Rates for Gateway USA
(1) Minimum Period of Coverage is 15 days, maximum is
18 months. For any term of coverage more than 15 days, full Monthly
rates apply. The 15-day term cannot be combined with full month term on
the same Application form.
(2) Medical Benefit Amount for Ages 80 and over is $10,000.
(3) Use these rates for child(ren) who are insured independently and
are not included with parent(s) on this Application.
(4) Available only to persons 18 or older.
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)
$100,000 Additional AD&D(Optional benefit. If purchased, must
be included for both Insured and Spouse, if applicable).
$___________________ x (Number of adults) =
Total Base Monthly Premium(s) $______________
Multiply by Number of Months* x ______________
*(Only whole numbers, no fractions of months. If 15 Day plan, enter 1
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
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