2007-2008 IEEE Multiplan Brochure

7. Declarations: I request the group insurance shown in this section. To the best of my knowledge and belief: (a) I am eligible for such insurance; and (b) the statements I have made are true and complete. I understand that New York Life Insurance Company has the right to require additional information and, if necessary, an examination by a physician. I ask New York Life Insurance Company 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 in this section and that any material misstatements or failures to report information material to the risk may be used as the basis for rescission of my insurance subject to the incontestable period provision of the policy. I understand that insurance will become effective on the date approved by New York Life Insurance Company if I and any approved dependents are performing the normal activities (normal activities requirement does not apply to eligible children) of a person in good health of like age [NC residents: a person of like age] on that date and the initial contribution is paid within 31 days after the date I am billed. I understand that: (a) dependent insurance will not take effect unless my insurance is in effect on a premium paying basis, and (b) any person who is not performing his/her normal daily activities as required will not become insured until the day he/she is performing such activities, provided such date is within three months of the date insurance would have otherwise been effective and the person is still eligible. I understand that any dividend apportioned to the Group Policy will be paid to the Trustee of the IEEE Life Insurance Plan. Fraud Warning Statements Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. For residents of CO, the following also applies: Any insurance company or agent who defrauds or attempts to defraud an insured shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. For residents of DC, the following also applies: An insurer may deny insurance benefits if false information materially related to a claim was provided by applicant. Residents of FL: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Residents of LA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Residents of OK: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Residents of PR: Any person, who knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps or has presented a fraudulent claim for payment of a loss or other benefit, or presents more than one claim for the same damage or loss will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollars nor more than ten thousand (10,000), or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years. Residents of VA: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statements may have violated state law. AUTHORIZATION: I authorize disclosure of the types of information detailed in this AUTHORIZATION for New York Life Insurance Company’s use in considering this request for insurance. I have read the IMPORTANT NOTICE, which describes how New York Life Insurance Company underwrites this request for insurance, including how information is exchanged with MIB (Medical Information Bureau). My request for insurance will not be accepted unless this AUTHORIZATION is signed. s I authorize any physician, medical practitioner, hospital, medical or medically related facility, insurance company or MIB to release information to New York Life Insurance Company, its subsidiaries or the Plan Administrator about the physical and mental health of any persons proposed for insurance, including significant history, findings, diagnosis and treatment, but excluding psychotherapy notes. MIB and other insurance companies may also furnish New York Life Insurance Company, its subsidiaries or the Plan Administrator with non-medical information (such as driving records, any criminal activity or association, hazardous sport or aviation activity, use of alcohol or drugs, and other applications for insurance). I understand that the information provided may include information that may predate the time frame stated on the medical questions section on this application. I also understand and agree that this information may be used during the underwriting and claims processes, where permitted by law. s New York Life Insurance Company may release information covered by this AUTHORIZATION to the Plan Administrator, MIB, other insurance companies and to others whom I authorize in writing. However, this will not be done in connection with information concerning Acquired Immune Deficiency Syndrome (AIDS). s This AUTHORIZATION may be used for a period of 24 months from the date signed below unless sooner revoked. I may revoke this AUTHORIZATION at any time by notifying the Administrator in writing at the address given on this form. My revocation will not be effective to the extent New York Life Insurance Company or any other person already has disclosed or collected information or taken other action in reliance on it, or to the extent that New York Life Insurance Company has a legal right to contest a claim under an insurance certificate or the certificate itself. A photocopy of this request form shall be as valid as the original. I acknowledge that I or my authorized agent may request a copy of this signed AUTHORIZATION. To the best of my knowledge and belief, the statements made regarding my health are true and complete. Member’s Signature X Date (PLEASE SIGN AND DATE IN INK.) Spouse’s Signature X Date (NECESSARY ONLY IF SPOUSE COVERAGE IS REQUESTED. PLEASE SIGN AND DATE IN INK.) Owner Information, required if owner is other than the member. (If Owner is a Trust, please submit a copy of the document with this application.) FULL NAME: LAST MAILING ADDRESS: STREET TAX ID# FIRST CITY MI RELATIONSHIP TO PROPOSED INSURED STATE DAYTIME PHONE ZIP CODE / / DATE OF BIRTH s s s -s s -s s s s SOCIAL SECURITY NUMBER (NECESSARY ONLY IF OTHER THAN MEMBER) Owner’s Signature X Date G-29133-0 4/07 ed. PAGE 4 29224/44375-9/07 GMA-PRS1

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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