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1 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 Funds Transfer (EFT) as a secure payment option. PGA Member Number: I request and authorize the PGA-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. The death benefit will be paid in the following order of survival: Spouse, children equally, parents equally, brothers and sisters equally or to the owner's estate. An alternative beneficiary(ies) can be designated by contacting the Plan Administrator at I hereby enroll with New York Life Insurance Company of New York, New York, for coverage under the PGA 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 PGA Copyright 2017 Mercer LLC. All rights reserved. New York Life Insurance Company 51 Madison Avenue, New York, NY EnFr /47594/ 1018/
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3 For PGA 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 PGA 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 PGA 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. This coverage is available to residents of the United States (except FL, NC, OR, SD, VT, WA and territories) and Puerto Rico
4 If applicable, an additional $2 billing fee will be included on your billing notice payable to the administrator. To save the fee, select Electronic Funds Transfer (EFT) as a safe and secure payment option. The premium contributions shown reflect the current rate and benefit structure. Premium contributions may be changed by New York Life Insurance Company on any premium due date and any date on which benefits are changed. However, your rates may change only if they are changed for all others in the same class of insureds. For example, a class of insureds is a group of people all with the same issue age. Benefit option amounts are not guaranteed and are subject to change by agreement between New York Life Insurance Company and the Trustee of the Preferred Group Trust. * *
5 for a Beneficiary Form.!
6 Before you request for coverage, you must be a member in good standing of PGA. If you have any questions regarding membership, please contact PGA directly. This Group Accidental Death & Dismemberment Insurance Plan is Underwritten by: Administrator, PGA Group Insurance Program P.O. Box Des Moines, IA (Residents of Puerto Rico, please see instructions below.) 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: 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. HOW TO FILE A CLAIM To file a claim, write the Administrator for claim forms or call Mercer Consumer, a service of Mercer Health & Benefits Administration LLC PGA Group Insurance Program P.O. Box Des Moines, IA AR Insurance License # CA Insurance License #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC The PGA incurs certain costs in connection with this group plan. To provide and maintain this valuable membership benefit, it is reimbursed for these costs. PGA also receives a fee for the license of its name and logo for use in connection with the Plan. Copyright 2017 Mercer LLC. All rights reserved. AD113P /17 ed * * "
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
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
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,
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
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
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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
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?
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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: NARFE GROUP INSURANCE PROGRAM
3. Please read, sign and date: To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever receive
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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: ASME GROUP INSURANCE PROGRAM
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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
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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
Norfolk Public Schools Norfolk, NE. All Other Employees
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