a. Initial Member Insurance Amount: $ Initial Spouse* Insurance Amount: $ Initial Child Insurance Amount: ($10,000 each eligible child): G Note: Membe

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1 Request for Group Insurance From: New York Life Insurance Company 51 Madison Ave.. New York, NY To Apply: Complete This Form And Return To: ADMINISTRATOR AAAS GROUP INSURANCE PROGRAM P.O. Box Des Moines, IA For residents of PR, the address is: Global Insurance Agency, Inc. P.O. Box San Juan, PR QUESTIONS? Call: 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: Add 1: Add 2: City, St., Zip: Last First MI Are you presently insured under any Engineering Associations Insurance Trust (of which AAAS 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 Association for The Advancement of Science? G Yes G No Membership # Exp. Date (Membership in AAAS is required for participation in this plan.) G OPTION 1: ELECTRONIC FUNDS TRANSFER (EFT): I request and authorize the AAAS 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 GMA-PR /40057/ 1018/

2 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. 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 d. 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 All 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 * * G GMA-PR

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9 For American Association for The Advancement of Science 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 Association for The Advancement of Science has proven just that. American Association for The Advancement of Science 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 AAAS is a participant), may not exceed the maximum benefit option for any insured person

10 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 AAAS, (c) AAAS 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, 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. * *

11 Before you request coverage, you must be a member in good standing with AAAS. Please wait until your application for membership is accepted before initiating an insurance request. If you have any questions regarding membership, please contact AAAS directly. If you have questions about your eligibility or the features of this Plan, call a Customer Service Representative toll-free at This Group Term Life Insurance Plan Is Administered By: Marsh U.S. Consumer, a service of Seabury & Smith, Inc. AAAS Group Insurance Program PO Box Des Moines, IA AR Ins. Lic. # CA Ins. Lic. # 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. This Group Term Life Insurance Plan Is Underwritten By: 2. Make out your check for the total premium contribution due, payable to: Administrator, AAAS Group Insurance Program. If you choose the convenient Electronic Funds Transfer (EFT) Option, be sure to include a voided check in addition to the check for the first payment due. If your state of residence mandates recognition of a Domestic Partner as an eligible spouse, contact the Administrator for a Declaration of Domestic Partnership form or go to to download the form. IMPORTANT TAX INFORMATION FOR RESIDENTS OF MANITOBA AND ONTARIO, CANADA: Manitoba and Ontario, Canada have enacted laws requiring taxation of all group insurance purchased by individuals: 7% for Manitoba and 8% for Ontario. The applicable 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 AAAS Group Insurance Program PO Box Des Moines, IA Residents Of Puerto Rico: Please send your completed application and check for the initial premium contribution to: Global Insurance Agency, Inc. P.O. Box San Juan, PR New York Life Insurance Company 51 Madison Avenue New York, NY under Group Policy No. G on Policy Form GMR-FACE/G The Engineering Associations Insurance Trust incurs costs in connection with this sponsored plan. To provide and maintain this valuable membership benefit, it is reimbursed for these costs. AAAS may also receive a fee for the license of its name and logo for use in connection with this Plan

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a. Initial Member Insurance Amount: $ Initial Spouse* Insurance Amount: $ Initial Child Insurance Amount: ($10,000 each eligible child): G Note: Membe

a. Initial Member Insurance Amount: $ Initial Spouse* Insurance Amount: $ Initial Child Insurance Amount: ($10,000 each eligible child): G Note: Membe epsmoore_awwa-40054-lifeinsurance Request for Group Insurance From: New York Life Insurance Company 51 Madison Ave.. New York, NY 10010 To Apply: Complete This Form And Return To: ADMINISTRATOR AWWA GROUP