Cigna Insurance Application

INSURANCE APPLICATION

Life Insurance Company of North America (LINA)

a CIGNA Company (herein called the Insurance Company)

For info and customer service call 1-800-732-1603.

• The applicant must sign and date this form.

• This form cannot be considered unless received within 30 days of the date it is dated.

Important: Please enter all dates in mm/dd/yyyy format.

Coverage: Group Insurance Life Accident Disability

I accept the insurance coverages elected above. If premiums are to be paid by payroll, I authorize my employer to deduct the necessary amounts from my earnings. If I have not elected coverage, I understand that if I wish to participate at a later date, I may be required to furnish evidence of insurability at my own expense and that coverage is subject to the insurance company's approval.

Signature:   Date:

Important: You must also sign and date the Agreements and Authorization section.

ACCEPTANCE/DECLINATION

Please print (preferably in black ink).

COMPLETE IF ELECTING SPOUSE COVERAGE

I am currently married and my date of marriage is

Name (First) (Last) Social Security #

Birthdate   Sex: M F

Mr. Mrs. Ms. (Check One)

Employee Name Social Security # Birthdate

Address City State Zip

Work Phone Home Phone Employee ID Number Sex: M F

Important: You must complete the medical questions in this application if: (1) as a newly hired employee you apply for life insurance exceeding the Guaranteed Coverage Amount, or life or disability insurance more than 31 days after you are eligible to elect benefits; or (2) you are currently insured under the prior life insurance plan and elect to increase your current insurance amount(s); or (3) you were eligible but did not enroll for insurance under the prior life insurance plan.

EMPLOYEE SECTION

Voluntary Employee-Paid Coverage

BENEFICIARY

To specify a beneficiary, complete the section below. You will be the beneficiary for your spouse and child(ren) unless you specify otherwise. When specifying multiple beneficiaries, you must indicate the percentage of distribution for each. If there is not enough room to specify all beneficiaries, attach, sign and date a separate sheet of paper using the format below.

☛ Please Sign Here

TERM LIFE INSURANCE POLICY NO. FLX-980054

Fold and staple to conceal health questions. Return to your employer. Be sure to make a copy for your own records.

EMPLOYER USE (MANDATORY DATA NEEDED)

In order to process this application, the employer must complete this information.

Employer

Class Location/Paycode # Date of Hire Annual Salary Verified By

Reason for Request: NEW HIRE INITIAL ENROLLMENT EVENT ONGOING ENROLLMENT EVENT LATE ENTRANT

Have you smoked or used any form of tobacco in the last 12 months? Employee: Yes No Spouse: Yes No

ACCIDENT INSURANCE — POLICY NO. OK-980081

Pennsylvania State System of Higher Education - California University of Pennsylvania

SECTION A

Within the last 5 years has the proposed insured been diagnosed with, told by a medical professional of, or treated for any of the listed conditions?

SECTION B

Within the last 5 years has the proposed insured had DUI/DWI/OUI, smoked cigarettes, used controlled substances, had tests or treatments, used prescribed medication or alternative treatment, or sought medical advice for any condition not listed above?

Use the space below to explain "Yes" answers. If more space is needed, use a new page. Sign and date it. Attach it to this form.

Height and Weight Information

PHYSICIAN SECTION

Employee Physician

Name Phone No.

Street Address City State Zip

Spouse Physician

Name Phone No.

Street Address City State Zip

Caution: Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals information concerning any fact material thereto, commits a fraudulent insurance act.

AGREEMENTS AND AUTHORIZATION

Notice: Personal information may be collected from persons other than those proposed for coverage. Information may be disclosed to third parties without your authorization as permitted by law. You have the right to access and correct all personal information collected. Additional information about the insurance company's privacy practices is available upon request.

To the best of my knowledge and belief all written, telephonic and electronic info I gave is true and complete. I understand that my insurance will not go into effect unless I am actively at work on the effective date. I also understand that coverage for each of my dependents will not go into effect unless the person is not confined in a hospital or institution, or receiving certain medical treatment. The conditions for the requested insurance to be effective are described in the policy and certificate. The approval of this request by the Insurance Company is one of those conditions. I understand and agree that:

(1) This request will be a part of the policy that provides the insurance.

(2) I may need to provide more medical info.

(3) I may need to take medical tests and report the results to the Insurance Company.

(4) I must report any change in my health that happens before the insurance is effective.

(5) Requested insurance will not be effective for a person if the person does not meet the underwriting requirements on the date insurance is to be effective.

Authorization. I permit any hospital, clinic, health care practitioner, pharmacy, benefit manager, employer, insurance company, the Medical Information Bureau (MIB) or any other person or organization having info about the health, medical history, physical or mental condition, diagnosis or treatment, employment or income, or motor vehicle driving record, of me or my children to disclose to the Insurance Company or its authorized agent, any such info, for the purpose of underwriting this application for insurance or administering any claim under any insurance which is approved.

This authorization is valid for 30 months from the date below. I accept that a copy of this Authorization is as valid as the original. I understand that I and/or my authorized agent have the right to receive a copy of this authorization upon request. I understand that the info will be used to assess my request for insurance. I may revoke this authorization at any time in writing. Any such revocation will not: (1) change any action taken in reliance on the Authorization; and (2) change the Insurance Company’s right to use the Authorization for contest of a claim or policy in accordance with applicable law. I understand that info provided pursuant to this authorization may be disclosed by the recipient and is no longer subject to the protections of the Health Insurance Portability and Accountability Act (HIPAA). (The Insurance Companies are subject to the Gramm-Leach-Bliley act and state privacy laws. They do not disclose protected information except as permitted by those laws.)

Notice: Personal information may be collected from persons other than those proposed for coverage. Information may be disclosed to third parties without your authorization as permitted by law. You have the right to access and correct all personal information collected. Additional information about the insurance company's privacy practices is available upon request.