Form Gma-Ez2 - Group Term Life Insurance Application Form (Page 3 of 4) in pdf

IMPORTANT REPLACEMENT INFORMATION RESIDENTS OF NEW YORK

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 insurance 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 insurance 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loaned against or withdrawn from, reduced in value by use of cash values or other policy values,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.

FRAUD NOTICE – For Residents of all states except those listed below and New York: 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 may be a crime and may subject such person to criminal and civil penalties. 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.

RESIDENTS OF AR/LA/MD/RI: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or

knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in

prison.

RESIDENTS OF CA: 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 may be a crime and

may subject such person to criminal and civil penalties. The falsity of any statement in the application for any policy shall not

bar the right to recovery under the policy unless such false statement was made with actual intent to deceive or unless it

materially affected either the acceptance of the risk or the hazard assumed by the insurer.

FOR RESIDENTS OF D.C., WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of

defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny

insurance benefits if false information materially related to a claim was provided by the applicant.

RESIDENTS OF FL: Any person who 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.

RESIDENTS OF KS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or

knowingly presents false information in an application for insurance may be guilty of insurance fraud as determined by a court of

law.

RESIDENTS OF NJ: WARNING: Any person who includes any false or misleading information on an application for an

insurance policy is subject to criminal and civil penalties.

RESIDENTS OF OK: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes

any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a

felony.

RESIDENTS OF PUERTO RICO: Any person who, knowingly and with the intent to defraud, presents false information in an

insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit,

or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for

each violation with a fine no less than five thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or

imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established

imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a

minimum of two (2) years.

RESIDENTS OF TN/WA: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance

company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

RESIDENTS OF VA: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer,

submits an application or files a claim containing false or deceptive statements may have violated state law.

GMA-EZ2

LAST PAGE OF APPLICATION

G-29293-0

GEVBP WEB 0615

Page 3

Once completed and dated, this form should be submitted at once to the GEVBP Plan Administrator:

Mass Benefits Consultants, Inc ♦ P.O. Box 828 ♦ Annandale, VA 22003-0828 ♦ Phone: 1-800-221-3083

Residents of Puerto Rico should mail applications to:

Global Insurance Agency ♦ P.O. Box 9023918 ♦ San Juan, Puerto Rico 00902-3918

Form Gma-Ez2 - Group Term Life Insurance Application Form Page 3

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