ASSOCIATION LIFE INSURANCE THROUGH THE ISMA INSURANCE AGENCY Thak you for your iterest i the ISMA s Group Term Life Isurace product. Per your request, please fid eclosed the followig: A product brochure for Group Term Life isurace, icludig rates, ad optioal beefits A applicatio If you wish to apply for coverage, please complete the applicatio i full ad retur to: ISMA Isurace Agecy, c/o Brow & Brow of Idiaa, 11555 N. Meridia Street Ste. 220, Carmel, IN 46032. If you prefer, you may fax the applicatio to (317)471-1700. Please DO NOT cacel ay existig isurace coverage util you are otified of approval ad give your effective date. If you have ay questios or eed assistace, please do ot hesitate to cotact Katie Brockway (317)396-1086 or toll free (877)647-2242.
30-day free look If you chage your mid, you ca retur your Certificate of Isurace withi 30 days after receivig it ad obtai a full refud of ay premium paid. Check out these valuable features Ecoomical group rates S pouse ad child(re) coverage available Reewable to age 75 A accelerated death beefit Now EFFECTIVE DATE: Coverage will begi o the first day of the moth followig the date your applicatio is approved, provided the required premium has bee paid. EXCLUSIONS AND LIMITATIONS: If a perso s age, sex or ay other data is misstated, the correct data will be used to determie if isurace is i force. If isurace is i force, the premium ad/or beefits will be adjusted accordig to the facts. If a perso commits suicide withi 2 years from the date his isurace takes effect, Uited States Life s liability will be limited to the premiums paid, plus iterest. No accidetal death will be paid for ay loss that results from or is caused directly, idirectly, wholly or partly by: suicide or itetioally self-iflicted ijury; isurrectio; war or a act of war; a physical or metal sickess, or treatmet of that sickess; volutary itake of poiso, drugs, gas or fumes, uless take as prescribed by a physicia; committig a crime, or a attempt to do so; beig itoxicated or uder the ifluece of ay drug, uless take as prescribed by a physicia; active military duty i the service of ay coutry; flight i ay type of aircraft, uless you travel as a fare payig passeger, or o a pass, ad if: the aircraft is licesed to carry passegers; the carrier is licesed to fly such aircraft; the aircraft is flow by a licesed pilot; ad the flight is regularly scheduled betwee established airports. A SOLID INSURER: This pla is uderwritte by The Uited States Life Isurace Compay i the City of New York. This brochure is a brief summary of beefits oly ad is subject to the terms, coditios, exclusios ad limitatios of Group Policy No. G-610,292, Form No. G-19000. Complete details ca be foud i the Certificate of Isurace, which will be set to you whe your applicatio is approved. Coverage may vary ad may ot be available i all states. s of the Idiaa State Medical Associatio ca apply for as much as $1,000,000 of Group Term Life Isurace at ecoomical group rates Admiistered by: Coversio privilege Idiaa State Medical Associatio 11555 N. Meridia Street, Ste. 220 Carmel, IN 46032 1-877-647-2242 Fax: 317-471-1700 Uderwritte by: The Uited States Life Isurace Compay i the City of New York New York, New York www.americageeral.com The uderwritig risks, fiacial ad cotractual obligatios ad support fuctios associated with products issued by The Uited States Life Isurace Compay i the City of New York (Uited States Life) are its resposibility. 2010. All rights reserved. ISMA-TERM AG8313 (12/10) 06673611-1671 R1/11
Why Group Term Life Isurace We ca sum it up i oe word cost. Term life isurace offers a cosiderable advatage over permaet life isurace because term policies provide pure protectio at a more ecoomical cost durig the time your growig family eeds it. Your Idiaa State Medical Associatio (ISMA) Group Term Life Isurace Pla combies ecoomical group rates with high-limit protectio. There are o extras such as cash loas or retiremet icome value to icrease the cost. This is truly a o-frills group pla offerig you oe of the best life isurace values available. Who ca apply? Ay ISMA member i good stadig ad their spouse, may apply for $10,000 to $1,000,000 of coverage (available i icremets of $5,000).All applicats must be uder age 65 to apply. s ad spouses, must be able to perform the ormal activities of a perso of like age ad sex, with like occupatio or retired status o the day isurace is to take effect. If ot, isurace will take effect o the day the isured resumes such activities. No medical exam typically required for up to $250,000* Aswers to the questios o the applicatio are typically all that is eeded for coverage up to $250,000, with o health exams or tests usually required.* Depedig o the amout of coverage applied for, a paramedical exam may be required, which will be scheduled at your coveiece ad at o cost to you. Acceptace is subject to evidece of isurability as determied by the uderwritig compay. * Issuace of a Certificate of Isurace or paymet of beefits may deped upo the aswers give i the applicatio ad the truthfuless of those aswers. A accelerated death beefit This attractive beefits provisio is available to members uder the age of 70. If you are termially ill, as defied by the policy, you may elect to receive a amout up to 50% (less the discout) of your group life isurace beefit. The remaiig beefit the becomes payable to your beeficiary after your death. Termial illess is a medical coditio which is expected to result i the isured perso s death withi six moths ad from which the isured perso is ot expected to recover. You are eligible for this beefit after a waitig period of 180 cosecutive days. Accelerated death beefits are ot payable if the isured perso has made a absolute assigmet of his life isurace uder the group policy, all or part of the isured perso s life isurace uder the group is to be paid to his child(re) or former spouse as part of a court approved divorce agreemet, the isurace compay does ot receive writte coset by ay irrevocable beeficiary or the termial illess is a result of itetioal selfiflicted ijury or attempted suicide. Receipt of livig beefits may be taxable. Cosult your tax advisor for details. Reewable to age 75 As log as you make your premium paymets o time, the master policy remais i force, ad isurace does ot ed for your class, you ca reew your isurace up to age 75. Coversio privilege If isurace eds for a reaso other tha o-paymet of premium, you may buy a idividual life isurace policy from the compay durig the coversio period, without providig evidece of isurability. Optioal Coverages: Disability Waiver of Premium If you become totally disabled, as defied i the policy, before age 60, all premiums after ie cotiuous moths of disability will be waived ad your coverage will remai i force. Waiver of premium will ed o the date total disability eds, proof of total disability is ot give by you whe due, you are ot examied whe required, or you attai age 70. Accidetal Death Beefit If you die as a result of a covered o-job-related ijury caused by a accidet, a accidetal death beefit will be paid i additio to your full life isurace beefit amout. The amout of the accidetal death beefit will be the lesser of $500,000 or twice the amout of your full life isurace beefit amout. The accidet must happe while you are isured ad the loss must occur withi 90 days after the date of that accidet. Childre s Coverage You may isure your umarried, depedet childre age 14 days to 19 years (up to age 25, if a full-time studet). Childre age 14 days, but ot over 6 moths, are eligible for $500 of coverage. Childre 6 moths to age 25 are eligible for $5,000 of coverage (subject to state variatios). Depedet childre must ot be hospitalized o the date isurace is to take effect; otherwise isurace will take effect o the day after the isured is discharged. Oe $10.00 semi-aual premium covers all of your childre. Group Term Life Isurace Semi-Aual Premiums per $10,000 of Coverage Preferred Rates $50,000 $100,000 $250,000 Age $99,999 $249,999 $1,000,000 20 24 $ 1.80 $ 1.62 $ 1.62 25 29 2.40 2.16 2.16 30 34 5.28 4.14 3.90 35 39 7.62 6.06 4.80 40 44 12.30 7.02 5.70 45 49 18.72 11.46 8.88 50 54 29.82 16.98 14.88 55 59 45.66 23.28 22.08 60 64 88.32 49.68 48.72 65 69 152.10 94.38 91.86 70 74 290.16 184.68 181.14 Optioal Beefits Semi-Aual Premiums per $10,000 of Coverage Disability Waiver Accidetal of Premium Death Beefit** $50,000 $50,000 Age $1,000,000 $500,000 20 24 $.54 $.54 25 29.54 1.62 30 34.54 1.62 35 39 1.08 1.62 40 44 1.08 1.62 45 49 2.16 1.62 50 54 3.78 1.62 55 59 6.48 2.16 60 64 NA 3.24 65 69 NA 3.78 70 74 NA 3.78 ** Maximum $500,000 Accidetal Death Beefit. For smoker or super preferred rates, please call the pla admiistrator at 1-877-647-2242. Coverage termiates at age 75. A $3.00 admiistrative fee will be added to your premium bill. Decide Today to add importat fiacial security for those who deped o you. Applyig is easy Simply complete ad retur the applicatio to: ISMA Isurace Agecy 11555 N. Meridia Street, Ste. 220 Carmel, IN 46032 Call 1-877-647-2242 with ay questios, or if you would like assistace with your applicatio. 06673611-1671 R1/11
PLEASE REPLY TODAY! It takes just miutes to give you ad your family this solid life isurace protectio. Call 1-877-647-2242 if you have ay questios. Simply complete ad retur to: ISMA Isurace Agecy, 11555 N. Meridia Street, Ste. 220, Carmel, IN 46032 A medical exam is typically ot required for coverage amouts uder $250,000. APPLICATION FOR GROUP TERM LIFE INSURANCE Uderwritte by The Uited States Life Isurace Compay i the City of New York (Herei called the Compay) iformatio Please prit or type Name of Associatio Name First Middle Last Home Phoe No. ( ) Number Street City State ZIP Work Phoe No. ( ) E-mail Social Security Beeficiary Relatioship Name ad of s Physicia (Uless otherwise requested, your spouse, if livig, will be the beeficiary. Otherwise, your beeficiary will be your childre, parets, sibligs, or estate, i that order.) iformatio Please prit or type Name First Middle Last E-mail Social Security Beeficiary Relatioship Name ad of s Physicia (Uless otherwise requested, the member will be the beeficiary of ay spouse ad/or childre isurace applied for.) Check Life Isurace (Uless otherwise pla(s) requested, desired the member will be the beeficiary of ay spouse/domestic parter isurace applied for.) Life Isurace for : $ ($10,000 $1,000,000, i $5,000 icremets) Life Isurace for : $ ($10,000 $1,000,000, i $5,000 icremets) Life Isurace for Childre*: Yes No (Up to $1,000,000 of coverage is available. Umarried, depedet childre age 14 days to 19 years (25 if a full-time studet) are eligible for coverage. Childre age 14 days, but ot over 6 moths, are eligible for $500 ad childre 6 moths to age 25 are eligible for $5,000. Oe ecoomical premium covers all eligible depedet childre.) Check optioal (Uless Isurace otherwise beefit(s) requested, the desired member will be the beeficiary of ay spouse/domestic parter isurace applied for.) Waiver of Premium for AD&D Isurace for : $ Waiver of Premium for AD&D Isurace for : $ (The lesser of $500,000 or twice the amout of the life isurace beefit desired) Select your preferred (Uless otherwise paymet requested, modethe member will be the beeficiary of ay spouse/domestic parter isurace applied for.) I wish to pay: Semi-aually Aually Complete the followig for the applicat /member ad childre for whom coverage is requested Isured Name Age Child Child of Birth (MM/DD/YY) Place of Birth Height Weight ft. i. lbs. ft. i. lbs. ft. i. lbs. ft. i. lbs. Sex (M/F) G-19430 IN TL-ISMA Group Policy No. G-610,292 AG8313 (12/10) 06673611-1672 R1/11 * Coverage for childre is optioal. Applicat or spouse may apply for child coverage, but ot both. Please cotiue this applicatio o the reverse side MEDICAL INFORMATION BUREAU (MIB) DISCLOSURE NOTICE (Retai for your records) Iformatio regardig your isurability will be treated as cofidetial. The Uited States Life Isurace Compay i the City of New York or its reisurers may, however, make a brief report thereo to the MIB, Ic., formerly kow as Medical Iformatio Bureau, a ot-for-profit membership orgaizatio of isurace compaies, which operates a iformatio exchage o behalf of its members. If you apply to aother MIB member compay for life or health isurace coverage, or a claim for beefits is submitted to such a compay, MIB, upo request, will supply such compay with the iformatio about you i its file. Upo receipt of a request from you, MIB will arrage disclosure of ay iformatio i your file. Please cotact MIB at 866-692-6901 (TTY 866-346-3642). If you questio the accuracy of the iformatio i MIB s file, you may cotact MIB ad seek a correctio i accordace with the procedures set forth i the Federal Fair Credit Reportig Act. The address of MIB s iformatio office is 50 Braitree Hill Park, Suite 400, Braitree, Massachusetts 02184-8734. The Uited States Life Isurace Compay i the City of New York, or its reisurers, may also release iformatio from its file to other isurace compaies to whom you may apply for life or health isurace, or to whom a claim for beefits may be submitted. Iformatio for cosumers about MIB may be obtaied o its website at www.mib.com. Note: Caadia s should cotiue to use the followig address: 330 Uiversity Aveue, Suite 501, Toroto, Otario, Caada, M5G 1R7, tel. o. 416-597-0590.
Please aswer these brief questios 1. Has the applicat/member or spouse, if applyig, durig the past 5 years, ever had, bee diagosed with, or bee treated for: chest pai; disease or disorder of the heart, liver, kideys, blood or lugs; high blood pressure; stroke or other eurological disorder; metal/ervous disorder; drug or alcohol abuse; diabetes; cacer or tumor; Acquired Immue Deficiecy Sydrome (AIDS), AIDS Related Complex (ARC) or tested positive for a immue disorder? 2. Has the applicat/member or spouse, if applyig, durig the past 5 years, cosulted ay physicia or other practitioer or bee cofied or treated i ay hospital or similar istitutio, for ay reaso other tha those stated above? 3. Has the applicat/member or spouse, if applyig, used tobacco or icotie i ay form durig the past 12 moths? 4. Is the applicat/member or spouse, if applyig, ow takig prescriptio medicatio or receivig medical attetio? 1. YES NO 2. YES NO 3. YES NO 4. YES NO 1. YES NO 2. YES NO 3. YES NO 4. YES NO 5. Has the applicat/member or spouse, if applyig, ever had life or health isurace declied, modified or rated? 6. Is this isurace iteded to replace or modify ay isurace with this or ay other compay? 5. YES NO 5. YES NO 6. YES NO 6. YES NO For Yes aswers to questios 1-6 above, please provide details i the space provided below. If more space is eeded, use a separate sheet of paper, siged ad dated. If additioal iformatio is attached, check Yes i the box at the right. YES NO Questio Coditio Occurred Duratio Degree of Recovery Name ad of Physicias, Hospitals or Cliics Cosulted Existig ad pedig isurace sectio Life Isurace i Force ad/or Pedig o Proposed Isured s Life, icludig Busiess Isurace: (If oe, check Noe.) Noe Name of Compay Type of Coverage Life Amout Year Issued Do you pla to replace this coverage? Yes No Please read the followig, the sig ad date below to apply AUTHORIZATION AND DECLARATION OF EACH PERSON GIVING A STATEMENT OF INSURABILITY: I hereby authorize ay licesed physicia, medical practitioer, pharmacy, pharmacy beefit maager ad other sources, hospital, cliic, or other medical or medically related facility, isurace compay, the Medical Iformatio Bureau, or other orgaizatio, istitutio or perso that has ay records or kowledge of me or my health, to give to The Uited States Life Isurace Compay i the City of New York or its reisurers ay such iformatio. Such iformatio will pertai to my employmet, or other isurace coverage ad medical care, advice, treatmet or supplies for ay physical or metal coditio. This icludes iformatio obtaied i coectio with the preparatio or procuremet of a ivestigative cosumer report as defied uder the Fair Credit Reportig Act(s). To facilitate the rapid submissio of such iformatio, I authorize all said sources, except the Medical Iformatio Bureau, to give such records or kowledge to ay agecy employed by the Compay to collect ad trasmit such iformatio. I uderstad that this iformatio will be used by the Compay solely to determie eligibility for isurace. I uderstad that I may revoke this authorizatio at aytime by givig writte otice to the Compay. I agree that such revocatio will ot affect ay actio that ay source has take i reliace upo this authorizatio. I uderstad this authorizatio will be valid for 24 moths from the effective date of coverage, if ot revoked earlier. I kow that I should retai a copy of this authorizatio for my records. I agree that a photocopy of this authorizatio is as valid as the origial. To the best of my kowledge ad belief, all statemets made above are true ad complete. I uderstad that my applicatio for group isurace will be accepted or declied o the basis of these statemets. Isurace will take effect oly if a certificate is issued based o this applicatio ad the first premium is paid i full (a) durig the lifetime of all proposed isureds; ad (b) while there is o chage i the isurability or health of such perso from that stated i the applicatio. *Depedet Child must be umarried, age 14 days to 25 years of age. All depedets must be depedet i accordace with IRS guidelies. IMPORTANT NOTICE Ay perso who kowigly ad with itet to defraud ay isurace compay or other perso files a statemet of claim cotaiig ay materially false iformatio, or coceals for the purpose of misleadig, iformatio cocerig ay fact material thereto, commits a fraudulet isurace act, which may be a crime. s Sigature / / s Sigature / / G-19430 IN TL-ISMA Group Policy No. G-610,292 AG8313 (12/10) 06673611-1672 R1/11 PLEASE REPLY TODAY! It takes just miutes to give you ad your family this solid life isurace protectio. A medical exam is typically ot required for coverage amouts uder $250,000. Sed No Moey Now! We ll sed you a premium otice upo approval. Complete the applicatio ad retur to: ISMA Isurace Agecy, 11555 N. Meridia Street, Ste. 220, Carmel, IN 46032 Questios? Call 1-877-647-2242 NOTICE AS REQUIRED UNDER THE FAIR CREDIT REPORTING ACT(s) This is to iform you that as part of our procedure for processig your isurace applicatio, a ivestigative cosumer report may be requested for the preparatio of a report whereby iformatio is obtaied through persoal iterviews with your eighbors, frieds or others with whom you are acquaited or who may have kowledge of ay such items of iformatio. This iquiry icludes iformatio as to your character, geeral reputatio, persoal characteristics, ad mode of livig. You have the right to make a writte request to be iformed as to whether or ot such a cosumer report was requested, ad if such report was requested, the ame ad address of the cosumer reportig agecy to whom the request was made. You may receive a copy of this report by cotactig such agecy.