Form 717 Benefit Inquiry Questionnaire

PBGC Form 717
Approval OMB 1212-0055
Expires xx/xx/xx

Benefit Inquiry Questionnaire

For assistance, call 1-800-400-7242

Inquirer Info
Full name

Relationship to worker

Address

Evening phone

Daytime phone

Email address

Worker Info

Full name

Social Security Number (SSN)

Other last name(s) used

Worker (or beneficiary) evening phone

Worker (or beneficiary) daytime phone

Worker (or beneficiary) address

Worker (or beneficiary) email address
Worker's gender (check one)

Male

Female

Worker's date of birth

If deceased, worker's date of death

Employer Info
Company name when worker was employed

If sold or merged, other name(s) company has used

Company current location

Company tax identification number (EIN)

If company was bankrupt or closed, when?

Company location when worker was employed

Employment Info

If there were periods of unemployment, when?

Position held by worker

If there were periods of unemployment, why? (e.g. layoff, furlough, disabilty)

First day of worker's employment

Name of one or two co-workers

Branch or division worked in

Worker's union name & local number
Was worker hourly or salaried

Hourly

Salaried

Was worker full or part time?

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.

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

Pension Info

Did worker receive a "distribution", "lump sum", or "cash-out" from the company? If so, amount, type & date.

Pension plan name
Was benefit rolled over to a pension plan or IRA?

Did worker or beneficiary receive a retirement benefit?

Yes

No

Benefit amount

Name of provider and contact info

Benefit start date

Benefit form (Straight life, J&S, etc.)

Full-time

SSA Info
If you received a ‘Social Security Administration Potential Private Pension Benefit Information’ Form:

Plan name

Plan number

Identification number

Plan administrator and address

PBGC Use Only

Date of call

CRM service request number

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