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FireFighter Cancer Foundation
The Fire Fighter Cancer Foundation promotes knowledge, awareness, and advocacy for the Fire Fighter diagnosed with cancer.

The IAFF Center of Excellence for Behavioral Health Treatment and Recovery is a one-of-a-kind addiction treatment facility specializing in PTSD for IAFF members – and IAFF members only – who are struggling with addiction, PTSD other related behavioral health challenges to receive the help they need in taking the first steps toward recovery. It is a safe haven for members to talk with other members who have faced or overcome similar challenges.
Member Benefit Enrollment/Service Form

First Responder Association Unit

 New Enrollee       Name Change       Coverage Change       Beneficiary Change
Association Information
Association Name Huntsville FireFighters Association            Policy Number FF0153AF2
Member / Applicant Information
Last Name 
First Name 
Middle Name 
SSN    DOB (MM/DD/YYYY)     Male     Female
Home Address:
Street Line 1 
Street Line 2 
City   State   Zip 
Home Phone Number   Cell Phone Number 
Email Address 
Membership Date    Coverage Effective Date 
Spouse Information
Spouse
Name 

Address 
SSN 
DOB 
New Enrollee Coverage
Member Basic Coverage Amount $10,000            Member AD&D Coverage Amount   N/A       
Coverage Change
Member Basic Coverage Amount Member Additional Coverage Amount   N/A       
Member AD&D Coverage Amount   N/A        Spouse/Family Coverage Amount     N/A       
Beneficiary Information
I designate my beneficiary(ies) to receive benefits as indicated below. The member is the beneficiary for all spouse/family coverages. If more than one beneficiary is named, the beneficiaries shall share equally unless otherwise stated below.

Primary
Name 

Address 
Relationship 
SSN 

DOB 

Secondary
Name 

Address 
Relationship 
SSN 

DOB 
Conditions Relating to this Enrollment Form
As a member of the Association, I am eligible to apply for this member benefit funded by group insurance. Agreement: I represent that all statements and answers in this enrollment form are complete, true and correctly recorded TO THE BEST OF MY KNOWLEDGE AND BELIEF. I agree that: 1) upon approval of this enrollment form by 5Star Life Insurance Company, it and the Certificate of Insurance issued to me will describe the benefits and terms of coverage provided under the Master Group Policy; 2) coverage applied for will not become effective until approved by 5Star Life Insurance Company and upon receipt of the full first contribution.
Member’s 
Signature:

Use your mouse, finger, or touch device to write your signature.
    Date 
Signed at (City, State) 
NOTE: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the law.
Underwritten by 5Star Life Insurance Company. Product not available in all states.
Admin. Office: 909 N. Washington Street, Alexandria, VA 22314 • 800-417-4408 • 703-636-3126 fax • www.afba.com


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Huntsville FireFighters Association IAFF Local 1833
2606 Artie Street
Huntsville, AL 35801
  256-652-8297 bldg rental

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