How to Apply
1. Print and fill out the Enrollment Form. Be sure to sign and date the enrollment/medical authorization form.
2. Use the Premium Table to decide on coverage and to figure the amount of your payment. Request the amount of coverage you desire on the application.
| AGE | Member or Spouse Quarterly Premiums (per $10,000 up to $300,000) | All Children $3,000* |
|---|---|---|
| Under 35 | $3.30 | $3.00 |
| 35 - 39 | 4.40 | $3.00 |
| 40 - 44 | 6.60 | $3.00 |
| 45 - 49 | 11.20 | $3.00 |
| 50 - 54 | 17.40 | $3.00 |
| 55 - 59 | 27.80 | $3.00 |
| 60 - 64 | 41.90 | $3.00 |
| 65 - 69 | 82.30 | $3.00 |
| 70 - 75** | 194.60 | $3.00 |
• All eligible children, regardless of the number of children you have, are covered for $3,000 each by one quarterly payment of $3.00.
• A $2.00 administrative billing charge will be added to each quarterly premium notice.
**At age 70 benefits are reduced 50%. Quarterly premiums are billed at a rate of $80.89 per $5,000 and are for renewal only.
3. Mail the signed form and check for your first semi-annual payment to:
Mass Benefits Consultants, Inc. NAPUS Administrator P.O. Box 828 Annandale, VA 22003-0828
4. Your insurance will become effective on the first day of the month after your application is approved and the required premium is paid. Payment of premium contributions with your application does not mean that there is any insurance in force before the effective date as determined by New York Life.
All dependent children (regardless of how many) may be insured for one payment of $1.25 per $2,500 unit of coverage – maximum of two units for each child 15 days through age 20; through age 24 if a full-time student).
