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. About you: Policy Holder American Federation of Teachers Policy Number 9908-80-61 & 9908-81-09 (if applicable) First name * Middle initial Last name * AFT Local Union Name and/or Number, or employer if currently working, or previous employer if retired * 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. Your AFT Member ID if you know it Email address * Date of birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 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 sign the form before submitting: Clear signature Date Signed * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20202021202220232024 Leave this field blank