees
If the employee is "on-call",
the title entered should reflect the employee's on-call status.
For example: "On-call Substitute Teacher", "On-call
Substitute Bus Driver," etc.
Item
12: Is applicant employed by more than one public employer?
Check "Yes" or "No".
If "Yes" is checked, please enter the full name of each
employing location.
Item 13: Item 13 information is
to be completed for TPAF applicants only. PERS applicants should
skip to Item 15.
Items 13 a-c: Date Employment Began,
Permanent Appointment Date, and Whether Position is Temporary
or Provisional
Item 14a (For PERS Applicants):
Date Employment Began
Enter the date on which applicant
began employment.(See
the notes below)
Item 14b: Regular or Permanent
Appointment Date
Enter the date of the applicant's
regular or permanent appointment.
This should be the date the employee
was given permanent status in their title, or the first day
of the 13th consecutive month of employment. The
answer will depend on whether your employing location is a Civil
Service location, a non-Civil Service location, or if the employee
is an on-call 10-month employee. (See the notes
immediately below.)
If employees are permanent in their
positions, they must be enrolled as of their regular or permanent
appointment date. They may
apply for a cost quotation to purchase all temporary service,
if any, rendered immediately preceding appointment.
Enrollment
of Optional Enrollees
If an employee's enrollment is
optional and the decision is made to enroll in the retirement
system, the enrollment will be effective on the first of
the month following receipt of the application at the Division
of Pensions and Benefits.
Item 14 c: Temporary or Provisional
Indicate whether the applicant is
still considered a temporary or prrovisional employee.
Temporary
(provisional) Employees Having 12 Consecutive Months of Service
If the
employee is temporary or provisional in his or her position
and has been employed in that position for 12 consecutive months,
he or she must be enrolled in the retirement system.
He or she may apply for
a cost quotation to purchase all prior temporary service.
Notes for
Civil Service Employers Regarding Items 14a-c.
- If the individual is still considered
a temporary (provisional) employee, only Item 14a, "Date
Employment Began", should be completed, not 14b:
The date employment began represents the date the employee began
continuous service covered by the PERS provisions. (Continuous
service is a key eligibility criterion for membership in the
PERS.) This may be a date later than when the employee was first
hired; if, for example, the employee had been intermittently
or seasonally employed, or on-call too infrequently to become
eligible for PERS membership.
- If an employee is hired from a
certified Civil Service list, or is hired in an unclassified
title, the dates in Items 14a and 14b would be the same.
- If a person is hired provisionally
and later certified through Civil Service to a position within
one year from the date employment began, the date in Item 14a
would be the date employment began, and 14b would be the date
of regular appointment (RA) status.
For Non-Civil Service Employers
Concerning Items 14 a-c
If the employee is working in a regularly
budgeted position (you can count on the position being funded
from year to year), then the answers to Items 14a and 14b would
be identical.
If for some reason the date of hire
and the date of permanent status are different, be sure to attach
a letter of explanation to the Enrollment Application.
This would avoid the need for Enrollment Section to send a letter
asking for clarification and thus avoid a delay in enrollment.
For example, an employee
began work on June 1 in a position that was only temporarily funded.
On November 1 the job became a regularly budgeted position. The
date of permanent appointment would be November 1 (Item 14b),
and the date of employment would be June 1 (Item 14a).
Date of Enrollment of On-call
Ten-month Employees
The minimum number of days a ten-month,
on-call employee can work to qualify for membership in PERS is
100. If the employee works 100 days or more during the regular
work year, then he or she becomes eligible when returning to work
to begin the second year, not when the 100 day mark is reached.
For example, an on-call, ten-month
employee was hired on September 10, 2000 and worked, on average,
20 days per month (100 days total) as of the end of January 2001.
Even though this employee has reached 100 days of on-call employment
with one employer by January, the employee is not yet eligible
for enrollment.
If the employee returns to work in
September 2001, the employee would be enrolled.
In this example, Item 14a
would show a date of September 10, 2000; Item 14b would
show September 1, 2001. The Enrollment Section at the Division
would enroll the on-call employee as of September 1, 2001.
The applicant would then be permitted
to buy the one year of temporary service that occurred before
enrollment.
Item 15: Elected Official
Indicate whether the applicant is an elected official. On or after July 1, 2007, a newly elected official is ineligible for enrollment in the PERS. (See Fact Sheet 80.)
Item 16: Appointed Official
Indicate whether the applicant is an appointed official. On or after July 1, 2007, a newly appointed official who does not have an existing PERS account is ineligible for enrollment in the PERS. (See Fact Sheet 80.)
Item 17: Professional Services Contract
Indicate whether the individual is working under a professional services contract or providing professional services without benefit of a contract.
Item 18: Current Base Annual Salary
Be sure to use the current annual
base salary only. Do not insert hourly or per diem rates. For
hourly employees, use the best estimate of current annual base
salary.
Base salary is the contractual salary
of the employee. Base salary should not include bonuses, overtime
pay, stipends or longevity pay, or sick or vacation time paid
as a lump sum.
The Division of Pensions and Benefits
cannot enter hourly or per diem rates. Base salary must be entered
as an annual figure.
Item 19: Ten-month or Twelve-month
Position
Indicate if the employee is employed
on a ten- or twelve-month per year basis.
Item 20: Hours Worked
Indicate if the employee's hours are fixed at 35 or more hours per week for State employees, or 32 or more hours per week for local employees. This requirement applies to PERS members enrolled after May 21, 2010.
Part III: Employer Certification
Item
21: Name of Employer Representative Completing Application
Please list the name of the employer representative completing the application.
Item 22: Phone Number and Extension
of Employer Representative
Please enter the phone number (with
area code) and extension of the employer representative
entered in Item 21 who is completing the application.
Item 23: Certifying Officer's
Signature and Date
Please enter the Certifying Officer's
name and today's date, using the format mm/dd/yyyy. After printing
the completed form, the Certifying Officer must also sign the
Enrollment Application in the space provided.
Before the Certifying Officer signs
the Enrollment Application, it is suggested that the application
be reviewed for missing, erroneous or inconsistent information.
A little effort at this juncture can prevent lengthy delays and
more work later.
The signature by the Certifying Officer
must be an original signature, not a stamped copy.
Item 24: Signature and Date of Supervisor of Certifying Officer
The Certifying Officer's supervisor must also sign the Enrollment Application in the space provided, along with today's date, using the format mm/dd/yyyy.
Before the Certifying Officer signs
the Enrollment Application, it is suggested that the application
be reviewed for missing, erroneous or inconsistent information.
A little effort at this juncture can prevent lengthy delays and
more work later.
The signature by the Certifying Officer
must be an original signature, not a stamped copy.
Designation of Beneficiary
There is no longer a section for beneficiary designation on the PERS/TPAF Enrollment Application. The member must use the Designation of Beneficiary form
to nominate a beneficiary, or beneficiaries, for his or her group
life insurance and/or pension benefit. There is an online version, available through MBOS, and a printed version: Designation
of Beneficiary
Employers should strongly recommend that new employees complete the online "Designation of Beneficiary" application through MBOS or the printed Designation of Beneficiary form in a timely manner (see below).
To designate or update beneficiary information using the online "Designation of Beneficiary" application, members must first register with the Member Benefits Online System (MBOS).
Members wishing to sign up for MBOS at this time should be directed to the "MBOS Registration Information" page, at: http://www.state.nj.us/treasury/pensions/mbosregister.htm
Or, the member may submit a printed Designation
of Beneficiary form, completed in its entirety.
Fact Sheet #68, Designating a Beneficiary, is available to provide information to members requiring help in making their beneficiary selections for pension and/or group life insurance. Some information about selecting beneficiaries is also provided below.
It is strongly recommended that
both the Enrollment Application (by the employer) and the Designation of Beneficiary (by the member) be submitted
at of the time of enrollment, whenever possible. If
the member does not complete the Designation of Beneficiary, the Division will still accept the
Enrollment Application so that the enrollment can be processed
in a timely manner, because delayed
and forced enrollments can be costly to the employer.
When a member does not complete the
Designation of Beneficiary form, the member's
estate will be listed as both the group life insurance and pension beneficiary.
In such cases, an insurance packet and policy rider confirming
the estate as beneficiary will be mailed to the member.
To subsequently change the beneficiary
information in effect once enrollment has occurred, the member
must either update his or her beneficiary information online using the MBOS Designation of Beneficiary application, or the member must submit a Designation
of Beneficiary form.
Benefits for Which
Beneficiary Is Named
Group Life Insurance: All
employees enrolled in the PERS will be be entitled to group life
insurance coverage. Members who are age 60 or older at the time
enrollment must prove insurability through a medical examination
administered by the Prudential Insurance Company. Additional
information regarding group life insurance for employees enrolled
in the PERS is available through this link.
Return of Member Contributions:
The pension benefit is the return of the member's contributions
to the PERS, paid in a lump sum to the member's designated beneficiary(ies)
upon the member's death.
Group Life
Insurance and Pension Benefit — Choosing Beneficiaries
Primary
Beneficiaries
A primary beneficiary is the person
(or persons) who will receive benefits at the time of an employee's
death.
The member should provide each primary
beneficiary's full name, current address, relationship to member,
and birth date. Providing each beneficiary's Social Security number
is not mandatory, but can expedite processing of the death claim.
Members should be made aware that
if more than one primary beneficiary is named, "share and
share alike" is the standard used for distribution of benefits,
unless otherwise specified — upon the member's death, all
living named primary beneficiaries will share the benefit equally.
For more information, please refer to
Fact Sheet #68, Designating a Beneficiary.
Contingent Beneficiaries
A contingent beneficiary is the
person (or persons) who will receive the benefits at the time
of the employee's death only if all of the primary beneficiaries
have predeceased the employee.
The member should provide each contingent
beneficiary's full name, current address, relationship to member,
and birth date. Providing each beneficiary's Social Security number
is not mandatory, but can expedite processing of the death claim.
Rules for Designation of Beneficiaries
- A member may nominate any person,
persons, institution, charity, corporation, trust, your estate,
etc., as primary or contingent beneficiary.
- If more than one person
is named as primary beneficiary, the following shall apply:
"Share and Share Alike, Survivor or Survivors."
If multiple beneficiaries are named, it is to be understood
that the beneficiaries living at the member's death will
share equally in the distribution of the death benefits.
The same applies to multiple contingent beneficiaries.
- The Division of Pensions an Benefits
cannot require that the member provide the beneficiary's Social
Security number. Providing the Social Security number
of a beneficiary, however, may expedite processing of the death
claim.
- If additional space is required,
an attachment sheet is acceptable, provided it is signed by
the member and the date is provided.
- Nicknames are not acceptable--use
the beneficiary's full name. When naming a married female as
beneficiary, be certain the proper name is given, e.g., Mary
J. Jones, not Mrs. John R. Jones.
- Definite dollar amounts should
not be indicated, since the amount of group life insurance changes
with every change in the member's salary (for active members)
or retirement allowance (for retirees).
- The member may change the beneficiary
designation for the group life insurance, accumulated pension
deductions or last check benefit (retired members) at any time.
- If no beneficiary designation
is in effect at the time of death, or the designation section
is incomplete or blank, payment will be made to the member's
estate.
When
a Beneficiary is a Minor
If a member wishes to name a minor
as a beneficiary for pension death and/or group life insurance
benefits, the manner of the designation can make a huge difference
in how benefits are paid.
- If a member dies leaving pension
death and/or group life insurance benefits to a minor, the Division
of Pensions and Benefits will withhold payment of the benefit
until one of the following occurs:
- A court ordered guardian of
the minor's property is appointed by the courts and
proof is forwarded to the Division, in which case the benefits
will be paid to the guardian on the minor's behalf, or;
- The minor attains age 18.
- The member may choose to leave
pension death benefits and/or group life insurance benefits
to a trust established on behalf of a minor beneficiary. There
are two types of trusts, "formal" and "informal".
- A "formal trust"
is established by formal, legal documents filed with a NJ
county court that establishes a person or persons or corporation
as "Trustee". When designating a formal trust
on behalf of a minor beneficiary, the member must clearly
state "Formal Trust" on behalf of the minor, include
the date of trust incorporation, and supply the name and
address of a trustee to contact upon the member's death.
All specified death benefits would then be paid to the trust.
- An "informal trust"
is one that has not been filed with the courts and need
not be a formal agreement. In this case, the member designates
a person or persons to act as "informal trustee(s)"
on behalf of the minor. The informal trustee(s) would be
paid the specified benefits on behalf of the minor beneficiary.
Do's
and Don'ts of Beneficiary Designation
Based on frequent experience at the
Division, the following "Do's and Don'ts" are
suggested as a means to reduce the number of errors on beneficiary
designation forms and ensure that members are well-served in this
important area.
Don't use "white-out"
or cross out names to make changes in designation. This makes
the form unacceptable. It will be rejected and a new form will
be mailed to the member.
Do have the member complete
a fresh form whenever the member makes a mistake in designating
a beneficiary. In the long run, this will save the member time
and will eliminate any uncertainty regarding the desired designation.
Don't name the same person
or persons in both the Primary and Contingent Beneficiary sections.
This makes the form unacceptable. It will be rejected and a new
form will be mailed to the member.
Do choose both primary and
contingent beneficiaries with care.
Don't leave the address for
any beneficiary blank. This will require the Division of Pensions
and Benefits to generate a letter requesting the required information.
Don't neglect the birth date
of each beneficiary. This will require the Division of Pensions
and Benefits to generate a letter to request the required information.
Don't
forget to list the relationship of each beneficiary to the member.
This will require the Division of Pensions and Benefits to generate
a letter to request the required information.
Don't use general phrases
like "My Children" or "My Grandchildren".
Provide your beneficiaries' specific names, addresses, birth dates,
and relationships to you, as well as their Social Security numbers
if you choose to provide SSNs.
Do have all beneficiary information
on hand when completing a Designation of Beneficiary Form.
The
Signature of the Applicant
An applicant's signature must be
the person's full, legal name. For example, if the applicant's
name is "Richard M. Jones", he should not sign "Dick
Jones." The applicant should also provide the date.
Updating Beneficiary Designation
Information
It is very important for members
to review beneficiary information periodically, especially when
major life events occur, and update this information when necessary.
Members wishing to change their named beneficiary(ies) should
use the MBOS Designation of Beneficiary application to update this information, or they may complete a printed Designation
of Beneficiary form, sign it, and send it in to the Division
at: The Division of Pensions and Benefits, 50 West State St.,
Trenton, NJ 08625-0295.