Local 177 Death Benefit Beneficiary Designation

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 *
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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             OtherIf other, please specify 

Secondary (Optional) Beneficiary

Members may list another beneficiary on file so that the total death benefit be split evenly amongst beneficiaries. 

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 

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 *