G Option 1: Electronic Funds Transfer (EFT): I request and authorize the American Society for Information Science and Technology Group Insurance Progr
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1 epsmoore_asist disability TO APPLY: Complete this form and return with your premium check to: ADMINISTRATOR ASIS&T 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 Request for Group Insurance From: New York Life Insurance Company 51 Madison Ave. l New York, NY QUESTIONS? Call: ASIS@marshpm.com Name: Add 1: Add 2: City, St., Zip: Last First MI a. Are you now a Member of American Society for Information Science and Technology? G Yes G No (Membership in ASIS&T is required for participation in the Plan.) G GPA-DI-FMU 45065/45088/ 1018/
2 G Option 1: Electronic Funds Transfer (EFT): I request and authorize the American Society for Information Science and Technology Group Insurance Program, Inc. to make G quarterly 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 Disability Income Insurance Plan. (Enclose a VOIDED check.) G * * GPA-DI-FMU
3 G GPA-DI-FMU
4 G * * GPA-DI-FMU
5 For American Society for Information Science and Technology Members Underwritten by New York Life Insurance Company Your most important asset is your ability to earn income. Even if you are young and healthy, a serious illness or injury could put you out of work for months or even years - thus jeopardizing your livelihood. A reliable source of disability income protection is this Group Disability Income Insurance Plan for ASIS&T members. American Society for Information Science and Technology members under age 65 who are at FULL-TIME WORK are eligible to request coverage, provided their gross annual income is at least $20,000. (Student members are not eligible unless working full-time.) Important Notice for Self-Employed Members: Please be advised that if you are applying for this Plan and you have been self-employed for less than one year, coverage is limited to a $1,100 Principal Monthly Benefit Option, with a 90-day waiting period under the Five-Year Plan (without the Catastrophic Disability Option). If you have any questions or would like additional information, please call the Plan Administrator at
6 Once your coverage is validly in force, it may be continued to the premium due date on or immediately after you reach age 70, unless: you cease FULL-TIME WORK other than for reasons of disability, you cease to be a ASIS&T member, ASIS&T ceases to be a participating organization, you fail to pay premium contributions when due, you enter full-time active duty in the armed forces (coverage may be restored upon termination of active duty status, subject to policy guidelines) or the group plan is modified or terminated by the policyholder or New York Life Insurance Company to end insurance on the group of insureds to which you belong. * *
7
8 Before you request coverage, you must be a member in good standing of ASIS&T. Please wait until your application for membership is accepted before initiating your insurance requests. If you have any questions regarding membership, contact ASIS&T directly. 1. Refer to the Plan description for benefits and premium cost as you fill out the application. Remember, only ASIS&T members (as described under Who Is Elegible) may apply. 2. Make out your check for the total amount of premium due payable to: Administrator, ASIS&T Group Insurance Program. (Also, be sure to include a voided check, if you select the Electronic Funds Transfer (EFT) Option.) Administrator ASIS&T Group Insurance Program PO BOX Des Moines, IA (Residents of Puerto Rico, please see instructions below.) RESIDENTS OF PUERTO RICO: Please send the application and premium contribution (with your check payable to "Administrator, Group Insurance Program") to: Global Insurance Agency, Inc. P.O. Box San Juan, PR * *
9 This Plan is Underwritten By: New York Life Insurance Company 51 Madison Avenue New York, NY under Group Policy No. G on Policy Form G /GMR-FACE This Plan is Administered By: ASIS&T Group Insurance Program P.O. Box Des Moines, IA Telephone Toll-Free: AR Ins. Lic. # CA License # 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. Questions? We're Only a Phone Call Away If you have questions about your eligibility, what the Plan covers or how to complete the application, just give us a call toll-free at between 7:30 AM and 6:00 PM, Monday through Friday, CST, or you can us at ASIS@marshpm.com. One of our service representatives will be able to immediately provide you with the information you need. The Engineering and Scientific Association Accident and Health Insurance Trust incurs costs in connection with this sponsored plan. To provide and maintain this valuable membership benefit, it is reimbursed for these costs. ASIS&T may also receive a fee for the license of its name and logo for use in connection with the Plan /09 DI113P-ESAHT
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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
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
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_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
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
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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
IEEE BENEFIT ENROLLMENT FORM IEEE Group Accidental Death & Dismemberment Insurance Plan
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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
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
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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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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
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