Forms
The below forms are used when a member would like to pay premiums through Direct Debit or a member needs to make a change to their beneficiary, name and/or address.
Click on the form name to access the form online.
CONTACT HOME OFFICE FOR INSURANCE APPLICATIONS, ANNUITY APPLICATIONS,
MEMBERSHIP FORMS AND LOST CERTIFICATE FORMS
BY CALLING 570-823-3513, (TOLL FREE) 888-834-6614 OR SEND E-MAIL TO LPSCU@LPSCU.ORG
DIRECT DEBIT FORM - This form is a convenient way to pay premiums on insurance and annuity certificates. Complete the authorization form and attach a voided check or saving deposit slip. Return the information to: LPSCU, 71 S. Washington Street, Wilkes-Barre, PA 18701.
CHANGE OF BENEFICIARY FORM - This form is used when the insured member amends either the primary or contingent beneficiary. The insured member can have more than one primary or contingent beneficiary to receive his/her death benefit. If there is more than one beneficiary, the death benefit will be divided equally. The insured member or owner of the insurance certificate may, at any time, change the primary or contingent beneficiary.
CHANGE OF ADDRESS FORM - This form is used to ensure the members address is correct on necessary information. The member may contact Home Office by phone, regular mail, e-mail or fax. In order to update an address change, Home Office must verify certain information with the member before the address can be changed.
NAME CHANGE FORM - This form is used to notify us of a name change; for example marriage, adoption, etc.The member may contact Home Office by phone, regular mail, email or fax. In order to update a name change, Home Office must verify certain information with the member before the name can be changed.