Please fill out the form completely. You may also update your beneficiary here. Items in Bold are required for  submission (sent via a secure server).

Title:  (Mr, Mrs, Ms, Dr, etc.) First Name: Middle Initial: Last Name: Address: City: State: Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Eur., Mid. East, Africa, Canada Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code: Please provide your home E-mail address to receive updates about NEA Member Benefits programs, Web Site offers and Giveaways. Home E-mail Address: Phone Number: ( ) - Date of Birth: - -  (mm-dd-yyyy) Member Number:   - -  (Social Security #) Gender: Male Female Major Wage Earner? Yes No About the same Family Income? $19,999 or below $20-29,999 $30-39,999 $40-49,999 $50-59,999 $60-69,999 $70,000 or above Housing Status: Rent living quarters Own condo or coop. Own mobile home Own house Live with relatives Other Employment Level: Elementary Intermediate/Jr High/Middle School High School Community/Junior College College/University Adult Education Other Subject Area: English/L.A./Speech Mathematics Science Related Social Studies/History Health Related/P.E. Fine Arts Voc/Business Ed Related Foreign Languages General Ed. Counselors/Psych./Soc. Workers Ed. Support System Other Marital Status: Single Married Domestic Partner Separated Divorced Widowed Spouse* First Name: Spouse* Last Name: Spouse* Employment Status: Educational employee Other professional Executive Unemployed Homemaker Student Retired Other Number of Children: No Children 1 2 3 4 or more Children's Birth Years: - 1st  - 2nd  - 3rd  - 4th  NEA DUES-TAB BENEFICIARY Please name your beneficiary/beneficiaries for the NEA DUES-TAB death benefit. Provide the relationship and percentage information in the fields below. If a beneficiary is not selected, any amount of insurance at your death will be paid to the first surviving beneficiary class as listed in the following order: Surviving Spouse; Surviving children; Surviving parents; Surviving Siblings; Your Estate. If you have any questions, please contact NEA Member Benefits at 1-800-637-4636 Monday - Friday, 8 a.m. to 8 p.m. (or Saturday, 9 a.m. to 1 p.m.) ET for assistance. Beneficiary 1: Name:   Relationship:   --select one-- Spouse Domestic Partner Son Daughter Mother Father Brother Sister Aunt Uncle Former Spouse Grandmother Grandfather Grandson Granddaughter Niece Nephew Cousin Foster Mother Foster Father Foster Son Foster Daughter Employee Friend Other Payout %:   Beneficiary 2: Name:   Relationship:   --select one-- Spouse Domestic Partner Son Daughter Mother Father Brother Sister Aunt Uncle Former Spouse Grandmother Grandfather Grandson Granddaughter Niece Nephew Cousin Foster Mother Foster Father Foster Son Foster Daughter Employee Friend Other Payout %:   Beneficiary 3: Name:   Relationship:   --select one-- Spouse Domestic Partner Son Daughter Mother Father Brother Sister Aunt Uncle Former Spouse Grandmother Grandfather Grandson Granddaughter Niece Nephew Cousin Foster Mother Foster Father Foster Son Foster Daughter Employee Friend Other Payout %:   Beneficiary 4: Name:   Relationship:   --select one-- Spouse Domestic Partner Son Daughter Mother Father Brother Sister Aunt Uncle Former Spouse Grandmother Grandfather Grandson Granddaughter Niece Nephew Cousin Foster Mother Foster Father Foster Son Foster Daughter Employee Friend Other Payout %:   Beneficiary 5: Name:   Relationship:   --select one-- Spouse Domestic Partner Son Daughter Mother Father Brother Sister Aunt Uncle Former Spouse Grandmother Grandfather Grandson Granddaughter Niece Nephew Cousin Foster Mother Foster Father Foster Son Foster Daughter Employee Friend Other Payout %:   Beneficiary 6: Name:   Relationship:   --select one-- Spouse Domestic Partner Son Daughter Mother Father Brother Sister Aunt Uncle Former Spouse Grandmother Grandfather Grandson Granddaughter Niece Nephew Cousin Foster Mother Foster Father Foster Son Foster Daughter Employee Friend Other Payout %:          *Includes Domestic Partner California COA # 1179 NAIC # 68241