WAEPA. Life Insurance. WAEPA Enables... Why You (Yes, You) Need Insurance... Apply Now...

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1 Serving Federal employees Since 1943 WAEPA Life Insurance Life Insurance for Civilian Federal Employees and their Families Why You (Yes, You) Need Insurance... Life insurance secures your family against the financial impact of your passing. It protects them against: The loss of your income Funeral costs and other expenses Outstanding debts Your WAEPA benefit will see your family through immediate difficulties if you die, and provide a foundation for their long-term financial security. See inside to learn how little piece of mind for your loved ones can cost. WAEPA Enables... Federal employees (and their families) to purchase life insurance, as an alternative or supplement to FEGLI. WAEPA gives its members: More coverage More benefits Greater flexibility Yet, WAEPA coverage costs up to as much as 89% less than FEGLI even though it includes higher coverage limits for you, more coverage for your family, and benefits for relatives FEGLI doesn t even cover! See page 2 to learn how WAEPA and FEGLI really compare in cost and coverage. Apply Now... No Open Season required Enjoy coverage levels of up to $750,000 More coverage for your spouse and dependent children Worldwide Assurance for Employees of Public Agencies, Inc. 433 Park Avenue, Falls Church, VA Toll Free: WAEPA a non-profit association promoting the health, welfare, and financial well-being of its members

2 Life Insurance WAEPA vs FEGLI... Benefits comparison We think you should be able to purchase exactly the amount of life insurance you need. This chart shows you how we offer more coverage in simple increments. There are no complicated options to calculate. WAEPA $25,000 up to $750,000 (in $25,000 increments) Spouse / Domestic Partner $10,000 up to $250,000 (in $10,000 increments) Member Coverage Dependent Coverage FEGLI Your Basic coverage is determined by your annual pay. Option A is an additional $10,000 of coverage. Option B is one to five times your annual pay. Spouse* Option C is $5,000 up to $25,000 (in $5,000 increments) *FEGLI does NOT provide domestic partner coverage. Children $1,000 up to $25,000 $2,500 up to $12,500 (in $2,500 increments) Associate Member Coverage (Spouses and domestic partners, non-dependent adult children and stepchildren, parents of WAEPA members, parents-in-law) $25,000 up to $750,000 Not Available (in $25,000 increments) Additional Benefits Your non-dependent adult children are eligible for their own WAEPA coverage, even if they re not federal employees. See WAEPA Associate Membership brochure for details... Premium Rates comparison These charts show you the actual difference in premium costs between WAEPA and FEGLI for every $1,000 of coverage you purchase. It s simple: if you re under 60, you will save money with WAEPA. Member s Age WAEPA FEGLI Basic Basic Coverage Savings Bi-weekly premiums per $1,000 of coverage % % % % % % % Member s Age WAEPA FEGLI Option A Bi-weekly premiums per $1,000 of coverage FEGLI Option B Optional Coverage Savings % % % % % % % % Page 2 Worldwide Assurance for Employees of Public Agencies

3 Life Insurance Insure Yourself: Our Most Popular Plans Member Life Insurance Schedule of Benefits Levels Life Insurance $25,000 $50,000 $100,000 $200,000 $250,000 $300,000 $500,000 $700,000 $750,000 AD & D $5,000 $10,000 $20,000 $40,000 $50,000 $60,000 $100,000 $140,000 $150,000 Common Carrier $10,000 $20,000 $40,000 $80,000 $100,000 $120,000 $200,000 $280,000 $300,000 Quarterly Premiums Based on Member/Associate Member s Age Under 25 $2.63 $5.25 $10.50 $21.00 $26.25 $31.50 $52.50 $73.50 $ $2.63 $5.25 $10.50 $21.00 $26.25 $31.50 $52.50 $73.50 $ $2.63 $5.25 $10.50 $21.00 $26.25 $31.50 $52.50 $73.50 $ $3.75 $7.50 $15.00 $30.00 $37.50 $45.00 $75.00 $ $ $7.00 $14.00 $28.00 $56.00 $70.00 $84.00 $ $ $ $10.00 $20.00 $40.00 $80.00 $ $ $ $ $ $15.25 $30.50 $61.00 $ $ $ $ $ $ $23.25 $46.50 $93.00 $ $ $ $ $ $ Please visit for a complete listing of benefits and rates. Life insurance premiums automatically increase as members enter new age groups. Coverage levels are limited above age 60. If a member s coverage exceeds the limit as he or she enters a new age group, it will automatically be reduced to the allowable amount. Accidental death and dismemberment (AD&D) and free common carrier coverage terminate at age 65. All WAEPA coverage terminates at age 85. Eligibility Requirements You re eligible if you re currently a non-military government or Postal Service employee, you are less than 65 years old, and you are a U.S. citizen. You re also eligible if you are a former non-military federal employee, under age 65, currently receiving a government retirement annuity. More Flexibility In addition to life insurance, your WAEPA policy also includes these benefits: Accidental death and dismemberment coverage Free common carrier coverage We also allow you to: Pay through convenient payroll deductions Change your coverage at any time Keep your coverage if you leave government See for full details on eligibility. Worldwide Assurance for Employees of Public Agencies Page 3

4 Life Insurance Insure Your Family: Our Most Popular Plans... Dependent Life Insurance (Spouse Life Insurance) Levels $10,000 $20,000 $50,000 $100,000 $150,000 $200,000 $250,000 Dependent Life Insurance (Children) 2wks - 2yrs $1,000 $2,000 $5,000 $10,000 $10,000 $10,000 $10,000 2yrs - 5yrs $2,000 $4,000 $10,000 $20,000 $20,000 $20,000 $20,000 5yrs - 19yrs $2,500 $5,000 $12,500 $25,000 $25,000 $25,000 $25,000 Quarterly Premiums Based on Member/Associate Member s Age Under 25 $1.50 $3.00 $7.50 $15.00 $22.50 $30.00 $ $2.00 $4.00 $10.00 $20.00 $30.00 $40.00 $ $2.25 $4.50 $11.25 $22.50 $33.75 $45.00 $ $3.00 $6.00 $15.00 $30.00 $45.00 $60.00 $ $4.00 $8.00 $20.00 $40.00 $60.00 $80.00 $ $5.50 $11.00 $27.50 $55.00 $82.50 $ $ $8.00 $16.00 $40.00 $80.00 $ $ $ $12.00 $24.00 $60.00 $ $ $ $ Please visit for a complete listing of benefits and rates. Eligibility Requirements As a WAEPA member, you can add coverage for the following to your WAEPA life insurance policy: Your spouse or domestic partner. Your dependent children under the age of 19 or up to age 26 if they are primarily supported by you, the WAEPA member. Children born to you and your spouse/domestic partner will automatically become insured under your established dependent coverage when they are two weeks old. If you remarry, you will have to complete a new application for your spouse and any adopted children. Benefits for your former spouse terminate when he or she is no longer married to you. Benefits for your children terminate when they marry, attain age 19, or cease to be a fulltime student up to age 23. All dependent coverage terminates when your spouse or domestic partner attains age 75. Purchasing WAEPA Insurance for Your Family One low premium covers all of your eligible dependents, including your spouse or domestic partner. (Domestic partners must complete the Domestic Partner Affidavit which can be found at While the chart above shows only our most popular plans, you can purchase exactly as much dependent coverage as you need in $10,000 increments, up to $250,000. Dependent coverage may not exceed 50% of your own member coverage. After you reach the age of 60, the amount of dependent coverage you can purchase is limited. If your dependent coverage exceeds this limit when you turn 60, it will automatically be reduced to the amount permitted. If you and your spouse/domestic partner are both WAEPA members, you cannot insure each other as dependents, and only one of you may insure dependent children. Both you and your spouse/domestic partner must be less than age 65 when you apply for dependent coverage. Spouses, domestic partners, or children who are full-time members of the Armed Forces are not eligible for dependent coverage. Page 4 Worldwide Assurance for Employees of Public Agencies

5 Life Insurance How to Apply: Application Instructions... Completing Your Application Select the level of coverage that best suits your needs. You can set your coverage anywhere from $25,000 to $750,000 in $25,000 increments. There are two parts to your application. Use the form on page seven to apply for a WAEPA Life Membership. This entitles you to all the benefits of joining WAEPA and makes you eligible for our low-cost coverage. Use the form on page eight to detail your physical condition. As part of our underwriting process, we may request further information about your medical history or require you to take a medical examination. That s it. You ll be covered on the date our carrier has certified your insurability and you have paid your first premium. Please sign the application on page seven and mail pages six, seven and eight of your completed application in the enclosed envelope to: WAEPA 433 Park Avenue Falls Church, VA Important Questions: Q: Who is eligible to apply for WAEPA coverage? A: Current or retired federal government employees, and Postal Services employees. Spouses and adult non-dependent children of WAEPA members may join WAEPA as Associate Members and purchase their own policies. Q: How much insurance may I apply for? A: Up to $750,000 for yourself, $250,000 for your spouse or domestic partner, and $25,000 for eligible dependent children. Q: How do I apply? A: Complete the attached application for WAEPA membership and life insurance and mail to WAEPA. Q: Is a medical examination required? A: An exam may be required, dependent upon your age, the amount of coverage you re applying for, and your health history. If you are requested to take an exam, it will be performed at no charge to you. Q: How long will it take to get my insurance? A: It may take as long as 12 weeks to complete the application process. Q: How are premiums calculated? A: Premiums for coverage are based on your age and will increase every five years as you enter a new age group. Q: How do I pay my premiums? A: Premiums can be paid through payroll deduction or monthly bank draft. You can also pay via check or online electronic funds transfer on a quarterly, semi-annual, or annual basis. Page 5 Worldwide Assurance for Employees of Public Agencies

6 WAEPA Application for Life Insurance Underwritten by the following CIGNA companies: Life Insurance Company of North America (LINA), Connecticut General Life Insurance Company (CG) and CIGNA Companies (herein called the Insurance Company) APPLICANT INFORMATION PLEASE COMPLETE PAGES 6, 7 & 8 OF THIS APPLICATION AND SIGN. LIST BELOW ONLY INDIVIDUALS APPLYING FOR COVERAGE ALIAS RELATIONSHIP ( TO APPLICANT ) APPLICANT (Full Name) BIRTH DATE ( MM/DD/YY ) AGE HEIGHT ( FT. IN. ) WEIGHT ( LBS. ) ELIGIBLE DEPENDENTS (Full Names) HEALTH QUESTIONS SECTION A By applying for this coverage, do you intend to replace, discontinue, or exchange existing life insurance coverage... n Yes or n No Tear here Within the last five years, have you or your eligible dependents been: diagnosed with any of the conditions shown in items A though J below, told by a medical professional he/she has, or may have, any of the conditions show in items A though J below, or been treated by a medical professional for any of the conditions shown in items A through J below? A. High blood pressure, heart attack, chest pain or Angina, a heart murmur, poor circulation, or any other condition affecting the heart or circulatory system?... n Yes or n No B. Diabetes, glandular condition, Hepatitis, or any condition affecting the esophagus, stomach, intestines, liver, or pancreas?... n Yes or n No C. Asthma, Chronic Bronchitis, Emphysema, or any other condition affecting the lungs or respiratory tract?... n Yes or n No D. Any condition affecting the kidneys, urinary tract, prostate gland, or reproductive system?... n Yes or n No E. HIV infection, AIDS, or any other condition affecting the immune system or lymph nodes?... n Yes or n No F. Stroke, Transient Ischemic Attack (TIA), Alzheimer s disease, paralysis, epilepsy, fainting, seizures, headaches, or other condition affecting the nervous system?... n Yes or n No G. Anemia or any other condition affecting the blood, Lupus, Arthritis, deformity, or loss of limb?... n Yes or n No H. Anxiety, Depression, Bipolar Disorder, or any other mental disorder or condition?... n Yes or n No I. Cancer, Tumor, Leukemia, Hodgkin s Disease, Polyps, or Moles?... n Yes or n No J. Alcohol or drug abuse or dependency?... n Yes or n No HEALTH QUESTIONS SECTION B Within the last five years, have you or your eligible dependents: A. Used any controlled or illegal drug or other substance?... n Yes or n No B. Been seen for, or been advised to have sought treatment for, observation and/or consultation for surgery, medical examination, and/or tests, such as blood, urine, X-rays, electrocardiograms, scans, biopsies, or any medical tests/exams not listed here or above, other than normal routine physical exams?... n Yes or n No C. Used any medication prescribed by a physician or other medical practitioner, or used any form of alternative and complementary medical treatment or remedy, including herbs or acupuncture?... n Yes or n No D. Been seen, sought treatment for, consulted, advised they had and/or received any medical advice from a health care practitioner for any disease, disorder and/or medical impairment not listed above?... n Yes or n No USE THE SPACE BELOW TO EXPLAIN YES ANSWERS. IF MORE SPACE IS NEEDED, USE A NEW PAGE, SIGN AND DATE IT AND ATTACH TO THIS FORM. Name of Person Condition Date Occurred Duration/Treatment Received Current Status Page 6

7 WAEPA Application for Life Insurance Caution: Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. Applicant Physician Spouse/Domestic Partner Physician Child(ren) Physician PHYSICIAN SECTION Name Contact Information Street Address (City, State, & Zip) Tel# Fax# Tel# Fax# Tel# Fax# AGREEMENTS AND AUTHORIZATION To the best of my knowledge and belief, all written, telephonic, and electronic information I gave is true and complete. I also understand that coverage for each of my dependents will not go into effect if a dependent is confined in a hospital or institution. The conditions for the requested insurance to be effective are described in the policy and certificate. The approval of this request by the Insurance Company is one of those conditions. I understand and agree that: (1) This request will be a part of the policy that provides the insurance. (2) I may need to provide more medical information. (3) I may need to take medical tests and report the results to the Insurance Company. (4) My dependent(s) may need to take medical tests. The results of those tests must be reported to the Insurance Company. (5) I must report any change in my health, or of a dependent for whom coverage is requested, that happens before the insurance is effective. (6) Requested insurance will not be effective for a person if the person does not meet the underwriting requirements on the date insurance is to be effective. AUTHORIZATION I permit any hospital, clinic, health care practitioner, pharmacy, benefit manager, employer, insurance company, or any other person or organization having information about the health, medical history, physical or mental condition, diagnosis or treatment, employment or income, or motor vehicle driving record, of me or my children to disclose to the Insurance Company or its authorized agent, any such information, for the purpose of underwriting this application for insurance or administering any claim under any insurance which is approved. This authorization is valid for 30 months from the date below. I accept that a copy of this Authorization is as valid as the original. I understand that I and/or my authorized agent have the right to receive a copy of this authorization upon request. I understand that the information will be used to assess my request for insurance. I may revoke this authorization at any time in writing. Any such revocation will not: (1) change any action taken in reliance on the Authorization; and (2) change the Insurance Company s right to use the Authorization for contest of a claim or policy in accordance with the applicable law. I understand that the information provided pursuant to this authorization may be disclosed by the recipient and is no longer subject to the protections of the Health Insurance Portability and Accountability Act (HIPAA). (The Insurance Companies are subject to the Gramm-Leach-Bliley act and state privacy laws. They do not disclose protected information except as permitted by those laws.) X X Applicant s Signature Date Signature of Spouse/Domestic Partner (if applying) Date Notice: Personal information may be collected from persons other than those proposed for coverage. Information may be disclosed to third parties without your authorization as permitted by law. You have the right to access and correct all personal information collected. Additional information about the insurance company s privacy practices is available upon request. TL (5/14) Worldwide Assurance for Employees of Public Agencies 433 Park Avenue, Falls Church, VA Toll Free: Page 7

8 WAEPA Application for Life Insurance APPLICANT INFORMATION PLEASE COMPLETE PAGES 6, 7 & 8 OF THIS APPLICATION AND SIGN. APPLICANT NAME: (Please Print) ( First ) ( M.I. ) ( Last ) n I hereby make application for membership in WAEPA. If admitted to membership, I hereby make application for Group Insurance for which I am eligible, and for the Accidental Death and Dismemberment benefits under the policies issued to WAEPA by The Life Insurance Company of North America. n I am a member of WAEPA, presently insured under Certificate Number, and wish to change my present Group Insurance coverage to the Group Insurance coverage selected below: 1. Amount of insurance coverage selected. a. Basic Group Life Insurance (Amount of Member Life Insurance) $ Level b. Dependent Group Life (DGL) Insurance (Amount of Spouse/Domestic Partner*/Children Life Insurance) $ Level Note: Your spouse/domestic partner s coverage may not be greater than one half (50%) of your coverage. Full-time members of the Armed Forces are not eligible for member, associate member, or dependent coverage. Note: To verify eligibility for dependent coverage, domestic partners must complete a Domestic Partner Affidavit and return the notarized affidavit with their application. The affidavit is available at or by calling Your sex: n Male n Female w 3. Your date of birth / / Age Occupation/Grade (MM/DD/YY - You must be less than age 65) Your spouse/domestic partner s date of birth / / Age Occupation (MM/DD/YY - Your spouse/domestic partner must be less than age 65) 4. I hereby certify the following: (complete a or b) n a. I am a civilian employee of the U.S. Government actively at work. I have been employed by since (Department, Agency, or Bureau) b. I am a retired civilian federal employee currently receiving a retirement annuity. (Please attach a copy of your Standard Form 50 Notification of Personnel Action.) 5. I am a citizen of the United States of America and my Social Security Number is 6. Spouse Social Security Number (ONLY if applying for spousal coverage) 7. I will pay premiums: n Annually n Semi-Annually n Quarterly n Monthly n Payroll Deduction 8. Initial Premium Payment Send No Money! Once your application has been received and approved, we will advise you of the amount due. Your coverage will be effective on the date you provide evidence of insurability satisfactory to the insurance carrier, and you forward the first premium. Your payment must reach us within 30 days of the date of notification. Your initial premium payment will also include your one-time $2.00 lifetime membership fee. 9. I designate as my beneficiary (please list legal name, e.g., Mary White Jones not Mrs. John Jones). Primary Relationship Contingent Relationship If you name a contingent beneficiary, the contingent beneficiary will receive the death benefit if your primary beneficiary is not living when you die. If you name more than one person as a primary beneficiary or a contingent beneficiary, specify the percentage of benefit payable to each beneficiary. The applicant/member will be the beneficiary of all dependent coverage. 10. Applicant Contact Information: An authorization form permitting us to transfer funds from your checking account will be mailed to you. Information regarding payroll deduction will be mailed to you after your application is approved. Street City State Zip Code Office Phone Home Phone Cell Number *Domestic Partner Coverage is not availiable in Virginia. Page 8

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