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 #69774-5-1, issued and delivered in Minnesota to Minnesota Benefit Association 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 LeClair Group, an insurance administrator licensed in Minnesota. Coverage may not be available in all states. Contact LeClair Group for further details. Policy form LP08GP.