This program is underwritten by New York Life Insurance Company, New York, NY 10010 on policy form GMR-FACE
New York Life Insurance Company (NAIC 66915) is licensed to transact business in all 50 states including the District of Columbia
and is domiciled in the state of New York at 51 Madison Avenue, New York, NY 10010.
What is the purpose of this Electronic Consent and Disclosure?
You are applying for Group 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 Application Forms for the coverage. To conduct this business electronically, you must provide New York Life and its authorized designees and agents with your consent. By initiating the completion of the Application on this site and/or by clicking the “I accept” 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 Application Forms, 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.
What does the Consent cover once I click “Accept” and apply my electronic signature?
The Consent covers your agreement to all of the terms and conditions of the Consent, including your agreement to:
Will you send me paper copies of my Application Forms and the Consent?
Yes. You will be sent paper copies of your Application Forms, other associated documents and the Consent via U.S. Mail using the address that you provided on the Application Form.
Should I maintain copies of these documents?
Yes. You should keep these documents for your records.
How long will this Consent remain in effect?
This Consent shall become effective once you click the “Accept” button and shall remain in effect until you withdraw your consent (as described in the next section) or the Certificate is issued, whichever occurs first.
What if I change my mind?
You may only withdraw your consent to do business electronically before the Certificate 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 application as of the date you sign your withdrawal, subject to any action New York Life took before recording the withdrawal. If we issue the Certificate 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.
Are there any hardware or software requirements to do business electronically with New York Life?
Yes. To complete your Application Forms 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)