Paramedical Form

Paramedical Supplement to Application

OM Financial Life Insurance Company Baltimore, MD

ADMIN 2449 (05-2003) Rev 01-2007

Insurer

Insured

Medical History Questions

1. Have you ever been treated for or diagnosed with:

a) Any heart disease, heart attack, chest pain, high blood pressure, high cholesterol, murmur, palpitations, or any other disorder of the heart or blood vessels? Y N

b) Any circulatory disease, stroke, TIA, aneurysm, or any other disorder of the veins or arteries? Y N

c) Any breathing or lung disorder, COPD, asthma, bronchitis, sleep apnea, or emphysema? Y N

d) Diabetes, disorder of the immune system, blood disorder, or disorder of the glands? Y N

e) Cancer, tumor, or cysts? Y N

f) Depression, anxiety, dementia, Alzheimer’s, or any other mental or nervous disease or disorder? Y N

g) Hepatitis, gastritis, colitis, or any disease or disorder of the liver, stomach, pancreas, or intestines? Y N

h) Any disease or disorder of the kidneys, bladder, prostate, urinary, or reproductive systems? Y N

i) Arthritis or any disease or disorder of the muscles (to include strains or sprains), tendons, bones, spine, back, or joints? Y N

j) Any disease or disorder of the skin, eyes, or ears? Y N

k) Acquired Immune Deficiency Syndrome (AIDS), AIDS related Complex (ARC) or positive test results indicating the presence of the AIDS virus? Y N

2. Are you currently prescribed any medication? Y N

3. Have you been prescribed medication in the past 5 years not previously mentioned? Y N

4. In the past 10 years, have you:

a) Been hospitalized or had surgery? Y N

b) Had any electrocardiograms, x-rays, laboratory tests, treatment, or surgery, or been advised to and not done so? Y N

c) Been recommended to have any test, treatment, or surgery, which has not been performed? Y N

d) Had any illness, disease, or injury that is not included in other answers? Y N

5. Has any parent, brother, or sister died from or had any occurrence of cancer, heart disease, diabetes, or any hereditary disease prior to age 60? Y N

6. Have you smoked cigarettes, pipes, or cigars, used snuff, chewed tobacco, or used any nicotine-based products such as the patch, or gum? If yes, please detail the type(s) of tobacco product used and date of last use below. Y N

7. In the past 10 years, have you sought or received treatment, advice, or counseling for the use of alcohol? Y N

8. Have you ever sought or received treatment, advice, or counseling for the use of any narcotic, barbiturate, stimulant, amphetamine, hallucinogenic, street, or prescription drugs? Have you ever been arrested for the use or possession of such drug or are you currently using these drugs? Y N

9. Within the past 10 years, have you made a claim or received benefits for disability or worker’s compensation as a result of a sickness or injury? Y N

CONTINUED

OM Financial Life Insurance Company Baltimore, MD

ADMIN 2449 (05-2003) Rev 01-2007

10. Personal Physician’s Name and Address:

Date and Reason Last Consulted:

What treatment was given or medication prescribed?

11. Give details of “Yes” answers. State question number and include where appropriate: diagnosis, date, duration, names and addresses of all attending physicians and medical facilities:

I have read the questions and answered on this Paramedical Supplement to Application. The statements made herein are complete, true and correctly recorded.

I agree that: a copy of this Paramedical Supplement to Application will form a part of any policy or certificate issued, and that no agent or medical examiner can pass upon insurability or modify any policy or certificate issued by the Company.

Signed at (City and State) on (Date)

Witness (Medical Examiner)

Signature of Proposed Insured age 15 or more; otherwise Parent or Legal Guardian of Proposed Insured

OM Financial Life Insurance Company Baltimore, MD

ADMIN 2449 (05-2003) Rev 01-2007

Medical Examiner’s Report

12. a. Height (in shoes) / Weight (Clothed) / Chest (Full Inspiration) / Chest (Forced Expiration) / Abdomen, at Umbilicus

12. b. Did you weigh? Yes No Did you measure? Yes No

12. c. Is appearance unhealthy or older than state age? Yes No

13. Blood Pressure

14. Pulse

15. Heart: Is there any:

16. Is there on examination any abnormality of the following: (Circle applicable item and give details.)

a. Eyes, ears, nose, mouth, pharynx? Yes No

b. Skin (incl. scars); lymph nodes; varicose veins or peripheral arteries? Yes No

c. Nervous system (include reflexes, gait, paralysis)? Yes No

d. Respiratory system? Yes No

e. Abdomen (include scars)? Yes No

f. Genitourinary system (include prostate)? Yes No

g. Endocrine system (include spine, joints, amputation, deformities)? Yes No

h. Musculoskeletal system (include spine, joints, amputations, deformities)? Yes No

17. a. Are there any hernias? Yes No

b. Any hemorrhoids? Yes No

18. Are you aware of additional medical history? Yes No

(A confidential report may be sent to the Medical Director)

Record any additional information here: it will be considered strictly confidential.

Anything regarding habits, character, residence, history or physical condition which may have a bearing on the risk will be appreciated.

Name of person who requested you to make this examination:

Place examined:

Signature of Medical Examiner

Address

HOME OFFICE USE ONLY: Fee Paid $

OM Financial Life Insurance Company Baltimore, MD

ADMIN 2449 (05-2003) Rev 01-2007