Gevbt (Usda) Group Term Life Insurance Application Form Page 2
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4STATEMENT OF HEALTH: To the best of my knowledge and belief:
Yes
No
A. Are you now taking any prescribed medication or receiving or contemplating any medical attention or
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❏
surgical treatment?
B. During the past five years has any person proposed for insurance ever been medically diagnosed by
a physician as having or been treated for: heart trouble, elevated blood pressure, gynecological or
genitourinary disorders, ulcers, cancer, diabetes, mental or nervous disorder or psycho therapeutic treatment,
epilepsy, respiratory disorder, kidney or liver disorder, (including hepatitis), enlarged lymph nodes or
immunodeficiency disorder, thyroid disorder, blood disorder, albumin, blood or sugar in urine, back trouble/
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disorder, arthritis, unexplained weight loss, or other illness disease or injury?
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C. During the past five years has any person been counseled, treated or hospitalized for the use of alcohol or drugs?
If you have answered yes to any of the above questions, please explain (attach a separate sheet if necessary, then sign and date it)
Illness or Condition-Date of Onset-Duration-Treatment-
Name and address of Physicians or other Medical Care
Name(s) of
Operations-Degree of Recovery and Date:
Practitioners and Hospitals where confined or treated:
Proposed Insured
YOU MAY BE CONTACTED BY A SERVICE PROVIDER ON BEHALF OF NEW YORK LIFE TO ASK ADDITIONAL
QUESTIONS ABOUT YOUR MEDICAL HISTORY
(Choose one of each)
Residence
Weekdays
Morning (7:00 – 12:00)
Afternoon (12:00 – 5:00)
Best place and time to
PLACE:
DAY:
TIME:
contact you:
Business
Weekends
Evening (5:00 – 8:00)
Night
( 8:00 – 11:00)
I understand that New York Life has the right to require additional information and, if necessary, an examination by a physician. I ask
New York Life to rely on all such statements made on this form, and any supplements to it, while considering this request. I also understand
that the coverage afforded will be in consideration of the answers and statements set forth above and that any material misstatements or
failures to report information material to the risk may be used as the basis to contest my insurance subject to the incontestable period
provision of the policy. I also understand that this application is to be attached and made part of the certificate.
AUTHORIZATION: I authorize any physician, medical practitioner, hospital, medical or medically related facility, laboratory,
insurance company or the MIB (Medical Information Bureau) to release information, including prescription drug records, maintained by
physicians, pharmacy benefit managers, and other sources of information to New York Life Insurance Company, its subsidiaries or the Plan
Administrator (Mass Benefits Consultants) about the physical and mental health of any persons proposed for insurance, including significant
history, findings, diagnosis or treatment, but excluding psychotherapy notes. A photocopy of this AUTHORIZATION and request form shall
be as valid as the original. In all circumstances, my authorized agent or I may request a copy of this AUTHORIZATION. This Authorization
may be used for a period of 24 months from the date signed, unless sooner revoked as stated in the IMPORTANT NOTICE.
By signing and dating this application, the member and any person proposed for insurance, request the insurance indicated, consent to
authorize the disclosure of information to and from the providers noted in the IMPORTANT NOTICE, attest to having read the IMPORTANT
NOTICE and Fraud Notices indicated on the attached, including how my information is exchanged with MIB (Medical Information Bureau),
and that to the best of my knowledge and belief, the provided answers to the questions are true and complete.
Member Signature X
(
DATE
PLEASE SIGN AND DATE IN INK)
Spouse’s Signature X
(NECESSARY ONLY IF SPOUSE COVERAGE IS REQUESTED)
DATE
IMPORTANT REPLACEMENT INFORMATION:
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 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 to 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 decide whether the replacement is on your best interest.
G-29165-0
GMA-EZ2
Page 2 of 2
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Mass Benefits Consultants, Inc. ◆ Insurance Plan Administrator ◆ P.O. Box 828, Annandale, VA 22003-0828 ◆ Toll Free: 800-221-3083
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