TEAMSTERS LIFE WITH DUES by yaofenjin

VIEWS: 0 PAGES: 1

									                                Please send the completed form by Email, Mail, or Fax to:


                                                          Regina Naterman
                                                  2855 Telegraph Avenue, Suite 301
                                                         Berkeley, CA 94705
                                                         Fax: (510) 845-7444
                                                    rnaterman@teamsters2010.org



  Please Print                                TEAMSTERS LIFE WITH DUES
  Name (First)         (Middle Initial)         (Last)                   Social Security Number             Employer Name

  Member Address                                                                        Phone Number                                    Local Union #
                                                                                                                                            2010
In the space below indicate the person or persons you wish to designate as your beneficiary. You may designate any person or persons including your estate.

             I request that any Death Benefits be paid in equal shares to the Beneficiaries I have listed below.

             I request that any Death Benefits be paid to the first Beneficiary named below who survives me.

  Full Name:                                                                          Relationship:
  Address:                                                                                                Phone:
  Full Name:                                                                          Relationship:
  Address:                                                                                                Phone:

  Date:                                                           Employee’s Signature:
                                          TYPE OR PRINT IN INK - DO NOT PRINT SIGNATURE
  ---------------------------------------------------------------------------------------------------------------------------------------------------




                              TOGETHER | STRONGER | TEAMSTERS LOCAL 2010

								
To top