Member Information

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First Name *

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Last Name *

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Email *

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Date Of Birth *

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Have you used tobacco or nicotine products of any kind in the past 12 months?

Are you currently working less than 17.5 hours per week at your regular occupation and place of business?

* INDICATES required FIELDS

Life insurance coverage is provided under the terms of a group life insurance policy, Group Policy #67182-7-7, issued and delivered in the District of Columbia to Civil Service Employees 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 Selman & Company, an insurance administrator licensed in the District of Columbia. Coverage may not be available in all states. Contact Selman & Company for further details. (The Selman & Company name will sometimes appear as Starr Wright USA Insurance Plan Administrator.) Policy form LP00GP.