Please note: This form is for online submission only. If you would like to print and mail a membership form, please click here.
Date of Application:
Phone: Email Address:
Date of Birth: Age (at time of initiation):Place of Birth:
Certificate Holding Member (must be between ages 0 through age 79)
Amount of Funeral Benefit desired:$500Amount of Funeral Benefit desired:$1000 (see rate chart on back of application)
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)
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.
National Treasurer’s Signature:Member Number:
National Secretary’s Signature:
Eligible members, aged birth through age 79, may elect to join the funeral benefit fund, which belongs to all Lodges in common.
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.
Aase Hansen, Membership Chairman