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.
Semi-Annual (Per $10,000 Unit Coverage)
| AGE | Member or Spouse Semi-Annual Premiums (per $10,000 up to $300,000) |
|
|---|---|---|
| Under 35 | $5.12 | |
| 35 - 39 | 6.20 | |
| 40 - 44 | 10.00 | |
| 45 - 49 | 16.52 | |
| 50 - 54 | 30.00 | |
| 55 - 59 | 58.00 | |
| 60 - 64 | 96.00 | |
| 65 - 69* | 135.00 | |
| 70 - 74* | 320.00 | |
| Children | $10.00 | $5,000 coverage ($1,000 age 15 days to 6 months) |
* 65+ rates are for renewal only. Upon attainment of age 70, benefits will reduce 50%. Coverage terminates at age 75.
Notes:
- “Age” means attained age at the time of application.
- Premiums increase as the insured enters a new age bracket.
- Maximum coverage is $300,000 including any other coverage you may have through the GEVBT Group Term Life Plan
- Premium for a spouse is based on the spouse’s attained age.
- Spouse coverage may not exceed the member’s coverage.
- An administrative fee of $2.00 will be added to each account per billing cycle.
3. Mail the signed form and check for your first semi-annual payment to:
Mass Benefits Consultants, Inc. VAEA Administrator P.O. Box 828 Annandale, VA 22003-08284. 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 $10.00 for $5,000 coverage ($1,000 of coverage available for children age 15 days to 6 months).
