Form Gma-Ez2 - Group Term Life Insurance Application Form Page 4
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4IMPORTANT NOTICE
How New York Life Obtains Information and Underwrites Your Request for Group Life Insurance
In this notice, references to “you” and “your” include any person proposed for insurance. Information regarding insurability will
be treated as confidential. In considering whether the person(s) in your request for insurance qualify for insurance we will rely
on the medical information you provide, and on the information you AUTHORIZE us to obtain from your physician, other medical
practitioners and facilities, other insurance companies to which you have applied for insurance and MIB, Inc. (“MIB”). MIB is a
not-for-profit organization of insurance companies, which operates an information exchange on behalf of its members. If you
apply for life or health insurance coverage, or a claim for benefits is submitted to a MIB member company, medical or non-
medical information may be given to MIB, and such information may then be furnished by MIB, upon request, to a member
company.
Your AUTHORIZATION may be used for a period of 24 months from the date you signed the application for insurance, unless
sooner revoked. The AUTHORIZATION may be revoked at any time by notifying New York Life in writing at the address provided.
Your revocation will not be effective to the extent New York Life or any other person already has disclosed or collected
information or taken other action in reliance on it, or to the extent that New York Life has a legal right to contest a claim under an
insurance certificate or the certificate itself. The information New York Life obtains through your AUTHORIZATION may become
subject to further disclosure. For example, New York Life may be required to provide it to insurance, regulatory or other
government agencies. In this case, the information may no longer be protected by the rules governing your AUTHORIZATION.
MIB and other insurance companies may also furnish New York Life, its subsidiaries or the Plan Administrator with non-medical
information (such as driving records, past convictions, hazardous sport or aviation activity, use of alcohol or drugs, and other
applications for insurance). The information provided may include information that may predate the time frame stated on the
medical questions section, if any, of the application. This information may be used during the underwriting and claims processes,
where permitted by law.
New York Life may release this information to the Plan Administrator, other insurance companies to which you may apply for life
and health insurance, or to which a claim for benefits may be submitted and to others whom you authorize in writing. However,
this will not be done in connection with test results concerning Acquired Immune Deficiency Syndrome (AIDS) or Human
Immunodeficiency Virus (HIV). We may also make a brief report of your protected health information to MIB, but we will not
disclose our underwriting decision.
New York Life will not disclose such information to anyone except those you authorize or where required or permitted by law.
Information in our files may be seen by New York Life and Plan Administrator 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
If we cannot provide the coverage you requested, 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. Upon written request to New York Life or MIB, you will be provided with
non-medical information. Generally, medical information will be given either directly to the proposed insured or to a medical
professional designated by the proposed insured. Your request is handled in accordance with the Federal Fair Credit Reporting Act
procedures. If you question the accuracy of the information provided by MIB, you may contact MIB and seek a correction. MIB's
information office is: MIB, Inc., 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734, telephone 866- 692-6901 (TTY 866 346-
3642). For Canadian residents, the address is: MIB Information Office, 330 University Avenue, Suite 501, Toronto, Ontario, Canada
M5G 1R7, telephone 416-597-0590. Information for consumers about MIB may be obtained on its website at
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have a right of access to certain C
we maintain in our files and
For NM Residents: P
ROTECTED PERSONS
ONFIDENTIAL ABUSE INFORMATION
they may choose to receive such information directly. You have the right to register as a P
by sending a signed request to
ROTECTED PERSON
the Administrator at the address listed on the application. Please include your full name, date of birth and address.
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means a victim of domestic abuse: who has notified us that he/she is or has been a victim of domestic abuse; and
P
ROTECTED PERSON
who is an insured person or prospective insured person.
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means information about: acts of domestic abuse or abuse status; the work or home address or
C
ONFIDENTIAL ABUSE INFORMATION
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 relationship.
New York Life Insurance Company 8.12ed
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