The GeoCare Benefits Group First-to-Die Term Life Insurance Plan

Transcription

1 The GeoCare Benefits Group First-to-Die Term Life Insurance Plan Underwritten by New York Life Insurance Company Traditional life insurance plans were designed to help protect families against the loss of just one income. Yet today, many American families have more than one breadwinner...and both incomes are important to their lifestyle and financial security. Many life insurance plans offer spouse coverage but at a lower benefit level. The GeoCare Benefits First-to-Die Term Life Insurance Plan provides equal protection for both marriage partners. This innovative group term life insurance plan provides the same amount of protection up to $200,000 each for both you and your spouse. The benefit you select is paid out when the first of you loses your life. The Life Insurance Plan Designed for Two Income Families! What s more, the First-to-Die Term Life Insurance Plan costs less than the GeoCare Benefits Term Life Insurance Plan* and may be less expensive than purchasing separate policies for each of you, making it an effective and affordable alternative to traditional life insurance plans. * Some benefit provisions differ between Plans. The First-to-Die Term Life Plan does not include Waiver of Premium and Accelerated Death Benefit provisions. Also, please see Exclusions on page 3. The Certificate of Insurance details features, limitations and exclusions. 1

2 The Group First-to-Die Insurance Plan Eligibility Requirements You are eligible to apply for the GeoCare Group First-to-Die Level Term Life Insurance Plan if: you are a member of AAPG, AAPL, AEG, AIPG, COPAS, EEGS, GSW, SEG (Society of Economic Geologists), SEG (Society of Exploration Geophysicists), or SEPM; you are legally married or have a domestic partner you and your lawful spouse or domestic partner are between years of age, and you are a resident of the United States (except territories). Certain state restrictions may apply. Due to state regulations, the Plan is not available in SD. Please note that filing approval is pending for: FL, NC, WA, and VT. Call the Administrator at for status of approval. A dependent that is also a member is eligible for either member or dependent coverage, but not both. If both spouses/ domestic partners are covered as members, neither may insure the other as spouse/ domestic partner and only one may insure eligible children. This group plan is particularly beneficial for two-income families with children to support. Schedule of Group Life Insurance Options of $200,000, $150,000, $100,000 or $50,000 are available. What benefit level is best for you? One good way to decide is to determine how many years your family would have to rely on these benefits to replace the loss of one partner s paycheck. Benefits of the Plan One Certificate is issued which provides the same coverage for both marriage partners. The benefit selected is paid when the first one dies. Joint coverage ends at that point. The surviving spouse can then convert to the GeoCare Benefits Group Term Life Insurance Plan. Simultaneous Loss Benefit. The full benefit amount will be paid to the beneficiary for each insured if one of the following tragedies occurs: If you and your spouse both lose your lives within one 24-hour period, or If you both die within three days of a common accident. A common accident is one accident or two separate accidents within the same 24-hour period, resulting in the death of both joint insureds. So, if you select a $200,000 benefit, your beneficiaries would receive $400,000. Current 2011 Semiannual Premiums for the First-to-Die Term Life Plan Member s $200,000* $150,000* $100,000* $50,000* Age Benefit Benefit Benefit Benefit Non-Smoker Smoker Non-Smoker Smoker Non-Smoker Smoker Non-Smoker Smoker Under 25 $ $ $ $ $ $ $ $ , , , *Please contact the Administrator at for rates over age 59. To qualify for the lower non-smoker rates, both the member and spouse must be non-smokers. The premium amount is based on the member s age at his/her last birthday. Your rates will increase on the next Policy anniversary date (December 1) following a member s entry into the next age bracket. The premium shown reflects the current rates and benefit structure. New York Life Insurance Company reserves the right to change rates on a classwide basis on any premium due date and on any date on which benefits are changed. For example, a class of insureds is a group of people with all the same issue age or benefit amount. Benefit option amounts are not guaranteed and are subject to change by agreement between New York Life Insurance Company and the Group Policyholder. Premiums may be paid semiannually or annually. To pay annually, multiply the premiums listed above by two. Please note: An administrative fee of $2.00 is added for the semiannual billing mode. 2

3 The Group First-to-Die Insurance Plan Conversion to GeoCare Benefits Term Life Insurance Plan. The surviving spouse has the right to enroll in the GeoCare Group Term Life Insurance Plan within 60 days of the first spouse s death, with no medical underwriting, when enrolling for benefits equal to or less than the amount insured under the First-to-Die Plan. To apply for additional benefits or after 60 days, underwriting will be necessary. Combined First-to-Die Life Insurance and GeoCare Term Life Insurance Coverage. The combined benefit from both plans for you, the member, can be a maximum of $1,000,000. That s the maximum of both plans added together. Your spouse can have coverage up to or equal to yours. Incontestability. The validity of any amount of insurance which has been in force for two years during your lifetime will not be contested except for nonpayment of premium. Discount for Non-smokers You and your spouse may qualify for reduced rates if both of you can certify on the application form that you have not used tobacco or nicotine in any form during the past 12 months. Exclusions The First-to-Die Insurance Plan covers death from all causes, except: death occurring while on active duty service in any armed forces. Choice of Beneficiaries You and your spouse can each choose your own beneficiaries. Name each other, your children, or anyone you wish. Premiums Premiums may be paid semiannually or annually. To pay annually, multiply the premiums listed on page 2 by two. Please note: An administrative fee of $2.00 is added for the semiannual billing mode. Effective Date Coverage starts on the date your application is approved by New York Life Insurance Company, provided the premium has been paid within 31 days after the date you are billed and you and your spouse are performing your normal activities on the later of the date of approval and the date the contribution is paid. (Residents of MD and NC: Any reference to performing normal activities of a person in good health of like age is replaced by the requirement that the health status of any proposed insured person remain the same as stated in your application.) Insurance Coverage After Age 59 On the Policy anniversary date (December 1) on or after the insured member turns age 60, benefits will be reduced to a percentage of the benefits in force immediately preceding the member s 60th birthday, as shown in the table below. Benefits for both insured and spouse reduce when the member turns age 60. Premiums are not reduced when coverage reduces. (Benefit options are not guaranteed and are subject to agreement between New York Life Insurance Company and the Policyholder.) Termination of Coverage Coverage will terminate for both you and your spouse on the earliest of the following: the December 1 after you reach age 90 or cease to be a member, if you fail to pay premiums when due, when the group policy is terminated, upon the death of either the member or spouse, or the date of legal separation, divorce or dissolution of marriage. Remember, the surviving spouse can convert to the GeoCare Group Term Life Insurance Plan. And in the case of separation, divorce or dissolution of marriage, the member can convert to the GeoCare Term Life Insurance Plan or request an individual policy. Age of Percentage Age of Percentage Insured of Member Insured of Member Member Benefit Member Benefit 60 78% 67 44% Benefit options are not guaranteed and are subject to agreement between New York Life Insurance Company and the Policyholder. 3

4 The Group First-to-Die Insurance Plan The insurance company cannot increase your rates, reduce your benefits or cancel your coverage individually for health reasons. Rates can only be increased on a classwide basis. A class is a group of people with the same age or gender. Understanding Your Certificate of Insurance 30-Day Free Look This brochure is only a partial description of the provisions of the GeoCare Group First-to-Die Joint Term Life Insurance Plan. Once approved, you will receive a Certificate of Insurance evidencing coverage provided under Group Policy G on Policy Form GMR. The Texas forms are as follows: GMR-FACE/ G It is important that you understand your coverage. Please read your Certificate thoroughly when it arrives and contact us with any questions. We want you to get the coverage that s right for your insurance needs. That s why we give you a 30-day period to review your Certificate. If you return your Certificate without claim within 30 days, we will refund your full premium and the Certificate will be null and void, as if it were never issued. How to Apply for Coverage 1. Complete, sign, and date the enclosed First-to-Die Term Life Plan Application. 2. Send no money now. You will be billed when your coverage goes into effect. 3. Mail your completed Application to: GeoCare Benefits Insurance Program P.O. Box 9159 Phoenix, AZ IMPORTANT NOTICE: How New York Life Obtains Information and Underwrites Your Request for Group First-to-Die Insurance Information regarding insurability will be treated as confidential. In considering your request for insurance, we will rely on the medical information you provide, and on the information you authorize us to obtain from your physician, other medical practitioners and facilities and other insurance companies to which you have applied for insurance. Other insurance companies may also furnish New York Life, its subsidiaries or the plan administrator with non-medical information (such as driving records, past convictions, hazardous sport or aviation activity, use of alcohol or drugs, and other application for insurance). The information provided may include information that may predate the time frame stated on the medical questions section, if any, on this application. This information may be used during the underwriting and claims processes, where permitted by law. Your AUTHORIZATION may be used for a period of 24 months from the date you signed the application, unless sooner revoked. The AUTHORIZATION may be revoked at any time by notifying the Administrator in writing at the address provided. Your revocation will not be effective to the extent New York Life or any other person already has disclosed or collected information or taken other action in reliance on it, or to the extent that New York Life has a legal right to contest a claim under an insurance certificate or the certificate itself. The information New York Life obtains through your AUTHORIZATION may be come subject to further disclosure. For example, New York Life may be required to provide it to insurance, regulatory or other government agencies. In this case, the information may no longer be protected by the rules governing your AUTHORIZATION. New York Life may release this information to the plan administrator, other insurance companies to whom you may apply for insurance, or to whom a claim for benefits may be submitted and to others whom you authorize in writing. However, this will not be done in connection with information concerning Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV). New York Life will not disclose such information to anyone except those you authorize or where required or permitted by law. Information in our files may be seen by New York Life and Plan Administrator employees, but only on a need to know basis in considering your request. Upon receipt of all requested information, we will make a determination as to whether your request for insurance can be approved. If we cannot provide the coverage you requested, we will tell you why. If you feel our information is inaccurate, you will be given a chance to correct or complete the information in our files. Upon written request to New York Life, you will be provided with non-medical information. Generally, medical information will be given either directly to the proposed insured or to a medical professional designated by the proposed insured. Your request is handled in accordance with the Federal Fair Credit Reporting Act procedures. For NM Residents: PROTECTED PERSONS 1 have a right of access to certain CONFIDENTIAL ABUSE INFORMATION 2 we maintain in our files and they may choose to receive such information directly. You have the 4

5 The Group First-to-Die Insurance Plan right to register as a PROTECTED PERSON by sending a signed request to the Administrator at the address listed on the application. Please include your full name, date of birth and address. 1 PROTECTED PERSON means a victim of domestic abuse: who has notified us that he/she is or has been a victim of domestic abuse; and who is an insured person or prospective insured person. 2 CONFIDENTIAL ABUSE INFORMATION means information about: acts of domestic abues or abuse status; the work or home address or telephone number of a victim of domestic abuse; or the status of an applicant or insured as family member, employer or associate or a victim of domestic abues or a person with whom an applicant or insured is known to have a direct, close, personal, family or abuse-related relationship. New York Life Insurance Company 2.09ed. The Broker of Record is: F. Michael Strunk P. O. Box Punta Gorda, FL Phone: CA License # 0C30823 Residents of Florida: F. Michael Strunk is a licensed Florida agent for service of Florida residents. The Association incurs certain administrative expenses in connection with this sponsored program. To provide and maintain this valuable membership benefit, it is reimbursed for such expenses. FIRST2011 Residents of New York: Please contact the Administrator for an application specific to New York State. The Group First-to-Die Term Life Insurance Plan is underwritten by New York Life Insurance Company, 51 Madison Avenue, New York, NY under Group Policy Form GMR, Policy No. G /FACE. Founded in 1845 and a recognized leader in the association group insurance field, it is one of the largest and most respected life insurance companies in the nation. It has received the highest ratings for financial strength from the leading independent ratings services: A.M. Best (A++), Fitch Ratings (AAA), Standard and Poor s (AAA), and Moody s Investor Services (Aaa). Source: Individual Third Party Ratings Reports (as of 7/7/10) 5

6 Group First-to-Die Term Life Insurance Plan Application For Participating Associations of the GeoCare Benefits Group Insurance Trust Not for Residents of New York State PLEASE PRINT IN INK OR TYPE ALL ANSWERS 1 Member s Full Name and Information: Name LAST FIRST MIDDLE Street Address City State (or Province) Zip Code - Request for Group Insurance from New York Life Insurance Company 51 Madison Avenue, NY, NY Social Security #: Applying Is Easy. Here s How: 1. Complete and Sign This Form in Ink. 2. Send No Money Now. You Will Be Billed Once Coverage is Approved. 3. Mail Completed Form to: GeoCare Benefits Insurance Program P.O. Box 9159, Phoenix, AZ Have a Question or Need Additional Information? Please Call or Place of Birth City State (or Province) Home Phone: ( ) AREA CODE NUMBER Business Phone: ( ) AREA CODE NUMBER Marital Status: Married Divorced Single Widowed Civil Union* or Domestic Partner* *As applicable only where jurisdictional law so mandates. Call the Administrator for Declaration of Domestic Partnership Form, complete, and return with application. (Not applicable in OR.) Are you presently insured under any other GeoCare Life Plans? Yes No If Yes, indicate which Plan(s) and provide details below (person insured and amount of insurance) Term Life First-to-Die Life 10-Year Level Term Life Details: Date of Birth Height Weight Sex Mo. Day Yr. Lbs. Member: / / ft. in. M F Member s Date of Birth Required if Requesting Only Spouse Coverage Spouse* or Domestic Partner* / / ft. in. M F Name if Proposed for Insurance Child(ren)*: / / ft. in. M F Name if Proposed for Insurance / / ft. in. M F Name if Proposed for Insurance If more than two children are proposed for insurance, attach a separate sheet. Please sign and date the additional sheet. *See Plan Information for definition of eligible dependents. In the next 12 months, does any person proposed for insurance intend to reside outside the U.S. or Canada? Member Yes No Country(ies) Spouse Yes No Country(ies) 2 Membership Affiliation The GeoCare Benefits Group Insurance Trust covers members in the following associations. Please check your affiliation(s) and provide your membership number(s), if available. American Association of Petroleum Geologists American Association of Professional Landmen Association of Environmental and Engineering Geologists G , G Form GMA-PR1 American Institute of Professional Geologists Council of Petroleum Accountants Societies Environmental and Engineering Geophysical Society Geological Society of Washington Society of Economic Geologists Society of Exploration Geophysicists SEPM Society for Sedimentary Geology Continued on reverse side.

7 3 Insurance Requested Refer to brochure for eligibility, options and coverage description. First-to-Die Term Life Plan A. Coverage Amount Requested: $50,000 $100,000 $150,000 $200, B. Tobacco/Nicotine Use: Have you or your spouse (if proposed for coverage) used tobacco or any Member Spouse nicotine substitute in any form (including nicotine patches and nicotine chewing gum)? Yes No Yes No If Yes, please state when you last used tobacco or nicotine products and specify the product used. Member: Spouse: MM/YYYY Product MM/YYYY Product C. I Wish to Pay: Annually Semiannually Enter Premium Contribution: Please note: A $2.00 administrative fee is added for billing modes other than annual. D. Insurance Replacement Member Spouse Is the insurance applied for intended to replace, discontinue or change an existing policy? Yes No Yes No Do you have other life insurance in force? If Yes, total amount in all companies: Member $ Spouse $ E. Do you have other life insurance applications pending? If Yes, indicate amount and company: Member: $ Company Spouse: $ Company 4 Beneficiary Designation Insert name, relationship and address. For the FIRST-TO-DIE Plan, I understand the automatic beneficiary for the Member s coverage is the Spouse; the automatic beneficiary for the Spouse s coverage is the Member. By filling out the information below I am acknowledging my wish to designate someone other than my spouse as my beneficiary. Primary Secondary % Beneficiary Name Beneficiary s Relationship to Member Beneficiary s Social Security # Street Address City State Zip Code Primary Secondary % Beneficiary Name Beneficiary s Relationship to Member Beneficiary s Social Security # Street Address City State Zip Code G , G Form GMA-PR1 Continued on next page.

8 5 Statement of Health (Please initial any changes you make to this form) To the best of your knowledge and belief, please answer the following questions as they apply to you and all dependents to be insured. A. Are you or any other person to be insured disabled or receiving any disability or workers compensation benefits or on waiver Yes No of premium for life or health insurance? B. Are you or any other person to be insured now ill or receiving medical attention or surgical treatment? C. During the past five years, has any person to be insured consulted any physician or other medical care practitioner other than for a routine physical examination, or check up, or been hospitalized or had an operation or had any illness, disease or injury? D. Are you or any person to be insured taking any kind of medication or, so far as you know, in impaired physical or mental health? E. Is any person to be insured now pregnant? F. During the past five years, has any person to be insured ever been medically diagnosed by a physician as having been treated for: Yes No 1. Heart or circulatory trouble, high blood pressure, pain or pressure in chest? 2. Arthritis, back trouble, bone or joint disorder? 3. Fainting spells, convulsions, or epilepsy? 4. Sugar, blood, albumin or pus in urine? 5. Diabetes, kidney trouble, ulcers or digestive disorder? 6. Disorder of breasts or reproductive organs or functions? 7. Nervous or mental disorder, emotional condition or psychiatric care? 8. Cancer, tumor or cyst? 9. Varicose veins, hemorrhoids or hernia? Yes No 10. Disorder of eyes, ears, nose or sinuses? 11. Thyroid, liver or respiratory disorder? 12. Alcoholism or drug habit? 13. Disorder of the blood? 14. Other health or physical impairment including: (i). Being medically diagnosed as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex (ARC)? (ii). Chronic cough, persistent diarrhea, enlarged lymph glands, chronic fatigue, in the past five years? (iii). Any other impairment? IF YOU HAVE ANSWERED ANY QUESTIONS YES, GIVE COMPLETE DETAILS BELOW: (If you need more space, use a signed and dated separate sheet. Please avoid the use of such terms as etc., various, or miscellaneous. ) Question Letter/No. Name(s) of Proposed Insured Illness or Condition Date of Onset Duration Treatment Operations Degree of Recovery and Date Name and Address of Physicians or Other Medical Care Practitioners and Hospitals Where Confined or Treated G , G Form GMA-PR1 Continued on reverse side.

9 FRAUD NOTICE For Residents of all states except those listed below and NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. RESIDENTS OF CO, the following also applies: Any insurance company or agent who defrauds or attempts to defraud an insured shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. RESIDENTS OF AR/LA/MD/RI: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FOR RESIDENTS OF D.C., WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. RESIDENTS OF FL: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. RESIDENTS OF KS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of insurance fraud as determined by a court of law. RESIDENTS OF ME: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. RESIDENTS OF NJ: WARNING: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. RESIDENTS OF OK: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. RESIDENTS OF PUERTO RICO: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years. RESIDENTS OF TN/WA: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. RESIDENTS OF VA: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statements may have violated state law. Authorization and Signature I understand that New York Life has the right to require additional information and, if necessary, an examination by a physician. I ask New York Life to rely on all such statements made on this form, and any supplements to it, while considering this request. I also understand that the coverage afforded will be in consideration of the answers and statements set forth above. AUTHORIZATION: I authorize any physician, medical practitioner, hospital, medical or medically related facility, laboratory, or insurance company to release information, including prescription drug records, maintained by physicians, pharmacy benefit managers, and other sources of information to New York Life Insurance Company, its subsidiaries or the plan administrator about the physical and mental health of any persons proposed for insurance, including significant history, findings, diagnosis and treatment, but excluding psychotherapy notes. A photocopy of this AUTHORIZATION and request form shall be as valid as the original. In all circumstances, my authorized agent or I may request a copy of this AUTHORIZATION. This AUTHORIZATION may be used for a period of 24 months from the date signed, unless sooner revoked as stated in the IMPORTANT NOTICE. By signing and dating this application, the member requests the insurance indicated; and the member and any person proposed for insurance consent to authorize the disclosure of information to and from the providers noted in the IMPORTANT NOTICE; and attest to having read the IMPORTANT NOTICE and Fraud Notices indicated above; and that to the best of his/her knowledge and belief, the answers provided to the questions are true and complete. Member s Signature X (PLEASE SIGN AND DATE IN INK) DATE Spouse s Signature X (NECESSARY ONLY IF SPOUSE COVERAGE IS REQUESTED) DATE G , G PAYMENT OF A PREMIUM CONTRIBUTION FOR INSURANCE DOES NOT MEAN THERE IS ANY COVERAGE IN FORCE BEFORE THE EFFECTIVE DATE AS SPECIFIED BY NEW YORK LIFE. Form GMA-PR1 1/11 ed. 1/11