Teamsters Local 177
Teamsters Local 177
 

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Beneficiary Designation

Local 177 Death Benefit Beneficiary Designation

All eligible members of Teamsters Local 177 are entitled to name a beneficiary for the Local Unions Death Benefit. In the event of your death, the named beneficiary of this form will receive the $5,000 Death Benefit. Please contact the Local Union Hall at 973-923-7070 if you would like further information on your named beneficiary.

Member Information

The following information must be filled out with the Teamsters Local 177's member information

First Name *
 Last Name *
 
Social Security No *

(SSN Format: xxx-xx-xxxx Example: 123-45-7891)		 Address *
City *
 State *
 Postal Code *

Beneficiary Information

The following information is the named beneficiary for the above-mentioned member
First Name *
 Last Name *
Social Security No *

(SSN Format: xxx-xx-xxxx Example: 123-45-7891)

Relationship to Member *
 Spouse
 Parent
 Child
 Significant Other
 Other If other, please specify 

Authorization Agreement

By signing this document electronically, I am giving consent to Teamsters Local 177 that the above-named beneficiary of this form will receive the Local 177 Death Benefit, in the amount of $5,000, in the event of my death. 
I have read, understand, and submit this application to be admitted as my named beneficiary.

 Agree

Electronic Signature

Printed Full Name *

Signature:

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