This group accident program is underwritten by New York Life Insurance Company,
New York, NY 10010 on Policy Form GMR.
You are enrolling in Group Accident Disability Income Protection Coverage (the “coverage”) from New York Life Insurance Company (“New York Life”) and have expressed your desire to electronically sign and/or initial the Enrollment Form for the coverage. To conduct this business electronically, you must provide New York Life and its authorized designees and agents with your consent. By clicking the “Submit” button, and applying your electronic signature, you will be providing New York Life and its authorized designees and agents, with your consent:
If you do not want to execute via electronic means the Enrollment Form, and/or if you do not agree with all of the terms and conditions of this Consent, you may not conduct business electronically with New York Life, and you must click the “Exit” link and cancel the transaction.
The Consent covers your agreement to all of the terms and conditions of the Consent, including your agreement to:
Yes. You will be sent electronic copies of your Enrollment Form, other associated documents and the Consent via email using the email address you provided on the Enrollment Form.
Yes. If you would like a paper copy of your Enrollment Form, other associated documents and the Consent via U.S. Mail, please email us and let us know.
Yes. You should keep these documents for your records.
This Consent shall become effective once you click the “Submit” button and shall remain in effect until you withdraw your consent (as described in the next section) or your Certificate of Insurance is issued, whichever occurs first.
You may only withdraw your consent to do business electronically before your Certificate of Insurance is issued. If you would like to do so, you must provide us with a written withdrawal of your consent to do business electronically. This will terminate the Consent and your Enrollment Form as of the date you sign your withdrawal, subject to any action New York Life took before recording the withdrawal. If we issue your Certificate of Insurance before we record your withdrawal, and you wish to cancel this coverage thereafter, you must exercise your right to surrender the Certificate according to its terms. There is no charge to withdraw your consent.
Yes. To complete your Enrollment Form electronically, New York Life requires that you have a personal computer with appropriate browser software, such as Microsoft Internet Explorer®, Mozilla® Firefox®, or equivalent, and email software as well as communications access to the Internet. This access may incur charges from Internet Service Providers and local telephone or cable companies. These costs are your responsibility. In order to view the Application Forms in the Portable Document Format (PDF), you must have Adobe® Acrobat® viewer software. This software is available for download, free of charge, from the Adobe Web site (www.adobe.com).
Form 19123 (8/13) Edited for Accident DI