Premium Rates for Gateway Global I
Basic Plan  
AD&D Principal Sum $200,000
Emergency Medical Evacuation Unlimited
Repatriation of Remains Unlimited
Return of Minor Children $5,000
Political Evacuation and Repatriation $10,000
Worldwide Assistance Services Included
Annual Premium Applicant Only: $130.00 Family Plan: $165.00
Enhanced Plan    
Option 1 Premium Applicant Only Family Plan
Increase AD&D to: $300,000 $30.00 N/A
to: $400,000  $60.00 N/A
to: $500,000 $90.00 N/A
to: $600.000(1) $120.00 N/A
to: $750,000(1) $165.00 N/A
to: $1,000,000(1) $270.00 N/A
Option 2 Premium Applicant Only Family Plan
$25,000 Maximum Benefit $40.00 $50.00
$100,000 Maximum Benefit $56.00 $70.00
Option 3 Premium Applicant Only Family Plan
Add War Risk Coverage (2)   N/A

(1) Coverage greater than $500,000 requires pre-approval. Contact the Administrator for the required supplemental application form.
(2) War Risk coverage requires pre-approval. Contact the Administrator for the required supplemental application form.

How to enroll:
If paying by check or money order, enclose check with completed Application and mail to the Gateway Plan Administrator. If paying by credit card, you may either mail or fax your application to: (please donot mail and fax your Application.)

Exec Relo USA
Gateway Plan Administrator
123 East 54th Street, Suite 5H
New York, NY 10022
Tel: (212) 752-0999 or 1 888 BENEFTS(236-3387) Fax: (212) 752-0791

Calculating Your Premium - Global I
(use form below and enter Premium Rates from chart at above)

Basic Plan   Premium
Applicant Only Family Plan $
Enhanced Plan    
Option 1: Increase AD&D to:
(Available for Applicant only)		 $ $
Option 2: Add Medical Coverage
Maximum Amount Selected:		 $ $
Option 3: Add War Coverage
Rates quoted by Administrator		 $ $
Total Premium: $

I hereby subscribe to the AIG Life Trust and enroll in the group coverage for which I am eligible under the group contract issued by The Insurance Company of the State of Pennsylvania, a member of American International Group, Inc. (AIG). I understant that Gateway Global I is intended for frequent, short-term international trips and that each trip abroad can be no more than 45 days.

________________________________________________________________________________
Signature of Applicant or Proxy                                           Date

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