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VOLUNTARY GROUP TERM LIFE INSURANCE PLANAs an active Principal Member in good standing of the Protective Association, you and your family are eligible to enroll for the Voluntary Group Term Life plan issued by The Prudential Insurance Company of America (Prudential). This brochure explains eligibility, available coverages, and how to enroll.

ELIGIBILITYWho is eligible?All active Principal Members under age 60 who are in good standing with the Protective Association are eligible for coverage, as well as their qualified dependents.

Who are my qualified dependents?Qualified dependents include your:

1. Spouse.

2. Unmarried children from live birth* to age 26.

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.

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 tax return as dependents.

Dependents can enroll for coverage without Principal Member election at age 19.

Note: We encourage qualified dependents to have 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.

AVAILABLE COVERAGES What coverages are available to me and my family?Voluntary Group Term Life–for you: Life insurance may be one of the best ways you can help protect your loved ones in the event something happens to you. Get up to $600,000 in Voluntary Group Term Life Insurance for yourself. As an Association Member, you can apply for Voluntary Group Term Life Insurance coverage issued by Prudential from $20,000 to $600,000, in increments of $10,000.

What are the Voluntary Group Term Life benefit reductions?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 80, coverage is terminated.

Do I need to submit evidence of insurability to enroll for or increase my Voluntary Group Term Life coverage?New hire members are Guaranteed Issue up to $200,000 of Voluntary Group Term Life insurance. Eligible members 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 satisfactory to Prudential.

What additional features are included in the Voluntary Group Term Life plan?Accelerated Benefit Option1: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.

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 Prudential.

* There is a limited benefit of $500 for children from live birth to 2 weeks of age.


Can my Voluntary Group Term Life coverage be cancelled?While the Master Group Policy remains in force, and as long as you pay your premiums, your coverage cannot be canceled until you reach age 80.

Are there Voluntary Group Term Life exclusions?No, benefits are payable for death from any cause including acts of terrorism or war (declared or undeclared).

How much does Voluntary Group Term Life Insurance cost?Annual rates per $1,000 of coverage:

Member Coverage Schedule of Premiums (Member coverage terminates at age 80.)

Age Rate

Under 25 $0.70

25-29 $0.80

30-34 $0.90

35-39 $1.10

40-44 $1.95

45-49 $2.15

50-54 $3.80

55-59 $6.50

60-64 $10.00

65-69 $24.00

70-74 $35.32

75-80 $89.53

Your premium will increase as you age, as indicated in the chart on the left. Please refer to the chart to determine your present and future premiums.

Voluntary Group Dependent Term Life – for your spouse and children:Available coverage for your spouse ranges from $15,000 to $5,000, dependent upon your age.

Available coverage for your children ranges from $3,000 to $1,000, dependent upon your age and the age of your child(ren).*

Below are the available coverage options and premiums for your spouse and children. Premiums will increase as you age, as indicated in the chart. Please refer to the chart below to determine present and future premiums.

Family/Dependent Coverage Schedule of Premiums (Coverage terminates for spouse and child when member reaches age 80.)

Member’s Age Spouse Coverage Children 2wks*-2yrs 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 $2,500 $4,500 $5,625 $29

45-49 $11,250 $2,500 $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

70-74 $4,000 $1,000 $2,000 $2,500 $96

75-79 $2,500 $1,000 $2,000 $2,500 $120

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ENROLLMENT AND QUESTIONSHow do I enroll myself and my family?1. Complete and sign the attached enrollment form. Use a separate

form for each family member requesting coverage in his/her own name (photocopies are acceptable).

2. DO NOT SEND PAYMENT AT THIS TIME. You will receive written notification and a premium statement upon issuance of coverage.

3. Return the completed form to: American Foreign Service Protective Association Attention: Life Insurance 1620 L Street NW, Suite 800 Washington, DC 20036-5629 Fax: 202-775-9082

Who do I contact if I have any questions?If you have any questions or require additional information, please contact American Foreign Service Protective Association via phone at 202-833-4910, e-mail at [email protected], or visit American Foreign Service Protective Association’s Life Insurance Home page: www.AFSPA.org/life.

Questions?Contact American Foreign Service Protective Association: Call: 202-833-4910 E-mail: [email protected] Web site: www.AFSPA.org/life

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GL.2014.192 Ed. 03/2016 Page 1 of 3

The Prudential Insurance Company of America 751 Broad Street, Newark, New Jersey 07102

1-877-232-3619

Coverage Election Coverage Amount Chosen

Voluntary Group Term Life: Member $

Voluntary Group Dependent Term Life: Spouse $

Voluntary Group Dependent Term Life: Child(ren) $

Company Name

Member General Information

Last Name First Name MI

Marital Status

Single Married Divorced Widowed

Social Security Number

Children are unmarried children from up to age 26.

– – / /

/ /

Date of Birth (Month/Day/Year)

Address City State Zip Code

Email Address Phone Number

Effective Date of Coverage (for office use only)

Control Number AgencyAmerican Foreign Service Protective Association 42001

Accelerated Death Benefit Option is a feature that is made available to group life insurance participants. It is not a health, nursing home, or long-term care insurance benefit and is not designed to eliminate the need for those types of insurance coverage. The death benefit is reduced by the amount of the accelerated death benefit paid. There is no administrative fee to accelerate benefits. Receipt of accelerated death benefits may affect eligibility for public assistance and may be taxable. The federal income tax treatment of payments made under this rider depends upon whether the insured is the recipient of the benefits and is considered terminally ill or chronically ill. You may wish to seek professional tax advice before exercising this option.

Date of Hire (Month/Day/Year)

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Acceptance or Waiver of Coverage

FOR INSUREDS WHO RESIDE IN MICHIGAN OR MINNESOTA ONLY– If you wish to enroll your Spouse or Domestic Partner, and/or eligible child 18 years of age or older for Dependent Life and/or Accidental Death and Dismemberment Insurance coverage, your Spouse or Domestic Partner, and/or each of your eligible children age 18 years or older must consent to such coverage by signing and dating this consent in the appropriate space(s) below. Coverage on your Spouse or Domestic Partner and child(ren) age 18 or older will not become effective unless and until the requisite consent is provided.

Spouse or Domestic Partner Signature ______________________________ Date (Month/Day/Year) ____________________

Child Signature ______________________________________________ Date (Month/Day/Year) ____________________




Last Name First Name Middle Initial Last 4 digits of Social Security No.

XXX-XX- ______________

I am enrolling for coverage and I authorize American Foreign Service Protective Association to deduct from my earnings until further notice my contributions for insurance under a contract issued by The Prudential Insurance Company of America. I understand that if I desire to increase the amount of my insurance or add dependent coverage hereafter, I may be required to furnish evidence of insurability for myself and/or my dependents. To the best of my knowledge and belief, I declare the statement above is true and understand it is the basis for determining the contribution for coverage. I also understand that for coverage to become effective, I must be actively at work on the effective date of the plan. If I apply for an amount that requires evidence of insurability satisfactory to The Prudential Insurance Company of America, I must be actively at work on the date of approval for the amount requiring satisfactory evidence of insurability.

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.

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) ____________________

I do not wish to enroll for any of the above optional coverages. I certify that I have been given the opportunity by American Foreign Service Protective Association to enroll for coverage. I understand that if I desire to enroll hereafter, I may be required to furnish satisfactory evidence of insurability to The Prudential Insurance Company of America for myself and/or my dependents.


GL.2014.192 Ed. 03/2016 443446

Optional Term Life and Optional Dependent Term Life Insurance coverages are issued by The Prudential Insurance Company of America, 751 Broad Street, Newark, NJ 07102. Life Claims: 1-800-524-0542. The Booklet-Certificate contains all 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.

©2016 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.

Page 3 of 3


Acceptance or Waiver of Coverage

Last Name First Name Middle Initial Last 4 digits of Social Security No.

XXX-XX- ______________

For residents of all states except Alabama, Arkansas, the District of Columbia, Florida, Kentucky, Louisiana, Maine, Maryland, New Jersey, New York, North Carolina, Pennsylvania, Puerto Rico, Rhode Island, 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.

ARKANSAS, DISTRICT OF COLUMBIA, LOUISIANA 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.

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.

MAINE AND 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.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.

NORTH CAROLINA RESIDENTS – Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant, knowing that the statement contains false or misleading information concerning a fact or matter material to the claim may be guilty of a Class H felony.

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.

PUERTO RICO RESIDENTS – Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

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, with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

Return completed form to: American Foreign Service Protective Association

1620 L Street NW Suite 800, Washington, DC 20036-5629 Fax: 202-775-9082

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Billing Option: Quarterly Annually

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GL.2001.169 Ed. 08/2015 Page 1 of 3

IMPORTANT INFORMATION ABOUT BENEFICIARY DESIGNATIONS

Use this form to designate or make changes to the beneficiary(ies) of your Group Insurance death proceeds. The information on this form will replace any prior beneficiary designation. You may name anyone or any entity as your beneficiary and you may change your beneficiary at any time by completing a new Group Insurance Beneficiary Designation/Change form. Common designations include individuals, estates, corporation/organizations and trusts. Payment will be made to the named beneficiary. If there is no named beneficiary, or the named beneficiary predeceased the insured, settlement will be made in accordance with the terms of your Group Contract.

DEFINITIONSYou may find the following definitions helpful in completing this form:Primary Beneficiary(ies) – the person(s) or entity you choose to receive your life insurance proceeds. Payment will be made in equal shares unless otherwise specified. In the event that a designated primary beneficiary predeceases the insured, the proceeds will be paid to the remaining primary beneficiaries in equal shares or all to the sole remaining primary beneficiary.Contingent Beneficiary(ies) – the person(s) or entity you choose to receive your life insurance proceeds if the primary beneficiary(ies) die (or the entity dissolves) before you die. Payment will be made in equal shares unless otherwise specified. In the event that a designated contingent beneficiary predeceases the insured, the proceeds will be paid to the remaining contingent beneficiaries in equal shares or all to the sole remaining contingent beneficiary.

INSTRUCTIONS FOR DESIGNATING A PRIMARY OR CONTINGENT BENEFICIARY

1. MEMBER INFORMATION• All information in this section is required.• Unless otherwise indicated in Section 1, the information supplied on the form will apply to ALL coverages offered under the association’s group plan.• Unless otherwise indicated in Section 2, the information supplied on the form will apply to all the Group Life coverage(s) issued by The Prudential

Insurance Company of America to the group contract holder.

2. BENEFICIARY DESIGNATION• You may name more than one primary and more than one contingent beneficiary. This form allows you to name up to four primary and four

contingent beneficiaries. If you need additional space, please attach a separate sheet of paper.• Please indicate the percentage share designated to each primary beneficiary. The total for all primary beneficiaries must equal 100%. If no

percentages are specified, the proceeds will be split evenly among those named. Payment will be made to the named beneficiary. If there isno named beneficiary, or the named beneficiary predeceased the insured, settlement will be made in accordance with the terms of your GroupContract. If designating percentages for contingent beneficiaries, the percentage for all contingent beneficiaries must also equal 100%.

• You can name an individual, corporation/organization, trust, or an estate as a beneficiary. The following examples may be helpful in designatingbeneficiaries:

Individual: “Mary A. Doe”• Each name should be listed as first name, middle initial, last name (“Mary A. Doe,” not “Mrs. M. Doe”)• Include the address, telephone number, social security number, relationship and Date of Birth for each individual listed.• Indicate the percentage to be assigned to each individual.Estate: “Estate of the Insured”• Select “Other” as the Beneficiary Description and write “Estate” in the blank space provided.• Indicate the percentage to be assigned to the Estate of the Insured.Corporation/Organization: “ABC Charitable Organization”• Select “Corporation/Organization” as the Beneficiary Description.• Write the legal name of the corporation or organization in the space for the Beneficiary’s First Name.• Include the address, city and state, telephone number and tax ID number of operation for each organization or corporation listed.• Indicate the percentage to be assigned to the corporation or organization.Trust: “The John Doe Trust. A Trust with a trust agreement dated 1/1/99 whose Trustee is Jane Smith.”• Select “Trust” as the Beneficiary Description.• Indicate the percentage to be assigned to the trust.• Complete Section 3, Trust Designation.

3. TRUST DESIGNATION• Complete this section if you have named a trust as a primary or contingent beneficiary in Section 2. Fill in the name and address for each trustee.• Fill in the title and date of the Trust Agreement in the space provided.

4. AUTHORIZATION/SIGNATURE• The member must read, sign and date the authorization.• Submit the completed form to your Benefits Administrator or Human Resources (as directed by your association) and keep a copy for your records.


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GL.2001.169 Ed. 08/2015

194405

Basic Life, Accidental Death & Dismem

berment, Optional Term

Life, Dependent Term Life Insurance coverages are issued by The Prudential Insurance Com

pany of America, 751 Broad Street, Newark, NJ 07102. Life Claim

s: 1-800-524-0542. The Booklet-Certificate contains all details, including any policy exclusions, lim

itations, and restrictions, which may apply. If there is a discrepancy between this docum

ent and the Booklet-Certificate/Group Contract issued by Prudential, the term

s of the Group Contract will govern. Contract provisions may vary by state. California COA #1179, NAIC#68241. Contract Series: 83500.

©2015 Prudential Financial, Inc. and its related entities.

Prudential, the Prudential logo and the Rock symbol are service m

arks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide.

Page 3 of 3


Prudential reserves the right to request additional health information on the basis of the responses given to the above questions.

Short Form Health Statement

Mail the completed form to:American Foreign Service Protective Association

1620 L Street NW Suite 800 Washington, DC 20036-5629

GROUP INSURANCEThe Prudential Insurance Company of America

* Civil Union Partner is a person with whom you have established a civil union relationship which is valid under the laws of the jurisdiction where itwas created. Domestic Partner includes a person who satisfies the requirements of being a domestic partner or registered domestic partner underthe laws of the jurisdiction where it was created.

Please answer these questions by checking “Yes” or “No”. Note: In this section, “you” refers to the person for whom the insurance is being requested.

Do you currently have any disorder, condition, or disease or are you currently taking prescription medication for any disorder, condition, or disease (other than: acid reflux; allergies; cold; cough; herniated disc; high cholesterol; nonrheumatoid arthritis; overactive or underactive thyroid; or pregnancy)?

In the last five years have you been diagnosed with, treated for, had any symptoms of, or been in a hospital or other facility for any of the following?

Yes No

Member

Name of Person for Whom Insurance is Being Requested

Yes No

_

_ _ _ _

_ _

(Submit a separate form for each person whose coverage requires Evidence of Insurability.)

0 0 4 2 0 0 1

Ame r i c a n F o r e i g n S e r v i c e P r o t e c t i v e A s s n

0 0 0 0 0 1

Relationship to Member: Self Spouse/Civil Union Partner* or Domestic Partner*

Coverage that requires Evidence of Insurability: Member Life Spouse/Civil Union Partner* or Domestic Partner* Life

Gender:

Female Male Height: Weight:

_ _

* L S F A D C 0 0 1 *GL.2015.035 (1) Ed. 02/2015 L DC 42001

• Chest pain, heart disease or disorder, high blood pressure;• Cancer, tumors;• Respiratory disease or disorder of the lungs;• Multiple sclerosis, epilepsy, seizure, stroke;• Kidney, liver or pancreas disease or disorder;• AIDS, AIDS-related complex;

• Diabetes;• Mental or nervous disorder;• Alcoholism, drug addiction;• Chronic pain, rheumatoid arthritis, lupus; or• Colitis, Crohn’s disease, gastric bypass.

First Name MI Last Name

Association:

Number and Street P.O. Box / Apt. Number

City State ZIP Code

Social Security Number Member ID Number Telephone

First Name MI Last Name Social Security Number

Group Contract No.(s):

Email Address

ft. in. lbs.

Date of Birth: (mm-dd-yyyy)

Branch No.:

Page 1 of 3

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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.

ARKANSAS, 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.

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.

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.

PUERTO RICO RESIDENTS—Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

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, with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

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.

GL.2015.035 (1) Ed. 02/2015 L DC 42001 * L S F A D C 0 0 2 *


0 0 4 2 0 0 1 0 0 0 0 0 1

Branch No.:

NORTH CAROLINA RESIDENTS – Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant, knowing that the statement contains false or misleading information concerning a fact or matter material to the claim may be guilty of a Class H felony.

For residents of all states except Alabama, Arkansas, the District of Columbia, Florida, Kentucky, Louisiana, Maine, Maryland, New Jersey, New York, North Carolina, Pennsylvania, Puerto Rico, Rhode Island, 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.

Page 2 of 3

I have reaI declare this subject t

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Page 2 of 3

I have read and understand the terms and requirements of the fraud warnings included as part 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.

Group Life Insurance coverage is issued by The Prudential Insurance Company of America, a New Jersey company, 751 Broad Street, Newark, NJ 07102.

© 2016 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.

* L S F A D C 0 0 3 *

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.

GL.2015.035 (1) Ed. 02/2015 L DC 42001 443417

_ _

_ _

_ _

Please keep a copy of this form for your records.

RelationshipIf Person for whom insurance is being requested is a minor, Signature of Parent, Guardian, or Person Liable for Support


Your Signature (unless a minor) Date Signed (mm-dd-yyyy)

Print Your First Name Last Name Your Social Security Number

Date Signed (mm-dd-yyyy)

Branch No.:

0 0 4 2 0 0 1 0 0 0 0 0 1

Page 3 of 3


Group Life and Disability Income Medical UnderwritingNOTICE

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 information 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 otherindividuals, if applicable, proposed for coverage;

• This personal information as well as other personal or privileged informationsubsequently collected by us may in certain circumstances be disclosed to thirdparties without authorization;

• You have a right of access and correction with respect to personal informationwe collect about you; and

• Upon request from you, we will provide you with a more detailed notice of ourinformation practices and your rights with respect to such information. Shouldyou 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 life 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. 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.


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Questions?Contact American Foreign Service Protective Association: Call: 202-833-4910 E-mail: [email protected] Web site: www.AFSPA.org/life


1 Accelerated Death Benefit option is a feature that is made available to group life insurance participants. It is not a health, nursing home, or long-term care insurance benefit and is not designed to eliminate the need for those types of insurance coverage. The death benefit is reduced by the amount of the accelerated death benefit paid. There is no administrative fee to accelerate benefits. Receipt of accelerated death benefits may affect eligibility for public assistance and may be taxable. The federal income tax treatment of payments made under this rider depends upon whether the insured is the recipient of the benefits and is considered “terminally ill.” You may wish to seek professional tax advice before exercising this option.

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.

Voluntary Group Term Life and Voluntary Group Dependent Term Life Insurance coverages are issued by The Prudential Insurance Company of America, a Prudential Financial company, Newark, NJ. The Booklet-Certificate contains all details, including any policy exclusions, limitations, and restrictions, which may apply. Contract Series: 83500.

©2016 Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, the Rock symbol, and Bring Your Challenges are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. 438568

0290127-00001-00

TN


because keeping promises requires planning...55-59 $6.50 60-64 $10.00 65-69 $24.00 70-74 $35.32...

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