Premium Rates for Gateway USA
. Plan A: $50,000 Medical Benefits  Plan B: $100,000 Medical Benefits
Adult Rates: 15 Days Only (1) Monthly 15 Days Only (1) Monthly
Age: 18-29 $30 $49 $40 $66
Age: 30-39 $38 $64 $53 $88
Age: 40-49 $55 $92 $77 $128
Age: 50-59 $75 $126 $100 $168
Age: 60-69 $93 $155 $124 $206
Age: 70-79 $108 $158 N/A N/A
Age: 80 and over (2) $165 $275 N/A N/A
Child Rates: . .
Each Dependent Child $16 $26 $20 $34
Each Child Alone (3) $25 $42 $40 $60
$100,000 Additional AD&D (Optional) (4) $9 $14 $9 $14
Other Benefits
Emergency Medical Evacuation $50,000
Repatriation of Remains $20,000
Medical and Travel Assistance Services Included
Accidental Death & Dismemberment (AD&D) $25,000
*Medical Expense Maximum is limited to $50,000 for Insureds age 70 through 79 and to $10,000 for Insureds age 80 and over

(1) Minimum Period of Coverage is 15 days, maximum is 18 months. For any term of coverage more than 15 days, full Monthly rates apply. The 15-day term cannot be combined with full month term on the same Application form.
(2) Medical Benefit Amount for Ages 80 and over is $10,000.
(3) Use these rates for child(ren) who are insured independently and are not included with parent(s) on this Application.
(4) Available only to persons 18 or older.

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
( use form below and enter Premium Rates from chart at above)

Names of person(s) to be insured Date of Birth (mm/dd/yy)  
Applicant     $
Spouse     $
Child     $
Child     $
Child     $


$100,000 Additional AD&D(Optional benefit. If purchased, must be included for both Insured and Spouse, if applicable).

$___________________  x  (Number of adults) = $______________
Total Base Monthly Premium(s) $______________
Multiply by Number of Months*  x ______________
*(Only whole numbers, no fractions of months. If 15 Day plan, enter 1 here)

Total Premium Enclosed $______________

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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