lifehelpgi.nylinsure2.com
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23.12.147.87
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URL:
https://lifehelpgi.nylinsure2.com/
Submission: On March 31 via api from US — Scanned from US
Submission: On March 31 via api from US — Scanned from US
Form analysis 3 forms found in the DOM
submit.html
<form action="submit.html" id="form" autocomplete="off">
<div class="pages">
<div class="eligibility page container mt-5 first">
<div class="">
<div data-fields="txtCampaignCode" class="hide">
<div class="field-txtCampaignCode form-group"> <label>Campaign Code</label>
<div>
<div data-editor=""><input id="txtCampaignCode" class="form-control form-control-lg" name="txtCampaignCode" type="text" autocomplete="on"></div>
<div class="error-text" data-error=""></div>
</div>
</div>
</div> <!-- page title -->
<div class="page-title mb-5">
<h1 class="page-name"></h1>
<p class="lead">This information will help determine your insurance options.</p>
</div> <!-- eligibility: self -->
<div class="applicant ">
<h5 class="applicant-header">Who is this insurance for?</h5>
<div class="row align-items-center chkWhomToCover">
<div id="coverageSelection" class="col-12 col-xl-4">
<div class="btn-group application-apply-for">
<div data-fields="chkWhomToCoverSlf">
<div data-editor="" class="custom-control custom-checkbox field-chkWhomToCoverSlf"><input id="chkWhomToCoverSlf" class="custom-control-input" name="chkWhomToCoverSlf" type="checkbox"> <label for="chkWhomToCoverSlf"
class="custom-control-label">Myself </label> </div>
</div>
<div data-fields="chkWhomToCoverSps">
<div data-editor="" class="custom-control custom-checkbox field-chkWhomToCoverSps"><input id="chkWhomToCoverSps" class="custom-control-input" name="chkWhomToCoverSps" type="checkbox"> <label for="chkWhomToCoverSps"
class="custom-control-label">My spouse </label> </div>
</div>
<div data-fields="chkWhomToCoverChd" style="display: none;">
<div data-editor="" class="custom-control custom-checkbox field-chkWhomToCoverChd"><input id="chkWhomToCoverChd" class="custom-control-input" name="chkWhomToCoverChd" type="checkbox"> <label for="chkWhomToCoverChd"
class="custom-control-label">My child(ren) </label> </div>
</div>
</div>
<div class="error-text" data-error=""></div>
</div>
</div>
</div>
<div class="applicant eligibility-self">
<h5 class="applicant-header">About You</h5>
<div class="info-box member-info mt-3">
<p class="mb-0">Member information is required even if you are not applying for insurance for yourself.</p>
</div>
<div class="applicant-fields"> <!-- self: membership -->
<div data-fields="hidAppInitUrl">
<div class="hide"> <label>Application URL</label>
<div data-editor=""><input id="hidAppInitUrl" class="form-control form-control-lg" name="hidAppInitUrl" type="text" autocomplete="on"></div>
</div>
</div>
<div class="row">
<div data-fields="rdEligIsMemberSlf" class="col-12 col-md-8 col-lg-6">
<div class=" p-0 form-group">
<div> <label for="rdEligIsMemberSlf" class="mandatory1">Are you an eligible member?</label> </div>
<div class="d-flex">
<div class="btn-group btn-group-toggle flex-fill" data-toggle="buttons" data-editor="">
<div id="rdEligIsMemberSlf" name="rdEligIsMemberSlf"> <label class="btn btn-outline-radio fill" for="rdEligIsMemberSlf-0">Yes <input type="radio" name="rdEligIsMemberSlf" value="Yes" id="rdEligIsMemberSlf-0"
data-ea-cta-link="yes-rdEligIsMemberSlf" data-ea-zone="form" data-ea-type="button"> </label> <label class="btn btn-outline-radio fill" for="rdEligIsMemberSlf-1">No <input type="radio" name="rdEligIsMemberSlf" value="No"
id="rdEligIsMemberSlf-1" data-ea-cta-link="no-rdEligIsMemberSlf" data-ea-zone="form" data-ea-type="button"> </label> </div>
</div>
</div> <span class="error-text" data-error=""></span>
</div>
</div>
</div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row">
<div data-fields="txtCreditUnionName" class="col-12 col-md-8 col-lg-6">
<div class="field-txtCreditUnionName form-group" style="display: none;"> <label class="mandatory1">Name of credit union</label>
<div>
<div data-editor=""><input id="txtCreditUnionName" class="form-control form-control-lg mandatory" name="txtCreditUnionName" maxlength="60" type="text" autocomplete="on" validateattr="false"></div>
<div class="error-text" data-error=""></div>
</div>
</div>
</div>
</div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> <!--<div class="col-12 col-sm-3 col-md-4" data-fields="txtEligOccupationOpt"></div>--> </div>
<div class="row"> </div>
<div class="row">
<div class="col-lg-12 memberShip-consent"> </div>
</div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row">
<div class="col-12 col-sm-2 col-md-2 "> </div> <!-- self: first name -->
<div class="col-12 col-sm-3 col-md-3 "> </div>
<div class="col-12 col-sm-2 col-md-2 "> </div> <!-- self: last name -->
<div class="col-12 col-sm-3 col-md-3 "> </div>
<div class="col-12 col-sm-2 col-md-2 "> </div>
</div>
<div class="row">
<div class="col-12 col-sm-3 col-md-4 "> </div>
<div class="col-12 col-sm-3 col-md-4"> </div>
</div>
<div class="row">
<div class="col-12 col-sm-6 col-md-3">
<div data-fields="dtEligBirthDateSlf">
<div class="field-dtEligBirthDateSlf form-group"> <label class="mandatory1">Birthday</label><span class="ml-1 small text-muted">mm/dd/yyyy</span>
<div>
<div data-editor="">
<div class="date-sign input-group date"> <input id="dtEligBirthDateSlf" class="form-control form-control-lg input-date inputDate" name="dtEligBirthDateSlf" type="tel" maxlength="30" mask="99/99/9999" autocomplete="off"
inputmode="numeric" pattern="[0-9]+(.[0-9]{0,2})?%?"></div>
</div>
<div class="error-text" data-error=""></div>
</div>
</div>
</div>
</div>
<div class="col-12 col-sm-4 col-md-4" id="rdGenderSlf"> </div> <!-- self: last name -->
<div class="col-12 col-sm-4 col-md-4 ">
<div data-fields="selEligStateSlf">
<div class="field-selEligStateSlf form-group"> <label class="mandatory1">State</label>
<div class="" data-editor=""><span><select id="selEligStateSlf" class="input-select selectized" name="selEligStateSlf" tabindex="-1" style="display: none;">
<option value="" selected="selected"></option>
</select>
<div class="selectize-control input-select single">
<div class="selectize-input items not-full has-options"><input type="select-one" autocomplete="off" tabindex="" id="selEligStateSlf-selectized" readonly="" style="width: 4px;"></div>
<div class="selectize-dropdown single input-select" style="display: none;">
<div class="selectize-dropdown-content"></div>
</div>
</div>
</span></div>
<div class="error-text" data-error=""></div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-4" data-fields="txtEmailSlf">
<div class="field-txtEmailSlf form-group"> <label class="mandatory1">Email</label>
<div>
<div data-editor=""><input id="txtEmailSlf" class="form-control form-control-lg mandatory" name="txtEmailSlf" maxlength="100" type="text" autocomplete="email"></div>
<div class="error-text" data-error=""></div>
</div>
</div>
</div>
</div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row">
<div class="col-12 col-md-8 col-lg-6"> </div>
</div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row coverage-category-slf" style="display: none;">
<div class="col-12 form-group"> <label class="mb-1 mandatory1 hide covg-type-label">Choose the group coverage(s) you are interested in:</label>
<div class="coverage-type-slf">
<div data-fields="chkLICategorySlf" class="category-slf">
<div data-editor="" class="custom-control custom-checkbox field-chkLICategorySlf" style="display: none;"><input id="chkLICategorySlf" class="custom-control-input" name="chkLICategorySlf" type="checkbox" validateattr="false">
<label for="chkLICategorySlf" class="custom-control-label">Life Insurance </label> </div>
</div>
</div>
</div>
</div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="container-li-category-slf">
<div class="row">
<div class="col-12 col-md-8 col-lg-6"> </div>
</div>
<div class="row">
<div class="col-12 col-sm-6 col-md-4 col-lg-3"> </div>
<div class="col-12 col-sm-6 col-md-5 col-lg-4 col-xl-4"> </div>
</div>
</div>
<div class="container-di-category-slf">
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row armedForcesTxt d-none">
<div class="col-12 col-md-8 col-lg-7">
<p class="text-muted mb-1">You are not eligible for Disability Insurance.</p> <!-- <p class="mb-1 small text-muted">You are not eligible for Disability Insurance.</p>-->
</div>
</div>
<div class="row"> </div>
</div>
<div class="container-oo-category-slf">
<div class="row"> </div>
</div>
<div class="container-hi-category-slf">
<div class="row"> </div>
<div class="row"> </div>
</div>
</div>
</div> <!-- eligibility: spouse -->
<div class="applicant eligibility-spouse" style="display: none;">
<h5 class="applicant-header d-flex align-items-center"><i class="fas fa-user mr-3"></i>About Spouse</h5>
<div class="applicant-fields">
<div data-fields="lblEligDomPrtnrMsgSps">
<div class="info-box member-info mt-3 field-lblEligDomPrtnrMsgSps">
<p class="mb-0">Domestic Partnership/Civil Union is determined by State Law and they will be referred to as "Spouse" throughout the application.</p>
</div>
</div> <!-- spouse: membership -->
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> </div>
<div class="row"> <!-- <div class="col-12 col-md-8 col-lg-6 form-group">-->
<div data-fields="rdEligIsMemberSps" class="col-12 col-md-8 col-lg-6">
<div class="p-0 form-group" style="display: none;">
<div> <label for="rdEligIsMemberSps" class="mandatory1">Is your spouse also a member of a participating credit union?</label> </div>
<div class="d-flex">
<div class="btn-group btn-group-toggle flex-fill" data-toggle="buttons" data-editor="">
<div id="rdEligIsMemberSps" name="rdEligIsMemberSps" validateattr="false"> <label class="btn btn-outline-radio fill" for="rdEligIsMemberSps-0">Yes <input type="radio" name="rdEligIsMemberSps" value="Yes" id="rdEligIsMemberSps-0"
data-ea-cta-link="yes-rdEligIsMemberSps" data-ea-zone="form" data-ea-type="button" validateattr="false"> </label> <label class="btn btn-outline-radio fill" for="rdEligIsMemberSps-1">No <input type="radio"
name="rdEligIsMemberSps" value="No" id="rdEligIsMemberSps-1" data-ea-cta-link="no-rdEligIsMemberSps" data-ea-zone="form" data-ea-type="button" validateattr="false"> </label> </div>
</div>
</div> <span class="error-text" data-error=""></span>
</div>
</div> <!-- </div>-->
</div>
<div class="row">
<div data-fields="lblEligMbrMsgSps" class="col-12 col-md-8 col-lg-12">
<div class="info-box member-info mt-3 field-lblEligMbrMsgSps" style="display: none;">
<p class="mb-0">A spouse who is also a member of the credit union can apply for member or dependent coverage, but not both.</p>
</div>
</div>
</div>
<div class="row">
<div class="col-12 col-sm-2 col-md-2 "> </div> <!-- spouse: first name -->
<div class="col-12 col-sm-3 col-md-3 form-group"> </div>
<div class="col-12 col-sm-2 col-md-2 "> </div> <!-- spouse: last name -->
<div class="col-12 col-sm-3 col-md-3 form-group"> </div>
<div class="col-12 col-sm-2 col-md-2 "> </div>
</div>
<div class="row">
<div class="col-12 col-sm-6 col-md-3 col-xl-2">
<div data-fields="dtEligBirthDateSps">
<div class="field-dtEligBirthDateSps form-group" style="display: none;"> <label class="mandatory1">Birthday</label><span class="ml-1 small text-muted">mm/dd/yyyy</span>
<div>
<div data-editor="">
<div class="date-sign input-group date" validateattr="false"> <input id="dtEligBirthDateSps" class="form-control form-control-lg input-date inputDate" name="dtEligBirthDateSps" type="tel" mask="99/99/9999" autocomplete="off"
inputmode="numeric" pattern="[0-9]+(.[0-9]{0,2})?%?" validateattr="false"></div>
</div>
<div class="error-text" data-error=""></div>
</div>
</div>
</div>
</div>
<div class="col-12 col-sm-4 col-md-4"> </div>
</div>
<div class="row">
<div class="col-lg-4" data-fields="txtEmailSps">
<div class="field-txtEmailSps form-group" style="display: none;"> <label class="mandatory1">Email</label>
<div>
<div data-editor=""><input id="txtEmailSps" class="form-control form-control-lg mandatory" name="txtEmailSps" maxlength="100" type="text" autocomplete="email" validateattr="false"></div>
<div class="error-text" data-error=""></div>
</div>
</div>
</div>
</div>
<div class="row"> </div>
<div class="row coverage-category-sps" style="display: none;">
<div class="col-12 form-group"> <label class="mb-1 mandatory1">Choose the group coverage(s) you are interested in:</label>
<div class="coverage-type-sps">
<div data-fields="chkLICategorySps" class="category-sps">
<div data-editor="" class="custom-control custom-checkbox field-chkLICategorySps" style="display: none;"><input id="chkLICategorySps" class="custom-control-input" name="chkLICategorySps" type="checkbox" validateattr="false">
<label for="chkLICategorySps" class="custom-control-label">Life Insurance </label> </div>
</div>
</div>
</div>
</div>
<div class="container-li-category-sps">
<div class="row">
<div class="col-12 col-md-8 col-lg-6"> </div>
</div>
<div class="row">
<div class="col-12 col-sm-6 col-md-4 col-lg-3"> </div>
<div class="col-12 col-sm-6 col-md-5 col-lg-4 col-xl-4"> </div>
</div>
</div>
<div class="container-di-category-sps">
<div class="row"> </div>
<div class="row"> </div>
<div class="row armedForcesSpouseTxt d-none">
<div class="col-12 col-md-8 col-lg-6">
<p class="text-muted mb-1">You are not eligible for Disability Insurance.</p> <!-- <p class="mb-1 small text-muted">You are not eligible for Disability Insurance.</p>-->
</div>
</div>
<div class="row"> </div>
</div>
<div class="row"> </div>
<div class="row"> </div>
<div class="container-hi-category-sps">
<div class="row"> </div>
</div>
</div>
</div>
<div class="applicant eligibility-child child-applying" style="display: none;">
<h5 class="applicant-header d-flex align-items-center"><i class="fas fa-child mr-3"></i>About Child(ren)</h5>
<div class="applicant-fields">
<div class="row child">
<div data-fields="eligAddChild" class="full-width">
<div class="col-xs-12 col-sm-12 col-md-12 col-lg-12 field-eligAddChild" data-editor="" style="display: none;">
<div class="col-xs-12 col-sm-12 col-md-12 col-lg-12 field-eligAddChild" data-editor="" validateattr="false"> </div>
</div>
</div>
</div>
</div>
</div>
</div> <!-- page nav -->
<div class="page-nav">
<hr class="my-5">
<div class="my-5 d-flex justify-content-between">
<div> <button id="back" class="btn btn-lg btn-light btn-back">Back</button> </div>
<div class="d-flex"> <button id="saveForLater" class="btn btn-link mr-2 btn-save" data-ea-cta-link="save application" data-ea-zone="application-nav-bottom" data-ea-type="link">Save</button>
<!-- <a href="" class="btn btn-link mr-2" data-toggle="modal" data-target="#modal-save">Save</a>--> <button id="next" class="btn btn-lg btn-primary btn-next">Next</button> </div>
</div>
</div>
</div> <!-- modal: not member -->
<div class="modal fade" id="modal-not-member" tabindex="-1" role="dialog" aria-labelledby="modal-not-member" aria-hidden="true">
<div class="modal-dialog">
<div class="modal-content">
<div class="modal-header modal-header-padding">
<h4 class="modal-title">Ineligible for Coverage</h4> <button type="button" id="close" class="close" data-dismiss="modal" aria-label="Close"> <span aria-hidden="true">×</span> </button>
</div>
<div class="modal-body" data-fields="lblEligNonMbrMessage">
<div class="info-note-sec field-lblEligNonMbrMessage">
<div class="info-note"> <label>We're sorry, but only members are eligible for coverage. If you need more information, please contact the Plan Administrator at the address below. To cancel this session, simply close this window.</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div id="modal-rdAllDutsRegSched" class="modal">
<div class="modal-rdAllDutsRegSched"> We're sorry, to be eligible for this coverage you must be performing all the duties of your occupation according to you regular schedule. </div>
</div>
</div>
</form><form class="form-horizontal">
<div class="calc-section-title">
<h5>Monthly Income Available</h5>
</div>
<hr class="mt-2 mb-4">
<div class="row form-group">
<div class="col-12 col-md-6"><label>Income from current group disability coverage</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-group-di income form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Income from current individual disability coverage</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-individual-di income form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Income from spouse or other family member</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-other-di income form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Monthly investment income</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-investment income form-control form-control-lg">
</div>
</div>
</div>
<div class="calc-section-title">
<h5>Monthly Expenses</h5>
</div>
<hr class="mt-2 mb-4">
<div class="row form-group">
<div class="col-12 col-md-6"><label>Mortgage (including property tax) or rent</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-mortgage expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Homeowners/renters insurance</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-home-insurance expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Car payments/car insurance</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-car expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Utilities</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-utilities expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Food/Clothing</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-food expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Child care expenses</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-child-care expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Bank loans/credit card payments</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-loan expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Medical expenses</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-medical expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Health insurance premiums</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-health-ins expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Insurance premiums (life, disability, dental, etc.)</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-life-insurace expense form-control">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Savings, investments, retirement contributions</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-savings expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Maintenance costs for the home</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-maintenance expense form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Other (education, entertainment, etc.)</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-other expense form-control form-control-lg">
</div>
</div>
</div>
</form><form class="form-horizontal">
<div class="calc-section-title">
<h5>Income</h5>
</div>
<hr class="mt-2 mb-4">
<div class="row form-group">
<div class="col-12 col-md-6"><label>Total annual income your family would need if something were to suddenly happen to you</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-annual-income form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Annual income from other sources</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-annual-income-other form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Years of Income Needed</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group"><select
class="calc-years-income-needed form-control form-control-lg">
<option value="10">10</option>
<option value="15">15</option>
<option value="20">20</option>
<option value="25">25</option>
<option value="30">30</option>
<option value="35">35</option>
</select></div>
</div>
</div>
<div class="calc-section-title">
<h5>Expenses</h5>
</div>
<hr class="mt-2 mb-4">
<div class="row form-group">
<div class="col-12 col-md-6"><label>Funeral and other final expenses</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-other-expenses form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Mortgage and other outstanding debts</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-outstanding-debts form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Capital needed for college</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-needed-for-college form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Years before college</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group"><select
class="calc-year-for-college form-control form-control-lg">
<option value="5">5</option>
<option value="10">10</option>
<option value="15">15</option>
</select></div>
</div>
</div>
<div class="calc-section-title">
<h5>Assets</h5>
</div>
<hr class="mt-2 mb-4">
<div class="row form-group">
<div class="col-12 col-md-6"><label>Savings and investments</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-savings-investments form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Retirement savings</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-retire-savings form-control form-control-lg">
</div>
</div>
</div>
<div class="row form-group">
<div class="col-12 col-md-6"><label>Present amount of life insurance</label></div>
<div class="col-12 col-md-6">
<div style=" position: relative;display: -ms-flexbox;display: flex;-ms-flex-wrap: wrap;flex-wrap: wrap;-ms-flex-align: stretch;align-items: stretch;width: 100%;" class="input-group">
<div style="margin-right: -1px;" class="input-group-prepend">
<div class="input-group-text">$</div>
</div><input style="border-radius: 0 !important;" onkeypress="return /^[0-9]/i.test(event.key)" type="numeric" class="calc-present-life-insurance form-control form-control-lg">
</div>
</div>
</div>
</form>Text Content
* Sign In
* Coverage Details
Guaranteed Approval Group Term Life Insurance
Help
HELP PROTECT THOSE YOU LOVE
Guaranteed Approval Group Term Life Insurance is available to you and your
spouse as a credit union benefit.
BASICS
Campaign Code
This information will help determine your insurance options.
WHO IS THIS INSURANCE FOR?
Myself
My spouse
My child(ren)
ABOUT YOU
Member information is required even if you are not applying for insurance for
yourself.
Application URL
Are you an eligible member?
Yes No
Name of credit union
Birthdaymm/dd/yyyy
State
Email
Choose the group coverage(s) you are interested in:
Life Insurance
You are not eligible for Disability Insurance.
ABOUT SPOUSE
Domestic Partnership/Civil Union is determined by State Law and they will be
referred to as "Spouse" throughout the application.
Is your spouse also a member of a participating credit union?
Yes No
A spouse who is also a member of the credit union can apply for member or
dependent coverage, but not both.
Birthdaymm/dd/yyyy
Email
Choose the group coverage(s) you are interested in:
Life Insurance
You are not eligible for Disability Insurance.
ABOUT CHILD(REN)
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INELIGIBLE FOR COVERAGE
×
We're sorry, but only members are eligible for coverage. If you need more
information, please contact the Plan Administrator at the address below. To
cancel this session, simply close this window.
We're sorry, to be eligible for this coverage you must be performing all the
duties of your occupation according to you regular schedule.
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COVERAGE
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PERSONAL
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PREVIEW
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E-SIGN
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Administered By:
LifeHelp
2990 Innsbruck Drive
Redding, CA 96003
Phone: (800) 345-4543
Email: memberservice@lifehelp.com
CA Insurance License #: CA-0449782
Underwritten By:
New York Life Insurance Company
on Policy Form GMR
51 Madison Avenue
New York, New York 10010
NYL Terms of Use | NYL Privacy Policy
New York Life Insurance Company is licensed/authorized to transact business in
all of the 50 United States, the District of Columbia, Puerto Rico and Canada.
However, not all group policies it underwrites are available in all
jurisdictions. Please check the Coverage detail sections for current
availability. New York Life Insurance Company's state of domicile is New York,
and NAIC ID is #66915.
NEW YORK LIFE and the NEW YORK LIFE Box Logo are trademarks of New York Life
Insurance Company.
NEED HELP? PLEASE CONTACT:
×
LifeHelp
Phone: (800) 345-4543
NEW YORK LIFE TERMS OF USE
×
NEW YORK LIFE TERMS OF USE
If you are applying online, you are applying for insurance coverage using
electronic processes that will include the use of electronic records and
electronic signatures. New York Life is required by law to provide you with
certain disclosures and information about your insurance application ("New York
Life Online Privacy Policy"). Upon your consent, New York Life will deliver its
online privacy policy to you electronically.
Please print or download "New York Life's Online Privacy Policy" and keep it for
your records. Your consent also permits the general use of electronic records
and electronic signatures in connection with your application.
If you do not consent to electronic delivery of New York Life's Online Privacy
Policy, you must be provided with a paper/hardcopy version. However, New York
Life cannot proceed with the acceptance and processing of your electronic
application.
This notice contains important information that you are entitled to receive
before you consent to electronic delivery. Please read carefully this notice
regarding use of your consent to e-signature and records print a copy for your
files.
By electronically signing this form you are consenting to the use of electronic
transactions and electronic signatures on New York Life's website, as well as
receipt of electronic versions of certain records. In addition you are agreeing
to be bound by any consent or agreement you make or transmit through the
internet on this website, including but not limited to any consent you give to
receive records or communications from New York Life solely through electronic
transmission.
You agree that, by using this site, your agreement or consent will be legally
binding and enforceable and the legal equivalent of your handwritten signature.
If you consent to electronic disclosures, that consent will apply to: (a) Any or
all information that New York Life is required to give you or may receive from
you in connection with your insurance, (b) this application, and (c) any
associated notices, disclosures, or other documents.
You may withdraw this consent at any time. By withdrawing your consent New York
Life cannot continue to process your electronic application. You may re-apply by
downloading a paper hardcopy version of the application. If you wish to withdraw
your consent to e-signatures or wish to receive have hardcopy/paper records or
have New York Life's Online Privacy Policy sent to you—please contact the plan
administrator.
In order to electronically complete your application/request for insurance, the
following computer hardware and software requirements must be supported:
* For your security, this site is protected with 128-bit encryption. You must
have a browser with this capacity to use this site.
* Best viewed with a screen resolution of 1280 x 800 or greater.
* Best viewed with a current version of Chrome browser. Other browsers or older
versions of these browsers are either not supported, or may not render an
ideal user experience.
11-1-11 ed.
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NEW YORK LIFE PRIVACY POLICY
×
NEW YORK LIFE PRIVACY POLICY
We know that keeping your personal information private is important to you.
That's why the New York Life Insurance Company wants you to know how we protect
the information you share with us and the measures we take to safeguard your
information.
OUR INFORMATION PRACTICES
Our policies and procedures protect the privacy of current and former customers.
We will follow the privacy law in your state if that law is different than the
policy described in this notice.
Click here to learn about our practices regarding the collection, use and
disclosure of personal information about California residents who are covered by
the California Consumer Privacy Act, and how covered individuals can exercise
their rights.
TYPES OF INFORMATION WE MAY COLLECT
In the normal course of business we may collect:
* Information provided on applications and other forms (including name,
address, income and other household information).
* Data about transactions (such as the types of products purchased and account
status).
* Information from outside sources such as public records.
* Information gathered from our websites, such as through online forms, site
visit data and online information collection devices ("cookies").
* Information collected from consumer credit reporting agencies; and health
information collected with permission when a person applies for insurance.
SAFEGUARDING INFORMATION
New York Life maintains physical, electronic, and procedural safeguards that
meet state and federal regulations. Access to customer information is limited to
people who need the information to perform their job responsibilities.
In order to most effectively protect you, the following security measures have
been taken when managing data through this website:
* All data processed and managed by this website is hosted on a ISO270001
Security Guidelines Compliant Infrastructure.
HOW WE USE INFORMATION
We may share the information we collect about a person as allowed by law,
including for normal business administration and related business services. The
information may be shared:
* Within New York Life; and
* With non-affiliates, such as banks or service providers that help us process
transactions or service accounts. New York Life may use service providers
such as billing, printing and mail service companies.
We may disclose the information we collect when required or permitted by law,
such as to:
* Respond to a subpoena;
* Prevent fraud and other crimes;
* Comply with legal requirements; or
* Respond to a government inquiry.
We will never share your health information with third parties for marketing
purposes.
KEEPING UP-TO-DATE WITH OUR PRIVACY POLICY
This notice is in effect as of July 2, 2014. We reserve the right to change our
privacy policy. You can always review the current privacy policy from the front
page of the site, or you can contact us for a copy by writing to:
New York Life Insurance Company
Group Association Membership Division
44 South Broadway - 15th Floor
White Plains, NY 10601
Our goal is to ensure that your relationship with us is handled with the high
degree of integrity and professionalism you expect. Thank you for your
continuing trust in New York Life.
QUESTIONS AND ANSWERS ABOUT PRIVACY
WHAT INFORMATION IS COLLECTED BY NEW YORK LIFE AND HOW IS IT USED?
When you do choose to provide us with information at the site, we will use it in
the following restricted ways:
When You Apply Online
When you apply online through our site you will have to identify yourself to us.
As a result, the personal information you provide to us will be captured. This
information will be used only for the purpose of processing your request. It
will never be sold to any non-affiliated companies.
Technical Information
Like many websites, we collect limited anonymous information about our users and
their systems. When users come to our site, we collect their IP addresses,
browser types, the domain they came from, and their likely country of origin.
This anonymous information is aggregated and is not associated with individual
users. It is collected to help us analyze usage patterns, improve the site's
overall performance, and provide information useful to our users.
HOW DOES THIS SITE USE COOKIES?
Like other websites, this website uses cookies. A cookie is a text file
containing a unique identifier that is placed on your computer when you visit
our site. Cookies are used to store information so that our server can properly
identify your computer. In order to protect your privacy, no personal
information of any kind is stored. Cookies do not damage your system or files in
any way.
Most browsers recognize when a cookie is offered and allow users to opt-out of
receiving them. If you are not sure whether your browser has this capability,
you should check with the software manufacturer or your Internet Service
Provider (ISP). Please be aware that if you choose to disable cookies, you will
not have access to many beneficial features of our website, including the
Customer Service Area.
DOES THIS SITE USE WEB BEACONS OR SO-CALLED "WEB BUGS"?
We employ services, which collect data remotely through the use of web beacons
or tags embedded in the website content. These services then return completely
anonymous data to New York Life within aggregated website traffic reports. The
web beacons used by these services do not collect, gather, monitor or share any
personal information about website visitors. They are merely the technology used
to compile anonymous observations about our website's usage and visitor
behavior. Web beacons are typically very small, usually 1 by 1 pixel in size,
and have no impact on the website's performance.
WHAT PRIVACY RULES APPLY WHEN I VISIT OTHER WEBSITES?
Our site provides links to other websites, including our subsidiaries and
affiliates, our business partners, and third party sites containing information
that we believe you may find useful. When you visit those sites, you will be
operating under their individual privacy policies. We encourage you to carefully
review the respective privacy policies.
WHAT SECURITY MEASURES DOES THE SITE MAINTAIN TO PROTECT MY PERSONAL
INFORMATION?
We have implemented generally accepted standards of technology and operational
security to protect personally identifiable information collected online from
loss, misuse, alteration, or destruction. All information you supply on the site
is encrypted during transmission and then stored on a secure server. We will not
send any email messages to you that include your personal information, as these
email messages cannot be encrypted and thus cannot be considered fully secure.
Non-encrypted e-mail can be intercepted and viewed by other Internet users
without your knowledge or consent.
New York Life employees follow a company wide security policy. Only authorized
personnel are allowed access to personally identifiable information collected
online and these employees have been trained to safeguard the confidentiality of
this information.
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ESTIMATED COST
×
PURE TERM LIFE INSURANCE
Benefit
AmountNon-SmokerSmoker$100,000$6/mo.$10/mo.$200,000$12/mo.$17/mo.$300,000$18/mo.$23/mo.
DISABILITYPRO OWN SPECIALTY DISABILITY INSURANCE
Benefit AmountMaleFemale $5,000 / mo.$24/mo.$30/mo.
APPLICATION SAVED
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APPLICATION SAVED
Your application progress has been saved.
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SAVE YOUR APPLICATION
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Do you want to save your Application ?
No Yes
SAVED APPLICATION
We’ve loaded your saved application information. Please continue to confirm your
responses and complete the application.
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DISABILITY INSURANCE NEEDS CALCULATOR
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Answer a few simple questions to find an estimate of how much coverage you may
need.
MONTHLY INCOME AVAILABLE
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Income from current group disability coverage
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Income from current individual disability coverage
$
Income from spouse or other family member
$
Monthly investment income
$
MONTHLY EXPENSES
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Mortgage (including property tax) or rent
$
Homeowners/renters insurance
$
Car payments/car insurance
$
Utilities
$
Food/Clothing
$
Child care expenses
$
Bank loans/credit card payments
$
Medical expenses
$
Health insurance premiums
$
Insurance premiums (life, disability, dental, etc.)
$
Savings, investments, retirement contributions
$
Maintenance costs for the home
$
Other (education, entertainment, etc.)
$
Calculate
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YOUR ESTIMATED DISABILITY INSURANCE NEED:
$0
The results and explanations generated by this calculator may vary due to user
input and assumptions. New York Life Insurance Company does not guarantee the
accuracy of the calculators, results, explanations, nor applicability to your
specific situation. We recommend that you use this calculator as a guideline
only and you ultimately seek the guidance of an experienced professional.
LIFE INSURANCE NEEDS CALCULATOR
×
Answer a few simple questions to find an estimate of how much coverage you may
need.
INCOME
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Total annual income your family would need if something were to suddenly happen
to you
$
Annual income from other sources
$
Years of Income Needed
101520253035
EXPENSES
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Funeral and other final expenses
$
Mortgage and other outstanding debts
$
Capital needed for college
$
Years before college
51015
ASSETS
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Savings and investments
$
Retirement savings
$
Present amount of life insurance
$
Calculate
--------------------------------------------------------------------------------
YOUR ESTIMATED LIFE INSURANCE NEED:
$0
The results and explanations generated by this calculator may vary due to user
input and assumptions. New York Life Insurance Company does not guarantee the
accuracy of the calculators, results, explanations, nor applicability to your
specific situation. We recommend that you use this calculator as a guideline
only and you ultimately seek the guidance of an experienced professional.
×