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I agree to the usage of electronic signature and electronic records for current and future transactions pertaining to my application conducted through this website, effective on the date I click "Submit".

I understand that I have the option to print and retain paper copies of any electronic records generated and to obtain paper copies of any electronic records generated during website transactions concerning my coverage(s).

I understand that to obtain paper copies of electronic records kept by Prudential concerning my coverage(s), or to withdraw my consent to the usage of electronic records, I must contact Prudential through any of the means provided.

I understand that in the event my personal contact information changes, I must immediately notify Prudential of the changes through any of the means provided in the "Help" section of this website.

I understand that to access and conduct transactions relating to my coverage via any prudential.com Internet site, I must have access to a personal computer at my home or workplace which can support Internet access, and a compatible browser.

I represent that all statements and answers made within or attached to this Request Form are true and compliance to the best of my knowledge and belief. BY CHECKING THE BOX BELOW, YOU ACKNOWLEDGE THAT YOU AGREE TO THE ELECTRONIC DELIVERY OF THE AGREEMENT AND TO BE LEGALLY BOUND, WITH RESPECT TO THIS AGREEMENT, AS IF YOU HAD SIGNED THIS AGREEMENT WITH A HAND-WRITTEN SIGNATURE. YOU MAY PRINT OR RETAIN A COPY OF THIS AGREEMENT FOR YOUR RECORDS.

I authorize the NEA Members Insurance Trust and its designated insurance plan administrator to establish an automatic bill payment to pay my insurance premiums when they come due. I also authorize my financial institution to charge my account accordingly. I understand if my premium changes, I will be notified and my deduction will be adjusted accordingly

If applying for NEA Guaranteed Issue Insurance Plan, I hereby certify that I am an NEA member in good standing and that I am age 45 or over. I hereby that if applying for Spouse/Domestic Partner coverage, that my Spouse/Domestic Partner is age 45 or over.

FLORIDA RESIDENTS – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

NEW YORK RESIDENTS – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or 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 is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. This notice ONLY applies to accident and disability income coverage.

I have read and understand the terms and requirements of the fraud warnings included as part of this enrollment. I certify that I am currently a member in good standing of the National Education Association. I declare by signing below that all the information I have provided is complete and true and understand that it is the basis of providing insurance under a contract(s) issued by NEA Member Insurance Trust.

Please Note: You can name your Beneficiary once you receive your issuance materials. Assign your beneficiary online at neamb.com/myaccount, or complete and return the Beneficiary Designation Form included in your issuance packet. Any amount of insurance for which there is no Beneficiary at your death will be payable to the first of the following: (a) surviving spouse or registered domestic partner; (b) surviving child(ren) in equal shares; (c) surviving parents in equal shares; (d) surviving siblings in equal shares; (e) estate. The spouse’s beneficiary will always be the member

For residents of all states except Alabama, Arkansas, the District of Columbia, Florida, Kentucky, Louisiana, Maine, Maryland, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, and Washington: WARNING – Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. ALABAMA RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. ARKANSAS, DISTRICT OF COLUMBIA, LOUISIANA and RHODE ISLAND RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. KENTUCKY RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. MAINE and WASHINGTON RESIDENTS: Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits. MARYLAND RESIDENTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW JERSEY RESIDENTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NORTH CAROLINA RESIDENTS: Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant, knowing that the statement contains false information concerning a fact or matter material to the claim may be guilty of a class H felony. PENNSYLVANIA and UTAH RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. VERMONT RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. VIRGINIA RESIDENTS: Any person, who with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

Group Life and Disability Income Medical Underwriting Notice

Thank you for choosing The Prudential Insurance Company of America (Prudential) for your insurance needs. Before we can issue coverage, we must review your Enrollment Form. To do this, we need to collect and evaluate personal information about you. This notice is being provided to inform you of certain information practices Prudential engages in, and your rights with regard to your personal information. We would like you to know that: personal information may be collected from persons other than yourself or other individuals, if applicable, proposed for coverage; this personal information as well as other personal or privileged information subsequently collected by us may, in certain circumstances, be disclosed to third parties without authorization; you have a right of access and correction with respect to personal information we collect about you; and upon request from you, we will provide you with a more detailed notice of our information practices and your rights with respect to such information. Should you wish to receive this notice, please contact: The Prudential Insurance Company of America, Group Medical Underwriting, P.O. Box 8796, Philadelphia, PA 19176.

Any information we obtain regarding a person’s insurability will be treated as confidential. We may, however, make a brief report of it to the Medical Information Bureau (the Bureau), a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. When you apply for life, disability, or health insurance to any company, including Prudential, which is a member of the Bureau, or submit a claim for benefits to such a company, the Bureau will, on request, give the company the information in its files. In addition, upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If the information came from the Bureau and you question the accuracy of the information in the Bureau’s files, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The Bureau’s address is: MIB Group, Inc., Customer Service, 50 Braintree Hill Park, Suite 400, Braintree, MA 02184, 1-866-692-6901.

This request for coverage form is to be attached to and made part of the Group Contract.

Please keep this notice for your records.

I agree to the usage of electronic signature and electronic records for current and future transactions pertaining to my application conducted through this website, effective on the date I click "Submit".

I understand that I have the option to print and retain paper copies of any electronic records generated and to obtain paper copies of any electronic records generated during website transactions concerning my coverage(s).

I understand that to obtain paper copies of electronic records kept by Prudential concerning my coverage(s), or to withdraw my consent to the usage of electronic records, I must contact Prudential through any of the means provided.

I understand that in the event my personal contact information changes, I must immediately notify Prudential of the changes through any of the means provided in the "Help" section of this website.

I understand that to access and conduct transactions relating to my coverage via any prudential.com Internet site, I must have access to a personal computer at my home or workplace which can support Internet access, and a compatible browser.

I represent that all statements and answers made within or attached to this Request Form are true and compliance to the best of my knowledge and belief. BY CHECKING THE BOX BELOW, YOU ACKNOWLEDGE THAT YOU AGREE TO THE ELECTRONIC DELIVERY OF THE AGREEMENT AND TO BE LEGALLY BOUND, WITH RESPECT TO THIS AGREEMENT, AS IF YOU HAD SIGNED THIS AGREEMENT WITH A HAND-WRITTEN SIGNATURE. YOU MAY PRINT OR RETAIN A COPY OF THIS AGREEMENT FOR YOUR RECORDS.

I authorize the NEA Members Insurance Trust and its designated insurance plan administrator to establish an automatic bill payment to pay my insurance premiums when they come due. I also authorize my financial institution to charge my account accordingly. I understand if my premium changes, I will be notified and my SAFEguardPAY® deduction will be adjusted accordingly

If applying for NEA Guaranteed Issue Insurance Plan, I hereby certify that I am an NEA member in good standing and that I am age 45 or over. I hereby that if applying for Spouse/Domestic Partner coverage, that my Spouse/Domestic Partner is age 45 or over.

FLORIDA RESIDENTS – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

NEW YORK RESIDENTS – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or 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 is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. This notice ONLY applies to accident and disability income coverage.

I have read and understand the terms and requirements of the fraud warnings included as part of this enrollment. I certify that I am currently a member in good standing of the National Education Association. I declare by signing below that all the information I have provided is complete and true and understand that it is the basis of providing insurance under a contract(s) issued by NEA Member Insurance Trust.

Please Note: You can name your Beneficiary once you receive your issuance materials. Assign your beneficiary online at neamb.com/myaccount, or complete and return the Beneficiary Designation Form included in your issuance packet. Any amount of insurance for which there is no Beneficiary at your death will be payable to the first of the following: (a) surviving spouse or registered domestic partner; (b) surviving child(ren) in equal shares; (c) surviving parents in equal shares; (d) surviving siblings in equal shares; (e) estate. The spouse’s beneficiary will always be the member

For residents of all states except Alabama, Arkansas, the District of Columbia, Florida, Kentucky, Louisiana, Maine, Maryland, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, and Washington: WARNING – Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. ALABAMA RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. ARKANSAS, DISTRICT OF COLUMBIA, LOUISIANA and RHODE ISLAND RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. KENTUCKY RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. MAINE and WASHINGTON RESIDENTS: Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits. MARYLAND RESIDENTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW JERSEY RESIDENTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NORTH CAROLINA RESIDENTS: Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant, knowing that the statement contains false information concerning a fact or matter material to the claim may be guilty of a class H felony. PENNSYLVANIA and UTAH RESIDENTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. VERMONT RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. VIRGINIA RESIDENTS: Any person, who with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

Group Life and Disability Income Medical Underwriting Notice

Thank you for choosing The Prudential Insurance Company of America (Prudential) for your insurance needs. Before we can issue coverage, we must review your Enrollment Form. To do this, we need to collect and evaluate personal information about you. This notice is being provided to inform you of certain information practices Prudential engages in, and your rights with regard to your personal information. We would like you to know that: personal information may be collected from persons other than yourself or other individuals, if applicable, proposed for coverage; this personal information as well as other personal or privileged information subsequently collected by us may, in certain circumstances, be disclosed to third parties without authorization; you have a right of access and correction with respect to personal information we collect about you; and upon request from you, we will provide you with a more detailed notice of our information practices and your rights with respect to such information. Should you wish to receive this notice, please contact: The Prudential Insurance Company of America, Group Medical Underwriting, P.O. Box 8796, Philadelphia, PA 19176.

Any information we obtain regarding a person’s insurability will be treated as confidential. We may, however, make a brief report of it to the Medical Information Bureau (the Bureau), a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. When you apply for life, disability, or health insurance to any company, including Prudential, which is a member of the Bureau, or submit a claim for benefits to such a company, the Bureau will, on request, give the company the information in its files. In addition, upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If the information came from the Bureau and you question the accuracy of the information in the Bureau’s files, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The Bureau’s address is: MIB Group, Inc., Customer Service, 50 Braintree Hill Park, Suite 400, Braintree, MA 02184, 1-866-692-6901.

This request for coverage form is to be attached to and made part of the Group Contract.

Please keep this notice for your records.

Authorization for the Release of Information. This authorization is intended to comply with the HIPAA Privacy Rule. I authorize and instruct any health plan, physician, health care professional, hospital, clinic, laboratory, medical facility, pharmacy benefit manager, retail pharmacy, clearinghouse, data warehouse or other comparable organization that aggregates and maintains pharmacy data, or other health care provider that has provided treatment or services to me within the past 5 years (“My Providers”) to disclose my entire medical record and any other health information concerning me to The Prudential Insurance Company of America (“Prudential”) and through it, to its reinsurers, authorized agents and MIB, Inc. This includes information on the diagnosis and treatment of Human Immunodeficiency Virus (HIV) infection (In Vermont and Wisconsin, this information is excluded) and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes. I also authorize the MIB, Inc. to release any data it may have about me for coverage to Prudential. By my signature below, I acknowledge that any agreements I have made to restrict the disclosure of health information do not apply to this Authorization and I instruct any of My Providers to release and disclose my entire medical record without restriction, including without limitation any restrictions on health care items or services for which a health care provider has been paid out of pocket in full. This health information is to be disclosed under this Authorization so that Prudential may: 1) underwrite an application for coverage and make risk determinations; 2) administer coverage; and 3) conduct other legally permissible activities that relate to any coverage I have or have applied for with Prudential. This Authorization shall remain in force for 24 months following the date of my signature below, and a copy of this Authorization is as valid as the original. I understand that I have the right to revoke this Authorization in writing, at any time, by sending a signed request for revocation to The Prudential Insurance Company of America; Group Medical Underwriting, P.O. Box 8796, Philadelphia, PA 19176, Attention: Senior Medical Underwriting Consultant. I understand that such a revocation is not effective to the extent that Prudential has taken action in reliance on this Authorization or to the extent that Prudential has a legal right to contest a claim under the insurance contract or to contest the contract itself. I understand that any information that is disclosed pursuant to this authorization may be re-disclosed to other parties and will not be protected by the HIPAA Privacy Rule. (In Montana only, I may request a record of any subsequent disclosures of protected health information). I understand that if I refuse to sign this Authorization to release my entire medical record and any other health information concerning me, Prudential may not be able to process an application for coverage. I understand that I have the right to request and receive a copy of this Authorization.