AAA BENEFIT ENROLLMENT FORM AAA Group Accidental Death & Dismemberment Insurance Plan Name: Add 1: Add 2: City, St., Zip: Last First MI After the firs
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1 AAA BENEFIT ENROLLMENT FORM AAA Group Accidental Death & Dismemberment Insurance Plan Name: Add 1: Add 2: City, St., Zip: Last First MI After the first billing, to avoid future billing fees, select Electronic Funds Transfer (EFT) as a secure payment option. AAA Member Number: I request and authorize the AAA-endorsed Group Insurance Programs, Inc. to make quarterly 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 Accidental Death & Dismemberment Insurance Plan. (Enclose a voided check.) G OPTION 2: PERIODIC BILLING: Semianually, Select Electronic Funds Transfer to save the $2.00 billing fee. I hereby enroll with New York Life Insurance Company of New York, New York, for coverage under the AAA Group Accidental Death and Dismemberment Plan. I have read and understand the conditions and exclusions of the program. I understand my coverage will become effective upon the first day of the month following the administrator's receipt of this enrollment form and my premium payment. Administrator, Group Insurance Program, P.O. Box 10374, Des Moines, IA For residents of Puerto Rico, the address is: Global Insurance Agency, Inc., P.O. Box , San Juan, PR Group Policy Number - G AAA œseabury & Smith, Inc New York Life Insurance Company 51 Madison Avenue, New York, NY EnFr /47715/ 1018/
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3 For AAA Members and Their Families Accidents. Television and newspapers report them every day. But what if one happened to you? Would your family have the financial resources to survive the crisis? If you travel a great deal in your work... or if you are subject to possible injury on the job... you may need the AAA Group Accidental Death & Dismemberment Insurance Plan. It helps protect you and your insured family members by providing accident protection that covers you year round... anywhere in the world. As a member of AAA under age 70, you are eligible to apply for coverage for yourself, your lawful spouse under age 70, and unmarried dependent children under age 19 (26 if a full-time student). To become insured, completed Form must be submitted and the required premium contribution must be paid when billed
4 All billing modes except annual will include a $2.00 billing fee. To avoid future billing fees, select EFT (a safe and secure payment option). * *
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6 Before you request for coverage, you must be a member in good standing of AAA. If you have any questions regarding membership, please contact AAA directly. This Group Accidental Death & Dismemberment Insurance Plan is Underwritten by: Administrator, AAA Group Insurance Program P.O. Box Des Moines, IA (Residents of Puerto Rico, please see instructions below.) Residents of Puerto Rico: Please send your completed Form to: Global Insurance Agency, Inc. P.O. Box San Juan, PR 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. New York Life Insurance Company 51 Madison Avenue New York, NY under Group Policy No. G on Policy Form GMR-FACE/G This Group Accidental Death & Dismemberment Insurance Plan is Administered by: AAA Group Insurance Program P.O. 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. To file a claim, write the Administrator for claim forms or call 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 or view the transparency disclaimer on the AD113P /11 ed * * "
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PGA BENEFIT ENROLLMENT FORM PGA Group Accidental Death & Dismemberment Insurance Plan Name: Add 1: Add 2: City, St., Zip: Last First MI After the first billing, to avoid future billing fees, select Electronic
I request and authorize the AAA Group Insurance Program, G * * GMA-GI
epsmoore_aaa-mn-28018-accidentaldeathanddismemberment To Apply: Complete this form and return to: ADMINISTRATOR AAA GROUP INSURANCE PROGRAM P.O. BOX 10374. Des Moines, IA 50306-0374 For Puerto Rico Residents,
a. Initial Member Insurance Amount: $ Initial Spouse* Insurance Amount: $ Initial Child Insurance Amount: ($10,000 each eligible child): G Note: Membe
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 AAAS GROUP INSURANCE PROGRAM P.O. Box 10374.
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
a. Initial Member Insurance Amount: $ Initial Spouse* Insurance Amount: $ Initial Child Insurance Amount: ($10,000 each eligible child): G Note: Membe
epsmoore_aatcc-mn-40054-grouptermlifeinsurnaceplan 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
G Option 1: Electronic Funds Transfer (EFT): I request and authorize the American Society for Information Science and Technology Group Insurance Progr
epsmoore_asist-45065-disability TO APPLY: Complete this form and return with your premium check to: ADMINISTRATOR ASIS&T GROUP INSURANCE PROGRAM P.O. BOX 10374. Des Moines, IA 50306-0374 For residents
IEEE BENEFIT ENROLLMENT FORM IEEE Group Accidental Death & Dismemberment Insurance Plan
IEEE BENEFIT ENROLLMENT FORM IEEE Group Accidental Death & Dismemberment Insurance Plan E Name: Last First MI Add 1: Add 2: City, St., Zip: PLEASE SEND NO MONEY Mail your completed Form in the enclosed
Office of the Administrator. P.O. Box Des Moines, IA
Office of the Administrator P.O. Box 14464 Des Moines, IA 50306-8993 Dear AFSA Member, Thank you for inquiring about the Air Force Sergeants Association Group Insurance Program. Enclosed you'll find the
I understand that the insurance applied for will take effect on the date specified by The United States Life Insurance Company in the City of New York
epsmoore_aao-33015-catastrophemajormedical American Academy of Ophthalmology Please print or type all information requested. NOTE: If you have previously applied for insurance, a copy of that application
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Endorsed by: National Active and Retired Federal Employees Association Name: Add 1: Add 2: City, St., Zip: Last First MI TO ENROLL: Send this completed form with your premium check payable to: ADMINISTRATOR
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imfmoore_mda-ca-groupdisabilityincome Office of the Administrator P.O. BOX 14464 Des Moines, IA 50306-9468 Dear, Thank you for inquiring about the Minnesota Dental Association Group Insurance Program.
RATE AND BILLING OPTIONS - Please check one: Please select the type of coverage you would like. Enclose a check for the rate selected and mail it with
American Speech-Language-Hearing Association GROUP DENTAL INSURANCE PLAN ENROLLMENT FORM The United States Life Insurance Company in the City of New York TO ENROLL: Send this completed form with your Premium
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epsmoore_aaa-40471-shorttermrecovery-over65 For Members of AAA GUARANTEED ACCEPTANCE AGP-5382 TO ENROLL: Send this completed form to: ADMINISTRATOR AAA GROUP INSURANCE PROGRAM P.O. BOX 10374 Des Moines,
To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever received treatment or been medically a
Endorsed by: American Association of Textile Chemists & Colorists CANCER INSURANCE PLAN APPLICATION FOR RESIDENTS OF WISCONSIN ONLY PLEASE PRINT IN INK OR TYPE. DO NOT USE CORRECTION FLUID OR GEL PENS.
TERM LIFE INSURANCE PLAN ENROLLMENT FORM
FOR MEMBERS OF THE THE ARC TERM LIFE INSURANCE PLAN ENROLLMENT FORM E TO ENROLL: Send this completed form to: ADMINISTRATOR The Arc GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS?
To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever received treatment or been medically a
Endorsed by: American Association of Textile Chemists & Colorists CANCER INSURANCE PLAN APPLICATION FOR RESIDENTS OF KANSAS ONLY PLEASE PRINT IN INK OR TYPE. DO NOT USE CORRECTION FLUID OR GEL PENS. INITIAL
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Academy of Nutrition and Dietetics GROUP HOSPITAL INCOME INSURANCE PLAN ENROLLMENT FORM AGP-5177 E (Please make any corrections to your full name and address printed below.) TO ENROLL: Send this completed
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HOSPITAL INCOME AND SHORT TERM RECOVERY INSURANCE PLAN CONFIRMATION FORM For Members of the AAA GUARANTEED ACCEPTANCE AGP-5476 SEND NO MONEY NOW! TO ENROLL: Send this completed form to: ADMINISTRATOR AAA
Covers accidents world wide, 24 hours per day, 365 days per year, on or off the job.
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Spouse/Domestic Partner's Name: (First, Middle Initial, Last), if applying Spouse/Domestic Partner's Occupation: Basic Monthly Pay: $ Section 4 COVERA
For Members of the American Dental Hygienists' Association TO APPLY: 1. Complete and sign the application. 2. Send no money with your application. You will be billed upon approval. 3. Use the postage paid
RATE AND BILLING OPTIONS - Please check one: Please select the type of coverage you would like. Enclose a check for the rate selected and mail it with
Federal Bar Association GROUP DENTAL INSURANCE PLAN ENROLLMENT FORM The United States Life Insurance Company in the City of New York TO ENROLL: Send this completed form with your Premium check payable
Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with you
Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with your premium check payable to: NARFE GROUP INSURANCE PROGRAM
RATE AND BILLING OPTIONS - Please check one: Please select the type of coverage you would like. Enclose a check for the rate selected and mail it with
American Society of Agricultural and Biological Engineers DISCOUNT DENTAL PLAN ENROLLMENT FORM The United States Life Insurance Company in the City of New York TO ENROLL: Send this completed form with
Section 5 MEMBER SPOUSE In the last 2 years have you or your Spouse been unable to perform the full-time duties of your occupation for 10 consecutive
HARTFORD LIFE INSURANCE COMPANY Hartford, Connecticut 06155 National Active and Retired Federal Employees Association AGL-1545 Spouse's Name: (First, Middle Initial, Last), if applying Section 4 Amount
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Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever had, been diagnosed with, or been treated
To Apply: Send this completed form with your premium check payable to: ADMINISTRATOR SPJ GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS? 1-800-503-9230 customerservice.service@mercer.com
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Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with your premium check payable to: AAA GROUP INSURANCE PROGRAM
Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with you
Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with your premium check payable to: NARFE GROUP INSURANCE PROGRAM
Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever been diagnosed with, or been treated for:
To Apply: Send this completed form with your premium check payable to: ADMINISTRATOR SPJ GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS? 1-800-503-9230 customerservice.service@mercer.com
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