The Company You Keep. Life Insurance. Conversion Instructions G-230G (11/08)

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1 The Company You Keep Life Insurance Conversion Instructions G-230G (11/08)

2 You are receiving this package because your Group Term Life Insurance will soon be terminating. Under the Group Term Life Insurance policy, you are eligible to convert all or part of your terminating group coverage to a New York Life Individual Whole Life Policy. Please take a moment to review the enclosed documents, which will assist you in completing the Application to New York Life Insurance Company for Conversion of Life Insurance Coverage. Please be aware that you have 31 days from your last day of coverage under your terminating Group Plan, to complete and mail the enclosed required documents. Should you have any questions on your eligible amount for conversion or how to complete any portion of the required forms, please contact your Group Administrator directly. The conversion privilege guarantees that you may obtain insurance without evidence of health. Therefore, if you are applying for, or considering the purchase of, any other life insurance from New York Life, you should still submit a timely separate application for conversion as described in this booklet, in order not to lose the valuable rights you have under that privilege. IMPORTANT NOTICE This booklet describes the steps necessary to exercise the life insurance conversion privilege of the Group Membership Life Insurance policy providing the Terminating Coverage. New York Life s premium rates for conversion policies are subject to change at any time without notice. The complete terms and conditions governing a conversion of life insurance are in the Terminating Coverage s policy. New York Life Insurance Company Conversion Package 1

3 LIFE INSURANCE CONVERSION INSTRUCTIONS Definitions Eligible Person, as used in this booklet, means a person who is entitled to exercise the life insurance conversion privilege of a Group Membership Association Insurance policy. Terminating Coverage, as used in this booklet, means an Eligible Person s terminating life insurance under the Group Membership Association Insurance policy. Availability of Conversion Read the conversion privilege summarized in the life insurance provisions of your certificate or Group Membership Association Insurance policy to determine the conditions governing conversion, including the following: a. Are you eligible to convert? Are your spouse and children, if any, eligible to convert? b. If so, what amount of Terminating Coverage can be converted? c. If you, your spouse or any of your children are eligible to convert, what is the deadline for submitting a conversion application to New York Life? Individual Life Insurance Plans Available on Conversion The individual life insurance plans available on conversion will be the Whole Life Insurance plans customarily being issued by New York Life at the time an application for conversion is received, other than a policy containing supplementary benefits such as disability and double indemnity benefits. Each New York Life individual permanent life insurance policy available at conversion includes provisions for the continuing accumulation of cash values. After the policy has remained inforce long enough to accumulate a cash value, policy loans against the cash value will be available. In the event that you discontinue premium payments after your individual policy has accumulated any such values, various non-forfeiture options become available. These options include the right to obtain a reduced amount of paid-up life insurance, or to remain insured for the face amount of the policy, for a specified period of time, or to surrender the policy for its cash value. For a complete statement of the benefits, terms and conditions of any policy, you should always refer to the policy itself. New York Life Insurance Company Conversion Package 2

4 Computation of the Premium on Conversion The premium will be in accordance with New York Life s established premium rates for individual insurance policies, applicable at the time the conversion policy takes effect, and will depend on the face amount of the conversion policy, sex, and insurance age, and the frequency of premium payment selected. The table of premium rates for the Whole Life Plan is available in this booklet. These premium rates are subject to change at anytime without notice. The following information should be helpful in using these tables: Insurance Age - Means the age of the Eligible Person on his or her birthday nearest the effective date of the conversion policy. The effective date will always be the 32 nd date from the last date you were covered under the Group Term policy. For Example: If your Group Term Life expires on December 31 st, your effective date becomes the 32 nd date after expiration, which is February 1 st. Insurance Age Determination Example 1: Birthday: June 12, 1940 Group Term Termination Date: 9/30/08 Individual Policy Effective Date: 11/1/08 Age: 68 Example 2: Birthday: June 12, 1940 Group Term Termination Date: 1/31/09 Individual Policy Effective Date: 3/1/09 Age: 69 (because your next birthday falls within six months of your new individual policy effective date) Sex - Separate male and female premium rates are applicable for all policies (except Montana). Policy Fee Premiums from the rate tables must be increased by the following Policy Fees: Face Amounts up to $49,999 Face Amounts $50,000 - $99,999 Check-O-Matic $5.50 Check-O-Matic $6.00 Quarterly $18.15 Quarterly $19.80 Semi-annual $30.80 Semi-annual $33.60 Annual $55.00 Annual $60.00 Face Amounts $100,000 - $249,000 Face Amounts $250,000 and over Check-O-Matic $6.50 Check-O-Matic $10.00 Quarterly $21.45 Quarterly $33.00 Semi-annual $36.40 Semi-annual $56.00 Annual $65.00 Annual $ New York Life Insurance Company Conversion Package 3

5 Frequency of Premium Payment You may elect to pay premiums annually, semiannually or quarterly, provided that each premium payable semiannually must be at least $15.00; and each premium payable quarterly must be at least $ Another arrangement, known as Check-O-Matic (C-O-M), auto withdrawal from your checking account, is also available. Depending on which mode of payment you choose, the following factors must be applied: semi-annual mode is.5200, the quarterly option is.2650 and the Check-O-Matic mode is Example of Premium Computation Male applicant age 50 to be insured for $50,000 Whole Life and paying premiums quarterly. Step 1: Select the appropriate rate per $1,000 from the Whole Life Premium Table for males - $33.06 Step 2: Multiply this rate by the number of 1,000 units being applied for: $33.06 x 50 =$1,653 Step 3: Multiply this result by the quarterly pro rata factor shown on the Rate Table: $1,653 x.2650 = $ Step 4: Add the appropriate Policy Fee as shown on the Rate Table: $ $19.80 = $ The New Policy Will Be Participating New York Life is a mutual company, and all individual life insurance policies now being issued by the Company provide for dividends from participation in any divisible surplus. Each dividend may be applied under one of several options, including an option to have the dividend applied toward payment of any premium then due, so as to reduce the insured's outlay. New York Life Insurance Company Conversion Package 4

6 Applying for the New Policy Instructions An Eligible Person may apply for a new policy as follows: Completing the Application A. Complete items 1 to 7 of the Application form at the back of this booklet. The following comments may be useful in completing the application: Item 1. Terminating Coverage Check the box Membership Plan Item 2. Proposed Insured Insert your First and Last Name and complete all other parts in item 2. Item 3. Plan of Life Insurance Enter Whole Life Amount of New Policy This may not exceed the amount of your terminating life insurance. The minimum amount is generally $10,000, unless your amount of terminating life insurance is less than $10,000 in which case the minimum is the actual amount of terminating life insurance, or, if the terminating insurance is under an individual policy, it is $1,000. Refer to the Schedule of New York Life Insurance Company Conversion Package 5

7 Benefits page of your group certificate (or individual Group Member Association Insurance policy) for the information needed to complete this section. Automatic Premium Loan This feature is designed to help prevent an unintended lapse in the future after your conversion policy has built up a loan value. If you elect to include this provision, a premium not paid when due will automatically be paid by a policy loan, if the loan value is sufficient to pay the overdue premium. Check the appropriate box. Dividend Option You may select any of four dividend options. Cash means that a check for the amount of each dividend will be sent to you as a policyowner. Premium means that each dividend will be applied toward payment of the premium then due, thus reducing your cash outlay. Addition means that each dividend will be applied to provide paid-up additions to the amount of insurance under the conversion policy. Deposit means that all dividends will be left on deposit with New York Life, to accumulate with interest credited at each policy anniversary at a rate declared by New York Life. Check the appropriate box. Premium Mode You may select the frequency of premium payments for the conversion policy by checking one of the first three boxes in the left-hand column or the first box from the right column. If you elect the Check-O-Matic ( C-O-M ) option, please fill out the enclosed Check-O- Matic Form. A voided check is required with the form and the first two months of premium payment must also be included at the time of conversion. Note that although the form provides for Savings Account withdrawals, only checking account withdrawals are permitted for conversion policies. (The other four boxes relate to alternative premium payment methods, available only for policies in certain specified circumstances.) Cash Paid Enter the amount of your check, which must be for not less than the first full premium for the conversion policy, as determined from the tables included with this booklet. (Two times that amount for Check-O-Matic) Item 4. If your answer to any of these questions is yes, New York Life will ask you to complete an additional form to supply further information necessary to determine your class of risk and the applicable premiums for your policy. Item 5. Beneficiary Be sure to clearly print the full name and relationship of the beneficiary under the conversion policy. The beneficiary need not be the same as under the terminating coverage. New York Life Insurance Company Conversion Package 6

8 Item 6. Owner You may designate either yourself or any other individual as owner of the conversion policy. Item 7. Concurrent Application Indicate whether any other application for individual insurance is to be considered concurrently with the conversion application, or as an alternative to obtaining insurance under the conversion privilege. Signature WITNESS Please sign the completed application in the space captioned Applicant. Make sure that spaces entitled Dated at and Witness are also completed.* *Normally, the member whose coverage is terminating is entitled to apply for the conversion policy and to designate the owner of the conversion policy. However, if you have previously transferred ownership of your group life insurance, only the present ownertransferee may submit an application to convert. An application for conversion of dependent life insurance is submitted by the dependent or, in the case of a minor child, by the member. New York Life Insurance Company Conversion Package 7

9 Item 8. If not already completed by the plan administrator of the Terminating Coverage, return the application to the administrator for completion of Item 8, Certification of Eligibility for Conversion. Any application received by us with Item 8 incomplete will be returned to the Administrator and not processed until complete. This section, of the Application, must be completed by the Group Administrator The Group Administrator s Signature and Date is required on the Application. Note: This section should be left blank by the Applicant as instructed in Item D. Mailing The Application. We will obtain the necessary certification from the Administrator. Please be aware that this may delay the policy getting to you. New York Life Insurance Company Conversion Package 8

10 B. W-9 - Please complete the attached Form W-9 - Taxpayer Identification Number and Certification. Your application will not be processed unless this form is completed. C. Completing the Check-O-Matic Form (If Applicable) - If you elect to pay for your premium on a monthly basis, please be aware that your application must include a completed Check-O-Matic Request Form along with a check that includes the first two months of premium payment. A voided check is also required as part of the Check-O-Matic Form. A sample of a completed Check-O-Matic form can be found as part of this document. D. Mailing The Application - Send the completed application form and your remittance for the full premium for the conversion policy directly to: New York Life Insurance Company Group Membership Association Division, Mail Drop 2S005 1 Rockwood Road Sleepy Hollow, NY Attn: Yvonne O. Baez-Last The application and first premium for the new policy must be received by New York Life within 31 days after a person becomes eligible to convert. E. Receiving the Policy It normally takes four to six weeks to receive the new Whole Life policy from New York Life Insurance. New York Life Insurance Company Conversion Package 9

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