ACTIVE
	RETIRED
	NONE
	YES
	NO
     
     
     
     
   
     
     
     
     
     
     
     
     
   
     
     
     
     
     
     
     
     
     
     
     
     
     
     
   
     
     
     
     
PRE-RETIREMENT DEATH BENEFIT PACKAGE PREPARED & SUBMITTED?	     
     
     
     
     
     

NOTICE OF DEATH - STATE EMPLOYEE

CO-638 REV. 8/2015 (Electronic Version)

INSTRUCTIONS

STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER

 1.  Please print or type.

 3.  If the deceased had deductions for Group Life Insurance, prepare 
     additional copies for each division affected.

 2.  Forward one copy to the Retirement Services Division

 4.  On each copy, check the division to which that copy is to be sent.

FORWARD TO: OFFICE OF THE STATE COMPTROLLER

RETIREMENT SERVICES DIVISION

GROUP LIFE INSURANCE - 
HEALTHCARE POLICY & BENEFITS DIVISION

DEFERRED COMP. AND OTHER - 
HEALTHCARE POLICY & BENEFITS DIVISION

FROM (Agency) (1)

CORE DEPT. ID.  (2)

STATUS (3)

NAME OF DECEASED (Last) (4)

First Name

M.I.

DATE OF BIRTH (5)

EMPLOYEE NO. (6)

BARG. UNIT (7)

SOCIAL SECURITY NO. (8)

ADDRESS OF DECEASED (Street, No., Name, City, State, Zip Code) (9)

DATE OF DEATH (10)

NAME OF SURVIVING SPOUSE (Last) (11)

First Name

M.I.

DATE OF BIRTH (12)

SOCIAL SECURITY NO. (13)

DATE OF MARRIAGE (14)

ADDRESS OF SPOUSE (If different from block 9) (15)

PAY PERIOD ENDING DATE OF LAST HOSPITAL
AND MEDICAL INSURANCE DEDUCTION (16)

AMOUNT OF DEDUCTION (17)

If deceased had Group Life Insurance deductions, complete this section; if not check 'NONE' in block 18 and complete block 19.

(18)

EMPLOYMENT IN STATE
SERVICE BEGAN (DATE) (19)

LAST DATE WORKED FOR THIS AGENCY (20)

REASON FOR NOT REPORTING TO WORK
AFTER DATE IN BLOCK (21)

PAY PERIOD ENDING DATE OF LAST GROUP LIFE INSURANCE DEDUCTION(22)

ANNUAL GROSS SALARY(23)

JOB TITLE WHEN LAST AT WORK (24)

The General Statutes of Connecticut (Sec. 5-253), provide for payment to the beneficiary(ies), if any, for extra hours of work and accumulated vacation allowance upon the death of the employee.  Additionally, certain collective bargaining agreements provide for the payment of one-fourth (1/4) of the deceased employee's daily salary for each day of sick leave accrued to his/her credit up to a maximum payment of sixty (60) days' pay.

BENEFICIARY NAME - AGENCY RECORDS (Last,) (25)

First Name

M.I.

ADDRESS (Street, No., Name, City, State, Zip Code) (26)

SOCIAL SECURITY NO.  (27)

DATE OF BIRTH (28)

IF EMPLOYEE WAS AGE 65 OR OVER ON DATE OF DEATH:

Was State paying Medicare Part B coverage? (29)

SOCIAL SECURITY CLAIM NO. (30)

PRE-RETIREMENT DEATH BENEFIT

The pre-retirement death benefit in Section 5-165(a) specifies that if a member dies while continuing to accrue state service or while on an authorized leave of absence, his/her spouse shall receive a lifetime income provided that at date of death the member was:

1.  Eligible to retire under Section 5-162, 5-173 or 5-188; or had completed 25 years service, and;
2.  Had been lawfully married to his/her spouse for the twelve months preceding death.

DATE 

DATE OF FINAL PAYROLL CHECK (31)

AMOUNT OF CHECK (32)

PAYROLL SUPERVISOR'S NAME (Please print) (33)

SIGNATURE (34)

DATE (35)

TELEPHONE NO. (36)