Long Beach Federation of Classified Employees Membership Contract

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Employee Information
Group Life Insurance

By clicking "Yes" I hereby certify that I am a new member within the last 12 months and I elect $5,000 of Group Term life Insurance which is available to me at no cost for one full year as a new AFT member. I want to be covered under the group plan for the benefits which I am or may become eligible for, as requested below. The AFT provides this insurance for one year as a benefit of AFT membership.  I certify that I am actively at work. (Retirees are not eligible.) I understand the $5,000 coverage will be reduced by 50 percent at age 65 and by 75 percent at age 70.

I hereby certify that all statements and answers in this form are full, complete, and true to the best of my knowledge and belief. I understand that to be eligible for coverage I must be a new AFT member, actively working, and not currently insured under the Group Term Life Insurance plan for AFT members. In no event will I be eligible for this coverage beyond 12 months from my AFT membership date. I understand that my coverage will become effective on the first day of the month following the date this application is signed. Any person who knowingly and with intent to defraud any insurance company or other person files an AFT application for insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. A portion of the premium collected from the AFT Insurance program's contributory policies is allocated to fund the premium for the Policyholder's Basic Life Insurance Program. For questions, phone toll-free (888) 423-8700 or visit www.aftbenefits.org.

Committee On Political Education

By clicking "Yes" I hereby authorize my employer to deduct from my salary the sum indicated below (contribution choices will appear after if you check the authorization box after this text) per pay period and forward that amount to The Local's Committee On Political Action (COPE). This authorization is signed freely and voluntarily and not out of any fear of reprisal, and I will not be favored or disadvantaged because I exercise this right. I understand this money will be used by AFT/COPE to make political contributions. AFT/COPE may engage in joint fundraising efforts with the AFL-CIO. This voluntary authorization may be revoked at any time by notifying The Local's COPE in writing of the desire to do so. Contributions or gifts to AFT/COPE are not deductible as charitable contributions for federal income tax purposes.

Use whole numbers only.