Page 16 - NMO State

Accidental Death (AD) Beneficiary Form
Customer Number TS 05050044-G Group Policyholder Name: Civil Service Employees Association, Inc.
SECTION I – Insured Information
First Name
Address – Street
City
Job Title
M.
Last name
Non-Work Email
State Zip SSN Place of Employment/Location
Date of Birth
Non-Work Phone Number
SECTION II – Beneficiary Information Complete the section that pertains to the type of 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
Address – Street
City
Relationship to Member
M. Last name
State Zip % Share
Date of Birth Phone Number SSN
You MUST designate at least one primary beneficiary. A person may only be listed once. The sum MUST equal 100%.
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
Address – Street
City
Relationship to Member
M. Last name
Date of Birth
Phone Number State Zip SSN
% Share
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
The sum of the Primary & Contingent Beneficiary percentages MUST equal 100%. Dollar amounts, fractions & decimals will not be accepted.
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.
Date (Must be date form was completed)
 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 I am a Member in good standing, which entitles me to this $10,000 AD policy.
Member Name (Please Print) Member Signature