Sample of the Designation of Beneficiaries Form – U.S. Dept. of Justice PSOB Program
Download & Apply Your Department Letterhead
» Designation of PSOB Beneficiaries Form
We encourage departments to put this form on their letterhead and distribute to their firefighters for completion and filing with your department. Firefighters may also want to keep a copy for your own personal records.
Reason for Completing This Form
If there are no spouse or children, then the individual(s) designated by the firefighter on the PSOB beneficiary form on file with the firefighter’s agency will receive benefits if the claim is approved. If there is no designation, then the individual designated as the beneficiary on the most recently executed life insurance policy on file with the firefighter’s agency will receive benefits if the claim is approved.
