AFT #2364 Beneficiary Form

As a member of a local union affiliated with the American Federation of Teachers, you automatically receive a $5,000 Accidental Death and Dismemberment Policy as part of your membership. Please use the form below to confirm your membership and designate your beneficiary.

This information will be stored on a secure server and only used in the event there is a claim. If you wish to complete a paper form please contact your steward/representative. Your email contact information may be used to inform you of other union benefits and services. Should you get such messages you simply need to unsubscribe if you don’t wish to receive them.

Please sign the form before submitting:

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About you:

Policy Holder

American Federation of Teachers

Policy Number

C4363 and CA4363 (if applicable)

First name

Middle initial

Last name

Last four digits of Social Security number

Date of birth

Email address

Personal Email Address

Cell Phone Number

xxx-xxx-xxxx

Home Address

City

State

(NJ, PA, NY, DE, etc.)

Please enter information on your beneficiary:

First name of beneficiary

Last name of beneficiary

Address

City

State

Zip

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