In this notice, references to "you" and "your" include any person proposed for insurance. Information regarding insurability will be treated as confidential. In considering whether the person(s) in your request for insurance qualify for insurance , we will rely on the medical information you provide, and on the information you AUTHORIZE us to obtain from your physician, other medical practitioners and facilities, other insurance companies to which you have applied for insurance and MIB, Inc. (“MIB”). MIB is a not-for-profit organization of insurance companies, which operates an information exchange on behalf of its members. If you apply for life or health insurance coverage, a claim for benefits is submitted to an MIB member company, medical or non-medical information may be given to MIB, and such information may then be furnished by MIB, upon request, to a member company.
Your AUTHORIZATION may be used for a period of 24 months from the date you signed the application for insurance, unless sooner revoked. The AUTHORIZATION may be revoked at any time by notifying New York Life in writing at the address provided. Your revocation will not be effective to the extent 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. The information New York Life obtains through your AUTHORIZATION may become subject to further disclosure. 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.
MIB and other insurance companies may also furnish New York Life, its subsidiaries or the Plan Administrator with non-medical information (such as driving records, past convictions, hazardous sport or aviation activity, use of alcohol or drugs, and other applications for insurance). The information provided may include information that may predate the time frame stated on the medical questions section, if any, on this application. This information may be used during the underwriting and claims processes, where permitted by law.
New York Life may release this information to the Plan Administrator, other insurance companies to which you may apply for life and health insurance, or to which a claim for benefits may be submitted and to others whom you authorize in writing, however, this will not be done in connection with test results concerning Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV). We may also make a brief report of your protected health information to MIB, but we will not disclose our underwriting decision
New York Life will not disclose such information to anyone except those you authorize or where required or permitted by law. Information in our files may be seen by New York Life and Plan Administrator employees, but only on a "need to know" basis in considering your request. Upon receipt of all requested information, we will make a determination as to whether your request for insurance can be approved.
If we cannot provide the coverage you requested, we will tell you why. If you feel our information is inaccurate, you will be given a chance to correct or complete the information in our files. Upon written request to New York Life or MIB, you will be provided with non-medical information. Generally, medical information will be given either directly to the proposed insured or to a medical professional designated by the proposed insured. Your request is handled in accordance with the Federal Fair Credit Reporting Act procedures. If you question the accuracy of the information provided by MIB, you may contact MIB and seek a correction. MIB's information office is: MIB, Inc., 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734, telephone 866-692-6901 (TTY 866 346-3642). For Canadian residents, the address is: MIB Information Office, 330 University Avenue, Suite 501, Toronto, Ontario, Canada M5G 1R7, telephone 416-597-0590. Information for consumers about MIB may be obtained on its website at mib.com.
For NM Residents: PROTECTED PERSONS1 have a right of access to certain CONFIDENTIAL ABUSE INFORMATION2 we maintain in our files and they may choose to receive such information directly. You have the right to register as a PROTECTED PERSON by sending a signed request to the Administrator at the address listed on the application. Please include your full name, date of birth and address.
1PROTECTED PERSON means a victim of domestic abuse: who has notified us that he/she is or has been a victim of domestic abuse; and who is an insured person or prospective insured person.
2CONFIDENTIAL ABUSE INFORMATION means information about: acts of domestic abuse or abuse status; the work or home address or telephone number of a victim of domestic abuse; or the status of an applicant or insured as family member, employer or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close, personal, family or abuse-related relationship.
New York Life Insurance Company 8.12 ed.
Your session will expire in one minute. If your session expires, any information you enter for this application will not be transferred to any subsequent application you fill out.
Transferring information from one application to another is a service GEBA offers, but only if applications are submitted within 30 minutes of each other.
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.
The Monthly Benefit Amount cannot exceed $ 1,600 or 67% of your gross monthly salary, whichever is less.
Member is automatically designated as the beneficiary for spousal coverage.
To the best of your knowledge and belief, answer the following 5 questions as they apply to you.
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.
You must include your ABA (Routing) Number for your bank. Use this image to see where your routing number is listed, if you don't already know. An ABA/Routing number is always 9 digits, no letters or punctuation.
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:
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
IMPORTANT NOTICE: How New York Life Obtains Information and Underwrites Your Request For Group Long Term Disability Insurance
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.
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:
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.
To view your rate, you must enter your date of birth, waiting period, and payment frequency. If you do not have all the required fields, this Rate will remain blank.