Montana Designation of Beneficiary AD&D

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

Date of birth

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:

Sign above

Date Signed

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