Federal Employee Service Center - Fed Value Application

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Membership Application

Thank you for your interest in the Federal Employee Service Center Fed-Value Program. Please fill out the application below and agree to the terms state for membership into the Fed-Value Program. An FESC representative will contact you shortly reguarding your application.

Fields in BOLD are required.

Name:

Address:

City:

State:

Zip/Postal Code:

Home Phone:

Work Phone:

Ext.

Email Address:

Agency:

Coverage:

Individual	Joint

$10,000 of AD&D and $100,000 Common Carrier Coverage is included in your account.

Family Coverage

An additional $20,000 AD&D Insurance plus $2,500 Dependant Children* coverage is available for an additional $1.00 a month.

Comments:

*Age birth to 25th birthday, unmarried and dependant on member for support. Includes step-child, adopted child and foster child. Children's coverage is also available to unmarried, divorced or widowed member. See certificate for further information.

This insurance benefit is provided through the Sisk Association of which Federal Employees Service Center is a sponsor. Premiums are paid from the general revenue received from this program. You are enrolled as a member of the Sisk Association when this form is received at Federal Employees Service Center. Your membership will remain in effect until either party terminates membership. Insurance coverage terminates on the earlier occurence of the date of policy termination or the date of membership termination. Membership Termination is effective the first day of the month following termination.

Insurance is subject to policy eligibility, terms and exclusions. It is not insured by the FDIC or any other federal government agency. There is no guarantee, and it is not a deposit.

Membership Agreement:

Upon approval by F.E.S.C., Inc. dba. Federal Employee Service Center (Fed-Value) of your application, you shall be entitled to the benefits and services of membership.

Upon submitting this form for membership of "Fed-Value" you do hereby agree to accept the following terms and conditions:

1. You will hereby authorize the Federal Employee Service Center (Fed-Value) to payroll deduct or draft your savings or checking account monthly or you may pay annually.

2. You may cancel this agreement at any time upon 30 days written notice to the Federal Employee Service Center, surrender your membership and ID cards, and make payment for all obligations hereunder to the Federal Employee Service Center (Fed-Value). The Federal Employee Service Center (Fed-Value) may cancel this agreement at any time, without notice, if you fail to abide by the provisions and terms herein set forth, or if your financial obligation is garnished by legal process.

3. This agreement  shall be subject to all applicable federal bylaws of the Federal Employee Service Center (Fed-Value), to all present and future amendments thereto, and all regulations, rules and practices therefore or hereafter adopted by the Federal Employee Services Center (Fed-Value). This agreement may bye amended from time to time by the Federal Employee Service Center (Fed-Value), but no such amendment shall be effective until thirty (30) days after written notice to you. A;; notices, demands and other communications by FESC, Inc. shall be mailed to you at your address set forth in your application, or at such address as you may notified the Federal Employee Service Center (Fed-Value) in writing hereafter.

I agree with the above terms and conditions.

I herby agree to maintain a relationship with FESC and authorize annual payment for said services or payroll deduction for the appropriate fee.

CCR Accredited
Government Contractor

Working with unions, non-profits and government agencies nationwide. A private enterprise not affiliated with any government agency.

Thank You for your interest in The Federal Employee Service Center!