HomeMy WebLinkAboutNew York Life Insurance - Voluntary LIfe Insurance Program for EmployeesNEW YORK LIFE WORKSITE EMPLOYER AGREEMENT FORM
p JC 7 h C n (Name of Employer), referred to as Employer, has selected and agreed to the following
Voluntary Worksite arrangement(s) as issued by New York Life Insurance Company (NYLIC) and/or its subsidiary, the New York Life
Insurance and Annuity Corporation (NYLIAC), collectively "New York Life", on the lives of eligible employees and/or their dependents.
I. Premiums, Coverage and Eligible Employee
• Payroll Deductions must be used to pay all premiums due. Employer funds cannot be accepted.
• Under this arrangement, coverage under the Temporary Coverage Agreement receipt, attached to the application, will be
provided subject to its terms and conditions, just as though the full first premium had been paid in cash with application.
• An Eligible Employee means a full-time employee of the Employer, who at the time he/she is applying for insurance:
• Is actively at work on a full-time basis (at least 30 hours a week)
• Has been employed continuously by the Employer fora minimum of 6 months on a full-time basis
• Is between the ages of 16 and 70 (nearest birthday)
II. Minimum Participation (Check either Simplified Issue or Guaranteed Issue)
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Simplified Issue means that New York Life does limited underwriting to determine acceptance. At least 5 policies (including
eligible employees and eligible family members) must be paid in order to make the arrangement active. At least 3 policies
must remain active to keep the arrangement in force.
For New York State only (check the box which applies)
Employers with 25 or fewer Eligible Employees - at least 3 employees must be enrolled
n Employers with more than 25 Eligible Employees (check the box which applies below)
0 With a group life insurance plan - at least 5 employees must be enrolled
n With no group life insurance plan - there are no minimum participation requirements
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Guaranteed Issue means that New York Life will issue a policy on the life of an Eligible Employee applying for insurance if
such Eligible Employee has not been absent from work for more than 5 days (except for vacation and normal non -working
days) during the 3 months prior to his or her application. The greater of the following two conditions must be met during
the initial enrollment period: 1) 10% of all eligible employee participation, or 2) 10 eligible employee policies written. In
addition:
• If the required minimum participation is achieved, all newly eligible employees hired after the initial enrollment
`period will be eligible to apply for Guaranteed Issue coverage during the next enrollment period, which will be an
open (30-90 day) enrollment period beginning on the same month and day as the original enrollment.
• If the required minimum participation is not achieved during the initial enrollment, only those employees that
purchased a policy during the initial enrollment will be eligible for Guaranteed Issue coverage during future
enrollments. All other employees may apply for Simplified Issue coverage during future enrollments.
• If an Eligible Employee chooses not to participate in the original Guaranteed Issue program or surrenders or
cancels a Guaranteed Issue policy, he/she is only eligible for a Simplified Issue policy during future enrollments.
• A Simplified Issue policy will require simplified underwriting and will have the same rates as a Guaranteed Issue
policy.
III. Marketing and Promotion
• The Employer agrees to allow the following marketing and promotion options during the enrollment period.
(Check all that apply; for Guaranteed Issue arrangements. a minimum of an additional 4 conditions must be chosen):
a-
0
(13
c
2
® Announcement Email/Letter
® Enrollments during Business Hours
• Onsite Solicitation
® Individual Meetings
® Payroll Dept. Meetings
21237 (09/16)
❑ Supervisor Meetings
❑ Group Meetings
❑ Private Enrollment Area
❑ Payroll Stuffers
❑ Customized Website
❑ Storefront Promotion
❑ Meeting Posters
❑ Brochure Handouts
❑ Flyer Handouts
❑ Other:
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I I
NEW YORK LIFE WORKSITE EMPLOYER AGREEMENT FORM
L'AN
I. Minimum Participation and Premiums
• At least 1 policy on an employee, and
• A minimum of $40 in payroll deducted premiums per month
11. Arrangement for Payment of First Premium (check one option below) :
Employee Funded
Premiums are fully (100%) paid via voluntary employee payroll deductions. Under this selected arrangement,
coverage under the Conditional Temporary Coverage receipt attached to the application will be provided subject to
its terms and conditions, just as though the full first premium had been paid in cash with the application.
Employer Funded
The Employer intends to purchase insurance on their employees, and will be paying all premiums. For these
arrangements only, employers will be required to provide a check for the first premium.
I 1
1rA "i
LZAN TERM
CONDITIONS.
Enrollments
• The Employer agrees that any on-site solicitation or sale of New York Life products to its employees may be
conducted only by career agents under contract with New York Life.
• The Employer shall receive no compensation in connection with this program.
• New York Life reserves the right to decline any Employer based upon eligibility criteria.
II. Remittance of Payroll Deductions
The Employer and Payroll Administrator agree to the following:
• Payroll Deductions from salaries, or other compensation, will be deducted as indicated on the Payroll Deduction
Authorization Forms turned in to the Employer. A new Payroll Deduction Authorization Form may be required if 'a
premium amount is changed.
• Payroll Deductions will start at the designated time to ensure sufficient deductions are collected prior to the billing
statement due date.
• The Payroll Administrator will reconcile all the payroll deductions taken against every billing statement. Any necessary
corrections (including removals, additions, and/or corrected amounts) must be indicated on the billing statement, and
returned to NYL along with the remitted payment.
• The Employer will only remit what was deducted (not what was billed) to New York Life by the due date. New York Life will
be responsible for any refunds which may be required.
• A premium will not be considered as paid until it is received in good order by New York Life.
Termination
• This arrangement may be terminated by either party by providing 15 days prior written notice to the other party.
• If the arrangement is terminated, any responsibility of the Employer for the remittance of deductions taken shall
cease upon payment of all deductions taken prior to the effective day of termination.
• New York Life may terminate a NYL-A-PLUS or NYL-A-PLAN arrangement if payment(s) are not received within 24
days of the remittance due date and/or due to the failure or inability of the employer to conduct timely reconciliation
of payroll deductions against each billing statement.
AblIEEMENT'AND1SIGNATURES
In consideration of the mutual promises set forth herein, New York Life and the Employer agree to the above.
NEW YORK LIFE INSURANCE COMPANY
President
NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (A Delaware Corporation)
ACCEPTED BY* VI/IN-\
President
(Sployer's Decision Maker with Title)
WITNESSED BY: Agent Name
ent's Si
21237 (09/16)
clry CONTRACT NO: Qt,/ 7-172.
RESOLUTION NO: /1 /A
Secretary
Secretary
(Signature of Employer's Payroll Administrator - recommended)
k 01 tom' Agent # (o37 (aa
/c)/.:!)q)
(Date)
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