Maryland Classified Employees Association #1935 AD&D Beneficiary Form

As a member of the Maryland Classified Employees Association, #1935 and the American Federation of Teachers, you are covered by an Accidental Death and Dismemberment Policy with a value of $5,000 as part of your membership. Please use the form below to confirm your membership and designate your beneficiary(ies) for this coverage.

This information will be stored on a secure server and only used in the event there is a claim. This form will supersede any previously submitted paper form received by AFT local #1935.

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.

About you:

Policy Holder

American Federation of Teachers

Policy Number

9908-80-61 & 9908-81-09 (if applicable)

First name *

Middle initial

Last name *

Current worksite *

Your AFT Member ID if you know it (not a required field)

Email address (nonwork) *

Date of birth *

Month

Day

Year

Cell/Mobile Number

Home Address

Home City

Home State (if other than Maryland)

Home Zip Code

The beneficiaries below will share the benefit, these are not a priority or ranking order.

Please enter first (or only) beneficiary here (name & address required, phone and email if you have the information) *

Please enter second beneficiary here (name& address required, phone and email if you have the information)

Please enter third beneficiary here (name& address required, phone and email if you have the information)

Please enter fourth beneficiary here (name & address required, phone and email if you have that information).

Please sign the form before submitting:

Clear signature

Date Signed *

Month

Day

Year

New short answer

Leave this field blank