YOUR INFORMATION
-   -  
 Social Security Number
E-mail (No work email addresses please)

First Name
Middle Initial		  
 Last Name

Mailing Address

City
County
State
Zip


PRIMARY BENEFICIARY

 *Claims are paid to the listed beneficiary regardless if the status of the relationship changes.

 
  -   -  
 Social Security Number		  
Date of Birth
 
 Current Relationship
 
First Name
Middle Initial		  
Last Name
 
Mailing Address
 
City		  
County
 
State		  
Zip
 
Home Phone

 
Other Phone

 

SECONDARY BENEFICIARY

         ** Secondary beneficiary is eligible for benefits if primary beneficiary is unavailable.
  -   -  
 Social Security Number		  
Date of Birth
 
 Current Relationship
 
First Name
Middle Initial		  
Last Name
 
Mailing Address
 
City		  
County
 
State		  
Zip
 
Home Phone		  
Other Phone

*** If no beneficiary is named or if beneficiary is unavailable, benefits will be paid to the member's estate.

 

Payment:  

  I hereby authorize my employer to deduct from my salary the membership dues as established by the Southern States Police Benevolent Association, Inc.  I understand that this amount will be deducted until 1) revoked by me at any time upon 30 days written notice to the employer, or 2) termination of my employment.  I understand that dues are calculated by SSPBA and are subject to change periodically, and I therefore authorize the agency to adjust my payroll deduction as necessary.  The deduction made pursuant to this authorization shall be transmitted to:
 

TERMS AND CONDITIONS:  By signing your name in the box below and submitting your application, you agree to becoming a member of the Southern States Police Benevolent Association and promise to abide by the constitution and by-laws of this association.

 
Date

  
Signature Required
 

Coverage will begin on the day provided to you by Southern States PBA, which will be done by email.  This date may not correspond with the date that you submitted your application. 

 

Thanks for your interest in PBA! Our dues include a $.50 per month voluntary contribution to our PAC fund.  For inquiries or to cancel this important contribution, call 800-233-3506.

 

To insure your beneficiary information is file.

Please read and fill this form to make sure the fields are correct.

THIS BENEFIT IS AT NO ADDITIONAL COST TO YOU!

 

Please print this form out and mail it in along with the form you printed out on the first page of this application to:
Southern States PBA
2155 Highway 42 S
McDonough, GA  30252