Gevbt (Usda) Group Term Life Insurance Application Form
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4GEVBT (USDA) GROUP TERM LIFE INSURANCE APPLICATION FORM
Request For Group Insurance From:
Complete This Form And Return To:
Mass Benefits Consultants, Inc.
New York Life Insurance Company
51 Madison Avenue
P.O. Box 828, Annandale, VA 22003-0828
New York, New York 10010
Toll Free: 800-221-3083
MEMBER INFORMATION
Group Policy: G-29165-0 Certificate No.
[PLEASE PRINT IN INK OR TYPE ALL ANSWERS]
Last Name
First Name
Initial
Social Security Number
Mailing Address:
Street
City
State/Province
Zip Code
(
)
(
)
(
)
e-Mail Address
Day Time Phone Number
Evening Phone Number
Day Fax Number
❏
❏
Date of Birth
/
/
(mm/dd/yyyy)
Height
.
Weight
Sex:
Male
Female
ft
in
lbs.
❏
❏
❏
❏
Marital Status:
Single
Married
Divorced
Domestic Partner* (Submit a completed Declaration of Domestic Partnership Form — Not Applicable in Oregon)
❏
Maiden Name
Civil Union*
*Eligibility is determined by State Law
❏
❏
Are you an employee of the U.S. Department of Agriculture?
Yes
No
Date of Employment:
/
/
(mm/dd/yyyy)
Annual Income:
❏
❏
Are you presently insured by any USDA / ESRA sponsored insurance plan?
No
Yes
If yes, details:
❏
❏
❏
❏
Do you intend to reside outside the U.S. or Canada in the next 12 months?
Yes
No
Yes
No
Member:
Spouse:
If yes, Country
How Long?
If yes, Country
How Long?
Member:
Spouse:
DEPENDENT INFORMATION:
If dependent coverage is requested, list eligible dependents (i.e. lawful spouse and unmarried, dependent
children under age 19, or 25 if a full time student.) Attach separate sheet to provide additional dependent information.
❏
SPOUSE’S FULL NAME
SOCIAL SECURITY NO.
DATE OF BIRTH
Male
HEIGHT
WEIGHT
(Last, First, MI)
❏
/
/
Female
FT.
IN.
LBS.
CHILD (Name)
DATE OF BIRTH
CHILD (Name)
DATE OF BIRTH
❏
❏
Male
Male
❏
❏
1.
/
/
Female
3.
/
/
Female
CHILD (Name)
DATE OF BIRTH
CHILD (Name)
DATE OF BIRTH
❏
❏
Male
Male
❏
❏
2.
/
/
Female
4.
/
/
Female
INSURANCE REQUESTED:
(Refer to your certificate, or the brochure for eligibility, options, plan maximums and coverage description)
❏
❏
I HEREBY APPLY FOR THE FOLLOWING GROUP LIFE COVERAGE(S):
New Coverage
Additional Coverage
NOTE: If your are increasing present coverage in any way, indicate the amount of increase only, Mass Benefits will indicate the Total Amount of Coverage for
underwriting purposes. UNDER NO CIRCUMSTANCES can your coverage amount exceed the maximum available under the group plan.
❏
Member Coverage
(from $10,000 to $300,000 in $10,000 increments) …… $
For Office Use Only
❏
Spouse Coverage
(from $10,000 to $300,000 in $10,000 increments) ……… $
Total Member Amt $
❏
Child(ren) Coverage
($3,000 for each eligible child)
(Spouse Amount of coverage cannot
Total Spouse Amt $
exceed Member Amount of coverage)
INSURANCE REPLACEMENT -
RESIDENTS OF NEW YORK: I have read the Important Replacement Information on the reverse
side of this application. Is the life insurance applied for intended to replace, in whole or in part, any existing insurance or annuity?
❏
❏
❏
❏
Yes
No
Yes
No
Member:
Spouse:
RESIDENT OF ALL OTHER STATES: Is insurance applied for intended to replace, discontinue or change an existing policy?
❏
❏
❏
❏
Yes
No
Yes
No
Member:
Spouse:
BENEFICIARY DESIGNATION:
I make the following beneficiary designation with respect to all the insurance on my life under this
Group Life Insurance Plan, and if I am already covered under the plan, I hereby revoke any prior beneficiary designation. The beneficiary
for dependent coverage shall be the insured member as provides in the Group Policy. 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. (Attach a separate sheet if necessary)
Beneficiary’s Name
Complete address
Relationship
Social Security Number
%
Beneficiary’s Name
Complete address
Relationship
Social Security Number
%
G-29165-0
GMA-EZ2
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