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Retiree Dental Plan Endorsed by

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Retiree Dental Plan

The MetLife Retiree Dental Plan is a NYSUT Member Benefits Trust (Member Benefits)-endorsed program. Member Benefits has an endorsement arrangement of 5% of gross premiums for this program. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, if appropriate, to enhance them. Member Benefits acts as your advocate; please contact Member Benefits at 800-626-8101 if you experience a problem with any endorsed program.

Agency fee payers to NYSUT are eligible to participate in NYSUT Member Benefits Trust-endorsed programs.

Like most group health insurance policies, MetLife group policies contain certain exclusions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife for complete details.

If there is a conflict between this brochure and the group insurance policy, including the certificate, the group policy will govern.

Metropolitan Life Insurance Company200 Park Avenue, New York, NY 10166www.metlife.com

0909-2753 1900030151(0909)L0209021894(exp0210)(DC,GU,MP,PR,VI)© 2009 METLIFE, INC.

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AIL PERMIT NO. 6226 NY NY

POSTAGE WILL BE PAID BY ADDRESSEE

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DECLARATION SECTION

Each person signing below declares that all the information given in this enrollment form is true and complete to the best of his/her knowledge andbelief.

For Changes Requested After Initial Enrollment Period Expires

I understand that if dental coverage is not elected, a waiting period may be required before I can enroll for such coverage after the initial enrollmentperiod has expired.

Fraud Warning:

If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning.

New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: Any person who knowingly and with intent to defraud any

insurance company or other person files an application for insurance containing any materially false information, or conceals for the purposeof misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subjectto a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application

containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact materialthereto commits a fraudulent insurance act, and may subject such person to criminal and civil penalties.

New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and

civil penalties.

Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an

insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Kansas, Oregon, and Vermont: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning anyfact material thereto may be guilty of insurance fraud, and may be subject to criminal and civil penalties.

Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who

presents, helps or has presented, a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the samedamage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollarsnor more than ten thousand (10,000), or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail,the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reducedto a minimum of two (2) years.

Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

All other states:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statementof claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material theretocommits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.

Signature(s): The member must sign in all cases. The person signing below acknowledges that they have read and understand the statements anddeclarations made in this enrollment form.

Member Signature Print Name Date Signed (Mo./Day/Yr.)

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Signature____________________________________________________________Date____________________________________

I belong to the Teachers' Retirement System ofthe

CITYof New York(TRS) and I hereby

request a monthly withholding of deductionsfrom my monthly benefit for the purchase ofunion-sponsored benefits as permitted byChapter 248, Laws of 1994. The TRS isauthorized to continue taking such deductionsuntil NYSUT

Member Benefits Trust receiveswritten notice from me to the contrary.

I belong to the New York City Board ofEducation Retirement System (BERS).

I belong to the NYSUTStaff Pension Program.

I belong to the New York STATETeachersÌ

Retirement System (NYSTRS), or

New York ST ATEEmployees' Retirement

System (NYSERS) and I hereby requestmonthly withholding of union deductions frommy monthly benefit as permitted by Section536 of the Education Law and Section 110-Cof the Retirement Social Security Law.NYSTRS or NYSERS is authorized to continuetaking such deduction until NYSUT

MemberBenefits Trust receives written notice from meto the contrary.

I am a TIAAand/or CREF annuitant and

hereby request a monthly withholding ofdeductions from my monthly TIAA

and/orCREF income for the purchase of coveragesprovided through NYSUT

Member BenefitsTrustÌs Pension Advantage program. TIAA-CREF is authorized to continue taking suchdeductions until Member Benefits receiveswritten notice from me to the contrary. If at anytime the total deductions equal or exceed mycombined monthly income payments fromTIAA-CREF, all deductions I have authorizedTIAA-CREF to take on my behalf will terminateimmediately.

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We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies:

Metropolitan Life Insurance Company MetLife Insurance Company of Connecticut General American Life Insurance Company SafeGuard Health Plans Inc. SafeGuard Life Insurance Company

The Retiree Dental PlanThe Retiree Dental Plan endorsed by NYSUT Member Benefits Trust*, which features the MetLife Preferred Dentist Program (PDP), offers easy-to-understand dental coverage that allows you to:

• Protect — you and your family by providing affordable dental coverage for most preventive and routine services that help promote long-term oral health.

• Choose — the dentist of your choice at the time of treatment. You do not have to select a primary dentist; there’s no ID card to show or referrals needed for specialty care.

• Save — on out-of-pocket expenses by receiving services from one of more than 117,000 participating PDP dentist locations nationwide that agree to charge fees typically 10 percent to 35 percent lower than the average charges in your area.

With the MetLife PDP, you receive a wide range of benefits that provides choice, savings** and convenience to help you make your dental health a priority.

If you have questions after you have read this benefit overview, please visit the NYSUT Member Benefits Trust website at www.memberbenefits.nysut.org and click on Retiree Dental Plan under the Insurance navigation bar on the left-hand side of the home page. You will find a Retiree Dental Plan link that will give more information including participating dentists. You can also call MetLife toll-free at 1-888-883-0046.

Note: You may already have retiree dental coverage provided to you through your local association. If not, you may wish to consider this plan when choosing your coverage.

How the Retiree Dental Plan Works The Retiree Dental Plan, underwritten by MetLife, pays benefits for three categories of service: Type A - Preventive, Type B - Basic Restorative, and Type C - Major Restorative. (Please reference the section entitled “Primary Covered Services” for examples of these services.

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* Coverage is provided under a group insurance policy (Policy form G.2130-S) issued by MetLife.

** Savings from enrolling in the Retiree Dental Plan will depend on various factors, including how often participants visit the dentist and the cost of services covered.

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GEF02-1 Please Retain A Copy of The Fully-Completed Form For Your Records andADM Return The Original to Retiree Dental Plan Administrator,17 Court Street Suite 500, Buffalo, NY 14202-9922

(Continued on Following Page)1 NYSUT – Retiree (12/08)

Metropolitan Life Insurance Company, New York, NY

DENTAL ENROLLMENT FORM FOR NYSUT RETIRED MEMBER

Name of Association

NYSUT Member Benefits Trust

Group Report No.

105643

Sub Division

N/A

Branch

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Association’s Street Address

800 Troy-Schenectady Road

City

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State

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Zip Code

12110-2455

Coverage Effective Date (Mo./Day/Yr.)

Work Status: Retiree

SECTION TO BE COMPLETED BY MEMBER (Please Print)

Name First Middle Last

Social Security No.

Date of Birth (Mo./Day/Yr.)

Male

Female

Address Street City State Zip Code

Marital Single Married

Status: Widowed Divorced

E-mail Address

Phone No. (include area code)

COVERAGE REQUEST DATA:I have received and read a copy of my association’s current announcement of the group plan. I want to be covered under the group plan for thebenefits for which I am or may become eligible, requested below.I request the following coverage:Coverage Options (Note: Only one of the following may be selected)

Retired Member Only

Retired Member + One Dependent

Retired Member + Spouse/Domestic Partner and Child(ren)

If applying for Dependent coverage (Spouse/Domestic Partner and Child), complete section below:

Number of dependents (including spouse/domestic partner)

Name of Spouse/Domestic Partner (Last, First, MI) Date of Birth Sex (M/F)

Name(s) of Child(ren) (Last, First, MI) Date of Birth Sex (M/F)

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The plan also offers you a choice; you may use a participating PDP dentist (in-network) or you may use an out-of-network dentist. If you choose to receive services from a participating PDP dentist, you will generally receive the greater benefit and incur the least out-of pocket expense.

If you use a participating PDP dentist, the plan provides paid-in-full benefits for Type A services. You will have out-of-pocket costs for Type B and Type C services provided by PDP dentists. Also, when PDP dentists are used, services are not subject to any deductibles.

If you use an out-of-network dentist, you generally will have higher out-of-pocket costs for all types of service. In addition, Type B and Type C services are subject to an annual deductible ($50 for individual coverage, $100 for family coverage).

There is an annual benefit maximum of $1,250 per person under this plan for covered services rendered by PDP and non-participating dentists.

IN-NETWORK BENEFITWhen you or your eligible dependent visit a participating Preferred Dentist Program (PDP) dentist, plan benefits are based on a negotiated fee schedule. You will be responsible for the difference between the negotiated PDP fee for a given service and the percentage of the PDP fee that your plan covers for that service.

Benefit Summary: Plan Coverage: Type A - Preventive 100% of PDP Fee* Type B - Basic Restorative 60% of PDP Fee* Type C - Major Restorative 35% of PDP Fee*

Annual Deductible: Amount: Individual None Family None

Annual Maximum Benefit: $1,250/person

3

* PDP fee refers to the fees that participating PDP dentists have agreed to accept as payment in full, typically 10 percent to 35 percent below community averages.

** The service categories shown above represent the coverage type for the majority of services within that category. Please refer to your benefits certificate for a complete list and description of covered services.

54

Benefit Summary: Plan Coverage: Annual Deductible: Amount: Type A - Preventive 100% of R&C Fee* Individual $50 Type B - Basic Restorative 60% of R&C Fee* Family $100 Type C - Major Restorative 35% of R&C Fee* Deductibles apply only to Type B and C Benefits

Annual Maximum Benefit: $1,250/person

PRIMARY COVERED SERVICES**Coverage Type of Service How OftenA – Preventive Cleanings • Two per calendar year, separated by a six-month period Exams • Two per calendar year, separated by a six-month period Fluoride Treatments • One per calendar year for dependent children up to 19th birthday X-rays • Full mouth X-rays: one per 60 months • Bitewing X-rays: one set per calendar year for adults; two per

calendar year for dependent children up to 19th birthday, separated by a six-month period

B – Basic Restorative Fillings, Amalgam or Resin • When dentally necessary Simple Extractions • When dentally necessary Labs and Other Tests • When dentally necessary Space Maintainers • For dependent children up to 19th birthday Periodontic Maintenance • Total number of periodontal maintenance treatments and

prophylaxis cannot exceed four in a calendar year Crown, Denture, Bridge Repair • When dentally necessary Endodontics • Root canal treatment limited to once per tooth per 24 months

C – Major Restorative Surgical Extractions • When dentally necessary General Anesthesia • When dentally necessary in connection with oral surgery,

extractions or other covered dental services Oral Surgery • When dentally necessary Periodontics • Periodontal scaling and root planing once per quadrant, every

24 months • Periodontal surgery once per quadrant, every 36 months Relines and Rebases • Relines and rebases to dentures, limited to 36 months (covered

only after six months following the initial installation) Crowns/Inlays/Onlays • Crowns/Inlays/Onlays replacement: once every five years Bridges and Dentures • Initial placement to replace one or more natural teeth which are

lost while covered by the plan • Dentures and bridgework replacement: once every 10 years • Replacement of an existing temporary full denture if the

temporary denture cannot be repaired and the permanent denture is installed within 12 months after the temporary denture was installed

* R&C fees are based on the lowest of a dentist’s usual, actual or community average charge as determined by MetLife.

Out-of-Network Benefit, continued

7

IMPORTANT ENROLLMENT PROVISIONS1. Coverage for all retired members and eligible

dependents who enroll in this dental program will become effective on the first of the month following the date your application was received and accepted.

2. You may change coverage only when you have a Qualifying Event, which changes your family status (e.g., marriage, divorce, the birth or adoption of a child, death of a dependent, termination of your spouse’s employment, etc.). You may enroll or change your enrollment option for coverage within 30 days of the above Qualifying Events.

3. If you leave the program, you will not be permitted to re-enroll.

30-DAY FREE LOOKAfter receiving your confirmation of acceptance in the plan, if you are not satisfied with the terms of your new coverage and no claims have been submitted/paid, simply return the confirmation to the Plan Administrator within 30 days of receipt, and any money you have paid or had deducted from your pension benefit will be refunded in full with no questions asked. Any claim submitted (subsequent to or before disenrollment) by a participant who disenrolls will be denied.

COORDINATION OF BENEFITSThe Retiree Dental Plan contains a Coordination of Benefits clause that may reduce the dental expense benefits payable by the amount of benefits received from another group, employer or government-sponsored plan.

CERTIFICATE OF INSURANCEPlease use the Retire Dental Plan link from www.memberbenefits.nysut.org to link to MetLife’s MyBenefits, where you can view a copy of the Retiree Dental Plan Certificate. The Certificate will describe all benefits, conditions, exclusions and limitations. Please read your Certificate carefully.

OUT-OF-NETWORK BENEFITWhen you or your eligible dependent visit a non-participating dentist, plan benefits are based on the Reasonable and Customary (R&C) charges of dentists in your area as determined by MetLife. You will be responsible for the difference between your dentist’s charge for a given service and the percentage of Reasonable and Customary fee that your plan covers, subject to deductible.

ELIGIBILITY REQUIREMENTSYou must be a NYSUT retiree member at the time of your enrollment to be eligible for the Retiree Dental Plan (underwritten by MetLife).

Coverage is also available for your spouse (or certified domestic partner) and your dependent children. Unmarried, dependent children are covered until the end of the month of their 23rd birthday.

If NYSUT member is deceased while having member and spouse coverage, the surviving spouse may continue the coverage if he or she becomes an associate member of NYSUT.

MONTHLY RATESThe following monthly rates are effective through December 31, 2009:

Retired Member Only – $42.59 per month

Retired Member + One – $94.87 per month

Retired Member + Family – $118.17 per month

PAYMENT METHODSelect your payment method by completing the attached “Authorization Agreement for Dental Insurance Payments” form. You can select from:

• Automatic monthly pension deduction (available if you are collecting a monthly pension benefit from NYSTRS, NYSERS, NYCTRS, or if you are receiving income from a monthly lifetime annuity from TIAA-CREF);

• Quarterly direct billing* (4 payments per year);

• Semi-annual direct billing* (2 payments per year);

• Annual direct billing* (1 payment per year).

6

* You will be charged a $4 service fee per billing cycle for direct billing. There are no service fees if you select pension deduction as your payment method.

methods of treatment that meet generally accepted dental standards. MetLife’s dental consultants may review dental services to determine whether the dental service is necessary in terms of generally accepted dental standards for the purpose of determining the extent to which dental expense benefits are payable under the Retiree Dental Plan.

PROGRAM EXCLUSIONS*This plan does not cover the following services, treatments and supplies:

1) Temporomandibular joint disorders (TMJ)

2) Those received before coverage begins

3) Those not performed by a dentist, except cleaning and scaling of teeth and fluoride treatments performed by a licensed dental hygienist who is supervised and billed by a dentist

4) Cosmetic services, surgery or supplies

5) When covered by any workers’ compensation laws, occupational disease laws or employer’s liability laws, or which an employer is required by law to furnish in whole or in part

6) Which are received through a medical department or similar facility maintained by your employer

7) Home health aids used to prevent decay, such as toothpaste and fluoride gels

8) Appliances or treatment for bruxism (grinding teeth), including, but not limited to, occlusal guards and night guards

9) Duplicate appliances or duplicate prosthetic devices

10) Received where no charge would have been made in the absence of dental expense benefits, or which are not required to be paid

11) Materials or services that are experimental under generally accepted dental standards

12) Received as a result of dental disease, defect or injury due to an act of war, or a warlike act in time of peace, which occurs while coverage is in effect

98

ANSWERS TO YOUR QUESTIONSWhat is a participating PDP dentist?A participating PDP dentist is a general dentist or specialist who meets MetLife’s strict credentialing standards and agree to accept negotiated scheduled fees as a payment in full for services rendered. There are more than 117,000 participating PDP dentist locations nationwide, including more than 27,000 specialists.

How do I find a Participating PDP dentist? You can conduct online provider searches (with direction and mapping capabilities) via the link from the Member Benefits’ website www.memberbenefits.nysut.org. You can also call MetLife toll-free 1-888-883-0046 Mon.-Fri., 6 a.m. to 11 p.m. or Sat., 6 a.m. to 4 p.m., ET. Note: be sure to verify that the dentist still participates in the PDP when you make your appointment.

How are claims paid? Filing a claim is simple. Complete the patient portion of your claim form and your dentist should complete the rest. Either you or your dentist can submit the claim to MetLife for processing. You will receive an explanation of benefits statement showing charges and payments. Benefits will be paid to you unless you have assigned payment to your dentist.

How do I file a claim? Claim forms can be downloaded and printed by using the link from the Member Benefits’ website, www.memberbenefits.nysut.org, or you can call MetLife toll-free at 1-888-883-0046.

Submit Claims To: MetLife Dental PO Box 14588 Lexington, KY 40512

COVERED BENEFITS LIMITATIONSThe fact that a dentist recommends a dental service does not mean dental expense benefits will be paid under the Retiree Dental Plan. Dental expense benefits will be based on the most cost-effective materials and

* Please refer to your benefits certificate for a complete list and description of program exclusions and limitations.

Our Privacy NoticeWe know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. “Personal information” as used here means anything we know about you personally.

Plan Sponsors and Group Insurance Contract Holders This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, or group insurance or annuity contract. In this notice, “you” refers to these individuals.

Protecting Your Information We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us.

Collecting Your Information We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have affiliates in other businesses.

How We Get Your Information We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources.

13) Instruction for oral care such as hygiene or diet

14) Periodontal splinting

15) Benefits otherwise provided under your employer’s plan or any other plan that your employer or an affiliate contributes to or sponsors

16) Implants

17) Charges for broken appointments or for completing dental forms

18) Sterilization supplies

19) Furnished by a family member

20) For Type C Expenses: 1) Replacement of a lost, missing or stolen crown, bridge or denture. 2) Initial installation of a denture or bridgework to replace one or more natural teeth lost before the Dental Expense Benefits started. 3) Replacement of an existing crown, removable denture or fixed bridgework unless it is needed because the existing crown, denture or bridgework can no longer be used and was installed at least 10 years prior (five years for crowns) to its replacement. 4) Replacement of existing immediate temporary full denture by a new permanent full denture unless: (a) the existing denture cannot be made permanent; and (b) the permanent denture is installed within 12 months after the existing denture was installed.

21) Orthodontia

22) Sealants

10 11

Using Your Information We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to:

• administer your products and services• process claims and other transactions• perform business research• confirm or correct your information• market new products to you• help us run our business• comply with applicable laws

Sharing Your Information With Others We may share your personal information with others with your consent, by agreement, or as permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out.

Other reasons we may share your information include:

• doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas)

• telling another company what we know about you if we are selling or merging any part of our business

• giving information to a governmental agency so it can decide if you are eligible for public benefits

• giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account)

We may ask for medical information. The Authorization that you sign when you request insurance permits these sources to tell us about you. We may also, at our expense:

• Ask for a medical exam• Ask for blood and urine tests• Ask health care providers to give us health data,

including information about alcohol or drug abuse

We may also ask a consumer reporting agency for a “consumer report” about you (or anyone else to be insured). Consumer reports may tell us about a lot of things, including information about:

• Reputation• Driving record• Finances• Work and work history• Hobbies and dangerous activities

The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency.

Another source of information is MIB Group, Inc. (“MIB”). It is a non-profit association of life insurance companies. We and our reinsurers may give MIB health or other information about you. If you apply for life or health coverage from another member of MIB, or claim benefits from another member company, MIB will give that company any information that it has about you. If you contact MIB, it will tell you what it knows about you. You have the right to ask MIB to correct its information about you. You may do so by writing to MIB, Inc., 50 Braintree Hill, Suite 400, Braintree, MA 02184-8734, by calling MIB at (866) 692-6901 (TTY (866) 346-3642 for the hearing impaired), or by contacting MIB at www.mib.com.

1312

• giving your information to your health care provider• having a peer review organization evaluate your

information, if you have health coverage with us• those listed in our “Using Your Information”

section above HIPAA

We will not share your health information with any other company – even one of our affiliates – for their own marketing purposes. If you have dental, long term care, or medical insurance from us, the Health Insurance Portability and Accountability Act (“HIPAA”) may further limit how we may use and share your information.

Accessing and Correcting Your Information You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is reasonably retrievable and within our control. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you anything we learned as part of a claim or lawsuit, unless required by law.

If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife.

Questions We want you to understand how we protect your privacy. If you have any questions about this notice, please contact us. When you write, include your name, address, and policy or account number.

Send privacy questions to: MetLife Privacy Office, P. O. Box 489, Warwick, RI 02887-9954 [email protected]

14

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We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies:

Metropolitan Life Insurance Company MetLife Insurance Company of Connecticut General American Life Insurance Company SafeGuard Health Plans Inc. SafeGuard Life Insurance Company

The Retiree Dental PlanThe Retiree Dental Plan endorsed by NYSUT Member Benefits Trust*, which features the MetLife Preferred Dentist Program (PDP), offers easy-to-understand dental coverage that allows you to:

• Protect — you and your family by providing affordable dental coverage for most preventive and routine services that help promote long-term oral health.

• Choose — the dentist of your choice at the time of treatment. You do not have to select a primary dentist; there’s no ID card to show or referrals needed for specialty care.

• Save — on out-of-pocket expenses by receiving services from one of more than 117,000 participating PDP dentist locations nationwide that agree to charge fees typically 10 percent to 35 percent lower than the average charges in your area.

With the MetLife PDP, you receive a wide range of benefits that provides choice, savings** and convenience to help you make your dental health a priority.

If you have questions after you have read this benefit overview, please visit the NYSUT Member Benefits Trust website at www.memberbenefits.nysut.org and click on Retiree Dental Plan under the Insurance navigation bar on the left-hand side of the home page. You will find a Retiree Dental Plan link that will give more information including participating dentists. You can also call MetLife toll-free at 1-888-883-0046.

Note: You may already have retiree dental coverage provided to you through your local association. If not, you may wish to consider this plan when choosing your coverage.

How the Retiree Dental Plan Works The Retiree Dental Plan, underwritten by MetLife, pays benefits for three categories of service: Type A - Preventive, Type B - Basic Restorative, and Type C - Major Restorative. (Please reference the section entitled “Primary Covered Services” for examples of these services.

2

* Coverage is provided under a group insurance policy (Policy form G.2130-S) issued by MetLife.

** Savings from enrolling in the Retiree Dental Plan will depend on various factors, including how often participants visit the dentist and the cost of services covered.

DetA

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GEF02-1 Please Retain A Copy of The Fully-Completed Form For Your Records andADM Return The Original to Retiree Dental Plan Administrator,17 Court Street Suite 500, Buffalo, NY 14202-9922

(Continued on Following Page)1 NYSUT – Retiree (12/08)

Metropolitan Life Insurance Company, New York, NY

DENTAL ENROLLMENT FORM FOR NYSUT RETIRED MEMBER

Name of Association

NYSUT Member Benefits Trust

Group Report No.

105643

Sub Division

N/A

Branch

N/A

Association’s Street Address

800 Troy-Schenectady Road

City

Latham

State

NY

Zip Code

12110-2455

Coverage Effective Date (Mo./Day/Yr.)

Work Status: Retiree

SECTION TO BE COMPLETED BY MEMBER (Please Print)

Name First Middle Last

Social Security No.

Date of Birth (Mo./Day/Yr.)

Male

Female

Address Street City State Zip Code

Marital Single Married

Status: Widowed Divorced

E-mail Address

Phone No. (include area code)

COVERAGE REQUEST DATA:I have received and read a copy of my association’s current announcement of the group plan. I want to be covered under the group plan for thebenefits for which I am or may become eligible, requested below.I request the following coverage:Coverage Options (Note: Only one of the following may be selected)

Retired Member Only

Retired Member + One Dependent

Retired Member + Spouse/Domestic Partner and Child(ren)

If applying for Dependent coverage (Spouse/Domestic Partner and Child), complete section below:

Number of dependents (including spouse/domestic partner)

Name of Spouse/Domestic Partner (Last, First, MI) Date of Birth Sex (M/F)

Name(s) of Child(ren) (Last, First, MI) Date of Birth Sex (M/F)

Last

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We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies:

Metropolitan Life Insurance Company MetLife Insurance Company of Connecticut General American Life Insurance Company SafeGuard Health Plans Inc. SafeGuard Life Insurance Company

The Retiree Dental PlanThe Retiree Dental Plan endorsed by NYSUT Member Benefits Trust*, which features the MetLife Preferred Dentist Program (PDP), offers easy-to-understand dental coverage that allows you to:

• Protect — you and your family by providing affordable dental coverage for most preventive and routine services that help promote long-term oral health.

• Choose — the dentist of your choice at the time of treatment. You do not have to select a primary dentist; there’s no ID card to show or referrals needed for specialty care.

• Save — on out-of-pocket expenses by receiving services from one of more than 117,000 participating PDP dentist locations nationwide that agree to charge fees typically 10 percent to 35 percent lower than the average charges in your area.

With the MetLife PDP, you receive a wide range of benefits that provides choice, savings** and convenience to help you make your dental health a priority.

If you have questions after you have read this benefit overview, please visit the NYSUT Member Benefits Trust website at www.memberbenefits.nysut.org and click on Retiree Dental Plan under the Insurance navigation bar on the left-hand side of the home page. You will find a Retiree Dental Plan link that will give more information including participating dentists. You can also call MetLife toll-free at 1-888-883-0046.

Note: You may already have retiree dental coverage provided to you through your local association. If not, you may wish to consider this plan when choosing your coverage.

How the Retiree Dental Plan Works The Retiree Dental Plan, underwritten by MetLife, pays benefits for three categories of service: Type A - Preventive, Type B - Basic Restorative, and Type C - Major Restorative. (Please reference the section entitled “Primary Covered Services” for examples of these services.

2

* Coverage is provided under a group insurance policy (Policy form G.2130-S) issued by MetLife.

** Savings from enrolling in the Retiree Dental Plan will depend on various factors, including how often participants visit the dentist and the cost of services covered.

DetA

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15

GEF02-1 Please Retain A Copy of The Fully-Completed Form For Your Records andADM Return The Original to Retiree Dental Plan Administrator,17 Court Street Suite 500, Buffalo, NY 14202-9922

(Continued on Following Page)1 NYSUT – Retiree (12/08)

Metropolitan Life Insurance Company, New York, NY

DENTAL ENROLLMENT FORM FOR NYSUT RETIRED MEMBER

Name of Association

NYSUT Member Benefits Trust

Group Report No.

105643

Sub Division

N/A

Branch

N/A

Association’s Street Address

800 Troy-Schenectady Road

City

Latham

State

NY

Zip Code

12110-2455

Coverage Effective Date (Mo./Day/Yr.)

Work Status: Retiree

SECTION TO BE COMPLETED BY MEMBER (Please Print)

Name First Middle Last

Social Security No.

Date of Birth (Mo./Day/Yr.)

Male

Female

Address Street City State Zip Code

Marital Single Married

Status: Widowed Divorced

E-mail Address

Phone No. (include area code)

COVERAGE REQUEST DATA:I have received and read a copy of my association’s current announcement of the group plan. I want to be covered under the group plan for thebenefits for which I am or may become eligible, requested below.I request the following coverage:Coverage Options (Note: Only one of the following may be selected)

Retired Member Only

Retired Member + One Dependent

Retired Member + Spouse/Domestic Partner and Child(ren)

If applying for Dependent coverage (Spouse/Domestic Partner and Child), complete section below:

Number of dependents (including spouse/domestic partner)

Name of Spouse/Domestic Partner (Last, First, MI) Date of Birth Sex (M/F)

Name(s) of Child(ren) (Last, First, MI) Date of Birth Sex (M/F)

Last

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____

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Retiree Dental Plan

The MetLife Retiree Dental Plan is a NYSUT Member Benefits Trust (Member Benefits)-endorsed program. Member Benefits has an endorsement arrangement of 5% of gross premiums for this program. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, if appropriate, to enhance them. Member Benefits acts as your advocate; please contact Member Benefits at 800-626-8101 if you experience a problem with any endorsed program.

Agency fee payers to NYSUT are eligible to participate in NYSUT Member Benefits Trust-endorsed programs.

Like most group health insurance policies, MetLife group policies contain certain exclusions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife for complete details.

If there is a conflict between this brochure and the group insurance policy, including the certificate, the group policy will govern.

Metropolitan Life Insurance Company200 Park Avenue, New York, NY 10166www.metlife.com

0909-2753 1900030151(0909)L0209021894(exp0210)(DC,GU,MP,PR,VI)© 2009 METLIFE, INC.

BUSINESS REPLY M

AILFIRST-CLASS M

AIL PERMIT NO. 6226 NY NY

POSTAGE WILL BE PAID BY ADDRESSEE

From_______________________

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GEF02-1aDEC 2

DECLARATION SECTION

Each person signing below declares that all the information given in this enrollment form is true and complete to the best of his/her knowledge andbelief.

For Changes Requested After Initial Enrollment Period Expires

I understand that if dental coverage is not elected, a waiting period may be required before I can enroll for such coverage after the initial enrollmentperiod has expired.

Fraud Warning:

If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning.

New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: Any person who knowingly and with intent to defraud any

insurance company or other person files an application for insurance containing any materially false information, or conceals for the purposeof misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subjectto a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application

containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact materialthereto commits a fraudulent insurance act, and may subject such person to criminal and civil penalties.

New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and

civil penalties.

Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an

insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Kansas, Oregon, and Vermont: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning anyfact material thereto may be guilty of insurance fraud, and may be subject to criminal and civil penalties.

Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who

presents, helps or has presented, a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the samedamage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollarsnor more than ten thousand (10,000), or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail,the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reducedto a minimum of two (2) years.

Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

All other states:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statementof claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material theretocommits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.

Signature(s): The member must sign in all cases. The person signing below acknowledges that they have read and understand the statements anddeclarations made in this enrollment form.

Member Signature Print Name Date Signed (Mo./Day/Yr.)

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regarding the amount will be directed by m

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ber Benefits. I hereby certify to TRS, NYSTRS, NYSERS or TIAA-CREF that I am a m

ember of NYSUT, an

employee organization entitled to receive union deduction paym

ents as providers by law.

Signature____________________________________________________________Date____________________________________

I belong to the Teachers' Retirement System ofthe

CITYof New York(TRS) and I hereby

request a monthly withholding of deductionsfrom my monthly benefit for the purchase ofunion-sponsored benefits as permitted byChapter 248, Laws of 1994. The TRS isauthorized to continue taking such deductionsuntil NYSUT

Member Benefits Trust receiveswritten notice from me to the contrary.

I belong to the New York City Board ofEducation Retirement System (BERS).

I belong to the NYSUTStaff Pension Program.

I belong to the New York ST ATETeachersÌ

Retirement System (NYSTRS), or

New York ST ATEEmployees' Retirement

System (NYSERS) and I hereby requestmonthly withholding of union deductions frommy monthly benefit as permitted by Section536 of the Education Law and Section 110-Cof the Retirement Social Security Law.NYSTRS or NYSERS is authorized to continuetaking such deduction until NYSUT

MemberBenefits Trust receives written notice from meto the contrary.

I am a TIAAand/or CREF annuitant and

hereby request a monthly withholding ofdeductions from my monthly TIAA

and/orCREF income for the purchase of coveragesprovided through NYSUT

Member BenefitsTrustÌs Pension Advantage program. TIAA-CREF is authorized to continue taking suchdeductions until Member Benefits receiveswritten notice from me to the contrary. If at anytime the total deductions equal or exceed mycombined monthly income payments fromTIAA-CREF, all deductions I have authorizedTIAA-CREF to take on my behalf will terminateimmediately.

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Life

Ret

iree

Den

tal

Plan

is

a N

YSU

T M

emb

er B

enef

its

Tru

st (

Mem

ber

Ben

efit

s)-e

nd

ors

ed p

rog

ram

. M

emb

er

Ben

efit

s h

as a

n e

nd

ors

emen

t ar

ran

gem

ent

of

5% o

f g

ross

p

rem

ium

s fo

r th

is p

rog

ram

. A

ll su

ch p

aym

ents

to

Mem

ber

B

enef

its

are

use

d s

ole

ly t

o d

efra

y th

e co

sts

of

adm

inis

teri

ng

it

s va

rio

us

pro

gra

ms

and

, if

ap

pro

pri

ate,

to

en

han

ce t

hem

. M

emb

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enef

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acts

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you

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ase

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tact

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emb

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enef

its

at 8

00-6

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if y

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nce

a

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m w

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gra

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Ag

ency

fee

pay

ers

to N

YSU

T ar

e el

igib

le t

o p

arti

cip

ate

in

NY

SUT

Mem

ber

Ben

efit

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ust

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ms.

Like

mo

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Life

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th

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ill g

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BUSINESS REPLY MAILFIRST-CLASS MAIL PERMIT NO. 6226 NY NY

POSTAGE WILL BE PAID BY ADDRESSEE

From_____________________________________________________________________________

NO POSTAGENECESSARYIF MAILED

IN THEUNITED STATES

Retiree Dental Plan Administrator17 Court Street Suite 500Buffalo NY 14202-9922

GE

F02-1

aD

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2

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CL

AR

AT

ION

SE

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ION

Eac

h pe

rson

sig

ning

bel

ow d

ecla

res

that

all

the

info

rmat

ion

give

n in

thi

s en

rollm

ent

form

is t

rue

and

com

plet

e to

the

bes

t of

his

/her

kno

wle

dge

and

be

lief.

Fo

r C

han

ges

Req

ues

ted

Aft

er In

itia

l En

rollm

ent

Per

iod

Exp

ires

I u

nd

erst

and

tha

t if

dent

al c

over

age

is n

ot e

lect

ed,

a w

aitin

g pe

riod

may

be

requ

ired

befo

re I

can

enr

oll f

or s

uch

cove

rage

afte

r th

e in

itial

enr

ollm

ent

pe

rio

d h

as

exp

ire

d.

Fra

ud

War

nin

g:

If yo

u re

side

in

or a

re a

pply

ing

for

insu

ranc

e un

der

a po

licy

issu

ed i

n on

e of

the

fol

low

ing

stat

es,

plea

se r

ead

the

appl

icab

le w

arni

ng.

New

Yo

rk

[on

ly a

pp

lies

to A

ccid

ent

and

Hea

lth

Ben

efit

s (A

D&

D/D

isab

ility

/Den

tal)

]:

An

y p

erso

n w

ho

kn

ow

ing

ly a

nd

wit

h i

nte

nt

to d

efra

ud

an

y

insu

ran

ce c

om

pan

y o

r o

ther

per

son

file

s an

ap

plic

atio

n f

or

insu

ran

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y m

ater

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rmat

ion

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r co

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als

for

the

pu

rpo

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isle

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info

rmat

ion

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nce

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g a

ny

fact

mat

eria

l th

eret

o,

com

mit

s a

frau

du

len

t in

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act

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hic

h i

s a

crim

e, a

nd

sh

all

also

be

sub

ject

to a

civ

il p

enal

ty n

ot

to e

xcee

d f

ive

tho

usa

nd

do

llars

an

d t

he

stat

ed v

alu

e o

f th

e cl

aim

fo

r ea

ch s

uch

vio

lati

on

.

Flo

rid

a: A

ny

per

son

wh

o k

no

win

gly

an

d w

ith

inte

nt

to in

jure

, def

rau

d o

r d

ecei

ve a

ny

insu

rer

file

s a

stat

emen

t o

f cl

aim

or

an a

pp

licat

ion

con

tain

ing

an

y fa

lse,

inco

mp

lete

or

mis

lead

ing

info

rmat

ion

is g

uilt

y o

f a

felo

ny

of

the

thir

d d

egre

e.

Mas

sach

use

tts:

A

ny

per

son

wh

o k

no

win

gly

an

d w

ith

in

ten

t to

def

rau

d a

ny

insu

ran

ce c

om

pan

y o

r o

ther

per

son

file

s an

ap

plic

atio

n f

or

insu

ran

ce c

on

tain

ing

an

y m

ater

ially

fal

se i

nfo

rmat

ion

or

con

ceal

s, f

or

the

pu

rpo

se o

f m

isle

adin

g,

info

rmat

ion

co

nce

rnin

g a

ny

fact

mat

eria

lth

eret

o c

om

mit

s a

frau

du

len

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sura

nce

act

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d m

ay s

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ject

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n t

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rim

inal

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ivil

pen

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New

Jer

sey:

An

y p

erso

n w

ho

in

clu

des

an

y fa

lse

or

mis

lead

ing

in

form

atio

n o

n a

n a

pp

licat

ion

fo

r an

in

sura

nce

po

licy

is s

ub

ject

to

cri

min

al a

nd

civi

l p

enal

ties

.

Okl

aho

ma:

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y p

erso

n w

ho

kn

ow

ing

ly,

and

wit

h i

nte

nt

to i

nju

re,

def

rau

d o

r d

ecei

ve a

ny

insu

rer,

mak

es a

ny

clai

m f

or

the

pro

ceed

s o

f an

insu

ran

ce p

olic

y co

nta

inin

g a

ny

fals

e, i

nco

mp

lete

or

mis

lead

ing

in

form

atio

n i

s g

uilt

y o

f a

felo

ny.

Kan

sas,

Ore

go

n, a

nd

Ver

mo

nt:

A

ny

per

son

wh

o k

no

win

gly

an

d w

ith

inte

nt

to d

efra

ud

an

y in

sura

nce

co

mp

any

or

oth

er p

erso

n f

iles

an

app

licat

ion

fo

r in

sura

nce

co

nta

inin

g a

ny

mat

eria

lly f

alse

in

form

atio

n o

r co

nce

als,

fo

r th

e p

urp

ose

of

mis

lead

ing

, in

form

atio

n c

on

cern

ing

an

yfa

ct m

ater

ial

ther

eto

may

be

gu

ilty

of

insu

ran

ce f

rau

d,

and

may

be

sub

ject

to

cri

min

al a

nd

civ

il p

enal

ties

.

Pu

erto

Ric

o:

An

y p

erso

n w

ho

, kn

ow

ing

ly a

nd

wit

h t

he

inte

nt

to d

efra

ud

, pre

sen

ts f

alse

info

rmat

ion

in a

n in

sura

nce

req

ues

t fo

rm, o

r w

ho

pre

sen

ts,

hel

ps

or

has

pre

sen

ted

, a

frau

du

len

t cl

aim

fo

r th

e p

aym

ent

of

a lo

ss o

r o

ther

ben

efit

, o

r p

rese

nts

mo

re t

han

on

e cl

aim

fo

r th

e sa

me

dam

age

or

loss

, will

incu

r a

felo

ny,

an

d u

po

n c

on

vict

ion

will

be

pen

aliz

ed f

or

each

vio

lati

on

wit

h a

fin

e n

o le

ss t

han

fiv

e th

ou

san

d (

5,00

0) d

olla

rsn

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mo

re t

han

ten

th

ou

san

d (

10,0

00),

or

imp

riso

nm

ent

for

a fi

xed

ter

m o

f th

ree

(3)

year

s, o

r b

oth

pen

alti

es.

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gg

rava

ted

cir

cum

stan

ces

pre

vail,

the

fixe

d e

stab

lish

ed i

mp

riso

nm

ent

may

be

incr

ease

d t

o a

max

imu

m o

f fi

ve (

5) y

ears

; if

att

enu

atin

g c

ircu

mst

ance

s p

reva

il, i

t m

ay b

e re

du

ced

to a

min

imu

m o

f tw

o (

2) y

ears

.

Vir

gin

ia a

nd

Was

hin

gto

n:

It is

a c

rim

e to

kn

ow

ing

ly p

rovi

de

fals

e, in

com

ple

te o

r m

isle

adin

g in

form

atio

n t

o a

n in

sura

nce

co

mp

any

for

the

pu

rpo

se o

f d

efra

ud

ing

th

e co

mp

any.

P

enal

ties

in

clu

de

imp

riso

nm

ent,

fin

es a

nd

den

ial

of

insu

ran

ce b

enef

its.

All

oth

er s

tate

s:

An

y p

erso

n w

ho

kn

ow

ing

ly a

nd

wit

h i

nte

nt

to d

efra

ud

an

y in

sura

nce

co

mp

any

or

oth

er p

erso

n f

iles

an a

pp

licat

ion

fo

r in

sura

nce

or

a st

atem

ent

of

clai

m c

on

tain

ing

an

y m

ater

ially

fal

se i

nfo

rmat

ion

or

con

ceal

s, f

or

the

pu

rpo

se o

f m

isle

adin

g,

info

rmat

ion

co

nce

rnin

g a

ny

fact

mat

eria

l th

eret

oco

mm

its

a fr

aud

ule

nt

insu

ran

ce a

ct,

wh

ich

may

be

a cr

ime

and

may

su

bje

ct s

uch

per

son

to

cri

min

al a

nd

civ

il p

enal

ties

.

Sig

nat

ure

(s):

T

he m

embe

r m

ust

sign

in a

ll ca

ses.

T

he p

erso

n si

gnin

g be

low

ack

now

ledg

es t

hat

they

hav

e re

ad a

nd u

nder

stan

d th

e st

atem

ents

and

decl

arat

ions

mad

e in

thi

s en

rollm

ent

form

.

M

embe

r S

igna

ture

Prin

t Nam

eD

ate

Sig

ned

(Mo.

/Day

/Yr.

)

End

orse

d by

Authorization Agreement for Dental Insurance Payments

You have two convenient ways to pay your Dental Insurance Premiums: Pension Deductions from your monthlypension benefit or Direct Billing.

Please check one, complete the information requested below and return this form with your enrollment form:

Direct BillMonthly Pension Deductionfrom pension benefits* Quarterly Direct Bill

Semi-Annual Direct Bill

Annual Direct Bill

* You must complete and sign the two-sided form attached in order to begin Pension deductions.

Do not send any payments now. You will be billed at a later date.

(Please print)

NYSUT Member Name: ____________________________________________________

SS#: _________________________ Phone Number: (____) ______________________

E-mail Address: __________________________________________________________

Street Address: __________________________________________________________

City, State & ZIP: _________________________________________________________

Please mail this completed form to P&A along with your enrollment form to:P&A Group, Attn – Group Insurance Services Department, 17 Court Street, Suite 500, Buffalo, NY 14202

CHECK ONE BOX ONLY - SIGN AND DATE BELOW

I expressly acknowledge and understand that NYSUT Member Benefits Trust will determine the exact deduction to be withheld monthly and that any questionsregarding the amount will be directed by me to Member Benefits. I hereby certify to TRS, NYSTRS, NYSERS or TIAA-CREF that I am a member of NYSUT, anemployee organization entitled to receive union deduction payments as providers by law.

Signature____________________________________________________________ Date____________________________________

I belong to the Teachers' Retirement System ofthe CITY of New York (TRS) and I herebyrequest a monthly withholding of deductionsfrom my monthly benefit for the purchase ofunion-sponsored benefits as permitted byChapter 248, Laws of 1994. The TRS isauthorized to continue taking such deductionsuntil NYSUT Member Benefits Trust receiveswritten notice from me to the contrary.

I belong to the New York City Board ofEducation Retirement System (BERS).

I belong to the NYSUT Staff Pension Program.

I belong to the New York STATE TeachersÌRetirement System (NYSTRS), or

New York STATE Employees' RetirementSystem (NYSERS) and I hereby requestmonthly withholding of union deductions frommy monthly benefit as permitted by Section536 of the Education Law and Section 110-Cof the Retirement Social Security Law.NYSTRS or NYSERS is authorized to continuetaking such deduction until NYSUT MemberBenefits Trust receives written notice from meto the contrary.

I am a TIAA and/or CREF annuitant andhereby request a monthly withholding ofdeductions from my monthly TIAA and/orCREF income for the purchase of coveragesprovided through NYSUT Member BenefitsTrustÌ s Pension Advantage program. TIAA-CREF is authorized to continue taking suchdeductions until Member Benefits receiveswritten notice from me to the contrary. If at anytime the total deductions equal or exceed mycombined monthly income payments fromTIAA-CREF, all deductions I have authorizedTIAA-CREF to take on my behalf will terminateimmediately.

Plac

e U

nio

n

Bu

g H

ere

Reti

ree

Den

tal P

lan

Th

e M

etL

ife R

eti

ree D

en

tal

Pla

n i

s a N

YSU

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em

ber

Ben

efi

ts

Tru

st (

Mem

ber

Ben

efi

ts)-

en

do

rsed

pro

gra

m.

Mem

ber

Ben

efi

ts h

as

an

en

do

rsem

en

t arr

an

gem

en

t o

f 5%

of

gro

ss

pre

miu

ms

for

this

pro

gra

m.

All

su

ch p

aym

en

ts t

o M

em

ber

Ben

efi

ts a

re u

sed

so

lely

to

defr

ay

the c

ost

s o

f ad

min

iste

rin

g

its

vari

ou

s p

rog

ram

s an

d,

if a

pp

rop

riate

, to

en

han

ce t

hem

. M

em

ber

Ben

efi

ts a

cts

as

you

r ad

voca

te;

ple

ase

co

nta

ct

Mem

ber

Ben

efi

ts a

t 800-6

26-8

101 i

f yo

u e

xperi

en

ce a

p

rob

lem

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h a

ny

en

do

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gra

m.

Ag

en

cy f

ee p

aye

rs t

o N

YSU

T a

re e

lig

ible

to

part

icip

ate

in

N

YSU

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em

ber

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efi

ts T

rust

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do

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pro

gra

ms.

Like m

ost

gro

up

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h i

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ran

ce p

oli

cies,

MetL

ife g

rou

p

po

lici

es

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tain

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ain

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lusi

on

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imit

ati

on

s, w

ait

ing

p

eri

od

s an

d t

erm

s fo

r keep

ing

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em

in

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ase

co

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ct

MetL

ife f

or

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ple

te d

eta

ils.

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BUSINESS REPLY MAILFIRST-CLASS MAIL PERMIT NO. 6226 NY NY

POSTAGE WILL BE PAID BY ADDRESSEE

From_____________________________________________________________________________

NO POSTAGENECESSARYIF MAILED

IN THEUNITED STATES

Retiree Dental Plan Administrator17 Court Street Suite 500Buffalo NY 14202-9922

GE

F02-1

aD

EC

2

DE

CL

AR

AT

ION

SE

CT

ION

Ea

ch p

ers

on

sig

nin

g b

elo

w d

ec

lare

s t

ha

t a

ll th

e i

nfo

rma

tion

giv

en

in

th

is e

nro

llme

nt

form

is

tru

e a

nd

co

mp

lete

to

th

e b

est

of

his

/he

r kn

ow

led

ge

an

db

elie

f.

Fo

r C

han

ge

s R

eq

ue

ste

d A

fte

r In

itia

l E

nro

llm

en

t P

eri

od

Ex

pir

es

I u

nd

ers

tan

d t

ha

t if

de

nta

l co

vera

ge

is

no

t e

lect

ed

, a

wa

itin

g p

eri

od

ma

y b

e r

eq

uir

ed

be

fore

I c

an

en

roll

for

such

co

vera

ge

aft

er

the

in

itia

l e

nro

llme

nt

pe

rio

d h

as

exp

ire

d.

Fra

ud

Wa

rnin

g:

If y

ou

re

sid

e i

n o

r a

re a

pp

lyin

g f

or

insu

ran

ce u

nd

er

a p

olic

y is

sue

d i

n o

ne

of

the

fo

llow

ing

sta

tes,

ple

ase

re

ad

th

e a

pp

lica

ble

wa

rnin

g.

Ne

w Y

ork

[o

nly

ap

pli

es

to

Ac

cid

en

t a

nd

He

alt

h B

en

efi

ts (

AD

&D

/Dis

ab

ilit

y/D

en

tal)

]:

An

y p

ers

on

wh

o k

no

win

gly

an

d w

ith

in

ten

t to

de

fra

ud

an

y

ins

ura

nc

e c

om

pa

ny

or

oth

er

pe

rso

n f

ile

s a

n a

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En

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Authorization Agreement for Dental Insurance Payments

You have two convenient ways to pay your Dental Insurance Premiums: Pension Deductions from your monthlypension benefit or Direct Billing.

Please check one, complete the information requested below and return this form with your enrollment form:

Direct BillMonthly Pension Deductionfrom pension benefits* Quarterly Direct Bill

Semi-Annual Direct Bill

Annual Direct Bill

* You must complete and sign the two-sided form attached in order to begin Pension deductions.

Do not send any payments now. You will be billed at a later date.

(Please print)

NYSUT Member Name: ____________________________________________________

SS#: _________________________ Phone Number: (____) ______________________

E-mail Address: __________________________________________________________

Street Address: __________________________________________________________

City, State & ZIP: _________________________________________________________

Please mail this completed form to P&A along with your enrollment form to:P&A Group, Attn – Group Insurance Services Department, 17 Court Street, Suite 500, Buffalo, NY 14202

CHECK ONE BOX ONLY - SIGN AND DATE BELOW

I expressly acknowledge and understand that NYSUT Member Benefits Trust will determine the exact deduction to be withheld monthly and that any questionsregarding the amount will be directed by me to Member Benefits. I hereby certify to TRS, NYSTRS, NYSERS or TIAA-CREF that I am a member of NYSUT, anemployee organization entitled to receive union deduction payments as providers by law.

Signature____________________________________________________________ Date____________________________________

I belong to the Teachers' Retirement System ofthe CITY of New York (TRS) and I herebyrequest a monthly withholding of deductionsfrom my monthly benefit for the purchase ofunion-sponsored benefits as permitted byChapter 248, Laws of 1994. The TRS isauthorized to continue taking such deductionsuntil NYSUT Member Benefits Trust receiveswritten notice from me to the contrary.

I belong to the New York City Board ofEducation Retirement System (BERS).

I belong to the NYSUT Staff Pension Program.

I belong to the New York STATE TeachersÌRetirement System (NYSTRS), or

New York STATE Employees' RetirementSystem (NYSERS) and I hereby requestmonthly withholding of union deductions frommy monthly benefit as permitted by Section536 of the Education Law and Section 110-Cof the Retirement Social Security Law.NYSTRS or NYSERS is authorized to continuetaking such deduction until NYSUT MemberBenefits Trust receives written notice from meto the contrary.

I am a TIAA and/or CREF annuitant andhereby request a monthly withholding ofdeductions from my monthly TIAA and/orCREF income for the purchase of coveragesprovided through NYSUT Member BenefitsTrustÌ s Pension Advantage program. TIAA-CREF is authorized to continue taking suchdeductions until Member Benefits receiveswritten notice from me to the contrary. If at anytime the total deductions equal or exceed mycombined monthly income payments fromTIAA-CREF, all deductions I have authorizedTIAA-CREF to take on my behalf will terminateimmediately.

Pla

ce U

nio

n

Bu

g H

ere

Moisten, fold and seal

We m

ay revise this privacy notice. If we m

ake any m

aterial changes, we w

ill notify you as required by law

. We provide this privacy notice to you on behalf of

these MetLife com

panies:

Metropolitan Life Insurance Com

pany M

etLife Insurance Company of Connecticut

General Am

erican Life Insurance Company

SafeGuard Health Plans Inc.

SafeGuard Life Insurance Com

pany

The Retiree Dental Plan

The Retiree D

ental Plan endorsed by NYSU

T Mem

ber Benefits Trust*, w

hich features the MetLife Preferred

Dentist Program

(PDP), offers easy-to-understand

dental coverage that allows you to:

• Protect — you and your fam

ily by providing affordable dental coverage for m

ost preventive and routine services that help prom

ote long-term oral health.

• Choose — the dentist of your choice at the tim

e of treatm

ent. You do not have to select a primary dentist;

there’s no ID card to show

or referrals needed for specialty care.

• Save — on out-of-pocket expenses by receiving

services from one of m

ore than 117,000 participating PD

P dentist locations nationwide that agree to charge

fees typically 10 percent to 35 percent lower than the

average charges in your area.

With the M

etLife PDP, you receive a w

ide range of benefits that provides choice, savings** and convenience to help you m

ake your dental health a priority.

If you have questions after you have read this benefit overview

, please visit the NYSU

T Mem

ber Benefits Trust w

ebsite at ww

w.m

emberbenefits.nysut.org and click

on Retiree Dental Plan under the Insurance navigation

bar on the left-hand side of the home page. You w

ill find a Retiree D

ental Plan link that will give m

ore information

including participating dentists. You can also call MetLife

toll-free at 1-888-883-0046.

Note: You m

ay already have retiree dental coverage provided to you through your local association. If not, you m

ay wish to consider this plan w

hen choosing your coverage.

How

the Retiree Dental Plan W

orks The R

etiree Dental Plan, underw

ritten by MetLife,

pays benefits for three categories of service: Type A -

Preventive, Type B - Basic Restorative, and Type C - Major

Restorative. (Please reference the section entitled “Primary

Covered Services” for examples of these services.

2

* Coverage is provided under a group insurance policy (Policy form G

.2130-S) issued by M

etLife.

** Savings from enrolling in the Retiree Dental Plan w

ill depend on various factors, including how

often participants visit the dentist and the cost of services covered.

DetACH AnD MAIL In enveLoPe

15

GE

F02-1

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Group R

eport No.

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Sub D

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N/A

Bra

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N/A

Association’s S

treet Address

800 Tro

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La

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State

NY

Zip C

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12

11

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Coverage E

ffective Date (M

o./Day/Y

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W

ork Status:

Retiree

SE

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TO

BE

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MP

LE

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lease Prin

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Nam

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Social S

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Date of B

irth (Mo./D

ay/Yr.)

Male

Fem

ale

Ad

dre

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treetC

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tateZ

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Marital

Single

Married

Status:

Widow

ed D

ivorced

E-m

ail Address

Phone N

o. (include area code)

CO

VE

RA

GE

RE

QU

ES

T D

AT

A:

I have received and read a copy of my association’s current announcem

ent of the group plan. I want to be covered under the group plan for the

benefits for which I am

or may becom

e eligible, requested below.

I requ

est the fo

llow

ing

coverag

e:C

overag

e Op

tion

s (No

te: Only one of the follow

ing may be selected)

Retired M

ember O

nly

Retired M

ember +

One D

ependent

Retired M

ember +

Spouse/D

omestic P

artner and Child(ren)

If app

lying

for D

epen

den

t coverag

e (Sp

ou

se/Do

mestic P

artner an

d C

hild

), com

plete sectio

n b

elow

:

Num

ber of dependents (including spouse/domestic partner)

Nam

e of Spouse/D

omestic P

artner (Last, First, M

I)D

ate of Birth

Sex (M

/F)

Nam

e(s) of Child(ren) (Last, F

irst, MI)

Date of B

irthS

ex (M/F

)

Last Name________________________________ First_______________ Initial______

Address________________________________________________________________

Home Telephone No. ( )_____________________________________________

Soc. Sec. No._____________________________ Authorization is for_______________(name of plan)

Read statements on the reverse side. Signature and date are required.

NYSUT MEMBER BENEFITS TRUST - 800 Troy-Schenectady Road, Latham, NY 12110-2455

NYSUT MEMBER BENEFITS TRUST PENSION DEDUCTION AUTHORIZATION

If you belong to NYS Employees’

Retirement System, please enter

your retirement/pension number

below. If you are a TIAA-CREF

annuitant, please enter your TIAA

contract number and CREF

certificate number below.

___________________________

(Please Print):

Retirement/Pension Number forNYSERS and TIAA-CREF

Participants:

Retiree Dental Plan

The MetLife Retiree Dental Plan is a NYSUT Member Benefits Trust (Member Benefits)-endorsed program. Member Benefits has an endorsement arrangement of 5% of gross premiums for this program. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, if appropriate, to enhance them. Member Benefits acts as your advocate; please contact Member Benefits at 800-626-8101 if you experience a problem with any endorsed program.

Agency fee payers to NYSUT are eligible to participate in NYSUT Member Benefits Trust-endorsed programs.

Like most group health insurance policies, MetLife group policies contain certain exclusions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife for complete details.

If there is a conflict between this brochure and the group insurance policy, including the certificate, the group policy will govern.

Metropolitan Life Insurance Company200 Park Avenue, New York, NY 10166www.metlife.com

0909-2753 1900030151(0909)L0209021894(exp0210)(DC,GU,MP,PR,VI)© 2009 METLIFE, INC.

BUSINESS REPLY M

AILFIRST-CLASS M

AIL PERMIT NO. 6226 NY NY

POSTAGE WILL BE PAID BY ADDRESSEE

From_______________________

______________________________________________________

NO

POSTAG

EN

ECESSARYIF M

AILEDIN

THE

UNITED

STATES

Retiree D

ental P

lan A

dm

inistrator

17 Cou

rt Street Suite 500

Bu

ffalo NY

14202-9922

GEF02-1aDEC 2

DECLARATION SECTION

Each person signing below declares that all the information given in this enrollment form is true and complete to the best of his/her knowledge andbelief.

For Changes Requested After Initial Enrollment Period Expires

I understand that if dental coverage is not elected, a waiting period may be required before I can enroll for such coverage after the initial enrollmentperiod has expired.

Fraud Warning:

If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning.

New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: Any person who knowingly and with intent to defraud any

insurance company or other person files an application for insurance containing any materially false information, or conceals for the purposeof misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subjectto a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application

containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact materialthereto commits a fraudulent insurance act, and may subject such person to criminal and civil penalties.

New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and

civil penalties.

Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an

insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Kansas, Oregon, and Vermont: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning anyfact material thereto may be guilty of insurance fraud, and may be subject to criminal and civil penalties.

Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who

presents, helps or has presented, a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the samedamage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollarsnor more than ten thousand (10,000), or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail,the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reducedto a minimum of two (2) years.

Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

All other states:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statementof claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material theretocommits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.

Signature(s): The member must sign in all cases. The person signing below acknowledges that they have read and understand the statements anddeclarations made in this enrollment form.

Member Signature Print Name Date Signed (Mo./Day/Yr.)

Endorsed by

Au

tho

riza

tion

Ag

ree

me

nt fo

r De

nta

l Ins

ura

nc

e P

ay

me

nts

Yo

u h

ave

two

co

nve

nie

nt w

ays to

pa

y y

ou

r De

nta

l Insu

ran

ce

Pre

miu

ms: P

en

sio

n D

ed

uctio

ns fro

m y

ou

r mo

nth

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CH

EC

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BO

X O

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- SIG

N A

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DA

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BE

LO

W

I expressly acknowledge and understand that NYSUTM

ember Benefits Trust will determ

ine the exact deduction to be withheld monthly and that any questions

regarding the amount will be directed by m

e to Mem

ber Benefits. I hereby certify to TRS, NYSTRS, NYSERS or TIAA-CREF that I am a m

ember of NYSUT, an

employee organization entitled to receive union deduction paym

ents as providers by law.

Signature____________________________________________________________Date____________________________________

I belong to the Teachers' Retirement System ofthe

CITYof New York(TRS) and I hereby

request a monthly withholding of deductionsfrom my monthly benefit for the purchase ofunion-sponsored benefits as permitted byChapter 248, Laws of 1994. The TRS isauthorized to continue taking such deductionsuntil NYSUT

Member Benefits Trust receiveswritten notice from me to the contrary.

I belong to the New York City Board ofEducation Retirement System (BERS).

I belong to the NYSUTStaff Pension Program.

I belong to the New York STATETeachersÌ

Retirement System (NYSTRS), or

New York ST ATEEmployees' Retirement

System (NYSERS) and I hereby requestmonthly withholding of union deductions frommy monthly benefit as permitted by Section536 of the Education Law and Section 110-Cof the Retirement Social Security Law.NYSTRS or NYSERS is authorized to continuetaking such deduction until NYSUT

MemberBenefits Trust receives written notice from meto the contrary.

I am a TIAAand/or CREF annuitant and

hereby request a monthly withholding ofdeductions from my monthly TIAA

and/orCREF income for the purchase of coveragesprovided through NYSUT

Member BenefitsTrustÌs Pension Advantage program. TIAA-CREF is authorized to continue taking suchdeductions until Member Benefits receiveswritten notice from me to the contrary. If at anytime the total deductions equal or exceed mycombined monthly income payments fromTIAA-CREF, all deductions I have authorizedTIAA-CREF to take on my behalf will terminateimmediately.

Place Union Bug Here