2024 KAFC Membership

Your Information

• * Department:
• * Job Title:

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Cell Phone:
• * County

• Fee

  Type	Fee
  Volunteer Membership	$25.00
  Career/Combination Membership	$50.00
  One time Retiree	$25.00
  Retired Chief Renewal NO FEE	No Charge

$10,000 AD&D Policy

• Complete the form below for your $10,000 AD&D coverage. The Kentucky Association of Fire Chiefs is the Policy Holder. Policy #9907-56-90 You will not be contacted by the insurance company.

• Hereby revoking any and all previous designation, I designate the person(s) on this form as my beneficiary(ies) to receive any payment from the policy or certificate number shown above. I fully understand that this designation of Beneficiary(ies) applies to the full accidental Loss of Life Benefit amount that is in force.

• Type of Deisgnation

  • Original Designation
  • Change of Designation

• You can designate up to 4 beneficiaries with an percentage of the benefit going to each

• Date
• Beneficiary name & Relationship
• %
• Address, City, St, Zip
• Beneficiary name & Relationship
• %
• Address, City, St, ZIP
• Beneficiary name & Relationship
• %

• Address, City, St, Zip
• Beneficiary name & Relationship
• %
• Address, City, St, Zip