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 * 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. Date of birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Local Name or Number * Personal email address * 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 Year20212022202320242025 Leave this field blank
