As a member of the Philadelphia Federation of Teachers and 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. 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 * 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. Your AFT Member ID if you know it Email address * Date of birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Cell/Mobile Number 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 MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Leave this field blank