Exclusions and Limitations
Benefits are paid for death from any cause, at anytime, anywhere in the world (subject to the U.S. government regulations on restricted countries) except suicide which is not covered within 24 months of issue date of your coverage. In the case of death due to suicide within 24 months of coverage, the benefit will be limited to the return of premiums paid.
Accelerated Benefits are not payable if there is an absolute assignment; there is an irrevocable beneficiary who does not give written consent; there is a court decree involving the life insurance in connection with a divorce agreement; or the illness is due to intentionally self-inflicted injury or attempted suicide. Receipt of Accelerated Benefits may be taxable. Consult your personal tax advisor for specific details.
Effective Date of Coverage
Residents of MD and NC: Any reference to "performing normal activities of a person in good health of like age" is replaced by the requirement that the heath status of any proposed insured person remains the same as stated in your application. Insurance will take effect on the date your application is approved, provided the initial contribution is paid within 31 days after you are billed and any person to be insured is performing normal activities of a person in good health of like age on the day of approval. If any dependent proposed for coverage is not performing his/her normal activities as required, coverage will not take effect until he/she is performing such activities provided such date is within three months after the date insurance would have been effective and the person is still eligible.
When Coverage Ends
Coverage will end when the insured person reaches age 80 (or 25 for children) or earlier if: (a) the premiums are not paid when due, (b) ACA membership ends, (c) the group plan is terminated or modified by the Policyholder to end insurance for the group of insureds to which the member belongs, and (d) if the insured requests to terminate insurance. In addition, dependent coverage will terminate when the dependent spouse or child ceases to be an eligible dependent.
You Name Your Beneficiary
Your beneficiary is the person(s) last designated by you in writing, and recorded by or on behalf of New York Life Insurance Company. You can name any beneficiary you wish for member coverage. You may change this beneficiary at any time, by written request. You are the automatic beneficiary for dependent insurance, as described in the Certificate of Insurance. If you wish to name another beneficiary for dependent spouse or child insurance, contact the Administrator at 1-800-626-9226 for the applicable form.
Certificate of Insurance This information is only a brief description of the principle provisions and features of the ACA Group Term Life Plan. The complete terms and conditions are set forth in the group policy issued by New York Life Insurance Company Trustee of the American Chiropractic Association Insurance Trust.
How New York Life Obtains Information and Underwrites Your Request For Group Term Life Insurance
In this notice, references to "you" and "your" include any person proposed for insurance. Information regarding insurability will be treated as confidential. In considering whether the person(s) in your request for insurance qualify for insurance , we will rely on the medical information you provide, and on the information you AUTHORIZE us to obtain from your physician, other medical practitioners and facilities, other insurance companies to which you have applied for insurance and MIB, Inc. ("MIB"). MIB is a not-for-profit organization of insurance companies, which operates an information exchange on behalf of its members. If you apply for life or health insurance coverage, a claim for benefits is submitted to an MIB member company, medical or non-medical information may be given to MIB, and such information may then be furnished by MIB, upon request, to a member company.
Your AUTHORIZATION may be used for a period of 24 months from the date you signed the application for insurance, unless sooner revoked. The AUTHORIZATION may be revoked at any time by notifying New York Life in writing at the address provided. Your revocation will not be effective to the extent 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. The information New York Life obtains through your AUTHORIZATION may become subject to further disclosure. 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.
MIB and other insurance companies may also furnish New York Life, its subsidiaries or the Plan Administrator with non-medical information (such as driving records, past convictions, hazardous sport or aviation activity, use of alcohol or drugs, and other applications for insurance). The information provided may include information that may predate the time frame stated on the medical questions section, if any, on this application. This information may be used during the underwriting and claims processes, where permitted by law.
New York Life may release this information to the Plan Administrator, other insurance companies to which you may apply for life and health insurance, or to which a claim for benefits may be submitted and to others whom you authorize in writing, however, this will not be done in connection with test results concerning Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV). We may also make a brief report of your protected health information to MIB, but we will not disclose our underwriting decision
New York Life will not disclose such information to anyone except those you authorize or where required or permitted by law. Information in our files may be seen by New York Life and Plan Administrator employees, but only on a "need to know" basis in considering your request. Upon receipt of all requested information, we will make a determination as to whether your request for insurance can be approved.
If we cannot provide the coverage you requested, we will tell you why. If you feel our information is inaccurate, you will be given a chance to correct or complete the information in our files. Upon written request to New York Life or MIB, you will be provided with non-medical information. Generally, medical information will be given either directly to the proposed insured or to a medical professional designated by the proposed insured. Your request is handled in accordance with the Federal Fair Credit Reporting Act procedures. If you question the accuracy of the information provided by MIB, you may contact MIB and seek a correction. MIB's information office is: MIB, Inc., 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734, telephone 866-692-6901 (TTY 866 346-3642). 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 website at www.mib.com.
For NM Residents: Protected persons 1 have a right of access to certain Confidential abuse information 2 we maintain in our files and they may choose to receive such information directly. You have the right to register as a Protected person by sending a signed request to the Administrator at the address listed on the application. Please include your full name, date of birth and address. 1 Protected person means a victim of domestic abuse: who has notified us that he/she is or has been a victim of domestic abuse; and who is an insured person or prospective insured person. 2 Confidential abuse information means information about: acts of domestic abuse or abuse status; the work or home address or telephone number of a victim of domestic abuse; or the status of an applicant or insured as family member, employer or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close, personal, family or abuse-related relationship.
New York Life Insurance Company 8.12 ed.
ACA incurs certain administrative expenses in connection with this sponsored program. To provide and maintain this valuable membership benefit it is reimbursed for such expenses.
P.O. Box 9159
Phoenix, AZ. 85068-9918
A.G.I.A., Inc. is licensed/authorized to transact business in all 50 United States, and the District of Columbia. Their state of domicile is California. John Wigle California Agent license number is 0482924. John Wigle Arkansas Agent License Number is 46424.
The Group Term Life plan is underwritten by:
New York Life Insurance Company
51 Madison Avenue, New York, NY 10010
Under Group Policy G-29051-1, on
Policy Form GMR-FACE/G-29051-1
New York Life is licensed/authorized to transact business in all 50 united states, District of Columbia, Puerto Rico and Canada. However, not all group plans it underwrites are available in all jurisdictions. Please check the plan details for current availability.
New York Life Insurance Company's state of domicile is New York and their NAIC ID # is 55915.