Page 20 - Work Force June 2019

Show that your home is a Proud Union Household
Cut this image out and attach it to your front door to let people know you plan to Stay Union, Stay Strong!
• This valuable benefit is available to you as a member in good standing at no cost to you!
• Since the program began in 2014, this benefit has already helped 34 families recover from a sudden, tragic loss.
Go to cseany.org/10KAD
to fill out the beneficiary form.
• Be sure to complete the beneficiary form (online or download and print) 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.
• Return completed forms to:
CSEA Insurance Department 143 Washington Avenue Albany, NY 12210
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$10,000 Accidental Death Benefit at no cost to you — sign up today!
cseany.org/10KAD
cseany.org
Published by CSEA 143 Washington Ave Albany, NY • 12210 Danny Donohue, President (518) 257-1000 • (800) 342-4146 CSEA • Local 1000 AFSCME • AFL-CIO
WorkForce
City
State
% Share
Zip SSN
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
M.
Last name Non-Work Email State Zip
Date of Birth Phone Number SSN
Address – Street
City
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
You MUST designate at least one primary beneficiary. A person may only be listed once. The sum MUST equal 100%.
Relationship to Member
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
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.
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
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.
Job Title
First Name Address – Street City
M.
Place of Employment/Location Last name
Non-Work Email Address Date of Birth
Phone Number
SSN
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