Life Insurance Medical History Statement for NY Residents

If your residence is other than NY State, contact the NYU Benefits Office for the applicable form.

For all employees who would like to purchase NYU Supplemental Group Life Insurance through payroll deduction but did not have a qualifying status change within the last 31 days, and:

• did not elect supplemental life insurance when first eligible, or
• did elect supplemental life insurance when first eligible and would like to increase the amount of their coverage.

Note: If you have experienced a qualifying status change within the past 31 days, you are not required to submit the Medical History Statement with your Life Insurance Enrollment Application.

Instructions

NYU provides you with basic group life and AD&D Coverage at no cost to you. You may purchase additional group life coverage through payroll deduction. If you wish to purchase additional coverage after your initial enrollment period expires, you may do so. However, you will be required to provide the insurance carrier with proof of good health (unless you apply for coverage within 31 days of qualifying status change)

Your completed Medical History Statement should be attached to your Life Insurance Enrollment Form. Both should be sent to the NYU Benefits Office at 7 East 12St., 12th Floor - Campus Mail Code: 8923, NY, NY 10003-4475. Coverage will not take effect until the insurance carrier has approved your application.

For more information:

• Code 100, 102, 103, click here
• Code 104, 106, 107, click here
• Code 107 PRG, click here
• Code 107 810, click here
• Sergeant Guards, click here