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MoDOT & Patrol Employees'
Retirement System

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Retiree/Beneficiary Forms
$5,000 Beneficiary Designation 
Allows you to list your beneficiary(ies) for the $5,000 death benefit
Change of Beneficiary to Receive Final Payment of Retiree/Survivor Benefits from MPERS 
Allows you to change the beneficiary you designated to receive your final benefit payment at the time of your death.
Change of Beneficiary to Receive Guaranteed Payments from MPERS 
If you chose a guaranteed payment benefit option, this will allow you to designate a new beneficiary.
Designation of Agent 
Allows you to choose an Agent who can make MPERS benefit decisions if you become disabled
Designation of Agent 
Allows you to choose an Agent who can make MPERS benefit decisions if you become disabled
MoDOT Cancer Insurance Deduction Authorization/Cancellation 
Cancer insurance through Central United Insurance Company for MoDOT employees only.
New Spouse Designation 
Opportunity to name new spouse as beneficiary (if eligible)
Pop-Up Application 
To be completed in the event you selected a joint & survivor form of payment and your spouse precedes you in death and must be accompanied by the required documentation.
Request for DBO Estimate 
Division of Benefits Order
Survivor Application 
This form must be completed by the survivor and accompanied by the required documentation before the survivor can begin receiving benefit payments after retiree's death
W4 P Substitute 
Use this form to make your Federal and Missouri State tax withholding elections


Mailing Address: PO Box 1930, Jefferson City, MO 65102-1930 • Office Location: 1913 William St., Jefferson City, MO 65109
Phone Number: (573) 298-6080 • Toll Free: (800) 270-1271 • Fax: (573) 526-5895 • Email:
mpers@modot.mo.gov