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General Information

NOTE: Long Term Disability Insurance is not available to members who reside in Maine, New Hampshire, Vermont and Oregon.

By providing your email address to us, you expressly consent to receive emails from us. We may use email to communicate with you, to send information that you have requested or to send information about other products or services developed or provided by us, provided that, we will not give your email address to another party to promote their products or services directly to you.


Coverage Amount Requested

Coverage Questions

The Monthly Benefit Amount cannot exceed $ 1,600 or 67% of your gross monthly salary, whichever is less.

1
Have you been actively engaged in the full-time duties (at least 30 hours per week) of your occupation for the 90-day period immediately before the date of this application?
2
Do you have any Disability Income Insurance in force or pending in this (New York Life) or any other company? If yes, give detail.
3
Is the Monthly Benefit Amount herein applied for equal to or less than 67% of your Basic Monthly Pay minus any Other Income Benefits?
Beneficiary Designation for Member Coverage

Member is automatically designated as the beneficiary for spousal coverage.


Statement of Health

To the best of your knowledge and belief, answer the following 5 questions as they apply to you.

1
Are you now taking any prescribed medication or receiving or contemplating any medical attention or surgical treatment?
2
During the past five years have you ever been medically diagnosed by a physician as having or been treated for: heart or circulatory trouble, elevated blood pressure, chest pain or pressure, gynecological or genitourinary disorders, ulcers, cancer, diabetes, mental or nervous disorder or psychotherapeutic 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/disorder, arthritis, or unexplained weight loss?
3
During the past five years have you ever been counseled, treated or hospitalized for the use of alcohol or drugs?
4
Are you now pregnant?
5
Are you now disabled, or applied or applying for, or receiving any disability or Workers’ Compensation benefits or on waiver of premium for life or health insurance?
6
Has any person to be insured been convicted of a crime or served time in prison because of a conviction or have an arrest pending?
Payment Options

 

I hereby authorize Government Employees’ Benefit Association, Inc. (GEBA) to debit my checking/savings account according to the published schedule. I understand that GEBA reserves the right, upon written notification, to terminate my participation in this payment option. If an automatic debit is returned for any reason including insufficient funds, closed or unauthorized account, GEBA will not be able to process payment. I understand that I may be subject to a $20 charge if payment is rejected, reversed, or refused by my financial institution. I may cancel participation in the GEBA Automatic Debit service with written notice 10 days prior to the premium due date.

Fraud Notice

Authorization

To be eligible for this limited-time offer, you must be age 50 or younger and not currently insured under this disability plan for a monthly benefit in excess of $1,600.

Moreover, you are not eligible for this offer if:

  • You are currently on waiver of premium.
  • Your last application was declined for medical reasons.

I hereby authorize any licensed physician, medical practitioner, hospital, pharmacy, clinic or other medical or medically related facility, laboratory, insurance company, MIB, Inc. (“MIB”), or other organization, institution or person, that has any records or knowledge of me or my health 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 reinsurers, 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 for the purpose of evaluating my application for insurance. Health information obtained will not be re-disclosed without my authorization unless permitted by law, in which case it may not be protected under federal privacy rules. For example, New York Life may be required to provide it to insurance, regulatory, or other government agencies. In this case, the information may no longer be protected by the rules governing your AUTHORIZATION.

A photocopy of this AUTHORIZATION and request form shall be as valid as the original. In all circumstances, my authorized agent, representative, or I may request a copy of this AUTHORIZATION. This AUTHORIZATION shall be valid for a period of 24 months from the date signed, unless sooner revoked. The AUTHORIZATION may be revoked at any time by sending written notice to New York Life Insurance Company. My revocation will not be effective to the extent that New York Life 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 has a legal right to contest a claim under an insurance certificate or the certificate itself.

By signing and dating this application, the member requests the insurance indicated; and the member and any person proposed for insurance consent to authorize the disclosure of information to and from the providers noted above and in the IMPORTANT NOTICE, including making a brief report of my protected health information to MIB, Inc.; and attest to having read the IMPORTANT NOTICE and Fraud Notices enclosed, including how my information is exchanged with MIB, and that to the best of my knowledge and belief, the answers provided to the questions are true and complete.

By signing and dating this application, I request the insurance indicated, attest to having read the Fraud Notice above, and that to the best of my knowledge and belief, the answers to the questions are true and complete.

Electronic Enrollment Signature

THE FOLLOWING TERMS AND CONDITIONS GOVERN YOUR USE OF THE ONLINE ENROLLMENT.

IF YOU AGREE WITH THESE TERMS AND CONDITIONS, PLEASE CLICK THE ACCEPT BUTTON BELOW.

By clicking the accept button below, I acknowledge that I read, understand and agree with all the following statements:

  • I agree to the usage of electronic signature and electronic records for current and future transactions pertaining to my enrollment conducted through GEBA’s website, effective on the date I click on the “Accept” button.
  • I understand that I have the option to print and retain paper copies of any electronic records generated and to obtain paper copies of any electronic records generated during website transactions concerning my coverage(s).
  • I understand that to obtain paper copies of electronic records kept by GEBA concerning my coverage(s), or to withdraw my consent prospectively only to the usage of electronic records, I must contact GEBA.
  • I understand that in the event my personal contact information changes or any error is detected, I must immediately notify GEBA of the changes.
  • I understand that to access and conduct transactions relating to my coverage via www.GEBA.com internet site, I must have access to a personal computer at my home or workplace, which is capable of supporting internet access and a compatible browser application.
  • I hereby certify that I am a federal employee and am eligible to enroll under the GEBA sponsored Professional Liability Insurance Policy. I also attest that, as of this date, I have no knowledge of any allegations, claim or suit, or any act, error, or omission which might reasonably be expected to result in a claim or suit.

BY CLICKING THE “ACCEPT”, YOU ACKNOWLEDGE THAT YOU AGREE TO THE ELECTRONIC DELIVERY OF THE AGREEMENT AND TO BE LEGALLY BOUND WITH RESPECT TO THIS AGREEMENT AS IF YOU HAD SIGNED THIS AGREEMENT WITH A HAND WRITTEN SIGNATURE. YOU MAY PRINT AND RETAIN A COPY OF THIS AGREEMENT FOR YOUR RECORDS.



G-29344-0



GPA-DI-EZ2
LTDI-SI
10/13 ed.