How to enroll:
If paying by check or money order, enclose check with completed Application and mail to the Gateway Plan Administrator. If paying by credit card, you may either mail or fax your application to: (please donot mail and fax your Application.)

Exec Relo USA
Gateway Plan Administrator
123 East 54th Street, Suite 5H
New York, NY 10022
Tel: (212) 752-0999 or 1 888 BENEFTS(236-3387) Fax: (212) 752-0791

Calculating Your Premium - Global II
(use form below and enter Premium Rates from chart at above)

I hereby subscribe to the AIG Life Trust and enroll in the group coverage for which I am eligible under the group contract issued by The Insurance Company of the State of Pennsylvania, a member of American International Group, Inc. (AIG)

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Signature of Applicant or Proxy                                           Date

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