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Member Certification

I, the undersigned member, certify that I have read, or have had read to me, the completed request for coverage form and I realize that any false statement or misrepresentation in the request for coverage form may result in loss of coverage under the Group Contract. By my eSignature below, I hereby request coverage. I acknowledge that I am a member of the American Foreign Service Protective Association and that I must continue such membership to keep this insurance in force.

Statement of Understanding

I represent that all statements and answers made within or attached to this Request Form are true and complete to the best of my knowledge and belief. I understand that my request for coverage form, including portions containing health information are submitted to the Plan Administrator, acting for the policyholder, and that the administrator shall forward the request for coverage form to the insurance company. Furthermore, I understand that coverage shall be in effect only after these conditions have been met: this request for coverage form has been approved by Prudential; the Certificate has been issued while all persons to be insured there under are alive; the answers and statements in this request for coverage form continue to be true and complete until the Effective Date; and the initial premium contribution has been paid. I also understand that coverage will not take effect if the facts have changed. I have also read and understand and agree to the additional terms, conditions and requirements as stated in the Authorization for the Release of Information and Important Notice sections. I understand that completion of this request for coverage form in no way implies that I will be accepted for insurance coverage.

State-Specific Fraud Warnings

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.

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.

Fraud Warnings Acknowledgment

Please consult Fraud warnings appearing on next page. I have read and understand the terms and requirements of these Fraud warnings.

I have received the Group Life and Disability Income Medical Underwriting Notice included with this form.

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.

Medical Information Bureau (MIB) Notice

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.

Electronic Signature and Records Agreement

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".

Paper Copies and Records

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).

Obtaining Paper Copies and Withdrawal

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.

Contact Information Updates

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.

System Requirements

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.

Legal Acknowledgment

I represent that all statements and answers made within or attached to this Request Form are true and complete 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.

Authorization for the Release of Information

This authorization is intended to comply with the HIPAA Privacy Rule.

Authorization to Disclose Medical Records

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.

Specific Information Included

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.

MIB Authorization

I also authorize 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.

Purpose of Disclosure

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.

Duration and Revocation

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.

Important Limitations

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).

Consequences of Refusal

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.

Automatic Payment Option (Account Deduction Authorization)

The Automatic Payment Option (Account Deduction Authorization) is subject to the following conditions:

Payment Processing

• Premium payments will be debited from your account on or about the premium due date.
• Additional premium that may be required in order to keep policy(ies)/certificate(s) current may be drawn from your account through the use of multiple debits.

Revocation and Fees

• The Rutgers may revoke the privilege of paying premium under this Automatic Payment Option (APO) if any payment is dishonored.
• A service fee of $15.00 may be assessed for each dishonored payment.

Discontinuation

• Payment of premium under APO may be discontinued by the Company or the undersigned upon thirty (30) days written notice.
• If APO is discontinued, an alternate payment mode acceptable to the Company will be used to remit the premiums needed to keep the policy(ies)/certificate(s) in force and current.

Premium Notices and Changes

• The Company will not send premium notices while APO is in effect.
• A request for change or adjustment to the APO must be sent directly to the Company's Customer Service Department.

Cancellation and Refunds

• If you cancel this service, any refund of premium due you will take sixty (60) days to process.

Coverage Limitations

This policy provides limited benefits as specified in the policy documents. Please review all terms, conditions, exclusions, and limitations before enrollment.

Pre-existing Conditions

Coverage for pre-existing medical conditions may be limited or excluded. Please review the policy documents for specific details regarding pre-existing condition limitations.

Effective Date

Coverage becomes effective on the date specified in your certificate of coverage, subject to approval of your application and payment of required premiums.

Right to Cancel

You have the right to cancel your coverage within the free look period specified in your state. Cancellation procedures and refund policies are outlined in your policy documents.

Claims Procedures

To file a claim, you must follow the procedures outlined in your policy documents. Failure to comply with claims procedures may result in denial or delay of benefits.

Premium Changes

Premiums may be subject to change based on factors such as age, coverage amount, and insurance company rate adjustments. You will be notified in advance of any premium changes.

State Specific Notices

Additional state-specific notices and requirements may apply based on your state of residence. Please refer to your policy documents for state-specific provisions.

Contact Information

For questions about your coverage, claims, or policy changes, please contact customer service at the number provided in your policy documents.