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Accidental Death & Dismemberment Insurance
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Presented and Administered
by Selman & Company

Accidental Death & Dismemberment Insurance
:: Eligibility Verification

Thank you for your interest in the Accidental Death & Dismemberment Insurance Plan. It's important that you familiarize yourself with all of the benefits and terms of this plan. If you have not already done so, click here to go back to the product description.

If you would prefer to have an Accidental Death & Dismemberment Insurance brochure and enrollment form mailed to you, please call Selman & Company, the plan administrator, at 1-877-665-7563.

* Required Field

PART 1: Member Information

  1. How did you learn about the Accidental Death & Dismemberment Insurance Plan?*

  2. Are you a current United Financial Credit Union member?*
    Yes No

  3. If you received a letter in the mail, please enter the 12-digit PromoCode located beneath the 'Reply By Date' of your letter (otherwise, leave blank):

  4. State in which you permanently reside*

  5. Date of Birth*

PART 2: Coverage

    $2,000 Basic Coverage - at no cost to you (paid for by your credit union)

    Additional Coverage:

    If you are a new applicant, indicate desired amount of coverage:


    - OR -
    If you are increasing coverage, indicate the total amount of coverage you desire:
    (Current coverage amount in force + increased amount, not to exceed $300,000)

    Coverage Type:*

    Member Only
    Family Plan (available with Additional Coverage only)

Accidental Death & Dismemberment Insurance
Underwritten by Monumental Life Insurance Company, Cedar Rapids, IA
Sponsored by United Financial Credit Union
Presented and Administered by Selman & Company
6110 Parkland Boulevard
Cleveland, OH 44124
877-665-7563 - Phone
440-646-9339 - Facsimile
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