Loyola University Chicago

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LUERP Estimate Request Form

Personal Information
*indicates required fields
*Full Name:
*Last 4-digits of your SSN:
*Address:
 		*Phone Number:


*Date of Birth:

Format: MM/DD/YYYY
E-mail Address:
*Employment Status: Current Employee
Former Employee
Beneficiary Information
Beneficiary Name:
Date of Birth:

Format: MM/DD/YYYY		 Single Married
Estimate Request

Please send me an estimate of the value of my LUERP account as of:

Current Date Future Date**

**If you selected "Future Date" above, please list specific date(s) below in order to determine the estimated value of your LUERP account.

Date Format: MM/DD/YYYY

Send estimate(s) to: My home address My e-mail address

Signature/Authorization
*By checking this box, I authorize the Human Resources department to perform any steps that are needed to fullfil this request.

*Date Signed:
Format: MM/DD/YYYY

For questions, please contact Dave Siembal at 312.915.7209 or dsiemba@luc.edu.

For information about LUERP, visit LUC.edu/hr/luerp.shtml.