Page 19 - Work Force September 2018

Keep our communities strong through SEFA
Membership Has its Benefits!
The Accidental Death Benefit has been increased to $10,000!
• 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 15 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
When unions are strong, our communities are strong.
CSEA members have long prided ourselves on being a vital part of our communities, on and off the job, and one way that our state Executive Branch employees work to make
a difference is through supporting the New York State Employees Federated Appeal (SEFA).
CSEA is a strong supporter
of SEFA, not only through our members’ donations, but through volunteer efforts.
SEFA is a state-sanctioned, charitable, payroll-contribution program established under state finance laws. The program is open only to state employees; SEFA does not apply to local government employees.
SEFA distributes money to nonprofit organizations that provide numerous types of vital community services, including health care, services for children and senior citizens, domestic violence shelters and disaster relief.
Many of these organizations
need our help more than ever, and you can help us make a difference through participating in SEFA.
This year’s SEFA campaign kicks off on September 1 and runs through December 31.
“Our members play an important role in our communities, and we have long stepped up to help our neighbors in any way we can,” said CSEA President Danny Donohue. “As many people from all walks
of life face challenges, we are proud to stick together and lift our communities. Our members truly give from their hearts and SEFA is a way to make a true impact.”
“We want to encourage donors to find one or more charities they are passionate about, and designate to that charity,” said Statewide SEFA Director Laurelee Dever.
To learn more, visit the SEFA website at sefanys.org to look at the directory or “2018-19 Charity Search” to find the charity code for your favorite charities. You may donate to one or several organizations.
Stay up-to-date on buying discounts at
facebook.com/cseabenefits.
For more information on available discounts, visit cseany.org/mb.
September 2018
The Work Force 19
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
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 Address – Street City
M. Last name
Date of Birth
State
% Share
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
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
SSN
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
Phone Number