2007-2008 IEEE Multiplan Brochure

(Insert name, relationship, Social Security number and address.) 5. Beneficiary Designation: I make the following beneficiary designation with respect to all the insurance on my life under this Group Term 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 provided in the group policy. (If you wish to name a different beneficiary for spouse coverage, contact the Administrator.) 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, then sign and date it.) Primary Secondary %: Primary Secondary %: BENEFICIARY’S NAME LAST FIRST MI BENEFICIARY’S NAME LAST FIRST MI BENEFICIARY’S RELATIONSHIP TO MEMBER BENEFICIARY’S SOCIAL SECURITY # STREET ADDRESS CITY STATE ZIP CODE BENEFICIARY’S RELATIONSHIP TO MEMBER BENEFICIARY’S SOCIAL SECURITY # STREET ADDRESS CITY STATE ZIP CODE 6. Statement of Health: (Please initial and date any changes you make on this form.) To the best of your knowledge and belief, answer the following questions as they apply to you and all dependents to be insured. A. Are you or any other person to be insured disabled or receiving any disability or workers compensation benefits or on waiver of premium for life or health insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . I B. Are you or any other person to be insured now ill or receiving medical attention or surgical treatment? . . . . . . . . I C. During the past five years, has any person to be insured consulted any physician or other medical care practitioner other than for a routine physical examination, or checkup, or been hospitalized or had an operation or had any illness, disease or injury? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I D. Are you or any other person to be insured taking any kind of medication or, so far as you know, in impaired physical or mental health?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I E. Is any person to be insured now pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I F. During the past five years, has any person to be insured ever been medically diagnosed by a physician as having or been treated for: Y N Y Y N I I I I I N 1. Heart or circulatory trouble, high blood pressure, pain or pressure in chest? . . . . . . . . . . . . . . . . . . . . . . I 2. Arthritis, back trouble, bone or joint disorder?. . . . . . . I 3. Fainting spells, convulsions or epilepsy? . . . . . . . . . . I 4. Sugar, blood, albumin or pus in urine? . . . . . . . . . . . . I 5. Diabetes, kidney trouble, ulcers or digestive disorder? . I 6. Disorder of the breasts or reproductive organs or functions?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 7. Nervous or mental disorder, emotional condition or psychiatric care? . . . . . . . . . . . . . . . . . . . . . . . . . . . I 8. Cancer, tumor or cyst? . . . . . . . . . . . . . . . . . . . . . . . . I 9. Varicose veins, hemorrhoids or hernia? . . . . . . . . . . . I 10. Disorder of eyes, ears, nose or sinuses? . . . . . . . . . . I I I I I I I I I I I 11. Thyroid, liver or respiratory disorder? . . . . . . . . . . . . I 12. Alcoholism or drug habit? . . . . . . . . . . . . . . . . . . . . . . I 13. Disorder of the blood? . . . . . . . . . . . . . . . . . . . . . . . . I 14. Other health or physical impairment including: I I I (i). Being medically diagnosed as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC)? .. . . . . . . . . . . . . . . . . . . . . . . . . . I I (ii). Chronic cough, persistent diarrhea, enlarged lymph glands or chronic fatigue in the past five years?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I (iii). Any other impairment? . . . . . . . . . . . . . . . . . . . . . I I I IF YOU HAVE ANSWERED ANY QUESTIONS “YES,” GIVE COMPLETE DETAILS BELOW. (If you need more space, use a signed and dated separate sheet. Please avoid the use of such terms as “etc.,” “various” or “miscellaneous.”) Question No./ Letter Name of proposed insured Illness or Condition-Date of Onset-Duration-TreatmentOperations-Degree of Recovery and Date Name and Address of Physicians or other Practitioners and Hospitals where confined or treated G-8100-1 PLEASE COMPLETE ALL PAGES AND SIGN THE LAST PAGE ± GMA-PR1 PAGE 3

Table of Contents Feed for the Digital Edition of 2007-2008 IEEE Multiplan Brochure

Group Term Life Insurance Plan Group 10-Year Level Term Life Insurance Plan Group 20-Year Term Life Insurance Plan Group Disability Income Insurance Plan Professional Liability Insurance Plan Long-Term Care Plan Additional Plans & Information

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