Group/Association Short Term Disability Benefits Form

Life Insurance Company of North America MAIL OR FAX TO: New York Life Group Benefit Solutions New York Life Group Insurance Company of NY P.O. Box 709015 Dallas, TX 75370-9015 Facsimile: (800) 642-8553 Email: GBSIntakePaper@newyorklife.com. Group/Association - Short Term Disability Benefits NEW YORK FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5000 and the stated value of the claim for each such violation. CAUTION: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act. For residents of the following states, please see the last page of this form: Arizona, California, Colorado, District of Columbia, Florida, Kansas, Kentucky, Louisiana, Maryland, Minnesota, New Jersey, Oregon, Pennsylvania, Puerto Rico, Rhode Island, Tennessee, Texas, Virginia or Washington. TO BE COMPLETED BY THE EMPLOYER / ADMINISTRATOR NAME OF EMPLOYEE/ASSOCIATION MEMBER (Last Name) (First Name) (Middle Initial) DATE OF BIRTH SOCIAL SECURITY NO. SEX M F ADDRESS (Street) (City) (State) (Zip Code) TELEPHONE # ( ) POLICY NO. OCCUPATION PLEASE CHECK THE APPROPRIATE BLOCKS REGARDING THE INSURED’S EMPLOYMENT STATUS. Hrs./wk Exempt Management Supervisory Union Local # Salaried Full-time Non-Exempt Non-Management Non-Supervisory Non-Union Hourly Part-time BASIC EARNINGS PER WEEK DATE OF LAST CHANGE IN EARNINGS DATE HIRED / MEMBER OF ASSOCIATION EFFECTIVE DATE OF INSURANCE WAS INSURANCE ISSUED ON THE BASIS OF A STATEMENT OF PHYSICAL CONDITION? EMPLOYEE’S / MEMBER’S CONTRIBUTIONS WERE MADE ON: Yes No If Yes, Attach Copy Pre-Tax Basis Post-Tax Basis LAST DAY WORKED DATE RETURNED TO WORK PREMIUM PAID THROUGH DATE % OF INSURED’S CONTRIBUTION # of Hours: TO PREMIUM PLEASE LIST ALL BENEFITS THAT THE INSURED IS RECEIVING OR ELIGIBLE TO RECEIVE AS A RESULT OF HIS/HER DISABILITY (E.G. SALARY CONTINUANCE, SICK PAY, STATE DISABILITY, WORKERS’ COMPENSATION, ETC.). BENEFIT GROSS WEEKLY AMOUNT DATE BEGAN PAID THRU DATE HAS EMPLOYEE/MEMBER BEEN LAID OFF? IF YES, DATE REASON Yes No HAS EMPLOYEE/MEMBER BEEN TERMINATED? IF YES, DATE REASON Yes No EMPLOYER’S / ADMINISTRATOR’S CERTIFICATION NAME OF EMPLOYER / ASSOCIATION DIVISION ADDRESS (Street) (City) (State) (Zip Code) TELEPHONE # ( ) EMPLOYER / ASSOCIATION Print: Signature: Date: © 2021, New York Life Insurance Company, New York, NY. All rights reserved. NEW YORK LIFE and the New York Life box logo are registered trademarks of New York Life Insurance Company. Life Insurance Company of North America and New York Life Group Insurance Company of NY are subsidiaries of New York Life Insurance Company. 500385 Rev. 10/2022