Who is Eligible?
ACP members between ages 50-74 are eligible to apply for coverage for themselves; and age 45-74 for their lawful spouses. In order to become insured, satisfactory evidence of insurability must be provided and the required premium must be paid. If both member and spouse are covered as members, neither may insure the other as spouse. This coverage is available only for residents of the United States (excluding CT, MA, NY, UT, WA and territories) and Puerto Rico.
Your Choice of Beneficiary
You may select any person, persons, trust or other legal entity as your beneficiary. If, at the time of your death, there are no surviving beneficiaries, benefits will be paid to the executor or administrator of your estate, or at the option of New York Life, to the surviving relatives in the following order of survival: spouse; children equally; parents equally; or brothers and sisters equally.
CURRENT 2017 MONTHLY PREMIUM CONTRIBUTIONS
The initial cost of insurance is based on the individual’s attained age when insurance becomes effective, the amount of insurance selected and tobacco/nicotine use. The cost increases as the insured grows older.
†† You will be billed semi-annually. Additional payment options including monthly Electronic Funds Transfer (EFT) can be selected after first billing.
†† Spousal rates only. Spouse amount cannot exceed member coverage.
* For rates after age 74, contact the administrator.
** Male rates apply to all coverage issued to Montana residents, regardless of a person’s gender.
The premium contributions shown reflect the current rates and benefit structure. Premium contributions may be changed by New York Life Insurance Company on any premium due date, but not more than once in any 12-month period, and on any date on which benefits are changed. However, your rates may change only if they are changed for all others in the same class of insureds under this group policy. For example, a class of insureds is a group of people all with the same issue age and tobacco/nicotine usage. Benefit option amounts are not guaranteed and are subject to change by agreement between New York Life Insurance Company and the Trustee.
Accelerated "Living" Benefits
Partial “living” benefits may be paid before death for any one cause: terminal illness, chronic illness or permanent critical condition.
|For Qualifying Event:†
||Life Benefit Amount
(50% of death benefit amount)
|Chronic Illness** or Permanent Critical Condition***
(25% of amount of insurance)
* Terminal Illness is a condition for which the patient has a life expectancy of 12 months or less.
** Chronic Illness means an illness: (a) with one or more of the following characteristics: permanency, residual disability,requires rehabilitation training, or requires a long period of supervision, observation or care; and (b) which a LICENSED HEALTH CARE PRACTITIONER* certifies the covered person is unable to perform any two of the following Activities of Daily Living for a continuous period of 180 days: bathing, dressing, toileting, Transferring (Defined as the ability to move in and out of bed, chair or wheelchair with or without the aid of equipment such as: a cane, walker, crutches, grab bars, or other support devices), eating or continence.
*** Permanent Critical Condition means a medical condition for which a covered person: (a) is certified by a LICENSED HEALTH CARE PRACTITIONER* as having a severe cognitive impairment; (b) is required to be continuously confined in a Convalescent Care Facility (does not include: a rest home; a place for care of the aged alcoholics, mentally ill or drug addicts; and/or a place for custodial care.) Hospice (to qualify, the HOSPICE must meet the standards of the National Hospice Organization and the applicable state licensing requirements), Nursing Home (does not include a rest home, an assisted living facility or a place for care of the aged, alcoholics or drug addicts) or at home; (c) is required to be under substantial supervision to protect the covered person from threats to health and safety due to such severe cognitive impairment; and (d) is required to be under a plan of care prescribed by a LICENSED HEALTH CARE PRACTITIONER.*
*LICENSED HEALTH CARE PRACTITIONER means: licensed physician or osteopath; a registered professional nurse, or licensed social worker, who is operating within the scope of his or her license.
† Maximum Benefit Payable: No more than one Accelerated Benefit is payable for any one (1) Terminal Illness; Chronic Illness; or Permanent Critical Condition. With respect to a Chronic Illness or Permanent Critical Condition, only one Qualifying Event is payable. Also, in order to have a minimum Death Benefit equal to 25% of the Amount of Insurance, no more than 75% of the Amount of Insurance is payable for Qualifying Events on each covered person. NOTE: If the Death Benefit is reduced by a payment of an accelerated benefit; premiums due are based on the reduced level of death benefit.
The plan provides conversion privileges under certain circumstances of involuntary termination as described in the Certificate of Insurance.
ADDITIONAL PLAN PROVISIONS
Insurance will take effect on the date your application is approved by New York Life Insurance Company provided the initial contribution is paid within 31 days after the date you are billed (send no money now) and any person to be insured is actively performing the normal activities of a person in good health of like age. Note: Residents of NC: Any reference to “performing the normal activities of a person in good health” is replaced by the requirement that the health status of any proposed insured person remains the same as stated in your application. Any person who is not performing his/her normal daily activities as required will not become insured until the day he/she is performing such activities, provided such date is within three months of the date insurance would have been effective and the person is still eligible.
Your insurance can remain in force until the insured person reaches age 90, provided you remain a member of ACP, you continue to pay premium contributions when due, and the group policy is not terminated by the Trustee or New York Life Insurance Company. Your spouse’s coverage ends when your coverage ends or earlier if he/she is no longer your lawful married spouse or when he/she reaches age 90. Upon your death, coverage for your spouse may continue as described in the Certificate of Insurance.
The validity of any amount of your insurance that has been in force for two years during your lifetime will not be contested except for insurance eligibility provisions or nonpayment of premium contributions.
Benefits will be paid in the event of death, anywhere in the world regardless of cause, except for suicide within 12 months of the certificate effective date, in which case the only amount payable is a return of the applicable contributions and except for insurance eligibility provisions or impairment and premium contributions (See limitations applicable to Accelerated Benefits at right).
HOW TO APPLY
Consider Your Eligibility
Before you request coverage, you must be a member in good standing with ACP. Please wait until your
application for membership is accepted before initiating insurance request. If you have any questions regarding
membership, please contact ACP directly.
Get Quicker, Easier Service When You Apply
The information provided when you fill out your Application can make the medical underwriting process
quicker and easier. By providing complete and accurate information, you avoid delays that may occur while
we wait for missing information to be received and shorten the time needed for underwriting decisions and
approvals. We also request that you provide the following information for everyone you are requesting coverage on as well as on any named beneficiary: full name, address, date of birth, Social Security number, and telephone number. Please call 1-888-643-0323 to complete this request. If you prefer enclose a separate piece of paper with this information together with your application. New York Life Insurance Company relies on your answers and statements. Misstatements or failures to report information on your application may be used as the basis for invalidating your insurance. The Senior Group Term Life Insurance Plan is medically
underwritten based on the information provided by you on your Application. It is important that you complete
the form truthfully and completely. Your Application is subject to New York Life Insurance Company’s approval
and more medical information may be requested. A physical exam, EKG, blood test or other medical
information may be required. If so we will arrange for an independent professional paramedic to contact
you and arrange to perform these simple tests at your convenience. The exam and the blood test will be paid
for by the Plan.
Apply in Three Easy Steps
1. Refer to the Plan description for benefits and premium costs as you fill out the application.
Be sure to indicate if you are requesting coverage for your spouse.
2. Complete, sign and date the Application.
DO NOT SEND MONEY NOW.
YOU’LL BE BILLED LATER.
3. Mail the completed application to:
ACP Group Insurance Program
P.O. Box 10374
Des Moines, IA 50306-8812
Residents of Puerto Rico:
Please send your completed application to:
Global Insurance Agency, Inc.
P.O. Box 9023918
San Juan, PR 00902-3918
If you have questions about your eligibility or the features of this Plan, call a Customer Service Representative toll-free at 1-888-643-0323.
|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 or 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 application 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). Information for consumers about MIB may be obtained on its Web site at www.mib.com.
|For NM Residents: PROTECTED PERSONS1 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.
|1PROTECTED 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 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 family member, employer or associate of a victim of domestic abuse or a person with whom the applicant or insured is known to have a direct, close, personal, family or abuse-related relationship.
|New York Life Insurance Company
If we can provide the coverage you requested, we will inform you as to when such coverage will be effective. Under no circumstances will coverage be effective prior to this date. Payment of a premium contribution with your application does not mean that there is any insurance in force before the effective date as determined by New York Life Insurance Company.
Certificate Of Insurance
This information is only a brief description of the principal provisions and features of the Plan. The complete terms and conditions are set forth in the group policy issued by New York Life Insurance Company to the Trustees of the Life Insurance Plan for Members of the American College of Physicians.
When you become insured, you will be sent a Certificate of Insurance summarizing your benefits under the Plan.
Underwritten by New York Life Insurance Company, 51 Madison Avenue, New York, NY 10010 under Group Policy No. G-29102-2 on Policy Form GMR-FACE/