Life Insurance Application

APPLICATION FOR LIFE INSURANCE PART 1

TIAA-CREF Life Insurance Company
730 Third Avenue
New York, NY 10017-3206
PLEASE PRINT.

Please be sure to answer all questions on both sides of this Application. Processing will begin upon receipt of your completed and signed Application.

1. First Name (Proposed Insured) Middle Name/Initial Last Name

Plan of Insurance: Annual Renewable Term    Amount of Insurance: $    Riders: I elect the optional Disability Waiver of Premium Rider.

If the answer is “YES” to any of the questions listed below, please provide full details in the REMARKS section on the reverse side. You may attach an additional sheet of paper if necessary.

a. Do you have other existing life insurance? YES NO

Company Name Amount of Insurance Year Issued

b. Will any existing life insurance or annuity be replaced, changed or used as a source of premium payment for the insurance applied for? YES NO

Company Name Amount of Insurance Year Issued

c. Have you used any tobacco or nicotine product within the past 36 months? YES NO

d. Are you applying for other life insurance with any other company? YES NO

e. Have you had life, health or disability insurance rated, modified, declined or cancelled within the past 5 years? YES NO

f. Are you currently receiving Disability Income? YES NO

g. Do you fly or have you flown as a pilot, co-pilot or crew member of an aircraft? YES NO

h. Within the past 2 years, have you participated in auto, boat or motorcycle racing, skin or scuba diving, hang gliding, mountain or rock climbing, sky diving or parachuting? YES NO

i. Do you have any intention of traveling or residing outside the U.S. or Canada within the next 12 months? YES NO

j. Within the past 5 years have you had two or more moving violations or traffic accidents? YES NO

Have your driver’s license suspended, revoked or have you been convicted of driving under the influence of alcohol or drugs? YES NO

Date of Birth: Street Address Apt. # City State Zip

Sex: Male Female    Social Security Number:    U.S. Citizen: Yes No

2. Date of Birth:   Birthplace:

5. Address: This is the address mail will be sent to unless otherwise requested.

Residence: City/Town State Zip Code Telephone

Fax #: E-Mail Address:

7. Name of Employer: Telephone Occupation/Duties:

10. Are you or your spouse currently or formerly employed by: College, university or other nonprofit education or research institution K-12 Other

14. If the beneficiary, the owner, or both, is a trust, please complete this item. Otherwise, skip to questions 15 and 16 for non-trust beneficiary and owner information.

A Trust is the: the beneficiary the owner both the beneficiary and the owner

Name of Trust: Trust Tax ID# Date of Trust Inception

Trustee(s) Name: Trustee(s) Address:

15. BENEFICIARY: Please use REMARKS on the reverse of the application if additional beneficiaries are named.

Primary Beneficiary

Name Address Relationship to Proposed insured Date of Birth Social Security #

Contingent Beneficiary

Name Address Relationship to Proposed insured Date of Birth Social Security #

16. OWNER (if other than proposed insured): Please use REMARKS on the reverse of the application if additional owner information is needed.

First Name Middle Initial Last Name Date of Birth: Social Security #:

If the answer is “YES” to any of the questions listed below, please provide full details in the REMARKS section on the reverse side. You may attach an additional sheet of paper if necessary.

17. a. Do you have other existing life insurance? YES NO

Company Name Amount of Insurance Year Issued

b. Will any existing life insurance or annuity be replaced, changed or used as a source of premium payment for the insurance applied for? YES NO

Company Name Amount of Insurance Year Issued

c. Have you used any tobacco or nicotine product within the past 36 months? YES NO

d. Are you applying for other life insurance with any other company? YES NO

e. Have you had life, health or disability insurance rated, modified, declined or cancelled within the past 5 years? YES NO

f. Are you currently receiving Disability Income? YES NO

g. Do you fly or have you flown as a pilot, co-pilot or crew member of an aircraft? YES NO

h. Within the past 2 years, have you participated in auto, boat or motorcycle racing, skin or scuba diving, hang gliding, mountain or rock climbing, sky diving or parachuting? YES NO

i. Do you have any intention of traveling or residing outside the U.S. or Canada within the next 12 months? YES NO

j. Within the past 5 years have you had two or more moving violations or traffic accidents? YES NO

Have your driver’s license suspended, revoked or have you been convicted of driving under the influence of alcohol or drugs? YES NO

I understand that the insurance applied for will not take effect unless and until, during the lifetime of the proposed insured, TIAA-CREF Life Insurance Company has both: (1) received the full first premium payment and (2) approved the insurance applied for on the life of the proposed insured.

I, the proposed insured, authorize any physician, medical practitioner, psychiatrist, psychologist, hospital, Veterans Administration clinic or other medical or medical-related facility, or mental health facility, the Medical Information Bureau (“MIB”), insurance company, consumer reporting agency, other organization, institution or person that has any records or knowledge of me or my health or mental condition, general character, driving records, and hobbies of a hazardous nature, to give to TIAA-CREF Life, its reinsurers, or the MIB, or other persons or organizations performing business or legal services in connection with my application for insurance.

REMARKS: (If you need additional space, please attach a separate piece of paper.)

I (proposed insured or owner, if other than proposed insured) elect:

To authorize Electronic Funds Transfer (EFT) for the initial and subsequent premiums. I choose to pay future premiums: Annually Semiannually Quarterly Monthly

Type of Account: Checking Savings Bank Account No. Bank Transit No.*

Name(s) on Account

Name and Address of Bank Telephone #

To pay my Annual Semiannual Quarterly premium by credit card. MasterCard Visa

Account # Expiry Date

To enclose a premium in the amount of $ . This payment will be returned to me if TIAA-CREF Life does not approve the insurance applied for. I choose to be billed for my future premiums: Annually Semiannually Quarterly

Living ChoicesSM benefit: Living Choices, TIAA-CREF Life’s accelerated death benefit requires no additional premiums. If exercised, benefits received under this benefit will be discounted to reflect the early payment of insurance proceeds and may be subject to a one-time administrative fee of not greater than $200 ($150 in Texas).

DEFINITION OF REPLACEMENT

In order to determine whether you are replacing or otherwise changing the status of existing life insurance policies or annuity contracts, and in order to receive the valuable information necessary to make a careful comparison if you are contemplating replacement, we are required to ask you the following questions and explain any items that you do not understand.

As part of your purchase of a new life insurance policy or annuity contract, has existing coverage been, or is it likely to be:

(1) Lapsed, surrendered, partially surrendered, forfeited, assigned to the insurer replacing the life insurance policy or annuity contract, or otherwise terminated? YES NO

(2) Changed or modified into paid-up insurance; continued as extended term insurance or under another form of nonforfeiture benefit; or otherwise reduced in value by the use of nonforfeiture benefits, dividend accumulations, dividend cash values or other cash values? YES NO

(3) Changed or modified so as to effect a reduction either in the amount of the existing life insurance or annuity benefit or in the period of time the existing life insurance or annuity benefit will continue in force? YES NO

(4) Reissued with a reduction in amount such that any cash values are released, including all transactions wherein an amount of dividend accumulations or paid-up additions is to be released on one or more of the existing policies? YES NO

(5) Assigned as collateral for a loan or made subject to borrowing or withdrawal of any portion of the loan value, including all transactions wherein any amount of dividend accumulations or paid-up additions is to be borrowed or withdrawn on one or more existing policies? YES NO

(6) Continued with a stoppage of premium payments or reduction in the amount of premium paid? YES NO

The existing insurance policy or annuity contract cannot meet your objectives because: