Annuity Fund Participant Enrollment

MID-ATLANTIC STATES DISTRICT COUNCIL PARTICIPATING LOCALS' ANNUITY FUND

P. O. BOX 1769 SALEM, VA 24153 (540) 345-7735
Participant Enrollment Information
Email sender
Participant's Name

First NameMiddle InitialLast Name
First Name*
Middle Initial
Last Name*
Address*

Street Address

Street Address Line 2

City

Zip Code
State*
Social Security Number*
Date of Birth*

MonthDayYear
Date
Phone No.*
Email*
example@example.com
Participant Local Union No.*
Marital Status:*

SingleMarriedSeparatedDivorcedWidow(er)
Beneficiary Information
Primary Beneficiary's Name

First NameMiddle InitialLast Name
Primary Beneficiary First Name
Primary Beneficiary Middle Initial
Primary Beneficiary Last Name
Relationship to Participant
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

City

Zip Code
State
SS No.
Secondary Beneficiary's Name

First NameMiddle InitialLast Name
Relationship to Participant
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

City

Zip Code
State
SS No.
Participant's Signature*

Clear
Date*

MonthDayYear
Date
Email
example@example.com
If you click "Save" below, you will be able to save your progress and complete the form later. You will receive a link by email to continue editing your submission.

Your information will not be received by Local 845 until you click "Submit."
Should be Empty:

MID-ATLANTIC STATES DISTRICT COUNCIL PARTICIPATING LOCALS' ANNUITY FUND