2007-2008 IEEE Multiplan Brochure

2. Membership Affiliation: Are you now a member of the Institute of Electrical and Electronics Engineers, Inc.? Yes s No s Membership # Exp. Date (Membership in IEEE is required for participation in this Plan. Affiliate members are not eligible.) 3. Payment Option Selection: Choose only one s OPTION 1: Electronic Funds Transfer (EFT): I request and authorize the IEEE Group Insurance Program, Inc., to make monthly withdrawals against the account specified on the attached voided check or any account subsequently named by me, and such bank to process these withdrawals as if I had signed them, for the purpose of collecting premium contributions due under this Group 10-Year Level Term Life Insurance Plan. (Enclose a VOIDED check.) SIGNATURE(S) AS REQUIRED ON CHECKS ISSUED AGAINST THIS ACCOUNT DATE s OPTION 2: Periodic Billing: Semiannually each March 1 and September 1 (Refer to Plan Details/Plan Information for eligibility, options and coverage description.) I HEREBY APPLY FOR THE FOLLOWING COVERAGES: A. Total* Member Insurance Amount Requested: $ Total* Spouse Insurance Amount** Requested: $ Total Child Insurance Amount Requested: s $10,000 s None *Increased coverage requested in this Application, if approved, will be issued in a separate, new Certificate of Insurance. **Spouse coverage cannot exceed 100% of member’s coverage. 4. Insurance Requested: B. TOBACCO/NICOTINE USE: Have you or your spouse (if proposed for insurance) used tobacco or nicotine in any form, including nicotine patches and nicotine chewing gum, within the last 24 months? Member: s Yes s No Spouse: s Yes s No If “Yes,” when did such person last use tobacco or nicotine products? Member: / Spouse: / C. INSURANCE REPLACEMENT: MONTH/YEAR MONTH/YEAR RESIDENTS OF NEW YORK — 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 a 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assigned, terminated, changed or modified into paid-up insurance or other forms of benefits, loaned against or withdrawn from, reduced in value by use of cash values or other policy values, changed in the length of time or in the amount of insurance that would continue or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 you decide whether the replacement is in your best interest. Y Residents of New York: I have read the Important Replacement Information above. Is the insurance applied for intended to replace, in whole or in part, any existing insurance or annuity? s Member N Spouse YN s s s s s s s s s Residents of Other States: Is the insurance applied for intended to replace, discontinue or change an existing policy? s All Residents: Do you have other insurance in force? s If “Yes,” total amount in all companies: Member: $ Spouse: $ Do you have other insurance applications pending? s If “Yes,” indicate amount and company: Member: $ Company Spouse: $ Company s s s G-29133-0 PLEASE COMPLETE ALL PAGES AND SIGN THE LAST PAGE ± GMA-PRS1 PAGE 2

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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