Application Information for Member

*
*
*
*
*
*
*
*
*
*
*
*
* INDICATES required FIELDS

Insurance coverage is provided under the terms of a group life insurance policy, Group Policy #67180-1, issued and delivered in California to California State Firefighters’ Employee Welfare Benefits Corporation as the policyholder. The group life insurance policy is issued by ReliaStar Life Insurance Company, Minneapolis, Minnesota. Coverage is underwritten by ReliaStar Life Insurance Company. Agent of record for the policy is Risk Strategies Company, an agency licensed in California. Coverage may not be available in all states. Contact Risk Strategies Company for further details. Policy form LP00GP.