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General Information

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Your Plan and Payment Options



Replacement Insurance Disclosure and Questions

Do you have other life insurance in force?

If 'Yes', total amount in all companies



Do you have other life insurance applications pending?



If 'Yes' indicate amount and company



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 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assigned, terminated, changed or modified into paid-up insurance or other forms of benefits, loaned against or withdrawn from, reduced in value, by use of cash values or other policy values, changed in length of time or in the amount of insurance that would continue or continued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 decide whether the replacement is in you best interest.

Is the insurance applied for intended to replace, discontinue or change an existing policy? RESIDENTS OF NEW YORK: I have read the Important Replacement Information above. Is the life insurance applied for intended to replace, in whole or in part, any existing insurance or annuity?



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.

Statement of Health

To the best of your knowledge and belief, answer the following questions as they apply to you and all dependents to be insured. Please have your medical records when completing this section. If you are requesting Spousal/Partner coverage, your spouse will fill out his/her section after you have completed your health section.

1
Is any person proposed for insurance now taking any prescribed medication or receiving or contemplating any medical attention or surgical treatments?
2
During the past five years, has any person proposed for insurance ever been medically diagnosed by a physician as having or been treated for: heart trouble; elevated blood 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, has any person proposed for insurance been counseled, treated or hospitalized for the use of alcohol or drugs?
4
Tobacco/Nicotine Use: Have you or your spouse used tobacco or any nicotine substitute in any form, including nicotine patches, nicotine chewing gum, and electronic cigarettes. If yes, please state when you last used tobacco or nicotine products and specify the product used.
1
Is any person proposed for insurance now taking any prescribed medication or receiving or contemplating any medical attention or surgical treatments?
2
During the past five years, has any person proposed for insurance ever been medically diagnosed by a physician as having or been treated for: heart trouble; elevated blood 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, has any person proposed for insurance been counseled, treated or hospitalized for the use of alcohol or drugs?
4
Tobacco/Nicotine Use: Have you or your spouse used tobacco or any nicotine substitute in any form, including nicotine patches, nicotine chewing gum, and electronic cigarettes. If yes, please state when you last used tobacco or nicotine products and specify the product used.
Beneficiary Designation for Member Coverage
Add Another Beneficiary
Authorization
  1. Personalized Certificate of Coverage Page will be mailed to policyholder upon plan approval. Certificate of Insurance can be viewed, downloaded and printed at www.geba.com. By signing this document, I certify that I am an employee of the agency denoted above which entitles me to become a member of GEBA.

  2. 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 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 above.

    AUTHORIZATION: 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/our] protected health information to MIB, Inc.; and attest to having read the IMPORTANT NOTICE and Fraud Notices indicated below, including how [my/our] information is exchanged with MIB, and that to the best of [my/our] knowledge and belief, the answers provided to the questions are true and complete.

  3. Please keep this notice for your records.
FRAUD NOTICE

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.

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.



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