Membership Application

Lodge #: Lodge Location: Date of Application:

Name:

Address:

City:State:Zip:

Phone: Email Address:

Date of Birth: Age (at time of initiation):Place of Birth:

Please check the type of membership desired:

Certificate Holding Member (must be between ages 0 through age 79)

Female Male

Amount of Funeral Benefit desired:$500Amount of Funeral Benefit desired:$1000 (see rate chart on back of application)

Beneficiary (required):

Beneficiary’s relationship to me (required):

By signing this application I am declaring that I am in good health, and have not been previously rejected, rated up or terminated by any insurance company.

Note: It is recommended that when naming your beneficiary you avoid “The Estate of...” unless you actually have an estate.
Additionally, naming beneficiaries with “and/or” or “or” creates difficulty when paying benefits.

Amber Member (all ages qualify—no funeral benefit provided)

Silver Member (ages 65 and over—no funeral benefit provided)

Applicant’s Signature: Sponsor’s Signature:

Date of Initiation:Lodge Secretary's Signature:

NOTICE to Lodge Secretary: When applicant has been initiated, please complete and send to the
National Treasurer within ten (10) days, AND include initiation fee if applicable.

Certificate Holding Member

ARTICLE IX. Funeral Benefit

Section 3. Eligibility

Eligible members, aged birth through age 79, may elect to join the funeral benefit fund, which belongs to all Lodges in common.

A. Assessments

1. When a new certificate holding member is initiated, she/he becomes a member of the funeral benefit fund. Members pay assessments to the local Lodge Treasurers according to age when joining, beginning with the month of initiation. Members are thereby entitled to the funeral benefit, up to $1,000 maximum. The local Lodge Treasurers may remit the assessments to the National Treasurer monthly or annually. The funeral benefit certificate has no cash surrender value.

Certificate Holding Membership

• Available to those qualified as described above.
• Initiation Fee: $10 (juvenile members through age 13 are exempt)
• National Dues: $13 annually (waived year of initiation)
• DSS Newsletter: $12 annually (pro-rated month of initiation)
• Assessments for Funeral Benefit (see charts at right)

Amber Member

$42 Annual Fee (no funeral benefit for this level of membership)

• Available to all ages
• Initiation fee waived
• DSS Newsletter included
• Membership fee prorated as follows:

Silver Member

$25 Annual Fee (no funeral benefit for this level of membership)

• Available to ages over 65 years
• Initiation fee $10
• DSS Newsletter included
• Membership fee prorated as follows:
• DSS Newsletter $12 annually (pro-rated month of initiation)

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Questions?

Aase Hansen, Membership Chairman
dssaasehansen@aol.com
(818) 845-5726