GROUP TERM LIFE INSURANCE EZ OFFER

Transcription

1 7583/7584/1002/43520-S 1. MEMBER INFORMATION: G TO APPLY: Send this completed form with your premium check payable to: ADMINISTRATOR, AIChE GROUP INSURANCE PROGRAM P.O. Box Des Moines, IA QUESTIONS? Call: AIChE ( ) The Company You Keep Request for Group Insurance from NEW YORK LIFE INSURANCE COMPANY 51 Madison Avenue New York, NY FULL NAME: LAST FIRST MIDDLE HOME (AREA CODE) STREET ADDRESS CITY BUSINESS (AREA CODE) GMA-GI 29310/43520 A9822 (9/07) Seabury & Smith, Inc ADDRESS (OPTIONAL) - STATE (OR PROVINCE) ZIP CODE DATE OF BIRTH SEX - - / / M F SOCIAL SECURITY NUMBER mo. day yr. Does any person proposed for insurance intend to reside outside the U.S. or Canada in the next 12 months? Yes Country(ies) For how long? No 2. MEMBERSHIP STATUS: Are you now a member of AIChE? Yes No Membership Number: GROUP TERM LIFE INSURANCE EZ OFFER FOR MEMBERS OF THE AMERICAN INSTITUTE OF CHEMICAL ENGINEERS ENROLLMENT DEADLINE: October 31, 2007 (PLEASE PRINT IN INK OR TYPE ALL ANSWERS. INITIAL AND DATE ANY CHANGES YOU MAKE. DO NOT USE CORRECTION FLUID OR GEL PENS.) Account No. (FROM PREMIUM NOTICE) Membership in the AIChE is required for participation in the Plan. 3. INSURANCE REQUESTED: (Refer to Certificate of Insurance for eligibility and coverage description.) I hereby apply for the $50,000 option. A. TOBACCO/NICOTINE USE: During the past 24 months, have you used tobacco or nicotine in any form, including nicotine patches or nicotine gum? Yes No PREMIUM CONTRIBUTION ENCLOSED:* $ B. PAYMENT OPTION SELECTED: (choose one) Total Premium Enclosed: $ *Please note that the Amount Due shown on the Notice of Payment Due is a smoker rate. It is also based upon the date of birth provided by your association. Please refer to the enclosed rate chart to verify the Amount Due, based upon your age as of November 1, 2007, and your tobacco/nicotine use as indicated above. OPTION 1: ELECTRONIC FUNDS TRANSFER (EFT): I request and authorize the AIChE Group Insurance Program, Inc., to make monthly semiannual withdrawals against the account specified on the attached voided check statement savings account deposit slip, or any account subsequently named by me, and such bank to process these withdrawals as if I had signed them, for the purpose of collecting premium contributions due under this Group Term Life Insurance Plan. (Enclose a VOIDED check or deposit slip, as applicable.) X SIGNATURE(S) AS REQUIRED ON CHECKS/WITHDRAWALS ISSUED AGAINST THIS ACCOUNT DATE OPTION 2: PERIODIC BILLING: Semiannual (May 1 and November 1) C. IMPORTANT REPLACEMENT INFORMATION FOR RESIDENTS OF NEW YORK: It may not be in your best interest to replace existing life insurance policies or annuity contracts in connection with the purchase of a new life insurance policy, whether issued by the same or a different insurance company. A replacement will occur if, as part of your purchase of a new life insurance policy, existing coverage has been, or is likely to be, lapsed, surrendered, forfeited, assigned, terminated, changed or modified into paidup insurance or other forms of benefits, loaned against or withdrawn from, reduced in value by use of cash values or other policy values, changed in the length of time or in the amount of insurance that would continue or continued with a stoppage or reduction in the amount of premium paid. Prior to completing a replacement transaction, you may want to contact the insurance company or agent who sold you the life insurance or annuity contract that will be replaced, to help you decide whether the replacement is in your best interest. NEW YORK RESIDENTS: I have read the Important Replacement Information above. Is the life insurance applied for intended to replace, in whole or in part, any existing insurance or annuity? Yes No RESIDENTS OF OTHER STATES: Is the insurance applied for intended to replace, discontinue or change an existing policy? Yes No ALL RESIDENTS: Do you have other life insurance in force? Yes No If Yes, total amount in all companies: $ Do you have other insurance applications pending? Yes No If Yes, indicate amount and company: $ Company BE SURE TO COMPLETE AND SIGN REVERSE SIDE

2 4. BENEFICIARY DESIGNATION: I hereby make the following beneficiary designation with respect to all the insurance on my life under this Group Term Life Insurance Plan, and I revoke any prior beneficiary designation. (Please print: person s name, address, relationship and Social Security #.) 5. MEMBER DECLARATIONS: I request the group insurance shown on the reverse side. To the best of my knowledge and belief: (a) I am eligible for such insurance as described in the brochure; and (b) the statements I have made are true and complete. I understand that insurance will be effective on the date approved by New York Life Insurance Company provided the initial contribution and this application are received by October 31, 2007, and I am actively performing the normal activities of a person in good health of like age [NC residents: a person of like age] on the approval date. I also understand that any dividend apportioned to the group policy will be paid to the Trustee of the Insurance Plan. Fraud Warning Statements 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. For CO residents, 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. For DC residents, the following also applies: An insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FL residents only: 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. LA residents only: 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. OK residents only: 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. VA residents only: 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. MEMBER S SIGNATURE (PLEASE SIGN AND DATE IN INK) DATE SIGNATURE OF OWNER (NECESSARY ONLY IF MEMBER PREVIOUSLY TRANSFERRED OWNERSHIP OF THIS GROUP TERM LIFE INSURANCE) 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 INSURANCE COMPANY. DATE G /07 ed. GMA-GI PLEASE NOTE: If you are age 50 or older and would like to request additional coverage, contact the Plan Administrator at AIChE ( ) for a copy of the standard fully underwritten application / /07

3 For the past six months, AIChE has provided you with a $50,000 option of Group Term Life Insurance coverage from New York Life Insurance Company. Your complimentary coverage ends on October 31, You can continue to protect yourself and loved ones with this offer of guaranteed acceptance at affordable group rates. This is your only such chance to continue this valuable protection. Your Valuable Insurance Coverage Doesn t Have to End Don t miss out. Take advantage of our offer by giving us your instructions today. You and your loved ones can rest easier knowing that their needs will be met if something should happen to you. Just complete the EZ Offer form on page 3 and you can continue this affordable coverage. If you choose not to do anything, the coverage initially provided to you at no cost will expire. This is the only notification you will receive regarding this valuable offer. Guaranteed Acceptance You are guaranteed acceptance to continue your $50,000 coverage option if you are a second-time renewing AIChE member age 60* and under, residing in the U.S. (except FL, NV, VT, WA and territories), and you respond by October 31, There are no health questions to answer and no medical exams to take. Just complete the EZ Offer form and be sure to note your tobacco/nicotine use. If you are a qualified non-nicotine user, your rate may be even lower than what is shown on the premium payment notice. Adjust your rate according to the nonsmoker rate table and send back your payment. Life Insurance is One of the Pillars of Financial Independence As a professional, you face growing financial responsibilities. But what if the unexpected happens? Will your loved ones be protected? Being young and healthy is no defense against a fatal accident or illness. This valuable one-time offer is a perfect way to begin building or adding to your insurance portfolio. As you grow professionally, and your income and financial responsibilities increase, you ll find the Group Term Life Insurance Plan is one of the most valuable benefits of your AIChE membership. Benefits of Coverage The AIChE Group Term Life Insurance Plan offers you these benefits and more. The premium contributions after your complimentary six months are competitively priced group rates. You can maintain this protection regardless of any career changes the insurance is portable and travels with you. Your premiums may be waived if you become disabled. You can apply for a portion of your benefits if you qualify as being terminally ill, subject to certain policy restrictions and limitations under the Living Benefit Option ( Accelerated Death Benefit ). After coverage is validly in force for two years, benefits are payable for death from any cause, at any time, anywhere in the world. Please refer to your Certificate of Insurance for information regarding limitations and renewability. *Amount Due quoted on Notice of Payment Due is a smoker rate. If you are a qualified nonsmoker, please review the rate chart to determine Amount Due. The age used to determine the Amount Due is based on the date of birth provided by your association. Please be sure to provide your current smoker status and date of birth on the attached enrollment form. (Over, please...)

4 It May Be Less Expensive Than You Think See for yourself how affordable the AIChE Group Term Life Insurance Plan is. Refer to the chart below. It May Be to Your Financial Advantage to Respond Remember, your guaranteed opportunity expires on October 31, After that date, you may be required to answer extensive health questions and submit to a medical exam. That is why it is important you act now. This Group Term Life Insurance Plan is Underwritten by: A History of Caring For more than 40 years, AIChE has worked with Marsh Affinity Group Services to offer a group insurance program that provides a variety of insurance plans to help members build a stronger financial future. Additional Coverage Is Also Available If you re like many members, you may prefer to increase your protection. If you qualify to continue coverage as described and you re under age 50, you also qualify to request an additional $50,000 option on a simplified issue basis. Visit to download and complete the Simplified Offer form. Your acceptance will be determined by your responses to three short health questions on the application. IMPORTANT NOTE: Please refer to the rate chart below to determine Amount Due. A separate payment should be submitted if you are applying for additional coverage. Do not combine your Amount Due for the EZ Offer and Simplified Offer into one payment. For example, a member age 30, who is a nonsmoker, would need to submit two separate payments of $ You may mail back both applications and payments in the same envelope. CURRENT 2007 SEMIANNUAL PREMIUM CONTRIBUTIONS MEMBER $50,000 OPTION Cost Is Based On Nonsmoker Rates*** Smoker Rates Your Age And Increases As You Grow Older Under 30 $ $ $ $ $ $ $ $ $ $ $ $ $ $ ** $ $ Call the Administrator for the renewal rates at ages ** Coverage decreases starting at age 60, as shown in your Certificate of Insurance. Coverage terminates at age 80. *** To qualify as a nonsmoker, a member must not have used tobacco or nicotine in any form, including nicotine patches or nicotine gum, in the past 24 months. The premium contributions shown reflect the current rate and benefit structure. Premium contributions may be changed by New York Life Insurance Company on any premium due date, but not more than once in any 12-month period, and on any date on which benefits are changed. However, your rates may be changed only if they are changed for all others in the same class of insureds. For example, a class of insureds is a group of people with all the same issue age. Premium contributions will vary with the amount of benefits selected. Benefit option amounts are not guaranteed and are subject to change by agreement between New York Life Insurance Company and the Trustee. The total amount of coverage for a member insured under this Plan issued by New York Life Insurance Company to the Trustees of the Life Insurance Plan for members of the AIChE may not exceed $1,000,000. The total amount of coverage a member may request for all group life insurance plans underwritten by New York Life Insurance Company cannot exceed $2,000,000. The AIChE insurance trust incurs certain costs in connection with this sponsored group Plan. To provide and maintain this valuable membership benefit, it is reimbursed for these costs. AIChE also receives a fee for the license of its name and logo for use in connection with the Plan. Marsh Affinity Group Services, a service of Seabury & Smith, receives compensation for services to provide this program; these services may include enrollments, ongoing servicing, billing, marketing, brokerage, customer administrative & claim servicing and communications. Refer to and enter in the security code E or call us at for specific details. This Group Term Life Insurance Plan is Administered by: The Company You Keep New York Life Insurance Company 51 Madison Avenue New York, NY Under Group Policy G On Policy Form GMR-FACE/G Affinity Group Services a service of Seabury & Smith Administrator AIChE Group Insurance Program 1776 West Lakes Parkway West Des Moines, IA AIChE@marshpm.com

5 IMPORTANT NOTICE FOR RESIDENTS OF NEW YORK If you answered Yes, to question 3C. on the Application, the enclosed form Important Notice Regarding Replacement or Change of Life Insurance Policies or Annuity Contracts must be completed. Please return this form with your Application and keep the second copy with your records. If coverage is approved and made active, a copy of your completed and signed Replacement form will be attached to your issuance material /43520 I8366 (9/07) Seabury & Smith, Inc. 2007

6 IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS THIS NOTICE IS FOR YOUR BENEFIT AND REQUIRED BY NEW YORK STATE REGULATION NO. 60 You are contemplating the purchase of a life insurance policy or an annuity contract in connection with the surrender, lapse or change of existing life insurance policies or annuity contracts. We are required to give you this notice. Your decision could be a good one - or a mistake - so make sure you understand the facts. You should: 1. Ask the company or agent from whom you bought your existing life insurance policies or annuity contracts to review with you the transaction. You may be able to effect the changes you desire more advantageously with them. 2. Consult your tax adviser. There may be unfavorable tax implications associated with the contemplated changes to your existing life insurance policies or annuity contracts. As a general rule, it is often not advantageous to drop or change existing coverage in favor of new coverage, whether issued by the same or a different insurance company. Some of the reasons it may be disadvantageous are: 1. The amount of the annual premium under an existing life insurance policy may be lower than that called for by a new life insurance policy having the same or similar benefits. Any replacement of the same type of policy will normally be at a higher premium rate based upon the insured s then attained age. 2. Since the initial costs of a life insurance policy are charged against the cash value increases in the earlier life insurance policy years, the replacement of an old life insurance policy by a new one results in the policyholder sustaining the burden of these costs twice. Annuity contracts usually contain provision for surrender charges, therefore a replacement involving annuity contracts may result in the imposition of surrender charges. 3. The incontestable and suicide clauses begin anew in a new life insurance policy. This could result in a claim being denied under the new life insurance policy that would have been paid under the life insurance policy that was replaced. 4. An existing life insurance policy or annuity contract often has more favorable provisions than a new life insurance policy or annuity contract in areas such as loan interest rate, settlement options, disability benefits and tax treatment. 5. There may have been changes in your health since the purchase of the existing coverage. 6. The insurance company with which you have existing coverage can often make a desired change on terms that would be more favorable than if you replaced existing coverage with new coverage. You have the right, within 60 days after receipt of the new life insurance policy or annuity contract, to return it to the insurer and receive an unconditional full refund of all premiums or considerations paid on it, or in the case of a variable or market value adjustment policy or contract, a payment of the cash surrender benefits provided under the policy or contract, plus the amount of all fees and other charges deducted from gross considerations or imposed under the life insurance policy or annuity contract, and Over Please Signature Required on Reverse Side

7 may have the right to reinstate or restore any life insurance policies and annuity contracts that were surrendered, lapsed or changed in the transaction to their former status to the extent possible and in accordance with the insurer s published reinstatement rules to the extent such rules are not inconsistent with the provisions of this part. IMPORTANT: THIS RIGHT SHOULD NOT BE VIEWED AS REINSTATING OR RESTORING YOUR LIFE INSURANCE POLICY OR ANNUITY CONTRACT TO THE SAME CONDITION AS IF IT HAD NEVER BEEN REPLACED. THERE MAY BE CONSEQUENCES IN REINSTATING OR RESTORING YOUR LIFE INSURANCE POLICY OR ANNUITY CONTRACT, INCLUDING BUT NOT LIMITED TO: The right to reinstate or restore your life insurance policy or annuity contract applies only to companies subject to New York insurance laws; Your life insurance policy or annuity contract is subject to your specific company s reinstatement rules, which may vary from company to company. These rules may require payment of both premium and interest; however, you will not be subject to evidence of insurability, or a new contestable or suicide period; You may not receive the interest or investment performance during the period the life insurance policy or annuity contract was replaced; and There may be unfavorable federal income tax consequences as a result of the reinstatement of your life insurance policy or annuity contract. IMPORTANT: In the case of a variable or market value adjustment policy or contract, the value of the policy or contract may increase or decrease during the 60-day period depending on the performance of the underlying investments, which may affect the value of the refund you receive. Please provide the information requested below for each existing policy or contract you are replacing. (Attach a separate sheet if necessary.) Sign and date the completed form and mail it in the postage paid envelope provided. Be sure to keep one copy for your records INSURER NAME CONTRACT OR INSURED OR REPLACED (R) OR REASON FOR POLICY # ANNUITANT FINANCING (F) REPLACEMENT I hereby acknowledge that I read the above IMPORTANT NOTICE. Date: Signature of member applicant: [Mr. Sample Sample] Date: Signature of joint applicant: [Mrs. Sample Sample] SM-NY60-IN-ND GMAD 10/2006 Office Use Only: Date Control # SS#