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Accidental Death & Dismemberment Insurance

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Printable Change Forms

Basic Certificate

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Presented and Administered
by Selman & Company

Group Accidental Death & Dismemberment Insurance
Underwritten by New York Life Insurance Company

For your convenience, printable Change Forms are available.
You will need Acrobat Reader 5 or higher to read these files.

Beneficiary Designation/Change
IMPORTANT: We cannot accept faxed or emailed beneficiary forms. Please mail completed forms to the address provided below.
Request For Change - Other (address, name, account number, etc.)

Complete the appropriate Change Form and mail to:

Selman & Company
Customer Service Department
6110 Parkland Boulevard
Cleveland, OH 44124

(NOTE: Please retain a copy of your completed form for your files.)

Accidental Death & Dismemberment Insurance
Underwritten by New York Life Insurance Company
51 Madison Avenue, New York, NY 10010 on Policy Form GMR
Sponsored by Velocity Credit Union
Presented and Administered by Selman & Company
6110 Parkland Boulevard
Cleveland, OH 44124
877-665-7563 - Phone
440-646-9339 - Facsimile
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