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APPLICATION FOR PARTICIPATION IN THE ASBESTOS WORKERS LOCAL 23
HEALTH AND WELFARE, PENSION AND ANNUITY FUNDS
 
* Required Information
I hereby make application to become, when eligible, a Participant under the above Health and Welfare, Pension and Annuity Funds.
For the keeping of necessary records in connection with my being a participant, I will supply you with this information:
 
   
* Name:
  (First, Middle, Last)
* Residence Address:
  (Street and No., Town or City, R.F.D., and State, Zip Code)
* Soc. Sec. No.:
* Date of Birth: Find Date
First date of employment under ASBESTOS WORKERS LOCAL 23: Find Date
* Home Local Number and Address:
   
Place of Birth:
  (City or Town, or Township and County, State)
Country:
  (if not the U.S.A.)

BENEFICIARY DESIGNATION
Please check Fund or Funds to which is Beneficiary Designation applies:
Health and Welfare Fund
Pension Fund
Annuity Fund

I hereby appoint the following beneficiaries and reserve the right to change, at any time and from time to time, the designation of beneficiaries for any amounts payable bat my death in accordance with my participation under said Funds; and I request that the Funds’ Trustees be instructed upon my death to arrange to make disbursements of such amounts to such beneficiaries.


PRIMARY BENEFICIARY
* First Name:
* Middle Initial:
* Last Name:
* Social Security Number:
* Relationship:
* Date of Birth: Find Date

SECONDARY BENEFICIARY
If the person named as PRIMARY BENEFICIARY doesn’t live to receive the applicable benefits, then I would like the balance of such benefits to be paid in equal shares to my surviving children, or to:
  Full Name Relationship Social Security Number
a.
b.
c.
Any final payment is to be made to the estate of the last to die of myself and said primary and secondary beneficiaries.

Today’s Date:
*  Find Date
Signed:
*
  Please type your name above as it appears on your Social Security Records.
Be sure to type your given name, and not just initials. In other words, “John J. Jones,” and not just “J.J. Jones”
*
I have confirmed that the name entered above is correct.