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47341/47765/ 1018/47255

epsmoore_ppa-mn-47341-accidentaldeathanddismemberment

For PPA Members and Their Families

TO APPLY:

Complete this form and return with

your premium check payable to:

ADMINISTRATOR

PPA GROUP INSURANCE PROGRAM

P.O. BOX 10374

.

Des Moines, IA 50306-0374

For Puerto Rico Residents, the address is:

Global Insurance Agency, Inc.

P.O. Box 9023918

.

San Juan, PR 00902-3918

QUESTIONS?

1-800-588-7518

http://www.personal-plans.com/ppa

Request for Group Insurance From:

New York Life Insurance Company l 51 Madison Ave. l New York, NY 10010

Name:

Last First MI

Add 1:

Add 2:

City, St., Zip:

Are you presently insured under any Preferred Group Trust (of which PPA is a participant) Group Accidental Death &

Dismemberment Insurance Plans? qYes qNo

Are you now a member of the Professional Photographers of America? qYes qNo

(Membership in the PPA is required for participation in this Plan.)

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I request and authorize the PPA Group Insurance Program,

Inc. to make qsemiannual qannual withdrawals against the account specified on the attached voided check, and such bank to

process these withdrawals as if I had signed them, for the purpose of collecting premium contributions due under this Group

Accidental Death & Dismemberment Insurance Plan. (Enclose a VOIDED check.)

Select EFT as a secure payment option.

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1

For PPA Members and Their Families

Accidents. Television and newspapers report them every

day. But what if one happened to you? Would your

family have the financial resources to survive the crisis?

If you travel a great deal in your work ... or if you are

subject to possible injury on the job ... you may need

the PPA Group Accidental Death & Dismemberment

Insurance Plan. It helps protect you and your insured

family members by providing accident protection that

covers you year round ... anywhere in the world.

As a member of PPA under age 70, you are eligible to

apply for coverage for yourself, your lawful spouse

under age 70, and unmarried dependent children under

age 19 (26 if a full-time student). To become insured,

an application must be submitted and the required

premium contribution must be paid.

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Select EFT as a secure payment option.

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Before you request for coverage, you must be a member

in good standing of PPA. If you have any questions

regarding membership, please contact PPA directly.

Administrator,

PPA Group Insurance Program

If your state of residence mandates recognition of a

Domestic Partner as an eligible spouse, contact the

Administrator for a Declaration of Domestic Partnership

form or go to http://www.personal-plans.com/ppa to

download the form.

Administrator

PPA Group Insurance Program

P.O. Box 10374

Des Moines, IA 50306-0374

Residents of Puerto Rico:

Please send your completed application and check for

the initial contribution to:

Global Insurance Agency, Inc.

P.O. Box 9023918

San Juan, PR 00902-3918

To file a claim, write the Administrator for claim forms

or call 1-800-588-7518.

This Group Accidental Death & Dismemberment

Insurance Plan is Underwritten by:

New York Life Insurance Company

51 Madison Avenue

New York, NY 10010

under Group Policy No. G-29319-0

on Policy Form GMR-FACE/G-29319-0

This Group Accidental Death & Dismemberment

Insurance Plan is Administered by:

PPA Group Insurance Program

P.O. Box 10374

Des Moines, IA 50306-0374

1-800-588-7518

http://www.personal-plans.com/ppa

AR Ins. Lic. #245544

CA Ins. Lic. #0633005

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

Management

This coverage is available to residents of Canada

through Marsh Canada Limited.

Stephen Fretwell, an employee of Marsh Canada

Limited, acts as broker with respect to residents of

Canada.

Marsh U.S. Consumer, a Service of Seabury & Smith,

Inc., receives compensation in the form of a percentage

of the premium for services provided for this program.

These services may include application processing,

on-going servicing, billing, marketing, brokerage, claims

administrative and communications. If you are

interested in obtaining the specific compensation Marsh

U.S. Consumer received for this program please call us

at 1-888-206-5088 or view the transparency disclaimer

on the http://www.personal-plans.com/ppa.

The PPA incurs certain costs in connection with this

sponsored group plan. To provide and maintain this

valuable membership benefit, it is reimbursed for these

costs. PPA also receives a fee for the license of its name

and logo for use in connection with the Plan.

AD113P-47341

12/10 ed