Premium Rates for Gateway Premier

Adult Rates: (If you are a US citizen, use rate column I.) I. Destination: Worldwide, NOT including U.S.  II. Destination: Worldwide, Including U.S.
Age: 29 or under $68 $80
Age: 30-54 $94 $125
Age: 55-64 $157 $205
Age: 65 or above $360 $432
Each Dependent Child (to Age 18) $37 $40
Additional Accidental Death & Dismemberment (Optional):
Option 1: Additional $100,000 Coverage Each Adult: $12
Option 2: Additional $250,000 Coverage Each Adult: $30

Please note:
(1) If the United States is among destination countries listed on this Application, use rate column II.
(2) If Child (under age 18) is the only person listed on Application, Adult rates (age 29 and under) will apply.
(3) Options 1 and 2 are available only to persons age 18 and older.
(4) The minimum Period of Coverage for Gateway Premier is 6 months, maximum 12 months. Coverage may be renewed for up to 12 months at a time, to a maximum total term of 5 years.

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
(Use form below and enter Premium Rates from chart at above)

Names of person(s) to be insured Date of Birth (mm/dd/yy)  
Applicant     $
Spouse     $
Child     $
Child     $
Child     $

Base Monthly Premium $ ______________

Deductible Option: (select Option A, B, or C, then multiply Base Monthly Premium by the corresponding discount factor to determine amount for Subtotal #1)

Option A ($100) - Enter 1.00
Option B ($500) - Enter 0.85
Option C (1000) - Enter 0.70

X ____________
Subtotal #1 $____________

Additional AD & D (Optional benefit - If purchased both Applicant and Spouse must have same benefit amount)

Option I or Option II Premium from chart at above   $   ___________
Number of Adults (1 or 2)   x   ___________
Subtotal #2   $   ___________
Total Base Monthly Premium (add Subtotal #1 and Subtotal #)   $   ___________
Multiply by number of months (minimum 6, maximum 12)   x   ___________
Total Premium Enclosed   $   ___________

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)

Signature of Applicant or Proxy                                           Date


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