Form Gma-Ez2 - Group Term Life Insurance Application Form
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4Group Term Life Insurance Application Form
Group Term Life Insurance
Government Employees Voluntary Benefit Trust (GEVBP)
Complete this form and return to:
Mass Benefits Consultants, Inc ♦ P.O. Box 828 ♦ Annandale, VA 22003-0828 ♦ Phone: 1-800-221-3083
PLEASE PRINT IN INK OR TYPE ALL ANSWERS AND INITIAL ANY CHANGES
GROUP POLICY
CERTIFICATE NO. (OFFICE USE ONLY)
Request for Group Insurance From
G-29293-0
New York Life Insurance Company
SOCIAL SECURITY NO.
DATE OF BIRTH
51 Madison Avenue • New York, NY 10010
MM
/
DD
/
YYYY
EMPLOYEE’S FULL NAME
MARITAL STATUS: Married
Single
Domestic Partner
Divorced
Widowed
Maiden Name__________________________________
MAILING ADDRESS
HEIGHT
WEIGHT
MALE
FEMALE
ft.
in.
lbs.
CITY
STATE
ZIP CODE
OFFICE PHONE
FAX NUMBER
E-MAIL ADDRESS
HOME PHONE
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Do you intend to reside outside the U.S. or Canada in the next 12 months? Employee
Yes
No Spouse
Yes
No
If yes, indicate the Country?
How Long?
□
□
Are you presently insured by any insurance Plan Administered by Mass Benefits Consultants?
Yes
No
If yes, details:
OCCUPATIONAL STATUS
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Are you an eligible Unites States government employee working full-time (30 or more hours per week)?
Yes
No
AGENCY:
DATE OF HIRE:
MM
/
DD
/
YYYY
ANNUAL INCOME: $
IF DEPENDENT COVERAGE IS REQUESTED, LIST ELIGIBLE DEPENDENTS
lawful Spouse under age 75 and unmarried,
dependent children under age 19 (23 if FT student)
If necessary attach a separate signed and dated sheet to provide additional dependent information
SPOUSE’S FULL NAME: (Last, First, MI)
SOCIAL SECURITY NO.
DATE OF BIRTH
HEIGHT
WEIGHT
MALE
FEMALE
ft.
in.
lbs.
Child (Name)
Date of Birth
MALE
Child (Name)
Date of Birth
MALE
FEMALE
FEMALE
1.
/
/
3.
/
/
Child (Name)
Date of Birth
MALE
Child (Name)
Date of Birth
MALE
FEMALE
FEMALE
2.
/
/
4.
/
/
INSURANCE REQUESTED
:
(Refer to your certificate, the brochure or the website for eligibility, options and coverage description
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I HEREBY APPLY FOR THE FOLLOWING GROUP LIFE COVERAGE:
New Coverage
Additional Coverage
NOTE: If you are increasing or altering present coverage in any way, indicate amount of increase only, Mass Benefits will
indicate the total amount of Coverage for underwriting purposes. Under No Circumstances can your coverage amount
exceed the maximum available under the plan.
Amounts Available from $25,000 to $300,000 ($150,000 age 70 through 74) in $25,000 increments
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For Office Use Only
Employee Amount
$__________________
□
Total Employee Amt $___________
Spouse Amount
$__________________
(Cannot exceed employee amount)
Total Spouse Amt
$___________
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Child(ren)
$ 2,500 each child
($500 age 15 days to 6 months)
INSURANCE QUESTION
(Must Be Completed)
Residents of ALL States (except New York): Is the Insurance applied for intended to replace, discontinue or change an
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existing insurance or annuity?
Yes
No
Residents of New York: I have read the Important Replacement Information on page 3
. Is the insurance applied for
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intended to replace, in whole or in part, any existing insurance or annuity?
Yes
No
GMA-EZ2
Application continued – see following page
G-29293-0
GEVBP WEB 0615
Page 1
Before you mail this application, it will greatly speed the underwriting process
if you review it carefully and initial any corrections you make.
Have all questions been answered? Did you sign and date it in all required places?
Have you provided the names and address of all doctors you have consulted (even routinely)?
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