Member Information

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First Name *

Middle Name

Last Name *

Suffix

Email *

Email Confirmation *

Gender *

Male
Female

Date Of Birth *

State Of Birth *

Social Security Number *

Department Name

Are you a member of CSFA?

If the answer to the above question is yes, please enter your CSFA number here.

Have you used tobacco products of any kind in the last 12 months?

Are you currently working at least 30 hours per week at your regular occupation and place of business?

If the answer to the above question is no, please explain here.

* 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.