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10365/17935/ 1018/52247

epsmoore_nysut-ny-10365-lifeinsurance

Home Office: 175 Water Street, New York, NY 10038

(Herein called the Company)

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Please note: Appendix 11 (enclosed) for applicant must be filled out, signed, dated, and returned with the application.

For Office use only:

NYSUT DB 14212/14214/1007/52248-S

NYSUT PRD 12380/12381/1008/52248

UFT DB 19630/19631/1004/52249-S

UFT PRD 19058/19059/1005/52249

NYSUT DB RET 19048/19049/1009/52248-S

NYSUT PEN RET 18915/18916/1010/52248

ADMINISTRATOR

Mercer Consumer

P.O. Box 9186

Des Moines, IA 50306-8838

QUESTIONS?

Call: 1-888-386-9788

Email: customerservice.service@mercer.com

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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.

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Mail your application, one copy of Appendix 11 (and

the appropriate deduction authorization form, if

applicable) to:

Mercer Consumer, a service of Mercer Health &

Benefits Administration LLC

Insurance Plans Administrator

P.O. Box 9186

Des Moines, IA 50306-8838

Plan Administrator:

Mercer Consumer, a service of Mercer Health &

Benefits Administration LLC

P.O. Box 9186

Des Moines, IA 50306-8838

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

AR Insurance License #100102691

CA Insurance License #0G39709

In CA d/b/a Mercer Health & Benefits

Insurance Services LLC

MN Insurance License #40291395

OK Insurance License #100100336

TX Insurance License #1850385

Underwritten By:

The United States Life Insurance Company in

the City of New York

Policies issued by The United States Life Insurance

Company in the City of New York (US Life). Issuing

company US Life is responsible for financial

obligations of insurance products and is a member of

American International Group, Inc. (AIG). Products

may not be available in all states and product features

may vary by state. Policy No. G-233,615 Form No.

G-19000.

This brochure is a brief description of benefits only

and is subject to the terms, conditions, exclusions and

limitations of the group policy.

Copyright 2017 Mercer LLC. All rights reserved.

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