Application Information for Member

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* INDICATES required FIELDS

Insurance coverage is provided under the terms of a group life insurance policy, Group Policy #29857-3-1, issued and delivered in Florida to Association Insurance Trust as the policyholder. The group life insurance policy is issued by ReliaStar Life Insurance Company, Minneapolis, Minnesota. The policy is administered on behalf of ReliaStar Life Insurance Company by Business Planning Concepts, Inc dba Member Benefits, an insurance administrator licensed in Florida. Coverage may not be available in all states. Contact Business Planning Concepts, Inc dba Member Benefits for further details. Policy form LP08GP.