0000001-0000001-0000001

44526/44527/ 1018/51857

epsmoore_-Acp--44526-termlifeinsurance

FOR MEMBERS OF THE AMERICAN COLLEGE OF PHYSICIANS

To Apply: Complete this form and return to:

ADMINISTRATOR

ACP GROUP INSURANCE PROGRAM

P.O. BOX 10374

.

Des Moines, IA 50306-8812

For residents of PR, the address is:

Global Insurance Agency, Inc.

P.O. Box 9023918

.

San Juan, PR 00902-3918

QUESTIONS?

CALL: 1-888-643-0323

ACPgroupins.service@mercer.com

Request for Group Insurance From:

New York Life Insurance Company l 51 Madison Ave. l New York, NY 10010

Name:

Last First MI

Add 1:

Add 2:

City, St., Zip:

G-29102-0

GMA-AC-IR

44526/44527/1018/52247

0000002-0000002-0000001

*00000601000*

G-29102-0

GMA-AC-IR

0000003-0000003-0000001

G-29102-0

GMA-AC-IR

0000004-0000004-0000001

*00010602000*

G-29102-0

GMA-AC-IR

0000005-0000005-0000001

G-29102-0

GMA-AC-IR

0000006-0000006-0000001

*00020603000*

6

Information for consumers about MIB may be obtained on its Web site at www.mib.com.

Group Decreasing Term Life Insurance Plan

0000063-0000007-0000156

0000064-0000008-0000156

*00310604000*

0000065-0000009-0000156

If your state of residence mandates recognition of a Domestic

Partner as an eligible spouse, contact the Administrator for a

Declaration of Domestic Partnership form or go to

www.personal-plans.com/acp to download the form.

Administrator

ACP Group Insurance Program

P.O. Box 10374

Des Moines, IA 50306-8812

Residents of Puerto Rico:

Please send your completed application to:

Global Insurance Agency, Inc.

P.O. Box 9023918

San Juan, PR 00902-3918

0000066-0000010-0000156

*00320605000*

The Group Decreasing Term Life and Accidental Death and

Dismemberment Insurance Plan is underwritten by:

New York Life Insurance Company

51 Madison Avenue

New York, NY 10010

under Group Policy No. G-29102-0

on Policy Form GMR

The Group Decreasing Term Life and Accidental Death and

Dismemberment Insurance Plan is administered by:

Mercer Consumer, a service of Mercer Health &

Benefits Administration LLC

ACP Group Insurance Program

P.O. Box 10374

Des Moines, IA 50306-8812

1-888-643-0323

www.personal-plans.com/acp

AR Insurance License #100102691

CA Insurance License #0G39709

In CA d/b/a Mercer Health & Benefits

Insurance Services LLC

Any questions?

Please call us toll-free at 1-888-643-0323, between the

hours of 7:30 am and 5:00 pm CT, Monday through

Friday.

Copyright 2017 Mercer LLC. All rights reserved.

Copyright 2018 Mercer LLC. All rights reserved.

0000067-0000011-0000156