Philadelphia Federation of Teachers #3 AD&D Beneficiary Form

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 *

Your AFT Member ID if you know it

Email address *

Date of birth *

Month

Day

Year

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

Day

Year

Leave this field blank