New York Life Insurance and Annuity Corporation (NYLIAC)

ACCIDENT, CRITICAL ILLNESS and HOSPITAL INDEMNITY INSURANCE ENROLLMENT FORM

Please use this form to apply for coverage. Simply fill in any requested information below. Don't forget to include your Social Security Number, herein shown as SSN, Birthdate, sign your name and enter today's date.

EMPLOYER: Greek Orthodox Archdiocese of America

COMPLETE THIS SECTION ONLY IF YOU WANT COVERAGE FOR YOUR SPOUSE OR DOMESTIC PARTNER**

To be eligible for Domestic Partner coverage, you must have a state-registered Domestic Partnership or Affidavit on file with your employer.

YOUR COVERAGE ELECTIONS

View the Summary of Benefits for costs and instructions for how to calculate premium.

Employee-Paid Accident Insurance - Policy # GAI100008 Underwritten by NYLIAC

Accept Coverage and then choose both a plan below and who you would like to include in your coverage. See the Summary of Benefits for costs.

 

Employee-Paid Critical Illness Insurance - Policy # GCI100008 Underwritten by NYLIAC

Accept Coverage and then choose both an amount below and who you would like to include in your coverage. See the Summary of Benefits for costs.

 

*If elected, Spouse or Domestic Partner and Child(ren) receive a percentage of employee elected coverage amount. If Children are elected, all eligible dependent children will be covered.

 

Employee-Paid Hospital Indemnity Insurance - Policy # GHI100008 Underwritten by NYLIAC

Accept Coverage and then choose both a plan below and who you would like to include in your coverage. See the Summary of Benefits for costs.

****This s the maximum coverage amount that you can choose under this plan. Coverage elected during this enrollment period will take effect on the later of 5/15/2025, the date your election form is received by your Employer, or if applicable the date your Evidence of Insurability Form is approved by the Insurance Company.

**Domestic Partner is defined in the Group Policy. For purposes of this form, wherever the term Spouse appears, it shall also include Domestic Partner and Domestic Partners registered under any state which legally recognizes Domestic Partnerships or Civil Unions. Additional information is available from your employer. Spouse includes Partners in Civil Union relationships for residents of Vermont and State registered Domestic Partners for residents of Oregon.

 

 

SIGN TO ACCEPT DEDUCTION FROM YOUR PAYCHECK

I accept the insurance options chosen above. If premiums are to be paid by payroll, I authorize my employer to deduct the necessary amounts from my paycheck. I understand that coverage is subject to the insurance company's approval and that my insurance will not go into effect unless I am actively at work on the effective date. I also understand that coverage for each of my dependents will go into effect only if the person is not confined in a hospital or institution, or receiving certain medical treatment. I understand my information is protected by privacy laws and will be released only in accordance with these laws. Additional information about the rules and conditions around the requested insurance is described in the policy and certificate. Insurance coverage is underwritten by New York Life Insurance and Annuity Corporation.

Disclaimers:

For Accident, Critical Illness and Hospital Indemnity Insurance: Each proposed insured person must be covered under a Qualified Major Medical plan on the date of this election.

Caution: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act.