The following information must be filled out with the Teamsters Local 177's member 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 OtherIf other, please specify
Members may list another beneficiary on file so that the total death benefit be split evenly amongst beneficiaries.
First Name
Last Name
Relationship to Member Spouse Parent Child Significant Other OtherIf other, please specify
Printed Full Name *