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Voluntary Group Term Life Insurance
0159297
American Foreign Service
Protective Association
Voluntary Group Term
Life Insurance Plan
Up to $600,000 of Coverage
Protect the
Ones You Love
Whatever is next in your life,
it’s always important to set
goals and plan for long-term
needs. Your plan for continued
You may apply for coverage between $20,000 to
$600,000, in increments of $10,000. Your premium
will increase as you age, as indicated in the Coverage
Schedule of Premiums charts found on pages four
and five of this brochure. Please refer to the charts
to determine your present and future premiums.
When you reach age 60, coverage is reduced by
30% of the original coverage amount; at age 65, it
is reduced by another 20%; and at age 70, coverage
is terminated.
financial wellness should include
Eligibility
life insurance, which can help
All active Principal Members under age 60 who are
in good standing with the Protective Association
are eligible.
your loved ones even if
something happens to you.
2
Life insurance is one of the best ways you can protect
your loved ones in the event something happens to
you. As an Association Member, you can apply for up
to $600,000 of Voluntary Group Term Life Insurance
issued by The Prudential Insurance Company of America
(Prudential). Benefits are payable for death from any
cause including acts of terrorism or war (declared
or undeclared).
Qualified Dependents Eligibility
As you’re just starting out,
You may obtain insurance for your dependents
who include:
it makes a lot of sense to plan
1. Spouse.
Buying life insurance at work
2. Unmarried children from 14 days to age 26.
is an easy and affordable way
3. Legally adopted children. A child placed with you for
adoption prior to legal adoption is considered your
qualified dependent from the date of placement for
adoption, and is treated as though the child were a
newborn child to you.
to prepare for the unexpected
now for your financial future.
and live forward with peace
of mind.
4. Stepchildren and foster children who are dependent
on you for support.
5. Grandchildren who are wholly dependent on you
and are claimed on your federal income tax return
as dependents.
Dependents can apply for coverage without Principal
Member election at age 19.
Note: We encourage qualified dependents to apply for
coverage in their own name. No eligible person may be
covered by more than one policy. If he/she has coverage
in his/her own name, he/she cannot be covered as a
dependent under another member’s policy.
Accelerated Benefit Option
The Accelerated Benefit Option allows, in certain cases,
early access to a portion of your life insurance benefits
that would eventually be paid at death. This is a
compassionate and flexible addition to your life
insurance coverage. You can use the benefit in any
way you wish—to pay medical bills, hire home health
aides, prepay funeral expenses, or even travel. If you
are diagnosed with a terminal illness and have a life
expectancy of nine months or less, this benefit will
pay 50% of your coverage amount up to $50,000.
3
Coverage Can Not Be Cancelled
While the Master Group Policy remains in force, and as
long as you pay your premiums, your coverage cannot
be cancelled until you reach age 70.
Guaranteed Conversion
When a member is no longer eligible for coverage
due to the limiting age, he or she may convert the
coverage, without medical examination, to an individual
policy issued by The Prudential Insurance Company
of America.
Exclusions
None.
You may be paying college tuition
New Guarantee Issue
bills, taking care of aging parents,
New hire employees are GUARANTEED ISSUE
up to $200,000 of life insurance, and their spouses
up to $50,000, without evidence of insurability!
or doing both. You may be thinking
about retirement, planning to
work for a while, or maybe,
you’re not sure. Life insurance
can help you protect the hopes
Eligible employees must apply for this coverage within
60 days of hire. If an application is received after 60 days
of hire, and/or coverage over $200,000 is requested,
completion of a health questionnaire will be required.
and dreams of those you love.
Coverage
Annual rates per $1,000 of coverage:
From building a career, to caring
for loved ones, to making sure
things are running smoothly at
Member Coverage
Schedule of Premiums
AgeRate
Age Rate
Under 25$0.70
45 – 49$2.15
insurance at work can help
25 – 29$0.80
50 – 54$3.80
protect those who depend on you.
30 – 34$0.90
55 – 59$6.50
35 – 39$1.10
60 – 64$10.00
40 – 44$1.95
65 – 69$24.00
home, you’re the one who
makes it all happen. Buying life
Coverage terminates at age 70.
4
Family/Dependent Coverage
Schedule of Premiums
Member’s Age
Spouse Coverage
Children 2 wks–2 yrs
Children
2–5 yrs
Children 5–26 yrs
Annual Premium
Under 25$15,000 $3,000 $6,000 $7,500 $19
25 – 29$15,000$3,000$6,000 $7,500 $21
30 – 34$15,000$3,000$6,000 $7,500 $23
35 – 39$15,000$3,000$6,000 $7,500 $27
40 – 44$11,250$2,250$4,500 $5,625 $29
45 – 49$11,250$2,250$4,500 $5,625 $33
50 – 54$7,500$1,500$3,000$3,750$38
55 – 59$7,500$1,500$3,000$3,750$49
60 – 64$6,250$1,250$2,500$3,125$60
65 – 69$5,000$1,000$2,000$2,500$90
Enrollment Information
1. Complete and sign the attached enrollment form
and short form health statement questionnaire. Use
a separate form for each family member requesting
coverage in his/her own name (photocopies are
acceptable). If you have any questions or require
additional information, please contact AFSPA via
phone at 202-833-4910, e-mail [email protected],
or visit our Web site www.AFSPA.org/life.
2. DO NOT SEND PAYMENT AT THIS TIME. You will
receive written notification and a premium statement
upon approval of coverage.
3. Return the completed forms to:
AFSPA
1716 N Street, NW
Washington, DC 20036-2902
Fax: 202-775-9082
This is not the insurance contract. This brochure provides
a brief description of the important provisions of the
Master Policy issued to the American Foreign Service
Protective Association. Policy provisions will prevail if
there are any conflicts between them and this description.
Group Accidental Death &
Dismemberment (AD&D) Insurance
You and your entire family are eligible for up to $600,000
of protection against accidents any place in the world.
If you are interested in AD&D Insurance, call AFSPA
at 202-833-4910 or e-mail [email protected] to request
more information. Also, the brochure and enrollment
form are available at AFSPA’s Life Insurance Home
page www.AFSPA.org/life.
5
Notes:
GROUP LIFE ENROLLMENT FORM
The Prudential Insurance Company of America
751 Broad Street, Newark, New Jersey 07102
Please refer to the description of your plan for coverage options and amounts available to you.
Member’s Last Name
First Name
MI
Company Name
Group Contract Number
AFSPA
42001
Member’s Address
Occupation
Social Security Number
Work Phone Number
Date of Birth
/
/
Home Phone Number
Please mark the appropriate box according to your plan.
Type of Coverage
Amount
Married
Single
E-mail Address
New Hire  Yes  No
Widowed
Male
Divorced
Female
Billing Option
Quarterly Annually
If Yes, Date of Hire
/
/
Effective Date
 Member Optional Term Life
 Optional Term Life – Spouse
 Optional Term Life – Children
Eligible children are unmarried children from 14 days up to age 26.
MY BENEFICIARY’S NAME (PLEASE PRINT) Example: Mary A. Doe, not Mrs. J. Doe
Primary Beneficiaries
First Name
MI Last Name
Address
Relationship
Percentage
Contingent Beneficiaries
First Name
MI Last Name
Percentage
Address
Relationship
If more than one primary beneficiary is designated, settlement will be made in equal shares to the designated beneficiaries
(or beneficiary) who are then still living, unless their shares are specified. If there is no named beneficiary, or no beneficiary survives
the insured, settlement will be made in accordance with the terms of your Group Contract.
For residents of all states except District of Columbia, Florida, Kentucky, New Jersey, New York, Pennsylvania, Utah, Vermont, Virginia and
Washington – WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or
knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing
an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and
may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison.
In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant
conceals, for the purpose of misleading, information concerning any fact material thereto.
ALABAMA RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any
combination thereof.
DISTRICT OF COLUMBIA and RHODE ISLAND RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of
a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
FLORIDA RESIDENTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
KENTUCKY RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime.
GL.2009.238
Ed. 6/2012
MARYLAND RESIDENTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
NEW JERSEY RESIDENTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
PENNSYLVANIA and UTAH RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information
concerning any material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
VERMONT RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false
statement in an application for insurance may be guilty of a criminal offense under state law.
VIRGINIA RESIDENTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or
knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing a
statement of claim for payment of a loss or benefit may have violated state law, is guilty of a crime and may be prosecuted and punished under state
law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading,
information concerning any fact material thereto.
WASHINGTON RESIDENTS: Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the
purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits.
MEMBER’S SIGNATURE
 I am enrolling for coverage. I understand that, if I desire to increase the amount of my insurance or my dependent insurance
coverage hereafter, I may be required to furnish evidence of good health satisfactory to Prudential for myself and/or my dependent. I
declare the statements above are true, accurate, and complete, and I understand they are the basis for determining my insurability and
contribution for coverage.
I have read and understand the terms and requirements of the fraud warnings included as part of this form.
Member Signature ______________________________________ Date (Month/Day/Year)________ / ________ / _______
MICHIGAN RESIDENTS ONLY: If you wish to enroll your spouse and/or eligible child 18 years of age or older for $10,000 or more of
Dependent Term Life Insurance coverage, your spouse and/or each eligible child age 18 years or older must acknowledge consent for such coverage
below.
Spouse Signature:_______________________________ Date (Month/Day/Year):___________
Child Signature:_________________________________Date (Month/Day/Year):___________
Child Signature:_________________________________Date (Month/Day/Year):___________
Notice to Montana Residents: You or your authorized representative is entitled to receive a copy of this authorization and, upon request, a record of
any subsequent disclosures of personal or privileged information.
Receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. There is no administrative fee to
accelerate death benefits. The accelerated amount is not discounted.
Return completed form to:
AFSPA
1716 N Street, NW
Washington, DC 20036-2902
Fax: 202-775-9082
Group Term Life Insurance coverage is issued by The Prudential Insurance Company of America, a Prudential Financial company, 751 Broad Street,
Newark, NJ 07102. Life Claims: 800-524-0542. Please refer to the Booklet-Certificate for all plan details, including any policy exclusions, limitations,
and restrictions, which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group Contract issued by Prudential,
the terms of the Group Contract will govern. Contract provisions may vary by state. California COA #1179, NAIC #68241. Contract Series: 83500.
© 2012 Prudential Financial, Inc. and its related entities.
Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many
jurisdictions worldwide.
GL.2009.238
Ed. 6/2012
GROUP INSURANCE
The Prudential Insurance Company of America
Mail the completed form to:
Employer/Association Name:
The Prudential Insurance Company of America
Group Medical Underwriting, P.O. Box 8796
Philadelphia, PA 19176
American
Foreign
Service Protective
Assn.
American
Foreign
Service
Protective Assn.
Group Contract No.(s):
Branch No.:
Or fax the completed form to:
0042001000001
0 0 42001
0 00 0 01
877-605-6671
Short Form Health Statement Questionnaire (A separate form must be completed for each person requiring Evidence of Insurability)
Employee/Member Information
First Name
MI
Last Name
Number and Street
P.O. Box / Apt. Number
City
State
Social Security Number
_
Employee/Member ID Number
_
ZIP Code
_
Telephone
_
_
E-Mail Address
Applicant Information Relationship to Employee/Member:
First Name
MI
Self
Spouse
Last Name
Social Security Number
_
Applicant Coverage requiring Evidence of Insurability: Employee/Member
Gender:
Female
Male
Life Spouse
Life
Weight:
Height:
Date of Birth: (mm-dd-yyyy)
_
_
_
ft.
in.
lbs.
Please answer these questions by checking “Yes” or “No.”
Yes
No
Do you currently have any disorder, condition (including pregnancy), or disease or are you currently taking medication
prescribed or provided by a medical or other practitioner for any disorder, condition (including pregnancy), or
disease other than a cold, cough, or allergies?
During the last five years, have you been in a hospital or other institution for observation, rest, diagnosis, or treatment?
Yes
No
During the last five years, have you had life, disability, or health insurance declined, postponed, changed, rated-up,
Yes
No
cancelled, or withdrawn by an insurer?
Yes
No
Within the last five years, have you been treated for or had any trouble with any of the following: heart; chest pain;
high blood pressure; cancer or tumors; diabetes; lungs; kidneys; liver; alcoholism; mental, or nervous disorder or
have you been diagnosed with, or treated by a member of the medical profession for, Acquired Immune Deficiency
Syndrome (AIDS) or AIDS-Related Complex (ARC)?
Prudential reserves the right to request additional health information on the basis of the responses given to the above questions.
I have read and understand the terms and requirements of the Important Notice included as page 2 of this form. I declare that, to the best of
my knowledge and belief, the statements made in this application are complete and true. I agree that the coverage applied for is subject to the
terms of the plan and shall become effective on the date or dates established by the plan, provided the evidence of good health is satisfactory.
_
———————————————————————————————————————————————————————————
Applicant’s Signature (unless a minor)
_
Date Signed (mm-dd-yyyy)
_
_
———————————————————————————————————————————————————————————
If applicant is a minor, Signature of Parent, Guardian or
Person Liable for Support of Applicant
Relationship Date Signed (mm-dd-yyyy)
*LSFHSQG001*
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Important Notice: For residents of all states except Florida, New Jersey, New York, Pennsylvania, Utah, Vermont, Virginia and
Washington: Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other
person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive, or misleading facts
or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent
insurance act, is or may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil
damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information
concerning any fact material thereto. Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the
third degree. New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties. New York Residents: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or 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
is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each
such violation. This notice ONLY applies to accident and disability income coverage. Pennsylvania and Utah Residents: Any person
who knowingly and with intent to defraud any insurance company or other person files an application for insurance or 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 is a crime and subjects such person to criminal and civil penalties.
Vermont Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false
statement in an application for insurance may be guilty of a criminal offense under state law. Virginia Residents: Any person who
knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating
commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing a statement of
claim for payment of a loss or benefit may have violated state law, is guilty of a crime and may be prosecuted and punished under
state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer
may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals,
for the purpose of misleading, information concerning any fact material thereto. Washington Residents: Any person who knowingly
provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits
a crime. Penalties include imprisonment, fines, and denial of insurance benefits.
Please keep a copy of this form for your records.
Group Life Insurance coverage is issued by The Prudential Insurance Company of America, a New Jersey company, 751 Broad Street,
Group Life
Newark,
NJcoverage
07102. is issued by The Prudential Insurance Company of America, a New Jersey company, 751 Broad Street,
Newark, NJ 07102.
Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered
Prudential
and the Rock
logo are registered service marks of The Prudential Insurance Company of America and its affiliates.
in
many jurisdictions
worldwide.
*LSFHSQG002*
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123729
Group Life and Disability Income Medical Underwriting
NOTICE
Thank you for choosing The Prudential Insurance Company of America (Prudential)
for your insurance needs. Before we can issue coverage we must review your
application/enrollment form. To do this, we need to collect and evaluate personal
information about you. This notice is being provided to inform you of certain
practices Prudential engages in, and your rights, with regard to your personal
information. We would like you to know that:
•
Personal information may be collected from persons other than yourself or other
individuals, if applicable, proposed for coverage;
•
This personal information as well as other personal or privileged information
subsequently collected by us may in certain circumstances be disclosed to third
parties without authorization;
•
You have a right of access and correction with respect to personal information we
collect about you; and
•
Upon request from you, we will provide you with a more detailed notice of our
information practices and your rights with respect to such information. Should
you wish to receive this notice, please contact:
The Prudential Insurance Company of America
Group Medical Underwriting
P.O. Box 8796
Philadelphia, PA 19176
Information regarding your insurability will be treated as confidential. We may, however,
make a brief report thereon to the MIB, Inc., formerly known as Medical Information
Bureau, a not-for-profit membership organization of insurance companies, which operates
an information exchange on behalf of its members. If you apply to another MIB member
company for life, disability, or health insurance coverage, or a claim for benefits is
submitted to such a company, MIB, upon request, will supply such company with the
information about you in its file. In addition, upon receipt of a request from you,
MIB will arrange disclosure of any information in your file. Please contact MIB at
866-692-6901 (TTY 866-346-3642). If you question the accuracy of the information in
MIB’s file, you may contact MIB and seek a correction in accordance with the procedures
set forth in the federal Fair Credit Reporting Act. The address of MIB’s information office
is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734. Information
for consumers about MIB may be obtained on its website at www.mib.com.
Please keep this notice for your records.
Group Life and Accidental Death & Dismemberment Insurance coverages are issued by The Prudential Insurance Company of America, a Prudential Financial Company,
751 Broad Street, Newark, NJ 07102. The Booklet-Certificate contains all details, including any policy exclusions, limitations and restrictions, which may apply.
Contract Series: 83500.
This policy provides ACCIDENT insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department.
IMPORTANT NOTICE — THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS.
© 2012 Prudential Financial, Inc. and its related entities.
Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. 123729
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