NEW FROM YOUR AC A D E M Y
G UARANTEED
LEVEL PREMIUM
LIFE INSURANCE
As an Academy member
age 50 through 59, you can
apply for up to $1 million of
life insurance at preferred rates.
Coverage is available for your spouse, too.
Guaranteed Level Premium Group Term Life Insurance o f fers simplicity, c o m p e t i t i ve pre fe rred rates for non-tobacco users in excellent health, a level death benefit and level premium contributions. Once coverage is issued,
your rates are guaranteed not to incre a s e.
Congratulations!
A ge has its benefits.
Jack, a family physician, had always slept well. He said it was because he had peace of mind. He and Velma had been married for more than 40 years when Jack died.
Velma expected her standard of living to decline significantly.
Fortunately, Jack had $750,000 of life insurance. Today, Velma continues to live comfortably, supplementing her Social Security and teacher’s retirement pension with earnings from Jack’s life insurance proceeds. These days, she sleeps well, thanks to what she calls her $750,000 security blanket. (This narrative is for illustration purposes onl y.)
“The last thing I need is life insurance.”
That’s the view of many men and women over age
50.Their family responsibilities are on the decline.
Plus, between Social Security, pension benefits and
a tidy nest egg that’s nearly ready to hatch, their
financial picture probably looks comfortable.
But, too often, life insurance needs don’t end;
they simply change.
As you get older, life insurance continues to be
a valuable tool. Here are just some of the ways
it can benefit your family:
• It can help cover the cost of children’s
college and graduate school educations,
or enable you to help establish an education fund
for grandchildren.
• It can help guarantee the
financial security of your spouse
by providing a nest egg
to supplement retirement income
from pensions, Social Security and
other sources.
• It can help pay death taxes and probate
costs. Depending on the size of your estate, there
may be state and federal estate taxes. Regardless,
there will be costs involved in valuing and
distributing your estate.The result can be a loss
of assets to a surviving spouse or other heirs. Life
insurance can help counter that estate shrinkage.
• It can provide funds to help pay your final
expenses and prevent the need to liquidate assets
to cover medical and funeral costs, as well as
outstanding debts.At death, regardless of the size
of your estate, there will be settlement costs.
Life insurance can provide the cash to meet these
obligations.
WHY LIFE INSURANCE AT MY AG E ?
There’s no single, one-size-fits-all answer.
The amount that’s right for you will depend
on a number of variables.
At Jack’s death, Velma
received a check for
$750,000 from the
insurance company.
From that amount,
she paid nearly $50,000
to cover Jack’s final
expenses and $85,000
to retire the mortgage.
Another $65,000 went
to cover estate taxes,
and $50,000 went into
a trust for Velma and
Jack’s granddaughter
with special needs.
The remaining $500,000? That became Velma’s
“financial security blanket.” Between her own
pension, Social Security and other assets, she is
financially comfortable. She elected to use only
the earnings from the remaining $500,000 as a
supplement to her other retirement income.
She plans to use this money to make sure their
daughter gets the wedding of her dreams, help their
grandchildren with their education, create a
medical slush fund to fill the gaps in her own
Medicare benefits, and perhaps do a little traveling.
The principal goes to their children at her death.
How much can she expect? That depends on the
rates of return.
H OW MUCH DO YOU NEED?
Premise:The principal earns 5% after taxes; interest only is withdrawn each year; the principal remains intact for emergencies or eventual distribution to heirs.
Do you need life insurance at your age?
Many people do.That’s why your Academy
recommends that you review your needs and
consider life insurance as one of your options.
ANNUAL LIFE INSURANCE
INCOME NEEDED
$5,000
$100,000
$10,000
$200,000
$20,000
$400,000
$25,000
$500,000
$37,500
$750,000
$50,000
$1,000,000
The chart below shows one example of income
each amount of life insurance proceeds can
generate. Example: Based on the assumptions
provided, $500,000 in proceeds can provide
$25,000 a year in supplemental income,
leaving the principal untouched and earmarked
as an inheritance to be passed on to the
next generation.
KEY POLICY
Features
This is a level term policy to age 65,when coverage ends. During the term of coverage, rates will not increase.
You can apply for up to $1,000,000 in benefits in
multiples of $10,000 if you are an Academy member,
age 50 through 59, and reside in the United States
(excluding territories). Note:Your total coverage
under this plan and the Academy’s traditional life
insurance plan underwritten by New York Life
Insurance Company cannot exceed $1,000,000.
Coverage for your lawful spouse, age 50 through 59.
If approved, your spouse’s coverage will be issued as
part of your Certificate . Once issued, your spouse’s
insurance can remain in force even if you terminate
your AAFP membership, die, legally separate, divorce
or remarry.
Guaranteed level premiums and level death benefit.
Rates are based on your age on the date your
insurance becomes effective and are guaranteed
not to increase for the term of your coverage.
Your death benefit is guaranteed to remain level;
it won’t decrease as you get older.
You can continue coverage to age 65 by the payment
of required premiums. Coverage terminates at the
end of the renewal period on or following your 65th
birthday. If your spouse is also insured, your spouse’s
coverage can also continue to age 65, even if your
insurance ends earlier.
Affordable rates. Premium contributions shown
on the enclosed application folder are for the
most competitive rates for non-tobacco users in
excellent health. If you do not qualify for these
rates, you may qualify for this coverage at a
somewhat higher rate.
Volume discounts offer additional savings. AAFP
Insurance Services reviews and compares insurance
policies from the nation’s leading insurers to offer
Academy members outstanding protection at
cost-effective prices.To provide you even better value,
this AAFP policy includes a volume discount at
$250,000.That is because the cost to the insurer
of processing and issuing a small amount is the
same as that for a large amount.This enables you
to (a) request additional coverage for practically
no additional cost, and (b) reduce your overall rate
when you request $250,000 or more of coverage.
The volume discount applies to the full amount of
coverage, not just the amount over the discount
threshold.As a result, members and spouses receive
the best buy when requesting amounts of $250,000
or higher.
Example:The preferred annual premium
contribution (male, non-tobacco user, age 50)
for $210,000 of coverage is $760.20.The cost
for $250,000 is $770.The result is $40,000 of
additional protection for less than $10 a year.
Choice of premium mode. No billing fees.
The rate shown is the total amount you pay.
You can make your premium contribution annually,
semi-annually or quarterly. No matter which
payment mode you select, you will not pay an
issuance fee or a billing service fee.
Proceeds can be paid under several distribution
options. At your death, your beneficiary can
receive proceeds in a lump sum or in a
Continued Interest Account option. Under this
option, proceeds of $10,000 or more are placed
in an interest-bearing checking account.While
your family evaluates their future financial plans
and takes the time necessary to adjust to the
emotional loss,the insurance proceeds are
guaranteed and accessible, earning interest
from the date of death.
There are no exclusions.
Benefits are paid for death from any cause, at any
time, anywhere in the world.The validity of any
amount of insurance that has been in force for
two years or more will not be contested except
for insurance eligibility provisions or non-payment
of premium contributions.
You and your spouse are eligible for living benefits
through the policy’s Accelerated Death Benefit
provision. If an insured is diagnosed as terminally
ill, with a life expectancy of 12 months or less, he
or she can request payment of 50% of the death
benefit while still alive.This request must be made
at least 12 months prior to the person’s coverage
termination age.The benefit payable at death will
be reduced by 50% and premium contributions
for the full amount will continue to be payable.
(This benefit is not available in Massachusetts.)Note: Receipt of this benefit may affect eligibility
for public assistance plans and may be taxable.
Prior to applying for this benefit, you should
consult the appropriate social services agency
and seek the advice of tax counsel.
New York Life cannot cancel the master policy
issued to the American Academy of Family
Physicians for any reason (other than non-payment
of premiums) as long as the Academy continues to
endorse this Plan and does not change its
sponsorship to another similar Plan.
Your protection is portable. It can continue without
penalty or loss even if you change employers,
change professions or terminate your AAFP
membership. Plus, your spouse’s insurance can
remain in force even if you terminate your AAFP
membership, die, legally separate, divorce or
remarry.
(See “When Insurance Ends” in the Certificate Of Insurance for details.)You can assign all or any part of your incidents
of ownership in this policy to any person or
legal entity.
Coverage effective date. If your (and your spouse’s)
coverage is approved by New York Life Insurance
Company, you will receive a premium notice with
your Certificate Of Insurance.Your effective date
of coverage will be the first day of the month
following approval, provided: (a) your initial
premium contribution is received within 31 days
after you are billed, and (b) any person to be
insured is performing the normal activities of a
person in good health of like age on that date
or the date you paid your premium contribution,
if later.
You have a 30-day free look at your coverage.
If you are not completely satisfied, you can return
the Certificate Of Insurance — without claim —
within 30 days.Your insurance will then be
invalidated and your premium contribution
refunded — no questions asked.
APPLY NOW
Fill out an easy-to-complete application.
Send no money now. If your coverage is
approved, you will be billed when your
Certificate Of Insurance is sent.
PLAN SPONSOR
American Academy of Family Physicians
11400 Tomahawk Creek Parkway
Leawood, KS 66211
UNDERWRITER
New York Life Insurance Company
51 Madison Avenue
New York, NY 10010
NAIC Number: 66915
Policy Form: GMR
Domiciled in the State of New York,
New York Life Insurance Company is
licensed/authorized to transact business in all of the 50 United
States, the District of Columbia and Puerto Rico. (If you live in
Puerto Rico, please contact AAFP/IS for special instructions about
how to submit your application.)
ADMINISTRATOR
AAFP Insurance Services, Inc.
11400 Tomahawk Creek Pkwy, Suite 430
Leawood, KS 66211
California agency license # 0547642
toll-free phone: 800-325-8166
toll-free fax:
800-223-7463
e-mail: insurance@aafp.org
web: http://aafp.org/aafpins/
The information in this brochure is subject to the terms and conditions of the Group Policy #G7200. Please refer to the Certificate Of Insurance for a summary of your coverage under the Plan. AAFP receives a fee for the license of its name and logo for use in connection with this plan.
“The Company You Keep.”
®A N N UAL PREMIUM CONTRIBUTION PER $1,000 UNIT
For Preferred, Non-Tobacco Users*
Amounts Under $250,000
$250,000 and Above
Issue
Age
Male
Female
Male
Female
50
$3.62
$2.70
$3.08
$2.30
51
3.63
2.71
3.09
2.31
52
3.67
2.74
3.12
2.33
53
3.75
2.81
3.19
2.39
54
3.87
2.92
3.29
2.49
55
4.03
3.05
3.43
2.60
56
4.23
3.22
3.60
2.74
57
4.46
3.41
3.80
2.90
58
4.73
3.64
4.03
3.10
59
5.04
3.91
4.29
3.33
Choice of premium modes with n o billing fees
.
While these charts show the annual cost for AAFP coverages, you may choose a
quarterly or semi-annual billing schedule. No matter which payment mode you
select, you will not pay a policy issuance fee or a billing service fee.
Example: The annual guaranteed level rate for a 55-year-old female
with $300,000 of life coverage is $780.
If she selects the semi-annual billing mode, she will be billed $390
($780 divided by 2)
every six months.
If she selects the quarterly billing mode, she will be billed $195
($780 divided by 4)
every three months.
This policy is issued to the American Academy of Family Physicians on Policy Form GMR and is underwritten by New York Life Insurance Co., 51 Madison Ave., NY, NY 10010. Domiciled in the State of New York, NAIC # 66915, NYL is licensed/authorized to transact business in all of the 50 United States, the District of Columbia and Puerto Rico. (If you live in Puerto Rico, please contact AAFP/IS for special instructions about how to submit your application.)If you have questions, contact the Plan Administrator: 800-325-8166, e-mail: insurance@aafp.org,
AAFP Insurance Services, Inc., 11400 Tomahawk Creek Pkwy., Ste. 430, Leawood, KS 66211.
I t ’s fast
and easy
to apply!
Your application
form is inside...
G7200-GLPL2-mm-I-1 07/01AAFP Guaranteed
L evel Premium
L i fe Plan
annual premium contributions
for member and spouse coverage
The cost of this level premium term life insurance is based on the individual’s sex, usage of tobacco/nicotine pro d u c t s , the amount of insurance requested, and attained age on the date coverage is i s s u e d .
You can calculate your annual cost using this chart. Locate the column for your sex and age. Use the left columns for amounts under $250,000; the right columns for $250,000 and above. The rates are per $1,000 unit
(so $130,000 of coverage is 130 units).
Multiply the rate per unit by the number of $1,000 units of coverage desired to determine your annual premium. Example: A woman requesting $300,000 of coverage at age 55 will pay annually $780 (300 units x $2.60 per unit).
A man age 51 requesting $320,000 of coverage would pay annually $988.80
(320 units x $3.09).
Volume discounts apply to the full amount of coverage, not just the amount over the discount threshold. As a result, members and spouses receive the best buy on their insurance when requesting amounts of $250,000 or higher. * The rates shown reflect the current rate and benefit structure for the
“Preferred, Non-Tobacco User”. To be eligible for this rate, you must meet New York Life’s highest underwriting standards. If you do not, you may be eligible for this coverage in the somewhat higher “Select” rate category. Call AAFP Insurance Services for those rates: (800) 325-8166.
Coverage is available in $10,000 multiples only.
(To determine the cost per $10,000 unit, move the decimal one place to the right.)
Making the right
decision begins
with asking
the right
questions.
This is a brief overview of some of the plan’s features and benefits under the AAFP Group Term Life Plan G7200 written on Policy Form GMR by
New York Life Insurance Company, NAIC # 66915, 51 Madison Ave., New York, NY 10010. Please refer to the enclosed brochure and your Certificate Of Insurance for details.
01GLPL2+
Will I have to search for carriers and products suited to the special needs of high-income family physicians to find a Guaranteed Level Premium Life policy?
Do I have to meet face-to-face with a sales agent to apply? Do I have to disclose my personal health and financial information over the Internet or to a sales agent? Do I have to write a check for the initial premium payment when I submit my application? (Even if I don't know whether I'll be approved for coverage?)
Does the Policy have affordable, level premiums to age 65? Once insured, are my rates guaranteed never to increase? Is a volume discount available?
Is the Policy available to my lawful spouse at appropriate sex-distinct rates?
Are there any exclusions?
Will I be required to pay a one-time policy issuance fee? Will I have to pay a surcharge based on the billing mode
(monthly, quarterly, semi-annual or annual) which I select?
Is the Policy endorsed by the American Academy of Family Physicians exclusively for members ages 50 through 59? Is the Policy underwritten by an insurance company with a proven record of having received A++ (the highest) rating from A.M. Best for financial strength?
Has that insurance carrier been in business for over 150 years?
ASK...Don’t assume you know how the
insurance provider will answer your questions.
AAFP
Guaranteed
Level
Premium Life Plan
No, your AAFP has done the research on your behalf.
No No No Yes Yes Yes Yes No No No Yes Yes Yes
Brand X
Insurance
Policy
Apply now by completing and mailing
the enclosed application
Questions? Call: 1-800-325-8166
Medical Requirements
Requests for insurance under the AAFP Term Life Insurance Policy are medically underwritten based on the information you provide and possible additional medical information as indicated below. • A professional Paramedic will be engaged by the AAFP Insurance Program to take your statement of health and perform a physical examination. Based on the age of the person proposed for insurance and the amount of coverage requested, the exam will include an EKG, physical measurements, and blood and urine specimens. The exam will be performed at a time and place specified by you and at the Program’s expense. • It is important that you provide full and accurate answers to all questions on the Application (Parts I and II). Failure to provide complete and truthful information may invalidate coverage. • Your Application is subject to New York Life Insurance Company approval. Occasionally, an Application must be declined due to past health history.
Important Notice – “How New York Life Underwrites Your Request For Life Insurance”
Information regarding insurability will be treated as confidential.
In considering whether the persons in your request for insurance qualify for coverage, we will rely on the medical information you provide and on the information you authorize us to obtain from your doctor, other medical practitioners and facilities, other insurance companies to which you have applied for insurance and MIB, Inc. (Medical Information Bureau). New York Life will not disclose such information to anyone except those you authorize or where required or permitted by law. We may make a brief report to MIB; however, we will not disclose our underwriting decision. Information in our files may be seen by New York Life and the Plan Administrator (AAFP Insurance Services, Inc.) employees, but only on a “need to know” basis in considering your request. Upon receipt of all requested information, we will make a determination as to whether your request for insurance can be approved. • MIB is a nonprofit organization of life insurance companies which operates an information exchange on behalf of its members. When you apply for insurance or submit a claim for benefits to a MIB member company, medical or nonmedical information may be given to the Bureau, which may then be furnished to member companies. • Upon written request to New York Life or MIB, you will be provided with nonmedical information; medical information, however, will only be given to a physician you designate. (Note: In certain jurisdictions, you may choose to receive medical information directly.) If you question the accuracy of the information provided by MIB, you may contact MIB and seek a correction. • For NM re s i d e n t s: In addition, PROTECTED PERSONS1have a right of access to certain CONFIDENTIAL A B U S E
I N F O R M AT I ON2we maintain in our files and they may choose to receive such
information dire c t l y. You have the right to register as a PROTECTED PERSON by sending a signed request to the Administrator at the address listed on the application. Please include your full name, date of birth and addre s s .
1PROTECTED PERSON means a victim of domestic abuse: who has notified us that
he/she is or has been a victim of domestic abuse; and who is an insured person or p rospective insured person.
2C O N F I D E N T I A L ABUSE INFORMATION means information about: acts of domestic
abuse or abuse status; the work or home address or telephone number of a victim of domestic abuse; or the status of an applicant or insured as family member, employer or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close, personal, family or abuse-related re l a t i o n s h i p .
• If we cannot provide the coverage you request, we will tell you why. If you feel our information is inaccurate, you will be given a chance to correct or complete the information in our files. • If we can provide the coverage you requested, we will inform you as to when such coverage will be effective. Under no circumstances will coverage be effective prior to this date. Payment of a premium contribution with your application does not mean there is any insurance in force before the effective date as determined by New York Life. New York Life Insurance Company 07/99 ed.
A u t h o r i z a t i o n
I authorize any physician, medical practitioner, hospital, medical or
medically-related facility, insurance company or MIB to release information to New York Life Insurance Company, its subsidiaries or the Plan Administrator about the physical and mental health of any persons proposed for insurance, including significant history, findings, diagnosis and treatment. I also authorize New York Life to obtain the motor vehicle records of any persons proposed for insurance. MIB and other insurance companies may also furnish New York Life, its subsidiaries or the Plan Administrator with nonmedical information (such as driving records, any criminal activity or association, hazardous sport or aviation activity, use of alcohol or drugs, and other applications for insurance). New York Life and its subsidiaries may release to the Plan Administrator, MIB, other insurance companies and to others whom I authorize in writing, information covered by this AUTHORIZATION. However, this will not be done in connection with information concerning Acquired Immune Deficiency Syndrome (AIDS). This AUTHORIZATION may be used for a period of 30 months (For MN residents: 26 months) from the date the application was signed. A photocopy of this request form shall be as valid as the original. I know that I may request a copy of this
AUTHORIZATION.
• For VA residents:
I know that I or my authorized representative may request a copy of this AUTHORIZATION.• For MN residents:
This AUTHORIZATION excludes the release of information about HIV (AIDS Virus) tests which were administered (1) to a criminal offender or crime victim as a result of a crime that was reported to the police; (2) to a patient who received the services of emergency medical services personnel at a hospital or medical care facility; (3) to emergency medical personnel who were tested as a result of performing emergency medical services. The term “emergency medical personnel” includes individuals employed to provide pre-hospital emergency services: licensed police officers, firefighters, paramedics, emergency medical technicians, licensed nurses, rescue squad personnel, or other individuals who serve as volunteers of an ambulance service who provide emergency medical services; crime lab personnel, correctional guards, including security guards at the Minnesota security hospital, who experience a significant exposure to an inmate who is transported to a facility for emergency medical care; and other persons who render emergency care or assistance at the scene of an emergency, or while an injured person is being transported to receive medical care and who would qualify for immunity under the good samaritan law.• For NY residents: 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 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 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.
H OW TO A P P LY
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1. Please indicate the amount of coverage you are requesting
for yourself and your eligible dependents by completing “Part I: Request For AAFP Group Insurance”.
2. Detach the Application at the perforation. Save this section for your records. Use the enclosed postage-free envelope to mail your signed Application Form - Part I to:
AAFP Insurance Services, Inc. Enclose no money at this time.
3. Part II of your Application consists of meeting with a Paramedic to take a simple exam, provide clinical specimens and give your statement of health. This information will be forwarded to New York Life Insurance Company for underwriting review.
4. Upon approval of your Application (Parts I and II), we will bill you.
G 7200-USA3-I-2 06/01
Application Form - Part I: Request for AAFP Group Term Life Insurance Policy G-7200
Be sure to complete and sign reverse side ➻
Insurance replacement–status of other coverage
New York residents: answer this question I have read the “Important Replacement Information” that accompanied this application.
Is the insurance applied for intended to replace, in whole or in part, any existing insurance or annuity? ■Yes ■No
All others: answer this question Is the insurance applied for intended to replace, discontinue or change an existing policy? ■Yes ■No
AAFP Guaranteed Level Premium Term Life Insurance
for Academy Members ages 50 through 59
Administered by AAFP Insurance Services, Inc., AAFP Headquarters, Ste. 430, 11400 Tomahawk Creek Parkway, Leawood, KS 66211 Call: 800-325-8166 • Fax: 800-223-7463 • E-mail: insurance@aafp.org
Underwritten by New York Life Insurance Company, 51 Madison Ave., New York, NY 10010
True and complete answers to all questions contained in Part I and II of the Application for insurance are required. Please print in ink or type all answers. Thank you.
Form GPA-AC-1 As Amd. by 996-535, G-7200 4/00 ed.
AAFP Member information:
Full name: last, first, middle____________________________________________________________________ Social Security # _____________________________________________________ Date of birth ________________________________________________________ Place of birth (city, state) ______________________________________________ Sex ■ M ■ F Ht._____ft._____in. Wt.______lbs.
Home address (street, city, state, zip)
____________________________________________________________________ ____________________________________________________________________ Business address (street, city, state, zip)
____________________________________________________________________ ____________________________________________________________________ What is the best time to call to arrange for a Paramedic visit to complete your Application Part II, PARA-MED statement of health?
_______a.m._______p.m. daytime phone_______________________________ _______a.m._______p.m. home phone_________________________________ Daytime fax _________________________________________________________ E-mail ______________________________________________________________ A re you a member of the American Academy of Family Physicians?
■ Yes ■ No AAFP Membership # (if available)____________________________
Your confidentiality is important to us.
Please indicate the address where you want to receive:
Medical underwriting information: ■ Home ■ Business Policy information and premium notices: ■ Home ■ Business
Non-smoker discount
Do you wish to apply for non-smoker rates? ■ Yes ■ No
During the past 12 months, have you used tobacco or nicotine in any form? ■ Yes ■ No
Do you understand that the answer to this question may result in a re d u c e d p remium contribution and that, if the answer is not true, coverage may be invalidated? ■ Yes ■ N o
Spouse name ________________________________________________________
First Middle/Maiden Last
Social Security # ______________________________________________________ Date of birth _________________________________________________________ Sex ■ M ■ F
Ht._____ft._____in. Wt.______lbs.
Do you wish to apply for the non-smoker discount? ■ Ye s ■ No During the past 12 months, has your spouse used tobacco or nicotine in any form?
■ Ye s ■ No
Do you understand that the answer to this question may result in a re d u c e d p remium contribution and that, if the answer is not true, coverage may be invalidated? ■ Ye s ■ N o
I hereby apply
for the cove rages indicated below,
based upon all my statements made in the Application -
Parts I and II:
Answer the following questions as they apply to you and, if applying for dependent coverage, to your spouse. ■ For AAFP Members
Please select your Guaranteed Level Pre m i u m Term Life Insurance benefit: ■ $100,000 ■ $200,000 ■ $250,000 ■ $300,000 ■ $400,000 ■ $500,000 ■ $600,000 ■ $700,000 ■ $800,000 ■ $900,000
■ $1,000,000
If you did not select a benefit amount above; enter your desired benefit here:
$________________ (in multiples of $10,000 only) ■ For AAFP Members requesting insurance for their SPOUSE
(Note: Spouse coverage cannot exceed 100% of AAFP Member’s coverage.)
■ $100,000 ■ $200,000 ■ $250,000 ■ $300,000 ■ $400,000 ■ $500,000 ■ $600,000 ■ $700,000 ■ $800,000 ■ $900,000 ■ $1,000,000
If you did not select a benefit amount above; enter your desired benefit here:
$________________ (in multiples of $10,000 only)
WEB
B E N E F I C I A RY DESIGNAT I O N :
I hereby make the following beneficiary designation with respect to my insurance under this G roup Guaranteed Level Premium Term Life Insurance Plan:
Beneficiary of AAFP MEMBER’S Insurance Social Security Number Relationship Full A d d re s s
I request the group insurance shown on the re v e r s e
side. To the best of my knowledge and belief: (a) I am eligible for such insurance; and (b) the statements I have made are true and complete. I understand that New York Life will re q u i re additional medical information and, if necessary, an examination by a physician. I ask New York Life to rely on all such statements made on this form, and all supplements to it, while considering my request. I also understand that the coverage a ff o rded will be in consideration of the answers and statements on this form and all supplements to it and that any misstatements or failures to report information material to the risk may be used as the basis for rescission of my insurance subject to the incontestable period provision of the policy.
I understand that: (a) insurance will become effective on the first of the month on or
immediately after the date approved by New York Life provided the initial contribution is paid within 31 days after the date I am billed, and I and any approved spouse are actively performing the normal activities of a person in good health of like age on the date of approval, or, if later, the date the contribution is paid; (For NC residents: I and any approved spouse are actively performing the normal activities of a person of like age on the date of approval, or, if later, the date the contribution is paid;) (b) spouse insurance will not take effect unless my insurance is in effect on a paying basis; and (c) any person who is not performing his/her normal daily activities as required will not become insured until the day he/she is performing such activities, provided such date is within three months of the date insurance would have been effective and the person is still eligible for insurance. I understand that any dividend apportioned to the group policy will be paid to the American Academy of Family Physicians. I authorize disclosure of the types of information detailed in the AUTHORIZATION in this pamphlet, for New York Life’s use in considering this request for coverage. I have read the IMPORTANT NOTICE in this pamphlet which describes how New York Life underwrites this request for coverage, including how information is exchanged with MIB (Medical Information Bureau).
Form GPA-AC-1 As Amd. by 996-535, G-7200 4/00 ed.
Residents of AR, CO, DC, HI, KY, LA, ME, NJ, NM, OH, OR and PA:Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Residents of FL:Any person knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any
false, incomplete, or misleading information is guilty of a felony of the third degree.
For residents of CO, the following also applies:Any insurance company or agent who defrauds or attempts to defraud an insured shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
For residents of DC, the following also applies: An insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Please sign in ink and date.
(Spouse’s signature necessary only if spouse coverage is applied for.)
To the best of my knowledge and belief, the statement made re g a rding my smoking status is true and complete.
Spouse’s signature X____________________________ Date ___________ Please sign in ink and date.
AAFP Member’s signature
X _______________________________________________ Date ___________
G7200-GLPL2-mm-I-1 07/01
