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WORKSHEET

(Associations to contact for life insurance coverage)

MEMBER INFORMATION

NAME:

ADDRESS:

SOCIAL SECURITY #:

ASSOCIATION INFORMATION

(Don’t forget professional trade and membership organizations!!)

DATES OF MEMBERSHIP:

ASSOCIATION:

ADDRESS:

PHONE:

BENEFITS CONTACT NAME:

DATES OF MEMBERSHIP:

ASSOCIATION:

ADDRESS:

PHONE:

BENEFITS CONTACT NAME:

DATES OF MEMBERSHIP:

ASSOCIATION:

ADDRESS:

PHONE:

BENEFITS CONTACT NAME:

DATES OF MEMBERSHIP:

ASSOCIATION:

ADDRESS:

PHONE:

BENEFITS CONTACT NAME: