20 Year Level Premium Group Term Life Insurance Plan
Underwritten by New York Life Insurance Company

How do I apply for coverage?

It is easy to apply. Simply print out the application form, complete it and return it to the Plan Administrator at the address indicated below. There is no need to send money now; you will be mailed a premium invoice after your coverage is issued.

YOUR PLAN ADMINISTRATOR
If you have questions...or would like assistance in completing your application...
call toll free:

1-800-223-1147
weekdays between 8:00 a.m. and 5:00 p.m., Central Time.

Plan Administrator
Columbia Alumni Association
Group Insurance Program
P.O. Box 152501
Irving, TX 75015-2501

This plan description is a summary of benefits only and is subject to the terms, conditions and limitations of Group Policy G29187-0/GMR-FACE. Complete details on benefits and provisions are included in the certificate of Insurance issued to each insured once approved for coverage.

Please click on checkbox below to indicate that you have read the important notice.

You will need Acrobat Reader the PDF form. If you do not have the Acrobat Reader, visit www.adobe.com to download it FREE!

Your Satisfaction Is Guaranteed
If you are not 100% satisfied with the terms of your Insurance Certificate, you may return it within 30 days without claim. Any premiums you have paid will be refunded promptly and your insurance will be invalidated. You will have no further obligation of any kind.

How New York Life Obtains Information and Underwrites Your Request Group Life Insurance

Information regarding insurability will be treated as confidential.  In considering your request 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. (formerly known as Medical Information Bureau).  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.

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 the Administrator 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.

New York Life may release this information to the plan administrator, MIB, other insurance companies to whom you may apply for insurance, or to whom a claim for benefits may be submitted and to others whom you authorize in writing.  However, this will not be done in connection with information concerning Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV).

New York Life will not disclose such information to anyone except those you authorize or where required or permitted by law.  We may make a brief report to MIB; however, we will not disclose our underwriting decision.  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.

MIB is a not-for-profit organization of insurance companies, which operates an information exchange on behalf of its members.  When you apply for insurance or submit a claim for benefits to a MIB member company, medical or non-medical information may be given to the Bureau, which may then be furnished to member companies.

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.  (Note: In certain jurisdictions, you may choose to receive medical information directly.) 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.
2Confidential 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.

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 there is any insurance in force before the effective date is determined by

New York Life Insurance Company 4.11 ed(s).

DISCLOSURE INFORMATION
The Columbia Alumni Association incurs certain costs in providing oversight and administration support for this sponsored plan.  To provide and maintain this valuable membership benefit, it is reimbursed for these costs.   The Columbia Alumni Association also receives a fee in connection with this plan which is applied to help support and improve all member services for The Alumni Association.

Domiciled in the state of New York, New York Life Insurance Company, 51 Madison Avenue, New York, NY 10010 (NAIC 66915) is licensed/authorized to transact business in all of the 50 United States, the District of Columbia and Puerto Rico.

Aon Consulting, Inc. (New York, NY), the Broker, is licensed and/or authorized to transact business in the 50 United States, District of Columbia and Puerto Rico. Dba: Aon Benefit and Insurance Services of New York in CA license # OD34031. Robert Moriarty is licensed in CA # OG89477 and AR # 266551.