LIFE INSURANCE

As one of our membership benefits Local 11-637 maintains a $1,000 term life insurance
policy on each member.  If you have not recently done so, please print out, fill out and
return the Beneficiary Designation Form below.

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BENEFICIARY DESIGNATION                                                                Local 11-637, AFM

PLEASE PRINT:

Your legal name in full  ___________________________________________________

Your permanent address _________________________________________________

                                          __________________________________________________

Social Security No. __________________________ Date of birth _________________

Name of Beneficiary ____________________________________________________
                                      (First)                (Middle or Maiden)                           (Last)
(If beneficiary is a married woman, please list her first name, maiden name and last name).

Relationship to Insured ___________________________________________________
                                        (wife, husband, parent, son, brother, fiance, friend etc.)

Member's signature ___________________________________ Date ______________

Witness _______________________________________________________________

Approved ______________________________________________________________
                              (Local 11-637 Officer Signature)

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