The GeoCare Benefits Group Term Life Insurance Plan

Transcription

1 The GeoCare Benefits Group Term Life Insurance Plan Underwritten by New York Life Insurance Company When you think about it, there s nothing that s more important than protecting your family s future. Now, you can help protect your family affordably, with quality Group Term Life Insurance coverage from GeoCare Benefits. With the GeoCare Benefits Group Term Life Insurance Plan, you can help assure that your family will remain financially secure that they re able to stay in the home you made for them regardless of what happens tomorrow. The GeoCare Benefits Term Life Insurance Plan provides up to $1,000,000 and offers you a wide range of options that can be tailored to fit your individual financial situation. With the Plan s Inflation Guard Option, you can choose to increase your coverage 10% for 10 years without having to requalify an easy way for your coverage to keep pace with inflation. Plus, rates are discounted for non-smokers and those with coverage of $220,000 or more. Help Protect Your Hopes and Dreams for Your Family s Future, With Affordable Group Term Life Insurance With the Inflation Guard Option So Your Coverage Can Keep Pace With the Cost of Living. Through the Plan s Accelerated Death Benefit,* insured members and their spouses who are terminally ill can receive part of their insurance benefit while they are still alive. 1 *The Accelerated Death Benefit is not available to residents of Massachusetts.

2 Eligibility Requirements You are eligible to apply for the GeoCare Benefits Group 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 under age 70, and you are a resident of the United States. Due to state regulations, the Plan is not available in SD. You can also apply for coverage for your lawful spouse or domestic partner (under age 70) and any unmarried, dependent children ages 15 days to 25 years. 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. Schedule of Group Life Insurance Member: Options of $25,000 to $1,000,000* (in multiples of $25,000) age 59 and under. Coverage for members between the ages of 60 and 69 who are applying is available in accordance with the Insurance Coverage After Age 59 section on page 5. Spouse or Domestic Partner: Options of $25,000 to $1,000,000* (in multiples of $25,000) age 59 and under. The amount of spouse or domestic partner s coverage may not exceed the member s. Coverage for spouses or domestic partners between the ages of 60 through 69 who are applying is available in accordance with the Insurance Coverage After Age 59 section on page 5. Children: Each unmarried child age 15 days to 25 years...$5,000. *Coverage remains level until the member or spouse reaches age 60 and then reduces as indicated in the Insurance Coverage After Age 59 section on page 5. Please note: The maximum amount of life insurance in force for combined New York Life Insurance group policies may not exceed $1,000,000 per insured association member. Discount for Coverage of $220,000 or More Premium for insureds whose coverage is $220,000 or more will be discounted approximately 10%. This volume discount is available to both members and spouses who are covered. Discount for Qualified Non-Smokers You and/or your spouse may qualify for reduced rates if either or 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. Inflation Guard Option On the December 1st renewal after your coverage has been in effect for one year, you will have the opportunity to elect the Plan s Inflation Guard Option. An easy way for your coverage to keep pace with the cost of living, Inflation Guard allows you to increase your coverage by 10% for each of the next 10 years without underwriting, provided you are under age 50, not disabled, and the increased coverage would not exceed the $1,000,000 Plan maximum. Your total premium amount will increase each year according to your then current age to reflect your increased coverage amount. You may elect this option for your spouse, too, if covered. Take Advantage of Discounted Non-Smoker Rates, Discounts for Coverage of $220,000 or More, and the Inflation Guard Option. Benefits of the Plan Waiver of premium. In the event you are totally and permanently disabled for six months prior to age 60, coverage for you and your dependents will continue without premium payment provided you remain totally disabled. Evidence of continued total disability will be required from time to time. 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. Experience Credits. When claims experience is favorable, you may receive an experience credit on your premium notice. These credits are used to reduce the semiannual premium payments you make. Experience credits are not guaranteed. Accelerated Death Benefit. The Accelerated Death Benefit has been designed to provide terminally ill insureds the option to have a portion of their life insurance benefit paid while they are still alive. You are then free to use that money any way you choose. This benefit has been added to the Term Life Plan to help enhance 2

3 your financial security. It can be used to help pay for the high cost of medical and hospital care or for personal expenses. To qualify for the Accelerated Death Benefit, you or your covered spouse must be insured under the Term Life Insurance Plan, under age 89 and diagnosed as having a life expectancy of 12 months (Illinois residents: 24 months) or less. Proof of terminal illness will consist of a statement from your physician and any other medical information the Insurance Company believes necessary to confirm your status. If you qualify, the Insurance Company will pay you, in lump sum, 50% of the benefit that would be in force 12 months from the date of your request. Full premiums continue to be payable. The amount of insurance payable upon your death will be reduced by the amount of the Accelerated Death Benefit previously paid. Some portion of the benefit may be taxable income. Your ability to receive certain government benefits/entitlements may be affected by receipt of this benefit. You should seek advice from a tax advisor and/or attorney if you have any questions about how the benefit may affect your personal situation. This benefit is not available to residents of Massachusetts. Choice of Beneficiary Your beneficiary can be anyone you choose. You may change your beneficiary at any time by written request. You are the beneficiary for your covered spouse and children. Effective Date Coverage for you and/or your dependents becomes effective on the date it is approved by the Insurance Company, provided your first contribution is paid within 31 days after the date you are billed and you and any of your approved dependents are performing the normal activities of a person of like age on the date of approval. (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 reaches age 60, coverage is reduced as shown on the table on page 19. Premiums are not reduced when coverage reduces. The insurance coverage listed is for each original $25,000 unit. Termination of Coverage All coverage terminates the December 1st on or after the member reaches age 90, the December 1st on or after you cease to qualify as a member, when the Master Group Policy is terminated by New York Life or the Group Policyholder, or when premiums are not paid. The Plan provides an opportunity to convert to an individual policy with no medical exam when coverage terminates subject to certain conditions which are described in your certificate. Coverage for dependents terminates when the member s coverage terminates, when their premiums are not paid, or when they are no longer eligible. The Insurance Company cannot terminate coverage or change benefits or premiums on an individual basis; it may do so on a classwide basis. A class of insureds is a group with the same age and gender. Premiums Premiums may be paid semiannually or annually. To pay annually, multiply the premiums listed on page 4 by two. Please note: An administrative fee of $2.00 is added for the semiannual billing mode. Understanding Your Certificate of Insurance 30-Day Free Look This brochure is only a partial description of the provisions of this insurance coverage. Once approved, you will receive a Certificate of Insurance as evidence of coverage provided under the Group Policy of (Policy Form GMR). The Certificate of Insurance details features, limitations, and exclusions. The Texas forms are as follows: GMR-G29067/FACE. 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 thirty day period to review your Certificate. If you return your Certificate without claim within thirty days, we will refund your full premium and the Certificate will be null and void, as if it were never issued. 3

4 Current 2011 Semiannual Premiums Member Benefit Amounts Less Than $220,000 Benefit Amounts $220,000 or More Non-smoker Smoker Non-smoker Smoker For each For each For each For each For each All $25,000 $25,000 $25,000 $25,000 $25,000 Children Unit Unit Unit Unit Unit $5,000 Under 25 $ 7.50 $ 9.00 $ 6.00 $ 7.50 $ * Current 2011 Semiannual Premiums Spouse Benefit Amounts Less Than $220,000 Benefit Amounts $220,000 or More Non-smoker Smoker Non-smoker Smoker For each For each For each For each For each All $25,000 $25,000 $25,000 $25,000 $25,000 Children Unit Unit Unit Unit Unit $5,000 Under 25 $ 6.00 $ 7.50 $ 4.50 $ 6.00 $ * 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. * On the Policy anniversary date (December 1) on or after the insured reaches age 60, coverage is reduced as described on page 5. Please contact the Administrator at for rates over age 69. Coverage terminates when the member reaches age 90. Dependent coverage terminates when the member s coverage terminates. 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. 4

5 Insurance Coverage After Age 59 Coverage reduces on the anniversary date following the insured s 60th birthday and continues to reduce thereafter according to the table below. Full premiums continue to be payable. Member or Member or Spouse Children Spouse Age $25,000 Unit 60 $19,500 $5, ,000 5, ,500 5, ,250 5, ,000 5, ,000 5, ,000 5, ,000 5, ,000 5, ,250 5, ,750 5, ,500 5, * 6,250 5, ** 5,000 5,000 * Maximum coverage at ages is $112,500 (18 units). Coverage reduces to a maximum amount of $112,500 on the December 1 following the insured s 80th birthday. ** Maximum coverage at ages is $75,000 (15 units). Coverage reduces to a maximum of $75,000 on the December 1 following the insured s 85th birthday. Benefit option amounts are not guaranteed and are subject to change by agreement between New York Life Insurance Company and the Group Policyholder. How to Apply for Coverage 1. Complete, sign, and date the enclosed 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 Residents of New York: Please contact the Administrator for an application specific to New York State. IMPORTANT NOTICE: How New York Life Obtains Information and Underwrites Your Request for Group Term Life 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. 5

6 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 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. If we can provide the coverage you requested, we will inform you as to when such coverage will be effective. Under no circumstances will coverage be effective prior to this date. Payment of a premium contribution with your application does not mean that there is any insurance in force before the effective date as determined by New York Life. Important Information From New York Life Insurance Company New York Life Insurance Company reserves the right to request medical information to determine an applicant s medical eligibility for coverage. Based on the age of the person proposed for insurance and the amount of coverage requested, a physical examination, EKG, blood test or other information may be required. Not all applicants will have to supply additional information. However, if it is required, we will arrange for an independent professional paramedic to contact you to perform these simple tests at your convenience. The exam and blood test are free-of-charge. The Group 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). New York Life Insurance Company 2.09ed. Source: Individual Third Party Ratings Reports (as of 7/7/10) 6

7 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. TERM2011 7

8 Group Term Life Insurance Plan Application For Participating Associations of the GeoCare Benefits Group Insurance Trust Not for Residents of New York State Request for Group Insurance from Applying Is Easy. Here s How: New York Life Insurance Company 51 Madison Avenue, NY, NY 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 . 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 - Social Security #: - - 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.

9 3 Insurance Requested Refer to brochure for eligibility, options and coverage description. Term Life Plan A1. For Members Not Currently Insured: I request Group Term Life Insurance in the INITIAL amount of $ for myself; $ for my spouse/domestic partner*. I also request coverage for my eligible child(ren). Yes No A2. For Members Currently Insured: I wish to INCREASE amounts of insurance as follows: from $ to $ for myself. from $ to $ for my spouse*. I wish to ADD dependent coverage as follows: for my spouse* in the initial amount of $. for my child(ren) Yes No *Spouse coverage cannot exceed member s coverage. 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 TERM LIFE Plan, I hereby make the following beneficiary designation with respect to all the insurance on my life under this Group Term Life Insurance Plan and, if I am already covered under the Plan, I hereby revoke any prior beneficiary designation. The beneficiary for dependent coverage shall be the insured member as provided in the Group Policy. (If you wish to name a different beneficiary for spouse coverage, contact the Administrator.) 1.) If naming more than one beneficiary, please note if each is to be primary and/or secondary, and also indicate the percentage of death proceeds to be distributed to each. 2.) If naming a trust, please indicate the full name and date of the trust. (Attach a separate sheet if necessary, then sign and date it.) 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.

10 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.

11 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