(UNTITLED)

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP58-00453R000200150027-9
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 2
• Document Creation Date: November 17, 2016
• Document Release Date: May 11, 2000
• Sequence Number: 27
• Publication Date: January 1, 1950
• Content Type: FORM

=Approved For,,tasQTOpI",A$M8EQ4>a5~3R000200150027-9
For Eligible Employees of the United States Government only. See instructions reverse side.
To The War Agencies Employees Protective Association
1040-43 Washington Bldg., 15th & New York Avenues, Washington 25, D. C.
I- --------------------- ?-------------- --.---------------------------------- -------------------------------------------------------------------------------(full name typed or printed)
hereby make application for membership in The War Agencies Employees Protective Association.
I understand that if admitted to membership I shall be eligible to apply for Group Life Insurance under the Group
Contract issued to the Association by The Equitable Life Assurance Society of the United States and I hereby apply for the
amount of insurance for which I shall become eligible under the Group Insurance Plan. For purposes of becoming insured
I certify that I am actively at work and in good health on the date of this application and eligible for membership under the
rules of the Association and have not attained the age of sixty (60) years.
I was born year ------------------------ month ------------------------ day------------------------- .I designate as my Group Life Insurance beneficiary
Primary ----------------------------------------------------------------------- -------------- -------------------------------- Relationship ----- --- ----------------------- ----------- ---
(Mary Smith Jones-NOT Mrr. John E. loner)
Home Address of Insured ----------------- -------------------------------------------- ----------------------------------------------------------------------------------------------- -----------
--------------- ---------------- ------------------------------------------ ------------------- -- -
NOTE: If more than one beneficiary is named, the death benefit, unless otherwise provided herein, will be paid in equal shares to the designated beneficiaries
who survive the member; if no such beneficiary survives, payment will be made in accordance with the terms of the policy.
You may elect to have the proceeds of your Group Life Insurance becoming due under the Group Insurance certificate
as a member of The War Agencies Employees Protective Association payable, in a single sum, or in a variety of installment
options offered by the Equitable Life Assurance Society. Write us for details.
My salary is $_________________________ Salary classification determines amount.
Date of overseas assignment ..........................
AMOUNT
OF
AGE BASIC BASIC
CURRENT DIVIDEND***
ADDITIONS
Accidental TOTAL
COST
PER
GROUP SALARY POLICY
Life Insurance Death Benefit COVERAGE
MO.*
Up to 40 incl. Less than $3,200 ------------ $ 5,000
$1,000
$ 7,500
$13,500
$4.17
3,200 and over---------------- 10,000
2,000
15,000
27,000
8.33
41-50 incl. Less than $3,200-------------- $ 5,000
$1,000
$ 7,500
$13,500
$5.21
$3,200 and over ------ -------- 10,000
2,000
15,000
27,000
10.42
51-60 Less than $3,200--. ---------- $ 5,000
$1,000
$ 7,500
$13,500
$6.25
$3,200 and over-------------- 10,000
*
2,000
15,000
27,000
12.50
In addition an initial $2 membership fee is required.
?'? The established policy of the Association has been to liberalize benefits
reasonably
certain that benefits once declared could be maintained in-
for members as fast as favorable experience warranted. We have followed
definitely
into the future. No benefits heretofore granted have ever been
a conservative policy so that when any action has been taken it seemed
retracted.
METHOD OF PREMIUM PAYMENT: In every case the applicant is required to make an initial quarterly pay-
ment together with a $2.00 membership fee.
ELIGIBILITY: Membership and Group Life Insurance is offered to:
1. All employees of American citizenship now outside the continental limits of the United States, wherever domiciled.
2. All employees located in the United States now in training for duties abroad or awaiting transportation.
3. All supervisory or administrative employees located in the United States who in the normal course of their duties
are required to make trips abroad.
4. Directors of training programs for such employees.
Membership is limited to individuals in the above classes who are actively engaged as employees of the U. S. Government.
You become insured as of the date you apply.
Applicant sign here--------------------------------------------------------------- ----------------------------------------------
(Print Full Name Here) Name of Agency or De?t. of Govt.
Date signed ----------------------- ,--------------------------------------------- _------------- Be sure and sign medical statement on reverse side.
Name and address of person to whom certificate is to be sent:
(Permanent reference point within United States unless otherwise indicated)
Eligibility of applicant certified by Personnel Officer,
Head of Mission or Superior Officer
Name ----------------------------------------------------------------------------------------------
Address --------------------------------------------------------------------------------------------
Signature of Certifying Officer
Title -------------------------------------------- Agency----------------- ------ --
Approved For Release 2000/08/25: #tA--RDP5S=fl0453R00G30015-0027-=9-----
NOTE: Application forms issued previous to 7-21-50 should be destroyed and new application forms requested.
 Approved For Rels000/08/25 : CIA-RDP58-00453`00?00150027-9 t
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