THE TRINIDAD BUILDING AND LOAN ASSOCIATION

89 Queen Street, Port of Spain

Tel:

My Membership No:

Date:

Dear Member,

As human beings we know that death, for our loved ones and us is unavoidable...IT WILL HAPPEN. At that time of distress we can either pay these final

expenses from savings or have them paid for us. Most of us are not financially prepared to deal with this unexpected burden.

Nothing is more important than your family. You want to protect and care for them during life's good and bad times. The Trinidad Building & Loan

Association is pleased to introduce the Family indemnity Plan to deal with some of the financial needs that are certain to arise at times like this.

This Plan was developed by the CUNA Mutual Group/CUNA Caribbean to provide financial assistance for you and your loved ones.

BENEFITS:

• Low rate that covers up to six (6) eligible family members (member, members' spouse or significant other, children between 1-26, parents

under age 76)

• No medical questions or examination required

• No waiting period if you enroll during the Open Enrollment Period - (September 1" to November 30•h 2007)

• No price discrimination based on age or health

• Lifetime insurance coverage (you must enroll before age 76)

• Five (5) levels of benefits from which to choose:

NB: This information is descriptive only, and the terms and conditions of the actual contract shall be controlling in all cases.

PLAN A - $10,000 PLAN B - $15,000 PLAN C - $20,000 PLAN D - $30,000 PLAN E - $40,000

$52.80 monthly $79.20 monthly $105.60 monthly $158.40 monthly $211.20 monthly

As a valued member of The Trinidad Building & Loan Association, you are eligible to take advantage of this opportunity to protect you and your loved

ones in the future.

We make it easy for you to make convenient monthly payments for this affordable coverage through salary deductions, bankers' order, linx, cash or

cheque. For your coverage to become effective from the first of the month following that in which you enrolled simply complete and detach the

enrollment form and return it to our office with the first monthly premium.

Enroll in the Family Indemnity Plan today! lf you need further information, please contact our offices at 623-1501/4.

Yours sincerely,

Manager.

NOTE: 1. Please be sure to include your first premium along with this enrollment form.

2. If you are the only insured person, please complete a Designation of Beneficiary Form

LAST NAME

FIRST NAME MIDDLE NAME

DATE OF BIRTH

yyyy/mm/dd

AGE SEX

RELATIONSHIP

TO MEMBER

NB The effective date of your certificate will always be the first of the month following enrollment.

Indicate the complete name, date of birth, age and the relationship of

All individuals enrolling in the plan, including yourself.

The Family Indemnity Plan

We reserve the right to request proof of the above information

Name of Organisation:

Plan A ($10,000.00)

Indicate the Plan selected

Plan B ($15,000.00)

Plan D ($30,000.00)

Plan C ($20,000.00)

City: Street Address 2:

Street Address:

My Complete Address

Staff Name:

1. Are you or any persons named above presently covered under another Family Indemnity Plan?

Yes

2. Have you or any of the persons named above previously had a Family Indemnity Plan with your current Credit Union?

Yes

It is the sole responsibility of the Member to ensure that eligible persons for whom application is being made are not insured persons who have existing coverage

under The Family Indemnity Plan as no person may be insured through more than one Family Indemnity Plan Certificate in accordance with the Non-Duplication of

Coverage clause contained in the Members Family Indemnity Plan Certificate. If a person is named under more than one Family Indemnity Plan Certificate on the death

of such a person the Insurer shall only be liable to pay the claim made under The Family Indemnity Plan that is first in time.

I understand that if this enrollment is made outside of the Open Enrollment Period, there will be a six-month waiting period before full coverage begins. During the

six·month waiting period, only Accidental Death Benefits are covered. I understand and certify that, to the best of my knowledge and belief, all statements contained in

this enrollment are true and agree that if there is any evasion, concealment, or misrepresentation in any of the statements made herein, the insurance issued on the

basis hereof shall be null and void.

I have read and understood the above information. In confirmation of this I have signed and dated this document.

Date:

(yyyy/mm/dd)

Signature:

Amt Paid:

Rec. #:

Date:

(yyyy/mm/dd)

Plan E ($40,000.00)

Reset