Page 4 - New Member Orientation Booklet (Updated March 2019)

The previous $5,000 Accidental Death benefit has been increased to $10,000!
“This new 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
“Access to affordable insurance programs has been a hallmark of CSEA membership
from the early days of our union. That tradition continues with this thoughtful new benefit that CSEA is offering at no cost to all of its members.”
— Don Lynskey NYS Unified Court System
The Accidental Death benefit
has been increased to $10,000!
• •
• Since the program began in 2014, this benefit has already Thheilpsebde1n2effiamt islieasvraeiclaobveler ftromyoausuadsdaenm, termagbicerloisns. good
standing. There is no cost to you!
• This benefit is available to you as a member in good standing. There are no premiums owed!
Go to https://cseany.org and click on
Since the program began in 2014, this benefit has already
$10K No Cost To You Accidental Death Benefit!
helped families recover from a sudden, tragic loss.
• Be sure to 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.
Fill out the beneficiary form on the back or go to cseany.org/10KAD
ReturncoLomcapl1l0e0t0e,dAFfSoCMrmE,sAFtLo-C:IO NewYork’sLeadingUnion CSEA Insurance Department
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 cseany.org/10KAD.
SECTION III – Signature & Attestation
Accidental Death (AD) Beneficiary Form Customer Number TS 05050044-G SECTION I – Insured Information
Group Policyholder Name: Civil Service Employees Association, Inc.
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 Address – Street City
M. Last name
Date of Birth
Relationship to Member
% Share
only be listed once. The sum MUST equal 100%.
Relationship to Member
% Share
MUST equal 100%.
State
Zip SSN
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
City
State
Zip SSN
If you need more space for additional beneficiaries, 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 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.
Job Title
First Name Address – Street City
M.
Place of Employment/Location Last name
Non-Work Email Address Date of Birth
Phone Number
SSN
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)
Phone Number
You MUST designate at least one primary beneficiary. A person may
The sum of the Primary & Contingent Beneficiary percentages
Dollar amounts, fractions and decimals will not be accepted.
Member Record Verification/Update
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.
State
Zip
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 Date
Stay up-to-date on buying discounts at facebook.com/cseabenefits
For more information on available discounts, visit the ‘For Members’ section on cseany.org