United Professors of Marin

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Group Life Insurance

I hereby certify that all statements and answers in this form are full, complete, and true to the best of my knowledge and belief. I understand that to be eligible for coverage I must be a new AFT member, actively working, and not currently insured under the Group Term Life Insurance plan for AFT members. In no event will I be eligible for this coverage beyond 12 months from my AFT membership date. I understand that my coverage will become effective on the first day of the month following the date this application is signed. Any person who knowingly and with intent to defraud any insurance company or other person files an AFT application for insurance or a 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 may be a crime and may subject such person to criminal and civil penalties. A portion of the premium collected from the AFT Insurance program's contributory policies is allocated to fund the premium for the Policyholder's Basic Life Insurance Program. For questions, phone toll-free (888) 423-8700 or visit www.aftbenefits.org.