Western Reserve Policy Reinstatement Fee Form

Application for Reinstatement and/or Policy Change

Western Reserve Life Assurance Co. of Ohio, P.O. Box 5068, Clearwater, Florida 33758

Policy Number: Insured Name:

If reinstatement is approved, the contestable period will start anew. This application must be accompanied by all required premiums.

PART 1. PROPOSED INSURED(S) INFORMATION

Telephone Number: Best time to call: AM PM

If additional space is necessary for CIR’s, list child’s name and date of birth on a separate sheet of paper.

PART 2. MEDICAL QUESTIONS

Has any proposed insured listed in Part 1

1) Within the last 5 years been treated for or been told by a member of the medical profession that they had heart disease or circulatory problems, stroke, cancer, diabetes, kidney or liver disorder, lung or respiratory disorder, Alzheimer’s Disease, mental or psychiatric disorder, alcohol or drug abuse? (Please circle the applicable ailments) YES NO

2) Within the last 5 years consulted a medical practitioner? YES NO

3) Within the last 5 years been tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection? YES NO

4) Within the last 12 months used tobacco or other nicotine products in any form? YES NO

Give details to all YES answers above. Please indicate person(s) to which details apply, dates of visit, reason for visit and findings. Give us the doctor, hospital, clinic, or health care providers full name and address.

PART 3. OCCUPATION AND MISCELLANEOUS QUESTIONS

5) Has any proposed insured listed in Part 1 had a change in occupation or income since the original application? YES NO

If yes, indicate whom and describe current occupation and income.

6) State occupation and income for any adult applicant listed in Part 1 to be added to policy:

7) Has any proposed insured listed in Part 1 had their drivers license suspended, revoked, restricted, or been convicted of a moving violation in the last 12 months? YES NO

If yes, provide Driver’s License number, State of issue, and details.

8) Does any proposed insured listed in Part 1 participate in aviation or any organized hazardous sport or activity? YES NO

If yes, complete an aviation or hazardous sports questionnaire and attach to application.

9) Will any proposed insured listed in Part 1 travel outside the United States within the next 12 months? YES NO

If yes, provide details of when, where, and length of time.

PART 4. REPRESENTATIONS

I represent that the statements and answers in this application are true and complete to the best of my knowledge and belief.

It is agreed that:

(a) The statements and answers given in this application, and any amendments or application supplements to it or statements made to the medical examiner, will be the basis of any reinstatement granted or insurance issued.

(b) No agent or medical examiner has the authority to make or alter any contract for the Company.

(c) No reinstatement will be effective or coverage provided until the date the application is approved by the company.

(d) If a premium deposit is given, no insurance shall take effect until the application is approved by the company while all persons shown in Part 1 are living and their health remains as stated in the reinstatement and policy change application.

(e) If a premium deposit is not given, no insurance shall take effect until the application is approved by the company and accepted by the owner, all premiums due have been paid and while all persons shown in Part 1 are living and their health remains as stated in the reinstatement and policy change application.

(f) I further agree that this application will be attached and shall be made a part of the contract for insurance.

PART 5. AUTHORIZATION TO OBTAIN INFORMATION

I authorize any physician, medical professional, hospital, clinic, other medical care institution, the Medical Information Bureau, Inc., insurance company, consumer reporting agency, or employer having information available as to employment, other insurance coverage, medical care, advice or treatment with respect to any physical or mental condition regarding me or any of my minor children who are to be insured, to give such information to Western Reserve Life Assurance Co. of Ohio, its reinsurers, or any consumer reporting agency except the Medical Information Bureau, acting on Western Reserve Life’s behalf.

I authorize Western Reserve Life Assurance Co. of Ohio to obtain an investigative consumer report on me and upon my request I am entitled to receive a free copy of this report.

I authorize Western Reserve Life Assurance Co. of Ohio to obtain a motor vehicle report on me.

I understand that this information will be used by Western Reserve Life or its reinsurers, to determine eligibility for life insurance.

I agree that this authorization is valid for two and one-half years from the date signed. I know that I or my authorized representative have a right to receive a copy of this authorization upon request. I agree that a photographic copy of this authorization is as valid as the original.

I also hereby authorize Western Reserve Life Assurance Co. of Ohio to provide its affiliated companies any and all information provided herein and obtained hereafter on me. This authorization shall be valid from the date signed below until affirmatively withdrawn in writing by myself.

I elect not to have personal information disclosed to non-affiliates of Western Reserve Life Assurance Co. of Ohio for marketing purposes.

I elect to be interviewed if an investigative consumer report is prepared in connection with this application.

FRAUD WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree.

Signed at (city) (state) on (date)

Printed Agent Name and Florida Agent License #:

FAIR CREDIT REPORTING ACT

A routine investigative consumer report may possibly be made regarding your general reputation, character, mode of living and personal characteristics. This information may be obtained through personal interviews with your friends, neighbors and associates. Should you desire additional information on the nature and scope of such a report, you may write the Underwriting Department, Western Reserve Life Assurance Co. of Ohio, PO Box 9009, Clearwater, FL 33758. You may also request information concerning the nature and scope of the investigation to be performed.

THE MEDICAL INFORMATION BUREAU PRE-NOTICE

The Medical Information Bureau (“MIB”) is a non-profit organization of life insurance companies which operates as an information exchange for its members.

We may make reports to the MIB regarding factors affecting your insurability. Underwriting decisions, however, are not reported to the MIB. If you apply to another Bureau member company for life or health insurance or submit a claim for benefits, the MIB will, upon request, provide that company with information in its file.

Upon your written request, the MIB will arrange for disclosure to you of any information it has in your file. If you feel the information in the MIB’s file is incorrect, you may contact the MIB and seek a correction in accordance with procedures outlined in the Federal Fair Credit Reporting Act. The address of the MIB’s office is: MIB, Inc., P.O. Box 105, Essex Station, Boston, MA 02112. MIB’s telephone number: (617) 426-3660.

If you would like to know more about how we collect, evaluate and control information about you as one of our applicants for insurance, our sales representatives will be happy to assist you or you may contact us at our office.