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Toll Free: 1-800-276-7619, Ext. 4264 AssureLINK Address: http://assurelink.assurity.com South Carolina Application for Critical Illness Insurance This application includes all forms needed to apply for Critical Illness Insurance. This application does not include the Life or Disability Income section(s). Thank you for your interest in writing business with Assurity Life Insurance Company. You may write a Life or Disability Income application* in combination with this Critical Illness application. In addition to this application, simply complete the appropriate Life or Disability Income section(s) obtained from AssureLINK or from a Life or Disability Income application. The advantages of writing a combined application are: • answer medical questions once • reviewed by Underwriting once • scheduling one medical exam • achieve two/three sales with one visit To enable us to process your application more quickly, please review the following checklist: For Disability Income and Critical Illness products, the application should coincide with the state in which the policy Owner resides for the states listed below. (For Disability applications, the Proposed Insured and the policy Owner must be the same person.) Disability Income (Form A-D109): CA, FL Simplified Critical Illness (Form CI 005): AR, CO, FL, ID, ME, MN, MT, NH, NC, ND, OK, PA, UT, WV Critical Illness (Form CI 007): AR, ID, ME, MT, NC, ND, OK, PA, UT, WV All other applications should coincide with the state where the application is signed. State specific applications and state forms can be found on AssureLINK. To comply with state regulations and protect your interest, you must be properly licensed and appointed by Assurity in the state coinciding with the application used. Print the application in black ink for faxing and photocopying purposes. Please verify that all questions on the application are answered. Obtain all required signatures. Have the Proposed Insured initial any changes. (Corrections with white correction fluid/tape are not acceptable.) Comply with all state regulations 1. NAIC Model Illustration or disclosure statement must accompany any whole life application. 2. Complete all other pertinent and applicable forms padded together in this application. If faxing an application directly to the Home Office, fax to (877) 864-6630. If mailing directly to the Home Office, address to: Assurity Life Insurance Company Attn: New Business Unit PO Box 82533 Lincoln NE 68501-2533 TO CHECK THE STATUS OF AN APPLICATION, ASK QUESTIONS RELATING TO UNDERWRITING (INCLUDING “WHAT IF” SCENARIOS) CALL TOLL FREE 800-276-7619, EXT. 4264 OR EMAIL TO underwriting@assurity.com. Critical Illness HIPAA Compliant South Carolina ASSURITY® LIFE INSURANCE COMPANY Application for Post Office Box 82533, Lincoln, NE 68501-2533 (402) 476-6500 • (800) 276-7619 • FAX (877) 864-6630 INSURANCE PLEASE PRINT IN BLUE OR BLACK INK 1. PROPOSED INSURED First Middle Last (MM/DD/YYYY) Legal Name / Date of Birth Social Security No. Male Female Street Address E-mail / Age City State ZIP+4 Home Address Personal Phone No. ( ) Birth State/Country Height ft. in. Weight Has the Proposed Insured ever used any form of tobacco or nicotine-based products, or substitutes such as patches or gum? ........... If YES, please list type: amount per day: lbs. Yes / last date of use (MM/DD/YYYY) Is the Proposed Insured a United States citizen, or does the Proposed Insured have permanent resident (green card) status? ................. No / Yes No If the Proposed Insured has permanent resident status, please list permanent resident (green card) number. Does the Proposed Insured have a valid driver’s license? Yes No If YES, please list state of issue and number. Years Is the Proposed Insured currently working at least 30 hours per week in primary occupation? Primary Employer Full-time Employment Employer’s Address Occupation Yes Street Address Duties No Length of employment City Part-time Employment State Occupation Middle ZIP+4 Duties Gross monthly income $ If self-employed, net monthly income 2. POLICYOWNER (Policyowner is the Proposed Insured unless otherwise indicated) If Ownership is a trust, complete the Trust Information/Additional Beneficiary form rather than this section. First Months / $ Last (MM/DD/YYYY) Legal Name / Date of Birth / Social Security No. Relationship to Insured Birth State/Country Street Address City State ZIP+4 Home E-mail Address First Middle Last Contingent Contingent Owner’s Owner’s Name Relationship to Insured 3. BENEFICIARIES (Do not complete if applying for Reversionary Annuity coverage) If Beneficiary is a trust, or if additional space is needed, complete the Trust Information/Additional Beneficiary form. Primary Beneficiary Name (First, Middle, Last) Relationship Soc. Sec. No. Date of Birth / Relationship Soc. Sec. No. / / Contingent Beneficiary Name (First, Middle, Last) Share % / Date of Birth / / / Share % / 4. PREMIUM PAYMENT Please indicate preference for payment type and billing frequency below: Type Direct Billing Automatic Credit Card List Billing (employer) Automatic Bank Withdrawal Payor Name Secondary Payor Info. First First 87-350-05051 (R05-10) Frequency Annual Semi-Annual Quarterly Monthly (not available with Direct Billing) Middle Last Billing Address Street Address City State ZIP+4 Middle Last Billing Address Street Address City State ZIP+4 SC [FR.05.21.10] TRUST INFORMATION/ADDITIONAL BENEFICIARY Please complete the following sections if Ownership and/or Beneficiary is a trust (or if additional room is needed to list beneficiaries of Policy): 1. POLICYOWNER (MM/DD/YYYY) Name of Trust Date of Trust Name of Trustee(s) Street Address Address of Trustee(s) 2. BENEFICIARIES / / Tax ID No. City Testamentary Trust (Will) ZIP+4 Share % Living Trust (Please complete information below.) State Share % (MM/DD/YYYY) Name of Living Trust Date of Trust Name of Trustee(s) / / Tax ID No. Street Address City State ZIP+4 Address of Trustee(s) 3. ADDITIONAL BENEFICIARIES (Do not complete if applying for Reversionary Annuity) Primary Beneficiary Name (First, Middle, Last) Relationship Social Security No. Date of Birth (MM/DD/YYYY) / / / / / / / / / / / / / Social Security No. / / Relationship / / Contingent Beneficiary Name (First, Middle, Last) / / / Date of Birth (MM/DD/YYYY) / / / / / / / / / / / [FR.05.21.10] / / SC / / 87-351-05051 (R05-10) Share % / Share % GENERAL SECTION Please answer the following questions: 1. Does any Proposed Insured belong to or intend to join the National Guard or military? .......................................................................... Yes No 2. During the past 5 years or within the next 12 months: a. Has any Proposed Insured flown other than as a fare-paying passenger, or is any Proposed Insured contemplating flying as a pilot, crew member or student? ........................................................................................................................................... Yes No b. Has any Proposed Insured participated in, or contemplated participation in, any hazardous sport or activities? ................................ Yes No Skin/Scuba Diving Bungee Jumping Skydiving/Parachuting/Hang Gliding If YES, check all that apply: Motor-powered Racing Boxing Rodeo Professional, Semi-professional or Club Sports Cave Exploration Mountain/Rock/Ice Climbing Hot Air Ballooning 3. During the next 12 months, does any Proposed Insured contemplate residence or travel outside of the United States? ...................... Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No If YES, please explain 4. During the past 12 months, has any Proposed Insured had a change in weight of more than 10 pounds? ........................................... If YES, please list Proposed Insured’s name, amount of weight change and reason for change: 5. During the past 5 years, has any Proposed Insured: a. Had a life, health or hospital expense insurance application postponed, rated up or declined; had a condition excluded; or had insurance renewal or reinstatement refused? ................................................................................................................................ If YES, please explain b. Received benefit payments for accident or sickness, or applied to any government or insurance organization for such benefits?..... If YES, please explain 6. Is any Proposed Insured currently negotiating for other insurance coverage? ........................................................................................ If YES, please explain 7. During the past 5 years, has any Proposed Insured: a. Had their driver’s license suspended or revoked, been convicted of or entered a plea of “guilty” or “no contest” to driving under the influence (DUI/DWI), or had more than 3 moving violations? ............................................................................................... If YES, please explain b. Been convicted of a felony? .................................................................................................................................................................. If YES, please explain 8. Is any Proposed Insured currently on probation? ..................................................................................................................................... If YES, please list Proposed Insured’s name, reason for probation and length of probationary period: 9. a. Is other insurance coverage in force for any Proposed Insured? ......................................................................................................... Yes No If YES, provide details below. If any Proposed Insured is applying for life coverage, complete and return the appropriate State Replacement Form. b. If this insurance is issued, will it replace, modify or borrow against existing or pending coverage? ..................................................... Yes No If YES and applying for health coverage, please complete and return the appropriate State Replacement Form. Insured’s Name Company Name Policy No. Benefits (monthly benefit Individual (I) and benefit period for DI Group (G) or face amount for Life) Issue Date (MM/DD/YYYY) DI Coverage Only Coordinates w/ Employer Soc. Sec.? Paid? I G / / Yes No Yes No I G / / Yes No Yes No I G / / Yes No Yes No 10. If the Proposed Insured is a juvenile, please list the total amount of life insurance in force and pending on all family members. If additional space is needed, attach a separate sheet of paper. Father $ 87-352-05051 (R05-10) Mother $ Sibling 1 $ (SC) Sibling 2 $ Sibling 3 $ Sibling 4 $ [FR.05.24.10] Sibling 5 $ HEALTH SECTION Please answer the following questions. If YES to any of the following, please provide details on page 2. 1. Has any Proposed Insured ever consulted with or been diagnosed, treated, hospitalized or prescribed medication by a medical professional for any of the following: a. Heart disorder, including a heart attack (myocardial infarction), angina, irregular heartbeat or abnormal heart rhythm (arrhythmia), chest pain, hypertension (high blood pressure), heart murmur, any blockage or narrowing of the arteries, any aneurysm, stroke or transient ischemic attack (TIA or mini-stroke), or rheumatic fever? ................................................................... Yes No Yes No e. Sleep apnea, cystic fibrosis, emphysema or chronic obstructive pulmonary disease (COPD), shortness of breath, asthma or other respiratory disorder, rheumatoid arthritis, paralysis or connective tissue disorder (lupus or scleroderma)? ........................ Yes No f. Dizziness, fainting spells, anxiety, depression, eating disorders or any other psychological or emotional disorder?......................... Yes No g. Arthritis, rheumatism or any disease or disorder of the back, spine, bones, joints or muscles? ........................................................ Yes No h. Varicose veins, varicose ulcer or phlebitis, syphilis or a hernia? ....................................................................................................... Yes No i. Any disease or disorder of the eyes, ears, nose or throat? ............................................................................................................... Yes No j. Any other illness or injury requiring medical attention or blood transfusions? ................................................................................... Yes No a. Been a patient in any hospital, clinic, dependency program, halfway house or other medical facility?.......................................... Yes No b. Used controlled substances such as cocaine, heroin, amphetamines, barbiturates, hallucinogens or any other controlled substance not prescribed by a physician? ......................................................................................................................................... Yes No c. Been treated by a physician, or advised by a physician to seek treatment, for drug or alcohol use? ............................................ Yes No d. Been advised to have any test (except HIV tests), treatment, surgery, hospitalization or consultation with a medical professional which has not been completed, or for which results have not been received?........................................................... Yes No e. Had any special examinations or laboratory tests such as X-rays, electrocardiograms, blood tests (other than AIDS-related blood tests) or urine tests? ................................................................................................................................................................. Yes No Has any Proposed Insured ever been diagnosed or treated by a medical professional for acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC) or antibodies to human T-lymphotropic virus type III (HTLV); or had a positive test for human immunodeficiency virus (HIV) antibodies? .................................................................................................................................. Yes No Has any Proposed Insured had a natural parent or sibling who was diagnosed with or died of cancer, heart disease or diabetes prior to the age of 60? If YES, please identify family member, relationship to Proposed Insured, disorder and age at death. .............. Yes No a. Has any Proposed Insured ever had any disorder of any genital or reproductive organ, or had a miscarriage, stillbirth or Caesarean section? ........................................................................................................................................................................... Yes No b. Is any Proposed Insured currently pregnant? .................................................................................................................................... 5. No d. Alzheimer’s disease, dementia, memory loss, seizures, mental retardation (including Down’s syndrome), multiple sclerosis (MS), muscular dystrophy (MD), Parkinson’s disease, amyotrophic lateral sclerosis (ALS), any brain or nervous system disorder, cerebral palsy or any form of muscular atrophy?.................................................................................... 4. Yes c. Internal cancer or tumor, cyst, melanoma, lymphoma, leukemia, disorder of lymph nodes or any glandular disorder? .................... 3. No b. Diabetes, high blood sugar or sugar in the urine, anemia, blood or platelet disorders, elevated cholesterol, liver disease, hemophilia, kidney disease (other than kidney stones), protein or blood in the urine, Crohn’s disease, ulcerative colitis, disease or disorder of the stomach, gall bladder, bladder or prostate, other intestinal or digestive tract disease, or pancreatitis? .................................. 2. Yes Yes No During the past 5 years, has any Proposed Insured: If YES, date child is expected (MM/DD/YYYY) / / DETAILS: Enter complete details from questions #1-5 on page 2. If more space is needed, attach additional Supplemental Information form. 87-353-05051 (R02-08) SC Page 1 [FR.03.03.08] SUPPLEMENTAL INFORMATION Question #/Letter Name Onset Date Duration (First, Middle, Last) (MM/DD/YYYY) (Days, Mos, Yrs) / / / / / / / / / / / / / / / / / / / / / / / / / Health Condition and Details / Additional Information: Home Office Use Only 87-353-05051 (R02-08) SC Page 2 [FR.03.03.08] Medical Care Provider’s Name/Address/Phone CRITICAL ILLNESS PRODUCT SECTION Plan of Insurance: (Check one) Critical Illness Other (Please specify) Base Amount $ ADDITIONAL BENEFITS (If available) Check benefit(s) desired and indicate amount requested. Accidental Death Benefit Rider $ Children’s Term Insurance Rider Waiver of Premium Rider Spouse Rider Other (Please specify) Other (Please specify) $ $ $ Additional Insured Rider(s) ―Please complete the information below. If additional space is needed, attach a separate sheet of paper. Additional Insured —Spouse First Middle Last Name Male Female (MM/DD/YYYY) Social Security No. Birth State/Country Age Primary Employer Additional Insured —Child Date of Birth / / Height First Middle ft. in. Weight lbs. Height ft. in. Weight lbs. Last Name Male Female (MM/DD/YYYY) Social Security No. Additional Insured —Child Birth State/Country First Middle Age Date of Birth / / Last Name Male Female Height ft. in. Weight lbs. (MM/DD/YYYY) Social Security No. Additional Insured —Child Birth State/Country First Middle Age Date of Birth / / Last Name Male Female Height ft. in. Weight lbs. (MM/DD/YYYY) Social Security No. Additional Insured —Child Birth State/Country First Middle Age Date of Birth / / Last Name Male Female Height ft. in. Weight lbs. (MM/DD/YYYY) Social Security No. Additional Insured —Child Birth State/Country First Middle Age Date of Birth / / Last Name Male Female Height ft. in. Weight lbs. (MM/DD/YYYY) Social Security No. Additional Insured —Child Birth State/Country First Middle Age Date of Birth / / Last Name Male Female Height ft. in. Weight (MM/DD/YYYY) Social Security No. 87-359-05051 Birth State/Country SC Page 1 Age [FR.03.10.08] Date of Birth / / lbs. CRITICAL ILLNESS HEALTH SECTION Please answer the following questions. If YES to any of the following, please provide details in #7 below. 1. Has any Proposed Insured ever consulted with or been diagnosed, treated, hospitalized or prescribed medication by a medical professional for, or had symptoms of any of the following: a. Heart attack, stroke, elevated or abnormal cholesterol, angina, coronary heart disease, disease of the blood vessels or TIA (transient ischemic attack)? ................................................................................................................................................................. b. Thyroid disorder, hepatitis, hepatitis carrier, anemia, fatigue, disorder of the pancreas, any lupus or any other blood or glandular disorder? ............................................................................................................................................................................. c. Polyp, mole, lump, other growth, breast disorder or abnormal mammogram, biopsy or abnormal prostate specific antigen (PSA) test? .......................................................................................................................................................................................... Yes No Yes No Yes No 2. Does any Proposed Insured regularly take any prescription medications? If YES, specify type and daily dosage in #7 below. ............ Yes No 3. During the past 5 years, has any Proposed Insured consulted any physician for any reason not detailed above? .............................. Yes No 4. Is any Proposed Insured aware of any symptoms or complaints regarding their health for which they have not yet consulted a physician?.... Yes No 5. Has any Proposed Insured been advised to have surgery, treatment or testing which has not been completed? .................................. Yes No 6. Has any Proposed Insured ever used marijuana or any illegal or addictive drugs?................................................................................. Yes No 7. DETAILS: Enter complete details from questions #1-6 below. If additional space is needed, attach a separate sheet of paper. Question #/Letter Name (First, Middle Last) Relationship Date of Condition to Insured (MM/DD/YYYY) / / / / / / / / / / / / / 8. / / Medical Care Provider’s Name/Address/Phone / / Health Condition & Details / Has any immediate family member (whether living or dead) of any Proposed Insured ever suffered from, or is currently suffering from: cancer, heart disease, stroke, kidney disease, diabetes, ALS (amyotrophic lateral sclerosis or Lou Gehrig’s disease), motor neuron disease, Alzheimer’s disease, Parkinson’s disease or any other hereditary disease prior to age 65? If YES, please provide details below. If additional space is needed, attach a separate sheet of paper. ......................................................... Family Member/ Relationship Name (First, Middle, Last) 87-359-05051 SC Diagnosis Page 2 [FR.03.10.08] Yes No Age at Time of Diagnosis PHYSICIAN INFORMATION Please list the last physician seen: Name Date last consulted / / MM/DD/YYYY Address Street Address Suite City State Phone No. ( ) Fax No. ( Is this your primary physician? Yes ZIP+4 ) No Reason for consultation Results AGREEMENT I (We) have read the above questions and answers and declare that they are complete and true to the best of my (our) knowledge and belief. I (We) agree that this application shall form a part of the policy if attached thereto. I (We) agree that: a. In the event the first full premium on the policy applied for is paid upon the date of this application, the insurance under such policy shall take effect as provided in the Temporary Conditional Insurance Agreement delivered by the Company’s agent in exchange for such payment. b. In the event the first full premium on the policy applied for is not paid upon the date of this application, the insurance under such policy shall not take effect unless: a) The application is approved by the Company at its home office, b) Such policy is issued and delivered to the Proposed Insured/ Owner, and c) Such first full premium is paid during the Proposed Insured’s lifetime and continued good health and the life and continued good health of any other person(s) covered under the policy. When such approval, issue, delivery and payment have occurred, the insurance under such policy shall take effect as of the date of issue specified in the policy. c. No agent or medical examiner is authorized or has power to change or waive any term, provision or condition of this application, the Temporary Conditional Insurance Agreement or the policy applied for, or to pass upon or approve insurability of any person for whom insurance is applied for. I acknowledge that I was provided an Outline of Coverage at the time this application for insurance was taken. 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 for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a substantial civil penalty where and to the extent allowed by state law. Substitute Form W-9 information (Request for Taxpayer Identification Number and Certification): I, the Owner (or each Joint Owner), certify under penalties of perjury that the number shown is my correct Taxpayer Identification Number. I am not subject to backup withholding due to failure to report interest and dividend income, and I am a U.S. Person (including a U.S. resident alien). The Internal Revenue Service does not require my consent to any provision of this document other than the certification required to avoid backup withholding. Signed at on City State / / Date (MM/DD/YYYY) Signature of Proposed Insured Signature of Additional Proposed Insured Signature of Parent/Guardian of Minor Child Signature of Additional Proposed Insured Signature of Owner(s) (If other than Proposed Insured) Signature of Beneficiary (If applying for Reversionary Annuity) Signature of Licensed Agent Print Agent Name and Agent No. 87-354-05051 (R05-10) (SC) [FR.05.26.10] FIELD UNDERWRITER’S STATEMENT 1. a. What amount was collected with this application? $ b. Has a Temporary Conditional Insurance Agreement been given to the Policyowner? .......................................................................... Yes No c. Has the Proposed Insured signed a Confidential Information Authorization and been given a Consumer Notice? ............................... Yes No 2. a. Did you personally see all Proposed Insured(s) on the date of application? ........................................................................................ Yes No b. How well do you know the Proposed Insured(s)? Well Slightly Not at all c. Are you aware of anything about the health, habits, hobbies or mode of living which might affect the insurability of the Proposed Insured? If YES, please provide details below. ..................................................................................................................................... Yes No 3. Is this application being submitted on a non-medical basis? If NO, check items below for which arrangements have been made. .............. Yes No Agent is responsible for scheduling exam items. NOTE: ANY PREFERRED PLANS REQURE AN EXAM, BLOOD SAMPLE (NOT A DRIED BLOOD SPOT) AND URINE SAMPLE. Paramedical examination Blood Sample Urine Sample Electrocardiogram (EKG) Treadmill EKG Medical exam by physician 4. Is other insurance coverage in force for any Proposed Insured? ............................................................................................................... Yes No 5. If this insurance is issued, will it replace, modify or borrow against existing or pending coverage? ......................................................... Yes No 6. Was sales material used in soliciting this application? .............................................................................................................................. Yes No 7. Was the sales material left with the applicant? .......................................................................................................................................... Yes No 8. Was the sales material approved by Assurity Life Insurance Company? .................................................................................................. Yes No 9. Are commissions to be split? Yes No Agent No. % Agent No. % AUTOMATIC PAYMENT OPTIONS Set up NEW bank withdrawal—submit signed authorization and to ensure accuracy, a voided check. Add to existing bank withdrawal—indicate other applicant and/or policy numbers Set up NEW credit card payment—submit signed authorization with the application. LIST BILL Set up NEW list bill— submit signed authorization with the application. Add to existing list bill; indicate list bill no. and/or name of company FOR TERM LIFE APPLICATION The premiums for this application were quoted on the following underwriting classification: $350,000 and under: Select + NT Select NT Standard NT $350,001 and over: Preferred + NT Preferred NT Standard NT Select + T Preferred T Select T Standard T Standard T Other Insured’s underwriting classification FOR WHOLE LIFE APPLICATION (either a signed illustration or a signed Illustration Disclosure Statement must be submitted with the application) The premiums for this application were quoted on the following underwriting classification: $99,999 and under: Select NT Standard T $100,000 and over: Preferred + NT Preferred NT Select NT Preferred T Standard T Other Insured’s underwriting classification FOR UNIVERSAL LIFE APPLICATION (either a signed illustration or a signed Illustration Disclosure Statement must be submitted with the application) The premiums for this application were quoted on the following underwriting classification: Preferred + NT Preferred NT Select NT Preferred T Standard T Additional Insured’s underwriting classification FOR REVERSIONARY ANNUITY APPLICATION (either a signed illustration or a signed Illustration Disclosure Statement must be submitted with the application) The premiums for this application were quoted on the following underwriting classification: Preferred NT Standard NT Tobacco I hereby certify that to the best of my knowledge and belief, the answers on the application and in this statement are true and correct. / / ( ) /( ) Signature of Soliciting Agent Date (MM/DD/YYYY) Business Phone No. and Fax No. Soliciting Agent’s Printed Name Agent No. Agent’s E-mail 87-362-05051 (R05-10) SC [FR.06.02.10] ASSURITY® LIFE INSURANCE COMPANY Confidential Information Post Office Box 82533, Lincoln, NE 68501-2533 (402) 476-6500 • (800) 276-7619 AUTHORIZATION / / Name of Applicant/Insured/Claimant (Please print) Date of Birth (MM/DD/YYYY) Name of Additional Applicant/Insured/Claimant (Please print) Date of Birth (MM/DD/YYYY) / / Applicant/Insured/Claimant Child(ren) Name Date of Birth Name Date of Birth I, on behalf of myself or the person named above (Individual), authorize any licensed physician, medical practitioner, hospital, clinic, pharmacy or pharmacy benefit manager, records custodians, other medical or medically related facility, insurance or reinsurance company, the Medical Information Bureau (MIB), consumer reporting agency, clearinghouse, employer or other organization or person that has any records or knowledge of the Individual or their health to disclose to Assurity Life Insurance Company (Assurity), its reinsurers and/or consumer reporting agencies and their authorized representatives (provided, however, consumer reporting agencies may not collect information under this authorization from the MIB): • Information as to diagnosis, treatment and prognosis pertaining to medical history, mental or physical condition, pharmacy and/or prescription drug records, or treatment and information pertaining to mode of living (except as may be related directly or indirectly to sexual orientation), occupation, finances, avocations and other characteristics. • Information on the diagnosis or treatment of human immunodeficiency virus (HIV) infection and sexually transmitted diseases (Except information about human immunodeficiency virus (HIV) infection for Individuals residing in Maine or Vermont.). For residents of Maine: this authorization excludes disclosure of the results of a test for HIV if the Individual has tested HIV positive but has not developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in this caveat will prohibit this authorization from including the fact that the Individual has AIDS. For residents of Vermont: this authorization excludes the release of any information about previously administered tests for HIV antibodies, T-cell counts, AIDS or ARC. The Individual is NOT authorizing Assurity to forward the results from any new test requested by Assurity to any outside, non-affiliated company or any entity not under specific contract to perform underwriting services. • Information on diagnosis and treatment for alcohol, drug and tobacco use, and mental illness. Excluded are psychotherapy notes, but included are medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests and any summary of the following items: diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date. • Information provided on applications to obtain driving records and credit information. The records obtained will be used to determine eligibility for insurance, including additional coverage to an existing policy. I authorize the release of any information contained in credit reports and driving records, including but not limited to information on motor vehicle accidents and/or violations. I understand that this information may be released by Assurity and/or its reinsurers to their consulting physicians, their attorneys, the MIB and to other insurance companies in which the Individual has policies or to whom applications may be made, or to whom claims for benefits have been made or may be submitted. By my signature below, I acknowledge that any agreements I have made to restrict protected health information of the Individual do not apply to this authorization, and I instruct any licensed physician, medical practitioner, hospital, clinic, pharmacy or pharmacy benefit manager, records custodians, other medical or medically related facility, insurance or reinsurance company, the Medical Information Bureau (MIB), consumer reporting agency, clearinghouse, employer or other organization or person that has any records or knowledge of the Individual or their health to release and disclose the Individual’s entire medical record as described above without restriction. The medical information so acquired will be used to determine eligibility for insurance, including additional coverage to an existing policy and/or eligibility for benefits under a policy. I understand that this information may be subject to re-disclosure by Assurity and may no longer be protected by the federal rules governing privacy of health information, and that this information may only be redisclosed in accordance with other applicable laws or regulations. This authorization is valid for twenty-four (24) months from the date of signature below (Except for residents of Arizona, authorization to disclose HIV-related information is valid for 180 days from the date of the signature below), for collecting information in connection with an application for an insurance policy, policy reinstatement or claim. A copy of this authorization is as valid as the original. I understand that I, or my authorized representative, will receive a copy of this authorization if requested. I understand that I have the right to revoke this authorization at any time by providing written notice to Assurity. I understand that a revocation is not effective to the extent that action has been taken in reliance on this authorization. I further understand that if I refuse to sign this authorization, Assurity may not be able to process this application, or if coverage has been issued, may not be able to make any benefit payments. This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Date (MM/DD/YYYY) Signature of Applicant/Insured/Claimant, Legal Representative or Parent of Child(ren) under age 18 Signature of Additional Applicant/Insured/Claimant or Legal Representative Signature of Applicant/Insured/Claimant Child (if age 18 or older) Description of Legal Representative’s Authority for Applicant/Insured/Claimant (please indicate which Individual is represented) 75-500-05055 [F09.10.07] ASSURITY® LIFE INSURANCE COMPANY Confidential Information Post Office Box 82533, Lincoln, NE 68501-2533 (402) 476-6500 • (800) 276-7619 AUTHORIZATION / / Name of Applicant/Insured/Claimant (Please print) Date of Birth (MM/DD/YYYY) Name of Additional Applicant/Insured/Claimant (Please print) Date of Birth (MM/DD/YYYY) / / Applicant/Insured/Claimant Child(ren) Name Date of Birth Name Date of Birth I, on behalf of myself or the person named above (Individual), authorize any licensed physician, medical practitioner, hospital, clinic, pharmacy or pharmacy benefit manager, records custodians, other medical or medically related facility, insurance or reinsurance company, the Medical Information Bureau (MIB), consumer reporting agency, clearinghouse, employer or other organization or person that has any records or knowledge of the Individual or their health to disclose to Assurity Life Insurance Company (Assurity), its reinsurers and/or consumer reporting agencies and their authorized representatives (provided, however, consumer reporting agencies may not collect information under this authorization from the MIB): • Information as to diagnosis, treatment and prognosis pertaining to medical history, mental or physical condition, pharmacy and/or prescription drug records, or treatment and information pertaining to mode of living (except as may be related directly or indirectly to sexual orientation), occupation, finances, avocations and other characteristics. • Information on the diagnosis or treatment of human immunodeficiency virus (HIV) infection and sexually transmitted diseases (Except information about human immunodeficiency virus (HIV) infection for Individuals residing in Maine or Vermont.). For residents of Maine: this authorization excludes disclosure of the results of a test for HIV if the Individual has tested HIV positive but has not developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in this caveat will prohibit this authorization from including the fact that the Individual has AIDS. For residents of Vermont: this authorization excludes the release of any information about previously administered tests for HIV antibodies, T-cell counts, AIDS or ARC. The Individual is NOT authorizing Assurity to forward the results from any new test requested by Assurity to any outside, non-affiliated company or any entity not under specific contract to perform underwriting services. • Information on diagnosis and treatment for alcohol, drug and tobacco use, and mental illness. Excluded are psychotherapy notes, but included are medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests and any summary of the following items: diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date. • Information provided on applications to obtain driving records and credit information. The records obtained will be used to determine eligibility for insurance, including additional coverage to an existing policy. I authorize the release of any information contained in credit reports and driving records, including but not limited to information on motor vehicle accidents and/or violations. I understand that this information may be released by Assurity and/or its reinsurers to their consulting physicians, their attorneys, the MIB and to other insurance companies in which the Individual has policies or to whom applications may be made, or to whom claims for benefits have been made or may be submitted. By my signature below, I acknowledge that any agreements I have made to restrict protected health information of the Individual do not apply to this authorization, and I instruct any licensed physician, medical practitioner, hospital, clinic, pharmacy or pharmacy benefit manager, records custodians, other medical or medically related facility, insurance or reinsurance company, the Medical Information Bureau (MIB), consumer reporting agency, clearinghouse, employer or other organization or person that has any records or knowledge of the Individual or their health to release and disclose the Individual’s entire medical record as described above without restriction. The medical information so acquired will be used to determine eligibility for insurance, including additional coverage to an existing policy and/or eligibility for benefits under a policy. I understand that this information may be subject to re-disclosure by Assurity and may no longer be protected by the federal rules governing privacy of health information, and that this information may only be redisclosed in accordance with other applicable laws or regulations. This authorization is valid for twenty-four (24) months from the date of signature below (Except for residents of Arizona, authorization to disclose HIV-related information is valid for 180 days from the date of the signature below), for collecting information in connection with an application for an insurance policy, policy reinstatement or claim. A copy of this authorization is as valid as the original. I understand that I, or my authorized representative, will receive a copy of this authorization if requested. I understand that I have the right to revoke this authorization at any time by providing written notice to Assurity. I understand that a revocation is not effective to the extent that action has been taken in reliance on this authorization. I further understand that if I refuse to sign this authorization, Assurity may not be able to process this application, or if coverage has been issued, may not be able to make any benefit payments. This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Date (MM/DD/YYYY) Signature of Applicant/Insured/Claimant, Legal Representative or Parent of Child(ren) under age 18 Signature of Additional Applicant/Insured/Claimant or Legal Representative Signature of Applicant/Insured/Claimant Child (if age 18 or older) Description of Legal Representative’s Authority for Applicant/Insured/Claimant (please indicate which Individual is represented) 75-500-05055 [F09.10.07] ASSURITY® LIFE INSURANCE COMPANY Temporary Conditional Insurance Agreement Post Office Box 82533, Lincoln, NE 68501-2533 (402) 476-6500 • (800) 276-7619 • FAX (402) 437-4591 (for use with all Health products) Proposed Insured No. 1 Date Application Signed / / Proposed Insured No. 2 Date Application Signed / / In consideration of the premium received with the health insurance application listed above (Application), Assurity Life Insurance Company (Assurity) will provide temporary health insurance coverage subject to the terms and conditions contained in this Agreement. Make all checks payable to Assurity. Do not make checks payable to the agent. Do not leave the check payee blank. If questions 3 a-d are answered YES or are left BLANK, there will be NO CONDITIONAL COVERAGE The agent is not authorized to accept a premium under these circumstances. 1. Is any Proposed Insured younger than 15 days old or older than 75 years old? ..................................................................................... Yes No 2. Does the Proposed Insured: a. Have Assurity policies for disability income or business overhead expense that, combined with the applied for coverage, exceeds $4,000 per month? .................................................................................................................................................................... b. Have Assurity hospital indemnity or Assurity critical illness coverage? ................................................................................................... Yes Yes No No Yes No Yes Yes No No Yes No 3. Has any Proposed Insured: a. Ever had a heart, lung, liver or kidney disease or disorder; diabetes; stroke; paralysis or cancer? ................................................... b. Ever been diagnosed or treated by a medical professional for acquired immune deficiency syndrome (AIDS) or AIDS-related complex (ARC)? ............................................................................................................................................................... c. During the past 5 years been treated, counseled or advised to seek treatment for drug/alcohol abuse? .......................................... d. During the past 90 days been admitted, or advised by a medical professional to be admitted to a hospital or other licensed health care facility; had surgery or had surgery recommended by a medical professional; or been advised by a medical professional to have any diagnostic test that was not completed (excluding an AIDS-related test)? ................................................. No coverage starts: ♦ Until the later of 1) the date the Proposed Insured completed and signed the Application and paid the first full modal premium (a check is not payment unless honored by the issuing institution when first presented); or 2) the date the Proposed Insured completed all medical tests required by Assurity and ♦ Unless the Proposed Insured is insurable on the date coverage starts at Assurity’s standard or better than average rates (no ratings included), according to its underwriting practices for the amount of insurance and any additional benefits applied for. If the Proposed Insured is diagnosed by a medical professional with a covered medical condition, Assurity shall not be liable for: ♦ More than $2,500 of disability coverage or business overhead coverage; or ♦ More than the applied for amount of hospital indemnity; or ♦ More than $50,000 of critical illness coverage. This includes any other critical illness coverage applied for with Assurity. If no Policy is issued and delivered and no benefit is paid under this Agreement, all premiums paid will be returned. If the Policy is issued as applied for, or if a Policy amendment is accepted by the Proposed Owner, premium paid will be applied to that Policy. No change in health will be used to deny a Policy if the change occurs after the later of: 1) the date of the Application; or 2) completion of all medical tests required by Assurity. Coverage under this Agreement terminates automatically on the earliest of the date: ♦ 90 days from the date of the Application; ♦ Premium is returned by Assurity (return is effective on being postmarked, properly addressed and postage prepaid); ♦ Coverage starts under any Policy resulting from the Application; or ♦ A Policy resulting from the Application is refused by the Proposed Owner. The undersigned states that the answers on this Agreement and the Application are true and complete to the best of his/her knowledge and belief, and understands that the answers are relied upon for coverage under this Agreement. Assurity’s liability will be limited to a return of the premium submitted if: 1) the Proposed Insured dies by suicide; or 2) the Application or this Agreement contains a material misrepresentation to Assurity. Dated at On City, State Date (MM/DD/YYYY) Signature of Proposed Insured No. 1 Signature of Proposed Insured No. 2 Signature of Agent or Witness (disinterested person) Print Agent or Witness Name Signature of Owner (if other than Proposed Insured) 75-803-02255 [FR.01.24.11] ASSURITY® LIFE INSURANCE COMPANY Temporary Conditional Insurance Agreement Post Office Box 82533, Lincoln, NE 68501-2533 (402) 476-6500 • (800) 276-7619 • FAX (402) 437-4591 (for use with all Health products) Proposed Insured No. 1 Date Application Signed / / Proposed Insured No. 2 Date Application Signed / / In consideration of the premium received with the health insurance application listed above (Application), Assurity Life Insurance Company (Assurity) will provide temporary health insurance coverage subject to the terms and conditions contained in this Agreement. Make all checks payable to Assurity. Do not make checks payable to the agent. Do not leave the check payee blank. If questions 3 a-d are answered YES or are left BLANK, there will be NO CONDITIONAL COVERAGE The agent is not authorized to accept a premium under these circumstances. 1. Is any Proposed Insured younger than 15 days old or older than 75 years old? ..................................................................................... Yes No 2. Does the Proposed Insured: a. Have Assurity policies for disability income or business overhead expense that, combined with the applied for coverage, exceeds $4,000 per month? .................................................................................................................................................................... b. Have Assurity hospital indemnity or Assurity critical illness coverage? ................................................................................................... Yes Yes No No Yes No Yes Yes No No Yes No 3. Has any Proposed Insured: a. Ever had a heart, lung, liver or kidney disease or disorder; diabetes; stroke; paralysis or cancer? ................................................... b. Ever been diagnosed or treated by a medical professional for acquired immune deficiency syndrome (AIDS) or AIDS-related complex (ARC)? ............................................................................................................................................................... c. During the past 5 years been treated, counseled or advised to seek treatment for drug/alcohol abuse? .......................................... d. During the past 90 days been admitted, or advised by a medical professional to be admitted to a hospital or other licensed health care facility; had surgery or had surgery recommended by a medical professional; or been advised by a medical professional to have any diagnostic test that was not completed (excluding an AIDS-related test)? ................................................. No coverage starts: ♦ Until the later of 1) the date the Proposed Insured completed and signed the Application and paid the first full modal premium (a check is not payment unless honored by the issuing institution when first presented); or 2) the date the Proposed Insured completed all medical tests required by Assurity and ♦ Unless the Proposed Insured is insurable on the date coverage starts at Assurity’s standard or better than average rates (no ratings included), according to its underwriting practices for the amount of insurance and any additional benefits applied for. If the Proposed Insured is diagnosed by a medical professional with a covered medical condition, Assurity shall not be liable for: ♦ More than $2,500 of disability coverage or business overhead coverage; or ♦ More than the applied for amount of hospital indemnity; or ♦ More than $50,000 of critical illness coverage. This includes any other critical illness coverage applied for with Assurity. If no Policy is issued and delivered and no benefit is paid under this Agreement, all premiums paid will be returned. If the Policy is issued as applied for, or if a Policy amendment is accepted by the Proposed Owner, premium paid will be applied to that Policy. No change in health will be used to deny a Policy if the change occurs after the later of: 1) the date of the Application; or 2) completion of all medical tests required by Assurity. Coverage under this Agreement terminates automatically on the earliest of the date: ♦ 90 days from the date of the Application; ♦ Premium is returned by Assurity (return is effective on being postmarked, properly addressed and postage prepaid); ♦ Coverage starts under any Policy resulting from the Application; or ♦ A Policy resulting from the Application is refused by the Proposed Owner. The undersigned states that the answers on this Agreement and the Application are true and complete to the best of his/her knowledge and belief, and understands that the answers are relied upon for coverage under this Agreement. Assurity’s liability will be limited to a return of the premium submitted if: 1) the Proposed Insured dies by suicide; or 2) the Application or this Agreement contains a material misrepresentation to Assurity. Dated at On City, State Date (MM/DD/YYYY) Signature of Proposed Insured No. 1 Signature of Proposed Insured No. 2 Signature of Agent or Witness (disinterested person) Print Agent or Witness Name Signature of Owner (if other than Proposed Insured) 75-803-02255 [FR.01.24.11] ASSURITY® LIFE INSURANCE COMPANY NOTICE AND CONSENT FOR BLOOD TESTING 1526 K Street, P.O. Box 82533, Lincoln, NE 68501 402.476.6500 • 800.276.7619 • FAX 402.437.4591 BLOOD TESTING MAY INCLUDE AIDS VIRUS (HIV) ANTIBODY/ANTIGEN TESTING INSURER: Assurity Life Insurance Company • P.O. Box 82533 • 1526 K Street • Lincoln, Nebraska 68501-2533 EXAMINER: Name Address To determine your insurability, the Insurer named above has requested that you provide a sample of your blood for testing and analysis. All tests will be performed by a licensed laboratory. Tests may be performed to determine the presence of antibodies or antigen to the Human Immunodeficiency Virus (HIV), also known as the AIDS virus. The HIV antibody test that we perform is actually a series of tests done by a medically accepted procedure. The HIV antigen test directly identifies AIDS particles. These tests are extremely reliable. Other tests which may be performed include determinations of blood cholesterol and related lipids (fats) and screening for liver or kidney disorders, diabetes and immune disorders. All test results will be treated confidentially. They will be reported by the laboratory to the Insurer. When necessary for business reasons in connection with insurance you have or have applied for with the Insurer, the Insurer may disclose test results to others involved in the underwriting and claims review process. Your test results will not be disclosed to your agent or broker. If the HIV test is positive, the results will be reported to the local health department or the State Department of Health, and if the insurer is a member of the Medical Information Bureau (MIB, Inc.) the Insurer may report the results in a generic code which signifies only nonspecific blood abnormalities. If your HIV test is normal, no report will be made about it to the MIB, Inc. Other test results may be reported to the MIB, Inc. in a more specific manner. The organizations described in this paragraph may maintain the test results in a file or data bank. There will be no other disclosure of test results, or even that the tests have been done, except as may be required or permitted by law or authorized by you. If your HIV test results are normal, no routine notification will be sent to you. If the HIV test results are other than normal, the Insurer or your designated physician will contact you. The Insurer may also contact you if there are other abnormal test results which, in the Insurer’s opinion, are significant. The Insurer may ask you for the name of a physician to whom you may authorize disclosure and with whom you may wish to discuss the results. Positive HIV antibody/antigen test results do not mean that you have AIDS, but that you are at significantly increased risk of developing AIDS or AIDS-related conditions. Federal authorities have concluded that persons who are HIV antibody/antigen-positive should be considered infected with the AIDS virus and capable of infecting others. Positive HIV antibody or antigen test results or other significant blood abnormalities will adversely affect your application for insurance. This means that your application may be declined, that an increased premium may be charged, or that other policy changes may be necessary. I have read and I understand this Notice of Consent for Blood Testing Which May Include HIV Antibody/Antigen Testing. I voluntarily consent to the withdrawal of blood from me by needle, the testing of that blood and the disclosure of the test results as described above. In the event of a positive HIV test result, I authorize Assurity Life Insurance to send the test results to the following health care professional for post-test counseling and for Health Department reporting purposes: Physician’s Name Physician’s Address I understand that I have the right to request and receive a copy of this authorization. A photocopy of this form will be as valid as the original. Proposed Insured (Printed) Signature of Proposed Insured or Parent/Guardian 87-820-05055 SC Date of Birth (MM/DD/YYYY) Date (MM/DD/YYYY) [R03.12.07] State of Residence ASSURITY® LIFE INSURANCE COMPANY Post Office Box 82533, Lincoln, NE 68501-2533 (402) 476-6500 • (800) 276-7619 • FAX (888) 255-2060 CONSUMER NOTICE MIB Pre-Notice Information regarding your insurability will be treated as confidential. Assurity or its reinsurers may, however, make a brief report thereon to the MIB Inc., formerly known as the Medical Information Bureau, a non-profit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information about you in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at (866) 692-6901 (TTY 866-346-3642). If you question the accuracy of the information in MIB’s file, you may contact MIB to seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the MIB’s information office is 50 Braintree Hill Park, Ste. 400, Braintree, MA 02184-8734. Assurity, or its reinsurers, may also release information from its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its Web site at www.mib.com. Insurance Information Practices To issue an insurance policy, we need to obtain information about you. Some of that information will come from you, and some will come from other sources. This information may in certain circumstances be disclosed to third parties without your specific authorization as permitted or required by law. You have the right to access and correct this information, except information that relates to a claim or a civil or criminal proceeding. Upon your written request, Assurity will provide you with a more detailed written notice explaining the types of information that may be collected, the types of sources and investigative techniques that may be used, the types of disclosures that may be made and the circumstances under which they may be made without your authorization, a description of your rights to access and correct information and the role of insurance support organizations with regard to your information. If you desire additional information on insurance information practices, please direct your requests to Assurity Life Insurance Company, P.O. Box 82533, Lincoln, NE 68501-2533. Fair Credit Reporting Act Pursuant to the Federal Fair Credit Reporting Act, as amended (15 U.S.C. 1681d), notice is hereby given that, as a component of our underwriting process relating to your application for life or health insurance, Assurity Life Insurance Company (Assurity) may request an investigative consumer report that may include information about your character, general reputation, personal characteristics and mode of living, except as may be related directly or indirectly to sexual orientation. This information may be obtained through personal interviews with your neighbors, friends, associates and others with whom you are acquainted or who may have knowledge concerning any such items of information. You have a right to request in writing, within a reasonable period of time after receiving this notice, a complete and accurate disclosure of the nature and scope of the investigation Assurity requests. Please direct this written request to Assurity Life Insurance Company, P.O. Box 82533, Lincoln, NE 68501-2533. Upon receipt of such a request, Assurity will respond by mail within five business days. Telephone Interview Information Assurity may require that you complete a confidential telephone interview as a part of your application for insurance. The interview will be conducted by a trained professional and may include (but is not limited to) the following topics: occupation, job history, income, personal and business financial information and medical history. All information obtained will be used for underwriting purposes only and will not be released without your written consent. 75-652-05055 [R.04.07.09] ASSURITY® LIFE INSURANCE COMPANY Post Office Box 82533, Lincoln, NE 68501-2533 (402) 476-6500 • (800) 276-7619 • FAX (402) 437-4591 Accident or Health Insurance REPLACEMENT NOTICE NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND HEALTH INSURANCE According to your application (information you have furnished), you intend to lapse or otherwise terminate existing accident and health insurance and replace it with a policy issued by Assurity Life Insurance Company. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy. In particular, study the comparison statement which your agent is required to furnish you upon taking your application. 1. Health conditions that you may presently have (pre-existing conditions), may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy. 2. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage. 3. If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded. The above “Notice to Applicant” was delivered to me on: Applicant’s Signature and Printed Name Date (MM/DD/YYYY) Signed form to be returned to the home office Applicant to receive a copy of the signed form at the time the application is taken 87-809-05055 (SC) Page 1 [R.02.06.08] COMPARATIVE INFORMATION EXISTING POLICY PROPOSED POLICY BENEFITS $ Monthly Amount $ Elimination Period Benefit Period RENEWABILITY Guaranteed Renewable? Yes No Yes No Non-cancellable? Yes No Yes No PRE-EXISTING DEFINITION Existing Policy: PROPOSED POLICY If your Total Disability is within 2 years from the Issue Date and is due to a Pre-existing Condition, Benefits will not be paid unless the condition: • was disclosed and not misrepresented on Your Application; and • is not excluded by a Policy Amendment Rider. Pre-existing Condition: A sickness or physical condition for which, before the Issue date: • symptoms existed which causes an ordinary prudent person to seek diagnosis, care or treatment; or • medical advice was recommended by or received from a Physician. Applicant to receive a completed copy 87-809-05055 (SC) Page 2 [R.02.06.08] ASSURITY® LIFE INSURANCE COMPANY Post Office Box 82533, Lincoln, NE 68501-2533 (402) 476-6500 • (800) 276-7619 • FAX (402) 437-4591 Accident or Health Insurance REPLACEMENT NOTICE NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND HEALTH INSURANCE According to your application (information you have furnished), you intend to lapse or otherwise terminate existing accident and health insurance and replace it with a policy issued by Assurity Life Insurance Company. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy. In particular, study the comparison statement which your agent is required to furnish you upon taking your application. 1. Health conditions that you may presently have (pre-existing conditions), may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy. 2. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage. 3. If, after d