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When you join CSEA, everyone benefits.
CSEA offers every member a $10,000 Accidental Death Benefit
• This benefit is available to you as a member in good standing. There is no cost to you!
• Since the program began in 2014, this benefit has already helped more than 60 families recover from a sudden, tragic loss.
Fill out the beneficiary form on the back or go to https://cseany.org/10KAD
Return completed forms to:
CSEA Member Solutions Center, Insurance Unit 143 Washington Avenue
Albany, NY 12210
Complete the beneficiary form so this benefit goes to who YOU designate as well as the Membership Verification/ Update form to ensure we have your most current information in the event of a claim by visiting https://cseany.org/10KAD.
5_2021
“This benefit
will really help
my family out if something should ever happen to me. It means a lot
to me to see how much CSEA cares about the well being of members and their families. Whether it’s on the job or off, CSEA has our back.”
— Jarvis “Tim”Brown Town of Oyster Bay
“I now have more peace of mind. If anything happens to me, whether I am on the job or not, there will be
additional coverage for my family because of CSEA.The more I learn about my union, the more I realize just how valuable my CSEA membership is.”
— Nikki Johnson, CSEA/VOICE Local 100A Dutchess County Chapter Representative
SECTION III – Signature & Attestation
Accidental Death (AD) Beneficiary Form
Group Policyholder Name: Civil Service Employees Association, Inc.
Customer Number TS 05050044-G
SECTION I – Insured Information
First Name Address – Street City
M.
Last name Non-Work Email State Zip
Date of Birth Phone Number SSN
SECTION II – Beneficiary Information
Complete the section that pertains to the type beneficiary you are designating.
PRIMARY BENEFICIARY - Your first choice to receive your life insurance proceeds in the event of your accidental death. If any primary beneficiaries predecease you, that person's share will be equally divided among any remaining primary beneficiaries.
First Name
M. Last name
Date of Birth
Address – Street
Phone Number Zip SSN
City
State
% Share
Relationship to Member
You MUST designate at least one primary beneficiary. A person may
CONTINGENT BENEFICIARY - Your second choice to receive your life insurance proceeds if ALL of your primary beneficiary(ies) are not living at the time of your death. If any contingent beneficiaries predecease you, that person's share will be equally divided among any remaining contingent beneficiaries.
First Name
M. Last name
Date of Birth
Address – Street
Phone Number Zip SSN
City
State
% Share
Relationship to Member
The sum of the Primary & Contingent Beneficiary percentages MUST equal 100%. Dollar amounts, fractions & decimals will not be accepted.
If you need more space for additional beneficiaries use back of this form. For living trust, or estate, visit www.cseainsurance.com/Products- Forms/Term-Life to download the full form and submit to CSEA, Inc., ATTN: Insurance Dept., 143 Washington Ave., Albany, NY 12210.g
SECTION III – Signature & Attestation
I hereby authorize the Civil Service Employees Association, Inc. (CSEA), Local 1000 AFSCME, AFL-CIO, to be my exclusive representative for collective bargaining and therefore revoke any other representative that I may have previously designated. I also hereby authorize the fiscal or payroll officer of my employer to deduct CSEA dues from my salary in the amount certified by CSEA in this and succeeding years of my employment and membership. Dues, contributions or gifts to CSEA are not tax deductible as charitable contributions. However, they may be deductible as ordinary and necessary business expenses.
I may revoke this authorization by sending a letter stating my intent to resign, along with my name, address, telephone number, and CSEA ID number, by United States Postal Service First Class Mail, to: CSEA Statewide Secretary, CSEA, Inc., 143 Washington Ave., Albany, NY 12210.
I hereby revoke any previous designations, and I designate the person, people, or entity named in Section II as Beneficiary(ies). I reserve the right to change or revoke this designation at any time.
 By checking this box I consent to receive calls (including recorded or autodialed calls or texts) at my cell phone number from CSEA and its
affiliated labor organizations on any subject matter. You may modify your preferences by calling CSEA at 1-800-342-4146 or visiting the CSEA website at cseany.org.
I acknowledge that my membership entitles me to this $10,000 AD policy.
Member Name (Please Print) Member Signature Date (Must be date form was completed)
only be listed once. The sum MUST equal 100%.
Stay up-to-date on buying discounts at facebook.com/cseabenefits
For more information on available discounts, visit the ‘Members’ section on cseany.org