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Presented and Administered
by Selman & Company

Term Life
:: Eligibility Verification

Please answer the following:

* Required Field

NOTE: Members and spouses ages 18-64 are eligible for coverage. $10,000 of coverage is available for your dependent child(ren), 14 days to 21 years of age (age 25 if full time student).

How did you hear about our Term Life Insurance Program?*

Are you a current Police and Fire Federal Credit Union member?*

Yes No

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

State in which you permanently reside*

Date of Birth*

Type of coverage you are applying for*

Term Life Insurance
Underwritten by Monumental Life Insurance Company, Cedar Rapids, IA
Form Numbers: TL1099GAM(rev 02-09).series; TL1099IAM(rev 02-09).series
Policy Form Numbers: TL1000GPM.series; TL1000IPM.series
Certificate Form Numbers: TL1000GCM.series; TL1000ICM.series
Administered by Selman & Company
6110 Parkland Boulevard
Cleveland, OH 44124
877-665-7563 - Phone
440-646-9339 - Facsimile
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