0159297 Voluntary Group Term Life Insurance
American Foreign Service Protective Association Voluntary Group Term Life Insurance Plan Up to $600,000 of Coverage Protect the Ones You Love Whatever is next in your life, it s always important to set goals and plan for long-term needs. Your plan for continued You may apply for coverage between $20,000 to $600,000, in increments of $10,000. Your premium will increase as you age, as indicated in the Coverage Schedule of Premiums charts found on pages four and five of this brochure. Please refer to the charts to determine your present and future premiums. When you reach age 60, coverage is reduced by 30% of the original coverage amount; at age 65, it is reduced by another 20%; and at age 70, coverage is terminated. financial wellness should include Eligibility life insurance, which can help All active Principal Members under age 60 who are in good standing with the Protective Association are eligible. your loved ones even if something happens to you. 2 Life insurance is one of the best ways you can protect your loved ones in the event something happens to you. As an Association Member, you can apply for up to $600,000 of Voluntary Group Term Life Insurance issued by The Prudential Insurance Company of America (Prudential). Benefits are payable for death from any cause including acts of terrorism or war (declared or undeclared).
Qualified Dependents Eligibility You may obtain insurance for your dependents who include: 1. Spouse. 2. Unmarried children from 14 days to age 26. 3. Legally adopted children. A child placed with you for adoption prior to legal adoption is considered your qualified dependent from the date of placement for adoption, and is treated as though the child were a newborn child to you. 4. Stepchildren and foster children who are dependent on you for support. 5. Grandchildren who are wholly dependent on you and are claimed on your federal income tax return as dependents. Dependents can apply for coverage without Principal Member election at age 19. Note: We encourage qualified dependents to apply for coverage in their own name. No eligible person may be covered by more than one policy. If he/she has coverage in his/her own name, he/she cannot be covered as a dependent under another member s policy. As you re just starting out, it makes a lot of sense to plan now for your financial future. Buying life insurance at work is an easy and affordable way to prepare for the unexpected and live forward with peace of mind. Accelerated Benefit Option The Accelerated Benefit Option allows, in certain cases, early access to a portion of your life insurance benefits that would eventually be paid at death. This is a compassionate and flexible addition to your life insurance coverage. You can use the benefit in any way you wish to pay medical bills, hire home health aides, prepay funeral expenses, or even travel. If you are diagnosed with a terminal illness and have a life expectancy of nine months or less, this benefit will pay 50% of your coverage amount up to $50,000. 3
Coverage Can Not Be Cancelled While the Master Group Policy remains in force, and as long as you pay your premiums, your coverage cannot be cancelled until you reach age 70. Guaranteed Conversion When a member is no longer eligible for coverage due to the limiting age, he or she may convert the coverage, without medical examination, to an individual policy issued by The Prudential Insurance Company of America. Exclusions None. You may be paying college tuition bills, taking care of aging parents, or doing both. You may be thinking about retirement, planning to work for a while, or maybe, you re not sure. Life insurance can help you protect the hopes and dreams of those you love. From building a career, to caring for loved ones, to making sure things are running smoothly at home, you re the one who makes it all happen. Buying life insurance at work can help protect those who depend on you. New Guarantee Issue New hire employees are GUARANTEED ISSUE up to $200,000 of life insurance, and their spouses up to $50,000, without evidence of insurability! Eligible employees must apply for this coverage within 60 days of hire. If an application is received after 60 days of hire, and/or coverage over $200,000 is requested, completion of a health questionnaire will be required. Coverage Annual rates per $1,000 of coverage: Member Coverage Schedule of Premiums Age Rate Age Rate Under 25 $0.70 45 49 $2.15 25 29 $0.80 50 54 $3.80 30 34 $0.90 55 59 $6.50 35 39 $1.10 60 64 $10.00 40 44 $1.95 65 69 $24.00 Coverage terminates at age 70. 4
Family/Dependent Coverage Schedule of Premiums Member s Spouse Children Children Children Annual Age Coverage 2 wks 2 yrs 2 5 yrs 5 26 yrs Premium Under 25 $15,000 $3,000 $6,000 $7,500 $19 25 29 $15,000 $3,000 $6,000 $7,500 $21 30 34 $15,000 $3,000 $6,000 $7,500 $23 35 39 $15,000 $3,000 $6,000 $7,500 $27 40 44 $11,250 $2,250 $4,500 $5,625 $29 45 49 $11,250 $2,250 $4,500 $5,625 $33 50 54 $7,500 $1,500 $3,000 $3,750 $38 55 59 $7,500 $1,500 $3,000 $3,750 $49 60 64 $6,250 $1,250 $2,500 $3,125 $60 65 69 $5,000 $1,000 $2,000 $2,500 $90 Enrollment Information 1. Complete and sign the attached enrollment form and short form health statement questionnaire. Use a separate form for each family member requesting coverage in his/her own name (photocopies are acceptable). If you have any questions or require additional information, please contact AFSPA via phone at 202-833-4910, e-mail life@afspa.org, or visit our Web site www.afspa.org/life. 2. DO NOT SEND PAYMENT AT THIS TIME. You will receive written notification and a premium statement upon approval of coverage. 3. Return the completed forms to: AFSPA 1716 N Street, NW Washington, DC 20036-2902 Fax: 202-775-9082 This is not the insurance contract. This brochure provides a brief description of the important provisions of the Master Policy issued to the American Foreign Service Protective Association. Policy provisions will prevail if there are any conflicts between them and this description. Group Accidental Death & Dismemberment (AD&D) Insurance You and your entire family are eligible for up to $600,000 of protection against accidents any place in the world. If you are interested in AD&D Insurance, call AFSPA at 202-833-4910 or e-mail life@afspa.org to request more information. Also, the brochure and enrollment form are available at AFSPA s Life Insurance Home page www.afspa.org/life. 5
Notes:
GROUP LIFE ENROLLMENT FORM The Prudential Insurance Company of America 751 Broad Street, Newark, New Jersey 07102 Please refer to the description of your plan for coverage options and amounts available to you. Member s Last Name First Name MI Company Name AFSPA Group Contract Number 42001 Member s Address Occupation Social Security Number Date of Birth Married Widowed Male - - / / Single Divorced Female Work Phone Number Home Phone Number E-mail Address Billing Option Quarterly Annually Please mark the appropriate box according to your plan. New Hire Yes No If Yes, Date of Hire / / Type of Coverage Amount Effective Date Member Optional Term Life Optional Term Life Spouse Optional Term Life Children Eligible children are unmarried children from 14 days up to age 26. MY BENEFICIARY S NAME (PLEASE PRINT) Example: Mary A. Doe, not Mrs. J. Doe Primary Beneficiaries First Name MI Last Name Address Relationship Percentage Contingent Beneficiaries First Name MI Last Name Address Relationship Percentage If more than one primary beneficiary is designated, settlement will be made in equal shares to the designated beneficiaries (or beneficiary) who are then still living, unless their shares are specified. If there is no named beneficiary, or no beneficiary survives the insured, settlement will be made in accordance with the terms of your Group Contract. For residents of all states except District of Columbia, Florida, Kentucky, New Jersey, New York, Pennsylvania, Utah, Vermont, Virginia and Washington WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. ALABAMA RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. DISTRICT OF COLUMBIA and RHODE ISLAND RESIDENTS: 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. FLORIDA RESIDENTS: 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. KENTUCKY RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. GL.2009.238 Ed. 6/2012
MARYLAND RESIDENTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW JERSEY RESIDENTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. PENNSYLVANIA and UTAH RESIDENTS: 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 material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. VERMONT RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. VIRGINIA RESIDENTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing a statement of claim for payment of a loss or benefit may have violated state law, is guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. WASHINGTON RESIDENTS: Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits. MEMBER S SIGNATURE I am enrolling for coverage. I understand that, if I desire to increase the amount of my insurance or my dependent insurance coverage hereafter, I may be required to furnish evidence of good health satisfactory to Prudential for myself and/or my dependent. I declare the statements above are true, accurate, and complete, and I understand they are the basis for determining my insurability and contribution for coverage. I have read and understand the terms and requirements of the fraud warnings included as part of this form. Member Signature Date (Month/Day/Year) / / MICHIGAN RESIDENTS ONLY: If you wish to enroll your spouse and/or eligible child 18 years of age or older for $10,000 or more of Dependent Term Life Insurance coverage, your spouse and/or each eligible child age 18 years or older must acknowledge consent for such coverage below. Spouse Signature: Date (Month/Day/Year): Child Signature: Date (Month/Day/Year): Child Signature: Date (Month/Day/Year): Notice to Montana Residents: You or your authorized representative is entitled to receive a copy of this authorization and, upon request, a record of any subsequent disclosures of personal or privileged information. Receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. There is no administrative fee to accelerate death benefits. The accelerated amount is not discounted. Return completed form to: AFSPA 1716 N Street, NW Washington, DC 20036-2902 Fax: 202-775-9082 Group Term Life Insurance coverage is issued by The Prudential Insurance Company of America, a Prudential Financial company, 751 Broad Street, Newark, NJ 07102. Life Claims: 800-524-0542. Please refer to the Booklet-Certificate for all plan details, including any policy exclusions, limitations, and restrictions, which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group Contract issued by Prudential, the terms of the Group Contract will govern. Contract provisions may vary by state. California COA #1179, NAIC #68241. Contract Series: 83500. 2012 Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. GL.2009.238 Ed. 6/2012
Employer/Association Name: American Foreign Foreign Service Protective Service Assn. Protective Assn. Group Contract No.(s): Branch No.: 0042001 0 0 42001 000001 Short Form Health Statement Questionnaire Employee/Member Information First Name MI Last Name GROUP INSURANCE The Prudential Insurance Company of America Mail the completed form to: The Prudential Insurance Company of America Group Medical Underwriting, P.O. Box 8796 Philadelphia, PA 19176 Or fax the completed form to: 877-605-6671 (A separate form must be completed for each person requiring Evidence of Insurability) Number and Street P.O. Box / Apt. Number City State ZIP Code _ Social Security Number Employee/Member ID Number Telephone E-Mail Address Applicant Information Relationship to Employee/Member: Self Spouse First Name MI Last Name Social Security Number Applicant Coverage requiring Evidence of Insurability: Employee/Member Life Spouse Life Gender: Female Male Date of Birth: (mm-dd-yyyy) Height: Please answer these questions by checking Yes or No. Yes Yes Yes Yes No No No No Do you currently have any disorder, condition (including pregnancy), or disease or are you currently taking medication prescribed or provided by a medical or other practitioner for any disorder, condition (including pregnancy), or disease other than a cold, cough, or allergies? During the last five years, have you been in a hospital or other institution for observation, rest, diagnosis, or treatment? During the last five years, have you had life, disability, or health insurance declined, postponed, changed, rated-up, cancelled, or withdrawn by an insurer? Within the last five years, have you been treated for or had any trouble with any of the following: heart; chest pain; high blood pressure; cancer or tumors; diabetes; lungs; kidneys; liver; alcoholism; mental, or nervous disorder or have you been diagnosed with, or treated by a member of the medical profession for, Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC)? Prudential reserves the right to request additional health information on the basis of the responses given to the above questions. I have read and understand the terms and requirements of the Important Notice included as page 2 of this form. I declare that, to the best of my knowledge and belief, the statements made in this application are complete and true. I agree that the coverage applied for is subject to the terms of the plan and shall become effective on the date or dates established by the plan, provided the evidence of good health is satisfactory. Applicant s Signature (unless a minor) Date Signed (mm-dd-yyyy) If applicant is a minor, Signature of Parent, Guardian or Relationship Date Signed (mm-dd-yyyy) Person Liable for Support of Applicant *LSFHSQG001* ft. in. Weight: GL.2007.761 G * L S F H S Q G 0 0 1 * L Ed. 0709 Page 1 of 2 lbs.
Important Notice: For residents of all states except Florida, New Jersey, New York, Pennsylvania, Utah, Vermont, Virginia and Washington: Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive, or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is or may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree. New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. New York Residents: 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 is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. This notice ONLY applies to accident and disability income coverage. Pennsylvania and Utah Residents: 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 is a crime and subjects such person to criminal and civil penalties. Vermont Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. Virginia Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing a statement of claim for payment of a loss or benefit may have violated state law, is guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. Washington Residents: Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits. Please keep a copy of this form for your records. Group Life Insurance coverage is issued by The Prudential Insurance Company of America, a New Jersey company, 751 Broad Street, Newark, Group Life NJ coverage 07102. is issued by The Prudential Insurance Company of America, a New Jersey company, 751 Broad Street, Newark, NJ 07102. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in Prudential many jurisdictions and the Rock worldwide. logo are registered service marks of The Prudential Insurance Company of America and its affiliates. *LSFHSQG002* GL.2007.761 G * L S F H S Q G 0 0 2 * 123729 111213 L Ed. 0709 Page 2 of 2
Group Life and Disability Income Medical Underwriting NOTICE Thank you for choosing The Prudential Insurance Company of America (Prudential) for your insurance needs. Before we can issue coverage we must review your application/enrollment form. To do this, we need to collect and evaluate personal information about you. This notice is being provided to inform you of certain practices Prudential engages in, and your rights, with regard to your personal information. We would like you to know that: Personal information may be collected from persons other than yourself or other individuals, if applicable, proposed for coverage; This personal information as well as other personal or privileged information subsequently collected by us may in certain circumstances be disclosed to third parties without authorization; You have a right of access and correction with respect to personal information we collect about you; and Upon request from you, we will provide you with a more detailed notice of our information practices and your rights with respect to such information. Should you wish to receive this notice, please contact: The Prudential Insurance Company of America Group Medical Underwriting P.O. Box 8796 Philadelphia, PA 19176 Information regarding your insurability will be treated as confidential. We may, however, make a brief report thereon to the MIB, Inc., formerly known as Medical Information Bureau, a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life, disability, or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information about you in its file. In addition, upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at 866-692-6901 (TTY 866-346-3642). If you question the accuracy of the information in MIB s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB s information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734. Information for consumers about MIB may be obtained on its website at www.mib.com. Please keep this notice for your records.
Group Life and Accidental Death & Dismemberment Insurance coverages are issued by The Prudential Insurance Company of America, a Prudential Financial Company, 751 Broad Street, Newark, NJ 07102. The Booklet-Certificate contains all details, including any policy exclusions, limitations and restrictions, which may apply. Contract Series: 83500. This policy provides ACCIDENT insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department. IMPORTANT NOTICE THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS. 2012 Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. 123729 0159297-00004-00