2007-2008 IEEE Multiplan Brochure

Signature X Signature(s) as required on checks issued/withdrawals made against this account. Date X e. Do you now have or are you applying for other insurance that provides benefits if you are unable to work because of a disability? s Yes (please list below) s No Company Plan Monthly Benefit Benefit Period f. Do you intend to discontinue any of the disability insurance listed in “e” above, if the coverage applied for is approved? s Yes s No (If “Yes,” please indicate which coverage and the date it will be terminated.) 4. Statement of Health: (Please initial any changes you make on this form.) To the best of your knowledge and belief, please answer the following questions as they apply to you. [California Residents: California law prohibits an HIV test from being required or used by health insurance companies as a condition for obtaining health insurance coverage.] [ME Residents only: You are not required to disclose whether you have been tested for HIV if you have not developed symptoms of the disease, AIDS or AIDS-Related Complex (ARC) in your answer to any of the following questions.] [For MN residents only: The applicant does not have to disclose an HIV (AIDS Virus) test that was administered: (1) to a criminal offender or crime victim as a result of a crime that was reported to the police; (2) to a patient who received the services of emergency medical services personnel at a hospital or medical facility; (3) to emergency medical personnel who were tested as a result of performing emergency medical services. Refer to the Authorization section for a definition of “Emergency Medical Personnel.”] YES NO 1. Are you now ill or taking any prescribed medication or receiving or contemplating any medical attention or surgical treatment? s s 2. During the past five years, have you ever been medically diagnosed by a physician or other medical care practitioner as having or been treated for: a) Heart or circulatory trouble, elevated blood pressure, chest pain or pressure, gynecological or genitourinary disorders, disorder of the breasts or reproductive organs or functions, ulcers or digestive disorders, cancer, tumor or cyst, diabetes, mental or nervous disorders, emotional conditions, psychiatric care or psychotherapeutic treatment, fainting spells, convulsions or epilepsy, respiratory disorder, kidney or liver disorder (including hepatitis), enlarged lymph nodes or immunodeficiency disorder, thyroid disorder, blood disorder, albumin, blood, pus or sugar in urine, back trouble/disorder, arthritis, bone or joint disorder, varicose veins, hemorrhoids or hernia, disorder of eyes, ears, nose or sinuses, unexplained weight loss or accidental injury? s s b) Other health or physical impairment including: (i) [This question applies to all applicants EXCEPT FL residents] Being medically diagnosed as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC)? s s [Florida residents only—answer the following:] Have you ever been tested positive for exposure to the HIV infection, or been diagnosed as having ARC (AIDS-Related Complex) or AIDS (Acquired Immune Deficiency Syndrome) caused by the HIV infection, or other sickness or condition derived from such infection? s s (ii) Chronic cough, persistent diarrhea, enlarged lymph glands, chronic fatigue in the past five years? (iii) Any other impairment? During the past five years, have you ever been counseled, treated or hospitalized for the use of alcohol or drugs? Are you now pregnant? Are you now disabled, applied or applying for, or receiving any disability or workers compensation benefits or on waiver of premium for life or health insurance? During the past two years, have you participated in, or do you plan to participate in: aircraft flying other than as a passenger, scuba diving, ultra light flying, ballooning, parachuting, mountaineering, rodeo riding, snowmobiling, hang gliding, parasailing, bungee jumping or organized motorcycle racing, or any type of organized motorized racing? .. Driver’s License No.: State Issued: During the past five years, have you had your driver’s license suspended, or revoked, or had any moving violations? During the past 24 months, have you ever used tobacco or nicotine in any form, including nicotine patches and nicotine chewing gum? Are you currently incarcerated, or have an arrest pending, or during the past 15 years (7 in Maryland) served time in prison? If you have answered any of the previous questions 1–10 “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 Illness or Condition-Date of Onset-Duration-TreatmentOperation-Degree of Recovery and Date Name and Address of Physicians or other Practitioners and Hospitals where confined or treated 3. 4. 5. 6. s s s s s s s s ss ss ss ss ss 7. 8. 9. 10. 11. G-12150-2 BE SURE TO COMPLETE NEXT PAGE AND SIGN LAST PAGE ± PAGE 2 GPA-DI-FMU

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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