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10365/17935/ 1018/52247
epsmoore_nysut-ny-10365-lifeinsurance
Home Office: 175 Water Street, New York, NY 10038
(Herein called the Company)
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Please note: Appendix 11 (enclosed) for applicant must be filled out, signed, dated, and returned with the application.
For Office use only:
NYSUT DB 14212/14214/1007/52248-S
NYSUT PRD 12380/12381/1008/52248
UFT DB 19630/19631/1004/52249-S
UFT PRD 19058/19059/1005/52249
NYSUT DB RET 19048/19049/1009/52248-S
NYSUT PEN RET 18915/18916/1010/52248
ADMINISTRATOR
Mercer Consumer
P.O. Box 9186
Des Moines, IA 50306-8838
QUESTIONS?
Call: 1-888-386-9788
Email: [email protected]
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If the total amount applied for, plus existing Member
Benefits-endorsed Term Life Insurance Plan coverage, equals
or exceeds $200,000, and in certain circumstances, a medical
examination is required. In addition to the medical exam,
additional medical information will be required for
applicants ages 65 and over. If additional information is
needed, you will be contacted by the underwriting company.
Do not cancel any other life insurance until after you are
accepted into this program.
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Mail your application, one copy of Appendix 11 (and
the appropriate deduction authorization form, if
applicable) to:
Mercer Consumer, a service of Mercer Health &
Benefits Administration LLC
Insurance Plans Administrator
P.O. Box 9186
Des Moines, IA 50306-8838
Plan Administrator:
Mercer Consumer, a service of Mercer Health &
Benefits Administration LLC
P.O. Box 9186
Des Moines, IA 50306-8838
Call Toll-Free: 1-888-386-9788
AR Insurance License #100102691
CA Insurance License #0G39709
In CA d/b/a Mercer Health & Benefits
Insurance Services LLC
MN Insurance License #40291395
OK Insurance License #100100336
TX Insurance License #1850385
Underwritten By:
The United States Life Insurance Company in
the City of New York
Policies issued by The United States Life Insurance
Company in the City of New York (US Life). Issuing
company US Life is responsible for financial
obligations of insurance products and is a member of
American International Group, Inc. (AIG). Products
may not be available in all states and product features
may vary by state. Policy No. G-233,615 Form No.
G-19000.
This brochure is a brief description of benefits only
and is subject to the terms, conditions, exclusions and
limitations of the group policy.
Copyright 2017 Mercer LLC. All rights reserved.
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