Application For Group Long Term Disability Income Insurance For Members Of The American Postal Workers Union (Apwu) - New York Life Insurance Company
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1
2Application for GROUP LONG TERM DISABILITY INCOME INSURANCE
for Members of the AMERICAN POSTAL WORKERS UNION (APWU)
Complete this form and return to:
This is a request for Group Insurance from:
VOLUNTARY BENEFITS PLAN
®
New York Life Insurance Company
P.O. Box 12009
51 Madison Avenue
Cheshire, CT 06410
New York, NY 10010
SECTION A – MEMBER INFORMATION
PLEASE PRINT IN INK OR TYPE ALL ANSWERS
Group Policy G-29315-2
Certificate No.________________
Member’s Name:
Social Security Number:
Middle Initial
Last Name
First
Home Address:
Street
State
Zip Code
City
Home E-mail Address:
Local:
Home Phone:
(
)
Work Phone:
(
)
Fax:
(
)
Height:
Weight:
Male
Female
Date of Birth:
ft
in
lbs.
Sex:
/
/
(MM/DD/YYYY)
Divorced
Single
Marital Status:
Married... Maiden Name:
Date of Marriage:
/
/
Widowed
(MM/DD/YYYY)
OCCUPATIONAL STATUS: FULL-TIME WORK means actively performing the regular duties of your normal occupation for pay or profit on the
basis of at least 20 hours each week at the place such duties are normally performed for the past 90 days with your present employer.
Are you now at FULL-TIME WORK?
Yes
No
Gross Annual Basic Salary: $
Date of Hire:
/
/
(MM/DD/YYYY)
Yes
No
Are you presently insured under any other benefit plans provided by the Voluntary Benefits Plan
®
?
If “Yes,” which other plan(s) from Voluntary Benefits Plan
®
do you have?
SECTION B – INSURANCE REQUESTED
(Refer to the brochure or your certificate for eligibility, options and coverage descriptions)
I HEREBY APPLY FOR THE FOLLOWING COVERAGE:
New
Additional
NOTE: If you are increasing or altering present coverage in any way, do not
indicate just the additional amount of coverage, instead indicate the TOTAL AMOUNT of coverage you are requesting.
GROUP LONG TERM DISABILITY INCOME:
a.) MONTHLY BENEFIT OPTION: $
b.) Deduction per pay period
c.) Do you now have or are you now applying for any other insurance which provides
benefits if you are unable to work because of disability?
Yes
No
(If “Yes”, please provide the requested information below))
COMPANY
PLAN
MONTHLY BENEFIT
BENEFIT PERIOD
G-29315-2
GPA-DI-EZ-2
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