To Apply: Complete This Form And Return To:
ADMINISTRATOR
.
AEA GROUP INSURANCE PROGRAM
P.O. Box 10374 Des Moines, IA 50306-0374
For residents of PR, the address is:
Request for Group Insurance From:
.
New York Life Insurance Company
51 Madison Ave. New York, NY 10010
.
Global Insurance Agency, Inc.
P.O. Box 9023918 San Juan, PR 00902-3918
QUESTIONS? Call: 1-800-424-9883
customerservice@marshpm.com
GROUP TERM LIFE INSURANCE APPLICATION
FOR MEMBERS OF ORGANIZATIONS PARTICIPATING IN THE
ENGINEERING ASSOCIATIONS INSURANCE TRUST
PLEASE PRINT IN INK OR TYPE ALL ANSWERS. DO NOT USE CORRECTION FLUID OR GEL PENS. INITIAL AND DATE ANY CHANGES YOU MAKE.
Name:
Last First MI
Add 1:
Add 2:
City, St., Zip:
Are you presently insured under any Engineering Associations Insurance Trust (of which AEA is a participant) Group
Life Insurance Plans? G Yes G No
If "yes," indicate which Plan(s) and provide details (person insured and amount of insurance):
G Term Life G 10-Year Level Term Life
Details: ______________________________________________________
(Person insured and amount of insurance)
Are you now a member of the American Economic Association? G Yes G No
Membership # ____________ Exp. Date ________
(Membership in AEA is required for participation in this plan.)
G OPTION 1: ELECTRONIC FUNDS TRANSFER (EFT): I request and authorize the AEA Group Insurance
Program to make G monthly G semiannual G annual withdrawals against the account specified on the attached
voided check 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.)
_X____________________________________________________
SIGNATURE(S) AS REQUIRED ON CHECKS ISSUED AGAINST THIS ACCOUNT DATE
G OPTION 2: PERIODIC BILLING: G Semiannual (April 1 and October 1) G Annual
* Select Annual Billing or EFT to avoid $2.00 billing fee.
G-9400-1
GMA-PR1 40054/40064/ 1018/48756
0000141-0000001-0000164
a.Initial Member Insurance Amount: $________ Initial Spouse* Insurance Amount: $________
Initial Child Insurance Amount: ($10,000 each eligible child): G
Note: Member coverage must be in force to request dependent coverage.
b.Increase Member Insurance Amount from $________ to $________
Increase Spouse* Insurance Amount from $________ to $________
*Spouse coverage cannot exceed 100% of Member's coverage.
c. INSURANCE REPLACEMENT:
Residents of New York - IMPORTANT REPLACEMENT INFORMATION: 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 paid-up
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.
Residents of New York: 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?
Member: G Yes G No Spouse: G Yes G No
Residents of Other States:
Is the insurance applied for intended to replace, discontinue or change an existing policy?
Member: G Yes G No Spouse: G Yes G No
All Residents:
Do you have other life insurance in force? If "yes," total amount in all companies:
Member: $_______ Spouse: $________
Do you have other insurance applications pending? If "yes," indicate amount and company:
Member: $_______ Company ___________ Spouse: $_______ Company ___________
*00700501000*
G-9400-1
GMA-PR1
0000142-0000002-0000164
G-9400-1
GMA-PR1
0000143-0000003-0000164
*00710502000*
G-9400-1
GMA-PR1
0000144-0000004-0000164
#
0000145-0000005-0000164
THIS PAGE IS INTENTIONALLY LEFT BLANK.
*00720503000*
0000146-0000006-0000164
For American Economic Association Members and Their Families
But the simple fact is, life insurance doesn't have to be
expensive. The economical Group Term Life Insurance Plan
designed for and available to members of the American
Economic Association has proven just that.
American Economic Association members under age 70 are
eligible to apply for coverage for themselves, their lawful
spouses and unmarried dependent children ages 14 days
through 22 years (24 if a full-time student). In order to become
insured, satisfactory evidence of insurability must be provided
and the required premium contribution must be paid.
In addition, the total amount of coverage for a member
insured by more than one group policy - or more than one
organization participating in such a group policy - issued by
New York Life Insurance Company to the Trustee of the
Engineering Associations Insurance Trust, (of which AEA is a
participant), may not exceed the maximum benefit option for
any insured person.
0000147-0000007-0000164
Insurance for you can remain in force to age 80, and for your
insured dependents as long as they remain otherwise eligible,
provided: (a) you continue to pay premium contributions
when due; (b) you remain a member of AEA, (c) AEA
continues to be a participating organization; and (d) the group
plan is not terminated or modified by the Policyholder or
New York Life Insurance Company to end insurance for the
group of insureds to which you belong. Upon your death,
*00730504000*
coverage for insured dependents may continue as described in
the Certificate of Insurance.
Group Conversion Privilege
The Plan provides conversion privileges under certain
circumstances of involuntary termination as described in the
Certificate of Insurance.
0000148-0000008-0000164
If you have questions about your eligibility or the features of
this Plan, call a Customer Service Representative toll-free at
1-800-424-9883.
Before you request coverage, you must be a member in good
standing with AEA. Please wait until your application for This Group Term Life Insurance Plan Is Administered By:
membership is accepted before initiating an insurance
request. If you have any questions regarding membership,
please contact AEA directly.
Administrator
AEA Group Insurance Program
PO Box 10374
Des Moines, IA 50306-0374
1-800-424-9883
http://www.insurancetrustsite.com/aea
AR Ins. Lic. #245544
CA Ins. Lic. #0633005
d/b/a in CA Seabury & Smith Insurance Program Management
This coverage is available to residents of Canada through Marsh
Canada Limited.
Stephen Fretwell, an employee of Marsh Canada Limited, acts
as broker with respect to residents of Canada.
Marsh U.S. Consumer, a Service of Seabury & Smith, Inc.,
receives compensation in the form of a percentage of the
premium for services provided for this program. These services
may include application processing, on-going servicing, billing,
marketing, brokerage, claims administrative and
communications. If you are interested in obtaining the specific
compensation Marsh U.S. Consumer received for this program
please call us at 1-888-206-5088.
This Group Term Life Insurance Plan Is Underwritten By:
New York Life Insurance Company
51 Madison Avenue
2. Make out your check for the total premium contribution New York, NY 10010
due, payable to: Administrator, AEA Group Insurance under Group Policy No. G-9400-1
Program. on Policy Form GMR-FACE/G-9400-1
If you choose the convenient Electronic Funds Transfer The Engineering Associations Insurance Trust incurs costs in
(EFT) Option, be sure to include a voided check in connection with this sponsored plan. To provide and maintain
addition to the check for the first payment due. this valuable membership benefit, it is reimbursed for these
If your state of residence mandates recognition of a Domestic costs. AEA may also receive a fee for the license of its name
Partner as an eligible spouse, contact the Administrator for a and logo for use in connection with this Plan.
Declaration of Domestic Partnership form.
IMPORTANT TAX INFORMATION FOR RESIDENTS OF
ONTARIO, CANADA: Ontario has enacted a law requiring
taxation of all group insurance purchased by individuals.
An 8% tax will be added to the amount of any premium
contributions due (in U.S. dollars).
3. Mail the completed application with your check to:
Administrator
AEA Group Insurance Program
PO Box 10374
Des Moines, IA 50306-0374
Residents Of Puerto Rico:
Please send your completed application and check for the
initial premium contribution to:
Global Insurance Agency, Inc.
P.O. Box 9023918
San Juan, PR 00902-3918
0000149-0000009-0000164
*00740505000*
0000150-0000010-0000164