Form Gr 902 Ny - Application For Group Insurance Page 3
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3Agreements
This application will be subject to review and approval by the Home Office of Ameritas Life Insurance Corp. of New York. If this applica-
tion is accepted, the final rates and benefits will be based on verification of this information and final enrollment numbers. This applicant
represents that he/she has read the statements and answers to the above questions and that they are complete and true to the best of
his/her knowledge and belief. Any policy including riders issued as a result of this application will, with this application, be the entire
insurance contract. If this application is accepted at the Home Office of Ameritas Life Insurance Corp. of New York., group insurance
at the Company’s rates and under the terms applied for shall take effect as of the date set forth in the policy. If this application is not
accepted, any premium advanced shall be refunded.
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 shall also be subject to a civil penalty not to exceed
five-thousand dollars and the stated value of the claim for each such violation.
If you do not want your company name used by Ameritas Life Insurance Corp. of New York in our effort to recruit PPO
providers, check this box.
Signed at: City ______________________________________ State____________________________ Date______________________
Signed by: (Policyholder Representative)
Printed name and title ____________________________________________________________________________________________
Signature________________________________________________________________________________________________________
Soliciting Agent: I understand and agree that if I’m not already appointed with Ameritas Life Insurance Corp. of New York, I must
apply to and be appointed with Ameritas Life Insurance Corp. of New York before I present this product to any client.
Printed Name ____________________________________________________________________________________________________
Signature________________________________________________________________________________________________________
The policy provides dental and/or vision benefi ts only. Review your policy carefully.
Was a binder check received?
Yes
No
If yes, then amount $____________________________.
Check received by (agent) _________________________________ Authorized by (policyholder)_______________________________
ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO AMERITAS LIFE INSURANCE CORP. OF NEW YORK
DO NOT MAKE CHECKS PAYABLE TO THE AGENT OR LEAVE PAYEE BLANK.
GR 902 NY Rev. 1-09
Page 3 of 3
091911L
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