epsmoore_cwru-34059-10yearleveltermlife.20130607040001

  The Alumni Association of Case Western Reserve University Residents of New York: Do not Use This Form Contact the Administrator for the Correct Form To Use To Apply: Complete this form and return to: ADMINISTRATOR ALUMNI GROUP INSURANCE PROGRAM P.O BOX 10374 Des Moines, IA 50306-8812 QUESTIONS? Call: 1-888-560-2586 Send No Money Now Name: Last First MI Add 1: Add 2: City, St., Zip: Request for Group Insurance From: New York Life Insurance Company 51 Madison Ave New York, NY 10010 I request and authorize the CWRU Group Insurance Program, Inc to make monthly withdrawals against the account specified on the attached and such bank to process these withdrawals as if I had signed them, for the purpose of collecting premium contributions due under this Group 10-Year Level Term Life Insurance Plan (Enclose a VOIDED check.) G-29124-0 GMA-PRS1 34059/50034/ 1018/50530 0000001-0000001-0000151  *00000601000* G-29124-0 GMA-PRS1 0000002-0000002-0000151  G-29124-0 GMA-PRS1 0000003-0000003-0000151  *00010602000* G-29124-0 GMA-PRS1 0000004-0000004-0000151  G-29124-0 GMA-PRS1 0000005-0000005-0000151 Group 10-Year Level Term Life Plan 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 Web site at www.mib.com *00020603000*  $ 0000006-0000006-0000151  The Alumni Association of Case Western Reserve University Sponsored Life Insurance Program Underwritten by New York Life Insurance Company Attention The Alumni Association of Case Western Reserve University 0000007-0000007-0000151  Please call toll-free at 1-888-560-2586 for more information about these and other insurance products Marsh/Alumni Services P.O Box 10374 Des Moines, IA 50306-8812 Alumni and their spouses under age 65 are eligible to apply This coverage is available only for residents of the United States (except territories) and Puerto Rico Coverage may not be available in all states Call Marsh U.S Consumer at 1-888-560-2586 for details Administered by: New York Life Insurance Company 51 Madison Ave New York, NY 10010 under Group Policy G-29124-0 on Policy Form GMR-FACE/G-29124-0 *00030604000* Marsh U.S Consumer, a service of Seabury & Smith, Inc P.O Box 10374 Des Moines, IA 50306-8812 Questions? If you have any questions or need more information about the Alumni-sponsored 10-Year Group Term Life Insurance Plan, please call toll-free at 1-888-560-2586 Underwritten by: 0000008-0000008-0000151  The 10-Year Group Term Life Insurance Plan is sponsored by CWRU Alumni as an Alumni service to you It allows you and your spouse to supplement your current insurance plan at an affordable group rate CWRU Alumni incur no expense through the sponsorship of these programs Administered by: Marsh U.S Consumer, a service of Seabury & Smith, Inc P.O Box 10374 Des Moines, IA 50306-8812 If you have any questions or need more information about the CWRU Alumni-sponsored 10-Year Group Term Life Insurance Plan, please call toll-free at 1-888-560-2586 Underwritten by: New York Life Insurance Company 51 Madison Ave New York, NY 10010 This brochure provides a general description of the insurance plan offered and is not a contract Complete terms are detailed in Group Policy No G-29124-0, Policy Form GMR, issued to the Group Policyholder, the Trustee of the Alumni Group Insurance Trust Each insured individual will be provided with a Certificate of Insurance that summarizes the policy provisions affecting his/her coverage 0000009-0000009-0000151  *00040605000* 0000010-0000010-0000151  0000011-0000011-0000151 Residents of Puerto Rico: Please send the completed application to: Global Insurance Agency, Inc P.O Box 9023918 San Juan, Puerto Rico 00902-3918 The 10-Year Level Term Life Plan is underwritten by: New York Life Insurance Company 51 Madison Ave New York, NY 10010 under Group Policy G-29124-0 on Policy Form GMR-FACE/G-29124-0 The 10-Year Level Term Life Plan is administered by: *00050606000* Marsh U.S Consumer, a service of Seabury & Smith, Inc P.O Box 10374 Des Moines, IA 50306-8812 AR Ins Lic #245544 CA Ins Lic #0633005 d/b/a in CA Seabury & Smith Insurance Program Management Questions? If you have any questions or need more information about the 10-Year Group Term Life Insurance Plan or other insurance products, please call toll-free at 1-888-560-2586 This brochure provides a general description of the insurance plan offered and is not a contract Complete terms are detailed in Group Policy No G-29124-0 (Policy Form GMR) issued to the Group Policyholder, the Trustee of the Alumni Group Insurance Trust Each insured individual will be provided with a Certificate of Insurance that summarizes the policy provisions affecting his/her coverage LYA113P-34059 May 2013  0000012-0000012-0000151