NMFT 1794 Designation for A D & D Policy

As a member of the Newport Mesa Federation of Teachers, a local affiliate 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

C4363 and CA4363 (if applicable)

First name *

Middle initial

Last name *

Email address *

Date of birth *

Month

Day

Year

Please enter information on your beneficiary:

First name of beneficiary *

Last name of beneficiary *

Address *

City *

State *

Zip *

Please sign the form before submitting:

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