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: Clear signature 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 * This information is kept on a secure server and is used only in the event of a claim. If you wish to complete a paper form please contact your steward/representative. Date of birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 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 * - Select -ALAKAZARCACOCTDCDEFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAVIWAWVWIWY Zip * Leave this field blank