0001089-0000001-0000100

40054/40121/ 1018/44704

epsmoore_s_p_e_-40054-lifeinsurance

Request for Group Insurance From:

New York Life Insurance Company

.

51 Madison Ave.

.

New York, NY 10010

To Apply:

Complete this form and return with your

premium check payable to:

ADMINISTRATOR

SPE GROUP INSURANCE PROGRAM

P.O. BOX 10374

.

Des Moines, IA 50306

For residents of PR, the address is:

Global Insurance Agency, Inc.

P.O. Box 9023918

.

San Juan, PR 00902-3918

QUESTIONS?

Call: 1-800-424-9883

E-mail: dsmgroupinsurance@marshpm.com

Name:

Last First MI

Add 1:

Add 2:

City, St., Zip:

Are you presently insured under any Engineering Associations Insurance Trust (of which SPE is a participant) Group Life

Insurance Plans? q Yes q No

(Membership in the SPE is required for participation in this plan.)

Are you now a member of Society of Plastics Engineers? qYes qNo

I request and authorize the SPE Group Insurance

G-9400-1

GMA-PR1

0001090-0000002-0000100

*05440501000*

G-9400-1

GMA-PR1

0001091-0000003-0000100

G-9400-1

GMA-PR1

0001092-0000004-0000100

*05450502000*

G-9400-1

GMA-PR1

0001093-0000005-0000100

For Society of Plastics Engineers Members and Their Families

But the simple fact is, life insurance doesn't have to be

expensive. The economical Group Term Life Insurance Plan

designed for and available to members of the Society of

Plastics Engineers has proven just that.

Society of Plastics Engineers members under age 70 are eligible

to apply for coverage for themselves, their lawful spouses and

unmarried dependent children ages 14 days through 22 years

(24 if a full-time student). In order to become insured,

satisfactory evidence of insurability must be provided and the

required premium contribution must be paid.

In addition, the total amount of coverage for a member

insured by more than one group policy - or more than one

organization participating in such a group policy - issued by

New York Life Insurance Company to the Trustee of the

Engineering Associations Insurance Trust, (of which SPE is a

participant), may not exceed the maximum benefit option for

any insured person.

0001094-0000006-0000100

*05460503000*

Insurance for you can remain in force to age 80, and for your

insured dependents as long as they remain otherwise eligible,

provided: (a) you continue to pay premium contributions

when due; (b) you remain a member of SPE, (c) SPE

continues to be a participating organization; and (d) the group

plan is not terminated or modified by the Policyholder or

New York Life Insurance Company to end insurance for the

group of insureds to which you belong. Upon your death,

coverage for insured dependents may continue as described in

the Certificate of Insurance.

0001095-0000007-0000100

Before you request coverage, you must be a member in good

standing with SPE. Please wait until your application for

membership is accepted before initiating an insurance

request. If you have any questions regarding membership,

please contact SPE directly.

2. Make out your check for the total premium contribution

due, payable to: Administrator, SPE Group Insurance

Program.

If you choose the convenient Electronic Funds Transfer

(EFT) Option, be sure to include a voided check in

addition to the check for the first payment due.

3. Mail the completed application with your check to:

Administrator

SPE Group Insurance Program

PO Box 10374

Des Moines, IA 50306

Residents Of Puerto Rico:

Please send your completed application and check for the

initial premium contribution to:

Global Insurance Agency, Inc.

P.O. Box 9023918

San Juan, PR 00902-3918

0001096-0000008-0000100

*05470504000*

This Group Term Life Insurance Plan Is

Administered By:

SPE Group Insurance Program

PO Box 10374

Des Moines, IA 50306

1-800-424-9883

dsmgroupinsurance@marshpm.com

This Group Term Life Insurance Plan Is

Underwritten By:

New York Life Insurance Company

51 Madison Avenue

New York, NY 10010

under Group Policy No. G-9400-1

on Policy Form GMR-FACE/G-9400-1

The Engineering Associations Insurance Trust incurs costs

in connection with this sponsored plan. To provide and

maintain this valuable membership benefit, it is reimbursed

for these costs. SPE may also may receive a fee for the

license of its name and logo for use in connection with this

Plan.

0001097-0000009-0000100

0001098-0000010-0000100

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*05480605000*