I request and authorize the AAA Group Insurance Program, G * * GMA-GI
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1 epsmoore_aaa-mn accidentaldeathanddismemberment To Apply: Complete this form and return to: ADMINISTRATOR AAA GROUP INSURANCE PROGRAM P.O. BOX Des Moines, IA For Puerto Rico Residents, the address is: Global Insurance Agency, Inc. P.O. Box San Juan, PR QUESTIONS? CALL: Request for Group Insurance From: New York Life Insurance Company l 51 Madison Ave. l New York, NY Name: Add 1: Add 2: City, St., Zip: Last First MI Are you presently insured under any Engineering and Scientific Associations Accident and Health Insurance Trust (of which AAA is a participant) Group High-Limit Accident Insurance Plans? G Yes G No Are you now a member of the American Anthropological Association? G Yes G No (Membership in the AAA is required for participation in this Plan.) G GMA-GI 28018/28019/ 1018/
2 I request and authorize the AAA Group Insurance Program, G * * GMA-GI
3 G GMA-GI
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7 For American Anthropological Association 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 High-Limit Accident 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 American Anthropological Association under age 70, you are eligible to apply for coverage for yourself, your lawful spouse under age 70, and unmarried dependent children under age 25. To become insured, an application must be submitted and the required premium contribution must be paid
8 Your insurance remains in force unless you cease to be an AAA member, AAA ceases to be a participating organization, you fail to pay premium contributions when due, the person enters full-time active duty in the Armed Forces or the Plan is terminated or modified by the Policyholder or New York Life Insurance Company to end insurance for the group of insureds to which you belong. Dependent coverage will also terminate when member coverage terminates or when the dependent ceases to be a lawful spouse or eligible dependent child. A member's surviving spouse and children may continue coverage if it was in force at the time of the member's death as described in the Certificate of Insurance. * *
9 This Group High-Limit Accident Insurance Plan is Underwritten by: New York Life Insurance Company 51 Madison Avenue New York, NY under Group Policy No. G on Policy Form GMR-FACE/G This Group High-Limit Accident Insurance Plan is Administered by: Consider Your Eligibility Before you request for coverage, you must be a member in good standing of AAA Please wait until your application for membership is accepted before initiating insurance. If you have any questions regarding membership, please contact AAA directly. 1. Select your Principal Sum and read the rate chart to find the premium for each individual to be covered under the amount of coverage desired. 2. Complete, sign and date the Application. 3. Make your premium check payable to: Administrator, AAA Group Insurance Program 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). 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. 4. Mail the Application together with your check to: Administrator AAA Group Insurance Program P.O. Box Des Moines, IA Residents of Puerto Rico: Please send your completed application and check for the initial contribution to: Global Insurance Agency, Inc. P.O. Box San Juan, PR AAA Group Insurance Program P.O. Box Des Moines, IA Telephone: 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. The Engineering and Scientific Associations 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. AAA may also receive a fee for the license of its name and logo for use in connection with this Plan
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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
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
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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,
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