Local 685 Term Life Beneficiary Card

AFSCME Local 685 Life Insurance
Secure Your Member Benefit – Quick Beneficiary Update

As a member of AFSCME Local 685, you automatically receive $14,000 in Term Life Insurance at no cost to you.

To make sure this benefit is paid quickly and correctly if it’s ever needed, we are updating our records and building a complete, secure digital file of all beneficiary designations.

Please take a moment to provide your beneficiary information below. This ensures that:
- Your chosen beneficiary can be contacted without delay
- Claims can be submitted and processed efficiently
- Your benefit is paid according to your wishes
This coverage is provided through Symetra.

Completing this form only takes a minute, but it makes a meaningful difference for your loved ones.
Your Information
First Name:*
Last Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Cell Phone:*
Please enter a valid cellphone number.Format: (000) 000-0000.
Personal Email Address:*
Note: The Union is blocked from County emails.
Birthdate:*

MonthDayYear
Date
Job Title:*
Employee #:*
Work Location:*
Beneficiary Information
Policy Number
Beneficiary #1*
Beneficiary #2
Beneficiary #3
Signature:*

Powered by Jotform SignClear
Should be Empty:

AFSCME Local 685 Life Insurance