0000265-0000001-0000017

19058/19059/ 1018/49741

epsmoore_-Nysut-ct-19058-lifeinsurance

ADMINISTRATOR

Marsh U.S. Consumer,

a Service of Seabury & Smith, Inc.

P.O. BOX 9186

Des Moines, IA 50306-8838

QUESTIONS?

Call: 1-888-386-9788

Email: customerservice@marshpm.com

Our hearing-impaired or voice-impaired members

may call the Relay Line at 1-800-855-2881.

For Office use only:

NYSUT DB 14212/14214/1007/49753-S

NYSUT PRD 12380/12381/1008/49753

UFT DB 19630/19631/1004/49755-S

UFT PRD 19058/19059/1005/49755

NYSUT DB RET 19048/19049/1009/49753-S

NYSUT PEN RET 18915/18916/1010/49753

Please increase my current Term Life Insurance coverage by $____. I understand that to apply for this increase,

my answers to the three health questions are usually all that is required, unless my total amount of coverage exceeds

$200,000.

G-19430 CT Group Policy No. G-233,615 and G-170,468 3/12

0000266-0000001-0000017

*01320001000*

Please answer these brief questions. Applicant

1. To the best of your knowledge and belief, have you ever had, been diagnosed with, or been treated for:

chest pain; disease or disorder of the heart, liver, kidneys, blood or lungs; high blood pressure; stroke or

other neurological disorder; mental/nervous disorder; drug or alcohol abuse; diabetes; cancer or tumor;

Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or AIDS related conditions? q Yes q No

2. Have you during the past 5 years, consulted any physician or other practitioner or been confined or treated

in any hospital or similar institution, for any reason other than those stated above? q Yes q No

3. Are you now taking prescription medication or receiving medical attention? q Yes q No

For "Yes" answers to questions 1-3 above, please provide details in the space provided below. If more space is needed,

use a separate sheet of paper, signed and dated.

Group Policy No. G-233,615 and G-170,468 3/12G-19430 CT

2

0000267-0000001-0000017

AUTHORIZATION AND DECLARATION OF EACH PERSON GIVING A STATEMENT OF INSURABILITY

I hereby authorize any licensed physician, medical practitioner, pharmacy, pharmacy benefit manager and other sources, hospital, clinic,

or other medical or medically related facility, insurance company, the MIB, Inc., formerly known as the Medical Information Bureau, or

other organization, institution or person that has any records or knowledge of me or my health, to give to the Company or its reinsurers

any such information. Such information will pertain to my employment, or other insurance coverage and medical care, advice, treatment

or supplies for any physical or mental condition. This includes information obtained in connection with the preparation or procurement of

an investigative consumer report as defined under the Fair Credit Reporting Act(s). To facilitate the rapid submission of such information, I

authorize all said sources, except the MIB, to give such records or knowledge to any agency employed by the Company to collect and

transmit such information. I understand that this information will be used by the Company solely to determine eligibility for insurance. I

understand that I may revoke this authorization at anytime by giving written notice to the Company. I agree that such revocation will not

affect any action, that any source has taken in reliance upon this authorization. I understand this authorization will be valid for 24 months

from the effective date of coverage, if not revoked earlier. I know that I should retain a copy of this authorization for my records. I agree

that a photocopy of this authorization is as valid as the original. To the best of my knowledge and belief, all statements made above are

true and complete. I understand that my application for group insurance will be accepted or declined on the basis of these statements.

Insurance will take effect only if a certificate is issued based on this application and the first premium is paid in full (a) during the lifetime

of all proposed insureds; and (b) while there is no change in the insurability or health of such person from that stated in the application.

+Dependent Children must be unmarried, up to 23 years of age.

Important Notice: Any person who knowingly and with intent to defraud any insurance company or other person files a

statement of claim containing any materially false information, or conceals for the purpose of misleading, information

concerning any fact material thereto, commits a fraudulent insurance act, which may be a crime.

Applicant's Signature Date

G-19430 CT 3 Group Policy No. G-233,615 and G-170,468 3/12

AG-9233

0000268-0000001-0000017

THIS PAGE IS INTENTIONALLY LEFT BLANK.

*01330001000*

0000269-0000001-0000017

0000270-0000001-0000017

THIS PAGE IS INTENTIONALLY LEFT BLANK.

*01340001000*

0000271-0000001-0000017

0000272-0000001-0000017

*01350001000*

0000273-0000001-0000017

0000274-0000001-0000017

*01360001000*

If the total amount applied for, plus existing Member

Benefits-endorsed Term Life Insurance Plan coverage, equals or

exceeds $200,000, and in certain circumstances, a medical

examination is required. In addition to the medical exam,

additional medical information will be required for applicants

ages 65 and over. If additional information is needed, you will

be contacted by the underwriting company. Do not cancel any

other life insurance until after you are accepted into this

program.

0000275-0000001-0000017

4. Mail your application (and the appropriate

deduction authorization form if applicable) to:

Marsh U.S. Consumer,

a service of Seabury & Smith, Inc.

Insurance Plans Administrator

P.O. Box 9186

Des Moines, IA 50306-8838

Plan Administrator:

Marsh U.S. Consumer,

a service of Seabury & Smith, Inc.

P.O. Box 9186

Des Moines, IA 50306-8838

Call Toll-Free: 1-888-386-9788

AR Ins. Lic. #245544

CA Ins. Lic. #0633005

d/b/a in CA Seabury & Smith Insurance Program

Management

Underwritten By:

The United States Life Insurance Company in

the City of New York

This is a brief description of coverage underwritten by

The United States Life Insurance Company in the City

of New York, and is subject to the terms, conditions,

exclusions and limitations of Group Policy Nos. G-233,

615, and G-170,468, Form No. G-19000. Please see

your Certificate of Insurance for details.

The underwriting risks, financial and contractual

obligations and support functions associated with the

products issued by the United State Life Insurance

Company in the City of New York are its

responsibility.

AG-9233

0000276-0000001-0000017

THIS PAGE IS INTENTIONALLY LEFT BLANK.

*01370001000*

0000277-0000001-0000017

6

0000278-0000001-0000017

THIS PAGE IS INTENTIONALLY LEFT BLANK.

*01380001000*

0000279-0000001-0000017

7

0000280-0000001-0000017

8

*01390001000*