Form Gma-Ez2 - Group Term Life Insurance Application Form (Page 2 of 4) in pdf

BENEFICIARY DESIGNATION

(If necessary, attach separate signed and dated sheet to provide additional beneficiary information)

I hereby make the following beneficiary designation with respect to all the insurance on my life under the Group Term Life

Insurance Plan, and if I am already covered under the Plan, I hereby revoke any prior beneficiary designation.

1) If naming

more than one beneficiary, note if each is to be primary and/or secondary, and the percentage of death proceeds to be distributed to each.

2) If naming a trust, please indicate the full name and date of the trust.

BENEFICIARY NAME

RELATIONSHIP

BENEFICIARY’S SOCIAL SECURITY #

BENEFICIARY STREET ADDRESS

CITY

STATE

ZIP CODE

% OF BENEFITS

STATEMENT OF HEALTH: To the best of my knowledge and belief:

Member

Spouse

Is any person to be insured now taking any prescribed medication or receiving or contemplating any

Yes No

□

medical attention or surgical treatment?

During the past five years has any person proposed for insurance ever been medically diagnosed by

a physician as having or been treated for: heart trouble, elevated blood pressure, gynecological or

genitourinary disorders, ulcers, cancer, diabetes, mental or nervous disorder or psychotherapeutic

treatment, epilepsy, respiratory disorder, kidney or liver disorder, (including hepatitis), enlarged

lymph nodes or immunodeficiency disorder, thyroid disorder, blood disorder, albumin, blood or sugar

Yes No

□

in urine, back trouble/disorder, arthritis, unexplained weight loss, or other illness disease or injury?

During the past five years has any person been counseled, treated or hospitalized for the use of

Yes No

□

alcohol or drugs?

If you have answered yes to any of the above questions, please explain

(attach a separate sheet if necessary, then sign and date it)

Name(s) of

Illness or Condition-Date of Onset-Duration-Treatment-

Name and address of Physicians or other Medical Care

Proposed Insured

Operations-Degree of Recovery and Date:

Practitioners and Hospitals where confined or treated:

YOU MAY BE CONTACTED BY A SERVICE PROVIDER ON BEHALF OF NEW YORK LIFE TO ASK ADDITIONAL

QUESTIONS ABOUT YOUR MEDICAL HISTORY

(Choose one of each)

Best place and time to

Residence

Weekdays

Morning (7:00 – 12:00)

Afternoon (12:00 – 5:00)

PLACE:

DAY:

TIME:

contact you:

Business

Weekends

Evening (5:00 – 8:00)

Night (8:00 – 11:00)

I understand that New York Life has the right to require additional 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 any supplements to it, while considering

this request. I also understand that the coverage afforded will be in consideration of the answers and statements set forth

above.

AUTHORIZATION:

I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or

medically related facility, laboratory, insurance company or MIB, Inc. (“MIB”), or other organization, institution or person, that

has any records or knowledge of me or my health, to release information, including prescription drug records, maintained by

physicians, pharmacy benefit managers, and other sources of information to New York Life, its reinsurers, 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, but excluding psychotherapy notes. A photocopy of this AUTHORIZATION and

request form shall be as valid as the original. In all circumstances, my authorized agent or representative, or I may request a

copy of this AUTHORIZATION. This AUTHORIZATION may be used for a period of 24 months from the date signed, unless

sooner revoked as stated in the IMPORTANT NOTICE.

By signing and dating this application, the member requests the insurance indicated; and the member and any person

proposed for insurance consent to authorize the disclosure of information to and from the providers noted in the IMPORTANT

NOTICE,

including making a brief report of my/our protected health information to MIB; and attest to having read the

IMPORTANT NOTICE and Fraud Notices indicated on the attached; including how my/our information is exchanged with MIB,

and that to the best of my/our knowledge and belief, the answers provided to the questions are true and complete.

Employee’s Signature____________________________________________________ Date_________________________

Spouse’s Signature ____________________________________________________

Date_________________________

(Necessary only if Spouse coverage is requested)

GMA-EZ2

Application continued – see following page

G-29293-0

GEVBP WEB 0615

PAYMENT OF PREMIUM WITH YOUR APPLICATION DOES NOT MEAN

Page 1

INSURANCE IS INFORCE BEFORE THE DATE SPECIFIED BY NEW YORK LIFE

Form Gma-Ez2 - Group Term Life Insurance Application Form Page 2

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