Newborn Benefit Application

This program is introduced as an added fraternal benefit to members of the
Ladies Pennsylvania Slovak Catholic Union upon the birth of a child.

Newborn children of a member(s) of the L.P.S.C.U. are eligible for this benefit
– One parent must be a member
– Parent(s) can be biological or adoptive
Coverage will be $2,000
– Benefit is for children between 10 days and 6 months of age
Notification
– Completion of Enrollment Form is required
– Child must be living at the time Enrollment is received by Home Office
– Certificate of Enrollment will be issued by Home Office
– Beneficiary(ies) will reflect enrolling parent(s)
In the event of death the benefit can be claimed by providing the following documentation:
— Claim For Payment of Death Benefits
— Original copy of death certificate
— Original Certificate of Enrollment

Newborn Benefit Application

Child's Name

Child's Date of Birth

Gender

Male

Female

Parent's Name (Mother & Father)

Parent's Phone

Parent's Address

I/We formally request that my/our child be enrolled in the NEWBORN BENEFIT PROGRAM. I/We understand that the enrolling parent(s) will be the named beneficiary on said Certificate of Enrollment.

Signature of Mother(Required)

Date
MM slash DD slash YYYY

Mother’s Certificate #

Branch #

Signature of Father(Required)

Date
MM slash DD slash YYYY

Father’s Certificate #

Branch #

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