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Term Life (ages 18-64)
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Guaranteed Issue Term Life (ages 45-75)
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Presented and Administered
by Selman & Company

Term Life
:: Quote

We only ask questions that are necessary to provide an accurate quote. The quote you will receive is based on your attained age at time of quote.

NOTE: Members and spouses ages 18-64 are eligible. $10,000 of coverage is available for your dependent children, 14 days to 21 years of age.

State you permanently reside in
Coverage Type
Member Information
Date of Birth
Gender
Amount of Coverage
Used a tobacco product
in the last 12 months?

Spouse Information
Date of Birth
Gender
Amount of Coverage
Used a tobacco product
in the last 12 months?

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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