Premium Rates for Gateway Int'l
  Under Age 70 70 or older
Plan A: $25,000 Medical Benefit Amount $3.00/day $7.50/day
Plan B: $100,000 Medical Benefit Amount $4.00/day $10.00/day
Option 1: Additional $100,00 AD&D $.55/day $.55/day
Option 2: Additional $250,000 AD&D $1.35/day $1.35/day

Note: If additional AD&D coverage is desired, all adults listed on this Application must purchase the same benefit (Option 1 or Option 2). Additional AD&D coverage is not available to persons under age 18.

How to enroll:
To enroll in Gateway International, complete the Application Form. 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:

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

The Gateway Plans are underwritten by the Insurance Company of the State of Pennsylvania, a member company of American International Group (AIG) - a leader in worldwide insurance services with the following company ratings: Best's A++ Superior, Standard & Poors AAA Superior, Moody's Aaa Exceptional.

Premium, Eligibility Criteria, Plan Benefits, Limitations and Exclusions are subject to change. Coverage is issued according to plan specifications and rates in effect at time of enrollment.

Calculating Your Premium

1. Select Coverage Plan A Plan B
Medical Benefit $25,000 $100,000
2. Calculate Premium (minimum 15 days, maximum 180 days)
(        )Number of days requested
 x (        )Number of persons to be insured x (       ) Daily cost per person  = $
3.Add Optional Coverage
Option 1: Additional $100,000 AD&D
(        )Number of days requested
 x (        )Number of persons to be insured x 0.55
Daily cost per person		  = $
Option 2: Additional $250,000 AD&D
(        )Number of days requested
 x (       )Number of persons to be insured x 1.35
Daily cost per person		  = $
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)

________________________________________________________________________________
Signature of Applicant or Proxy                                           Date

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