Article Please complete and submit this form to report the death of an ERSRI member or payee. Note: Fields with an asterisk* are required. YOUR CONTACT INFORMATION Your First Name Your Last Name Your Email address Your Phone Number Your Mailing Address Line 1 Your Mailing Address Line 2 City, State, Zip Your Relationship to Member MEMBER’S INFORMATION Member’s Full Name Member’s Date of Death Member’s Date of Birth Member’s SSN (last 4 digits) – if known: Additional Information Please enter any additional information as needed CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
