CONTINENTAL GENERAL INSURANCE COMPANY

Transcription

1 CONTINENTAL GENERAL INSURANCE COMPANY 2008 SENIOR WHOLE LIFE I N S U R A N C E P O L I C I E S PACKET CONTAINS: FAXAPP COVERSHEET GASBG APPLICATION CGCSACSB-TX BANK DRAFT FORM CGI RATES CGI REPLACEMENT FORMS CG-LIFE-REPLACE OFFICIAL RECEIPT CGI FORMS FOR USE IN TEXAS EFFECTIVE DATE 6/1/08 CGI TX 5/20/08

2 GREAT AMERICAN SUPPLEMENTAL BENEFITS GROUP New Business FaxApp for all business except Long-Term Care (For LTC applications use form # GALIC ) ONE APPLICATION PER COVER SHEET To: Great American Supplemental Benefi ts Group Fax #: Date: Number of Pages: NAME: Agent s Information (Must be Completed) PHONE #: FAX #: WRITING #: NAME: Applicant s Information (Must be Completed) SS#: CWA with application? Yes No Draft for fi rst Premium? Yes No Procedures: You simply complete the application and fax the following to FaxApp Cover Sheet Application (non-shaded) in numeric page order Any state specifi c or replacement forms where applicable Copy of the initial premium check if collected from the client at point-of-sale or a void check so that we can draft for the initial premium. You must submit one or the other or the application cannot be processed. Instructions: Please send one application per cover sheet and only one application per transmission Please set your fax machine to receive confi rmation to show that your fax went through You will receive a confi rmation by or fax verifying that we have received the application. This confirmation will include the policy number Do not fax applications that are shaded. A non-shaded application can be requested from the Supply Department Premium: Agents are encouraged to utilize the bank draft authorization to draft for the fi rst premium in lieu of collecting the initial premium from the applicant. If you collected initial premium from the applicant please indicate the policy number on the check and mail the check stapled to the top of the FaxApp cover page to: Imaging-New Business P.O. Box , Austin, TX We must receive the premium within 10 days of receipt of the application. If it is not received within 10 days we will send you a letter stating that the money for the policy must be submitted immediately. If we do not receive the check after 20 days, a letter will be sent stating the policy will be cancelled in 5 days unless we receive payment for the issued policy. If we do not receive payment after 25 days, a letter will be sent to you and the applicant stating the file has been closed and the policy has been cancelled due to non-payment of premium. Great American Supplemental Benefits Group of Companies include: Central Reserve Life Insurance Company Loyal American Life Insurance Company Continental General Insurance Company United Teacher Associates Insurance Company Great American Life Insurance Company Provident American Life & Health Insurance Company GASBG /1/08

3 Application for Senior Life Insurance & Graded Benefit Life Insurance - CONTINENTAL GENERAL INSURANCE COMPANY - P. O. Box Austin, TX Name of Proposed Insured (Print) Sex Birthdate Age Social Security No. Last First Initial Mo. Day Year Nearest Birthday Street Address City State Zip Birth Place State Telephone No. 2. Graded Benefit Life Amount $ Senior Life Amount $ 3. Premium $ Premium Payable: Annual Semi-Annual Quarterly Monthly Bank Draft (BOM) Amount of Premium Submitted with the Application: $ Requested Effective Date: (Check must be made payable to Continental General Insurance Company). Special Bill Date: 4. Primary Beneficiary Relationship Contingent Beneficiary Relationship 5. Owner, if other than the Proposed Insured Name Relationship Address Social Security No. 6. Will the proposed insurance replace any existing policy or annuity? Yes No If yes: Insurance Company Name and Address 7. Telephone Verification of Your Application To assure that we have all the information needed to process your application, you will be contacted by telephone shortly after your agent submits your application. We will ask you a number of questions to be sure that all information on your application is complete and correct. Please indicate the best day/time to call you: Telephone Number: 8. Tobacco Question. Have you used tobacco in any form within the last 2 years? Yes No 9. Height Weight Medical Questions When applying for either the Graded Benefit or Senior Life plan answer questions below. If any question is answered Yes, the Proposed Insured will not be eligible for either plan. (If applying for Senior Life, questions must also be answered.) 10. Are you now confined in a hospital, rest home, nursing home, hospice or convalescent home? Are you now being treated for Cancer or any terminal illness which would, in the absence of medical intervention, result in a life expectancy of 24 months or less? Are you now being treated for Alzheimer s Disease or Dementia, Renal or Kidney Failure, or any Respiratory Disease that requires the use of oxygen? Have you ever had any organ transplant? Have you ever been treated for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or have you tested positive for the Human Immunodeficiency Virus?... Yes No Senior Life Medical Questions When applying for the Senior Life plan answer questions below in addition to questions above. If any of the following questions are answered Yes, the Proposed Insured will not be eligible for the Senior Life plan but may be eligible for the Graded Benefit plan. 15. Have you ever been diagnosed with or treated for a terminal illness?... Senior Life Medical Questions continued on Page 2 CGCSACSB-TX Page 1 of 4 R06

4 Senior Life Medical Questions (continued) Yes No 16. Have you been hospitalized within the last 30 days or been hospitalized two or more times in the last two years or been confined to a nursing facility in the last two years? Within the past 2 years have you had, or been diagnosed as having: a) Angina, Heart Attack, Angioplasty, Cardiac or Vascular Stent, Cardiac Bypass Surgery, Heart Valve Surgery, or implantation of Cardiac Pacemaker or Defibrillator?... b) Stroke, MiniStroke, or Transient Ischemic Attack (TIA)?... c) Internal Cancer or Melanoma?... d) Epilepsy or Epileptic Seizure? Do you have now, or within the past 2 years, have you received medical advice, treatment, been advised to have treatment or surgery, or taken medication for: a) Cardiomyopathy or Congestive Heart Failure?... b) Cerebrovascular Blockage or Insufficiency, or Vascular Aneurysm?... c) Leukemia, Hodgkin s Disease or Lymphoma, or any other type of Cancer or Tumor not cured by surgery or treatment?. d) Chronic Lung Disease, Emphysema, or Chronic Obstructive Pulmonary Disease (COPD)? Or any type of other Chronic Pulmonary Disease that requires the use of oxygen?... e) Chronic Kidney Disease, Renal Failure, Renal Insufficiency, Chronic Liver Disease, Hepatitis, Cirrhosis, Disease of the Pancreas?... f) Diabetes associated with Retinopathy, Neuropathy, or Amputation, or Insulin Dependent Diabetes?... g) Parkinson s Disease, Paralysis, Myasthenia Gravis, Multiple Sclerosis, Lupus or Connective Tissue Disorder, Muscular Dystrophy, Huntington s Disease, or Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig s Disease?... h) Dementia, Senile Dementia, Alzheimer s Disease, Organic Brain Disorder, Paranoia, Schizophrenia, or Major Depressive Disorder?... i) Excessive use of Alcohol, Alcoholism, Drug Abuse, or Drug or Narcotic Addiction? Within the last 5 years, have you ever been advised by a medical professional to have tests, surgery, treatment, or further medical evaluation that have not been performed, or do you have any medical test results pending? Do you use a medical appliance such as a wheelchair, walker or hospital bed, or do you need assistance or supervision by another individual with dressing, eating, personal hygiene (bathing or toilet), walking, or transferring to or from a bed or chair? Within the last 90 days have you had undiagnosed chest pain, paralysis, fainting, bleeding moles, coughed or vomited blood, or passed blood through the bowels? Within the past 1 year have you had any application for life insurance declined or postponed for any reason?... Remarks: CGCSACSB-TX Page 2 of 4 R06

5 I hereby apply to Continental General Insurance Company, Austin, Texas, for insurance to be issued upon the truth and completeness of the answers to the above questions to the best of my knowledge, and agree that: (1) No agent has the authority to waive the answer to any question in the application; (2) no insurance will be effective until the Premium for the Mode selected has been paid in full and the policy delivered; and (3) the policy effective date will be the date this application is received by the company at the above address. AUTHORIZATION I hereby authorize any health care provider, including any physician, practitioner, pharmacy, prescription vendor, pharmacy benefit manager, hospital or medically-related facility, and any insurance company, the Medical Information Bureau (MIB) or other consumer reporting agency, employer, or, except in AZ, any other organization, institution or person that has my records or knowledge of me or my dependent(s) to disclose to Continental General Insurance Company (CGI), or its authorized representative, any such records or information. Records or information may include medical records in their entirety, which may contain mental health records (excluding psychotherapy notes), prescription drug records, use of alcohol, or use of controlled or prohibited substances, driving records, financial and employment records. Such records or information will be used by Company personnel to determine eligibility for insurance and/or benefits. CGI may disclose such information to its reinsurer(s), precertification firm, individual benefits management firms or any other organization which performs services in connection with the insurance relationship, including, but not limited to, the insurance agent, or as lawfully required. However, CGI shall not disclose to an agent information received from MIB. CGI reserves the right to require a medical examination or testing or both. There may be certain circumstances under which the information received may be disclosed to third parties who are not subject to the regulations under federal health privacy law. We contractually require such persons to agree to protect the confidentiality of the information. I understand that I have the right to request access to all personal information collected and, upon written request, I may ask CGI to correct, amend or delete any incorrect personal information. A copy of the Company s Privacy Notice and Notice of Insurance Information Practices is available upon request. This authorization shall be valid for a period of two (2) years from the date signed to determine eligibility for insurance. For determination of benefits, the authorization shall be valid for either the term of coverage of the policy for health insurance products or for the duration of the claim for all other insurance products. A photocopy of this authorization shall be as valid as the original. I understand that I, or my authorized representative may receive a copy of this authorization upon request. This authorization may be revoked at any time subject to the rights of anyone who acted in reliance upon the authorization prior to notice of its revocation. This authorization may be revoked upon submission of a written notice to the Home Office. If this authorization was obtained as a condition of obtaining insurance coverage, your right to revoke also is subject to the rights of the Company under any law granting the Company the right to contest a claim under the policy or the policy itself. Revocation or failure to sign the authorization may be a basis for denying an application or eligibility for benefits. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. Dated at Date: City State (MMDDYY) Signature of Applicant: Date: Signature of Owner ( if other than proposed insured): Date: Signature of Authorized Representative: Relationship/ Date: Authority to Represent: Authorized Representative s Address: Authorized Representative s Phone Number: AGENT S STATEMENT: Is insurance being applied for intended to replace any insurance now in force? Yes No I have truly and accurately recorded in this Application, the information supplied by applicant. X Signature of Licensed Agent Agent # Agent s Name (Please Print) INVESTIGATIVE CONSUMER REPORTS AUTHORIZATION As part of our normal procedure for processing your application, an investigative consumer report may be prepared whereby information is obtained as to the character, general reputation, personal characteristics and mode of living of persons proposed for insurance in this application. Personal interviews with friends, neighbors and associates may be used to develop this report. (In WV, no information collected concerning the sexual orientation of the proposed insured will be used to determine his or her eligibility for insurance.) You may request to be interviewed in connection with the preparation of the report. You have the right to request A Summary of Your Rights Under the Fair Credit Reporting Act. Upon written request, you or your representatives have a right to receive a copy of the report and additional information about the nature and scope of the investigation. CGCSACSB-TX Page 3 of 4 R06

6 MEDICAL INFORMATION BUREAU (MIB) AUTHORIZATION Information regarding your insurability will be treated as confidential. CGI or our reinsurers may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. I understand that if I apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such member company, the Bureau, upon request, will supply such member company with the information in its file. By signing below, I authorize release of my information to MIB and MIB to any member company. Signature of Applicant: Date: Signature of Authorized Representative: Relationship/ Date: Authority to Represent Authorized Representative s Address: Authorized Representative s Phone Number: NOTIFICATION REGARDING THE MEDICAL INFORMATION BUREAU (To Be Left With The Proposed Insured) Information regarding your insurability will be treated as confidential. CGI or it s reinsurers may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of it s members. If you apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the Bureau, upon request, will supply such company with the information in it s file. Upon a receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of the information in the Bureau s file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the Bureau s information office is P. O. Box 105, Essex Station, Boston, MA 02112, telephone number CGI or it s reinsurers may also release information in it s file to it s reinsurer(s) and to other life insurance companies to whom you may also apply for life or health insurance, or to whom a claim for benefits may be submitted. CGCSACSB-TX Page 4 of 4 R06

7 BANK AUTHORIZATION Checking Savings Special Bill Date CONTINENTAL GENERAL INSURANCE COMPANY is hereby requested and authorized to draw checks to be charged against the checking or savings account of: print name as shown on bank records with name of bank and branch name, if any Bank Routing Number: Bank Account Number: for the purpose of collecting premiums payable to CONTINENTAL GENERAL INSURANCE COMPANY under the bank check premium arrangement. The policy(ies) are to be placed under the bank check premium arrangement, upon approval by the Company, for premiums due. It is understood that CONTINENTAL GENERAL INSURANCE COMPANY S premium arrangement may be terminated by the policy owner or by the Company upon written notice. As a convenience to me, I hereby request and authorize the bank named above to pay and charge my account debits drawn by Continental General Insurance Company to its own order. This authorization will remain in effect until revoked by me in writing, and until you actually receive such notice I agree that you shall be fully protected in honoring any such debit. I agree that your treatment of each such check, and your rights in respect to it, shall be the same as if it were signed personally by me. I further agree that if any such check be dishonored, whether with or without cause, you shall be under no liability whatsoever even though such dishonor results in the forfeiture of insurance. date signature of bank depositor/premium payor (as shown on bank records for the account to which this authorization is applicable) INDEMNIFICATION AGREEMENT To: The Bank Named Above In consideration of your participation in a plan which the CONTINENTAL GENERAL INSURANCE COMPANY has put in effect by which amounts for premiums due on policies of insurance are collected by drafts drawn by the company on the accounts of persons who have made themselves responsible for these payments, the Company does hereby agree that subject to the terms and provisions of such insurance policies without varying, extending or altering the terms, thereof: (1) It will indemnify and hold you harmless from any liability to any person having an account with you arising out of the payment by you of any check drawn by the Company on the account of such person, or arising out of the dishonor by you, whether with or without cause or intentionally or inadvertently, of any such check drawn by the Company, whether or not such claim or liability asserted against you be based upon the forfeiture, or alleged forfeiture, of a policy of insurance the premium on which is sought to be collected by the Company by any such check; and (2) It will refund to you any amount erroneously paid by you on any such check if claim for the amount of such erroneous payment is made by you within a reasonable time from the date of the check on which such erroneous payment was made. (authorized Officer s signature) President Please Note: A VOIDED check must accompany the authorization. CGI /15/08

8 WHOLE LIFE INSURANCE POLICY - FORM L9190F GRADED BENEFIT WHOLE LIFE INSURANCE - POLICY L9710F MALE FEMALE MALE FEMALE NON-TOBACCO TOBACCO NON-TOBACCO TOBACCO ISSUE AGE* NON-TOBACCO TOBACCO NON-TOBACCO TOBACCO * Issue Age is age nearest birthday Mode Factors: Gross Premiums per $1,000 Face Amount Annual 1.00 Add $40.00 Policy Fee Semi-Annual Quarterly Monthly Bank Draft CGI /28/08

9 CONTINENTAL GENERAL INSURANCE COMPANY P. O. Box Austin, Texas IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES This document must be signed by the applicant and the producer, if there is one, and a copy left with the applicant. You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy to pay all or part of any premium payment due on the new policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interests. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? YES NO 2. Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? YES NO If you answered yes to either of the above questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number, if available) and whether each policy or contract will be replaced or used as a source of financing: INSURER NAME CONTRACT OR POLICY # INSURED OR ANNUITANT REPLACED (R) OR FINANCING (F) Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision. The existing policy or contract is being replaced because. NOTICE: YOU HAVE A 30 DAY RIGHT TO EXAMINE YOUR REPLACEMENT POLICY. Please review your policy carefully. If it is not satisfactory in any way, return it to us or our agent within 30 days after it is received. The policy will be void at such time. We will refund any premium paid, including policy fees or other charges. CG-LIFE-REPLACE

10 I certify that the responses herein are, to the best of my knowledge, accurate. I also certify that only Continental General Insurance Company approved sales materials were used in conjunction with this sale, and that copies of all sales materials used in this sale have been left with the applicant. However, any electronically presented sales material shall be provided in printed form to the applicant no later than at the time of policy delivery. Applicant s Signature and Printed Name Date Agent s Signature and Printed Name Date I do not want this notice read aloud to me. (Applicant must initial only if they do not want the notice read aloud.) A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense: PREMIUMS: Are they affordable? Could they change? You re older - are premiums higher for the proposed new policy? How long will you have to pay premiums on the new policy? On the old policy? POLICY VALUES: New policies usually take longer to build cash values and to pay dividends. Acquisition costs for the old policy may have been paid, you will incur costs for the new one. What surrender charges do the policies have? What expenses and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage? INSURABILITY: If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down. You may need a medical exam for a new policy. Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage. IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY: How are premiums for both policies being paid? How will the premiums on your existing policy be affected? Will a loan be deducted from death benefits? What values from the old policy are being used to pay premiums? IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT: Will you pay surrender charges on your old contract? What are the interest rate guarantees for the new contract? Have you compared the contract charges or other policy expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS: What are the tax consequences of buying the new policy? Is this a tax free exchange? (See your tax advisor.) Is there a benefit from favorable grandfathered treatment of the old policy under the Federal tax code? Will the existing insurer be willing to modify the old policy? How does the quality and financial stability of the new company compare with your existing company? CG-LIFE-REPLACE

11 CONTINENTAL GENERAL INSURANCE COMPANY P. O. Box Austin, Texas IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES This document must be signed by the applicant and the producer, if there is one, and a copy left with the applicant. You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy to pay all or part of any premium payment due on the new policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interests. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? YES NO 2. Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? YES NO If you answered yes to either of the above questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number, if available) and whether each policy or contract will be replaced or used as a source of financing: INSURER NAME CONTRACT OR POLICY # INSURED OR ANNUITANT REPLACED (R) OR FINANCING (F) Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision. The existing policy or contract is being replaced because. NOTICE: YOU HAVE A 30 DAY RIGHT TO EXAMINE YOUR REPLACEMENT POLICY. Please review your policy carefully. If it is not satisfactory in any way, return it to us or our agent within 30 days after it is received. The policy will be void at such time. We will refund any premium paid, including policy fees or other charges. CG-LIFE-REPLACE

12 I certify that the responses herein are, to the best of my knowledge, accurate. I also certify that only Continental General Insurance Company approved sales materials were used in conjunction with this sale, and that copies of all sales materials used in this sale have been left with the applicant. However, any electronically presented sales material shall be provided in printed form to the applicant no later than at the time of policy delivery. Applicant s Signature and Printed Name Date Agent s Signature and Printed Name Date I do not want this notice read aloud to me. (Applicant must initial only if they do not want the notice read aloud.) A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense: PREMIUMS: Are they affordable? Could they change? You re older - are premiums higher for the proposed new policy? How long will you have to pay premiums on the new policy? On the old policy? POLICY VALUES: New policies usually take longer to build cash values and to pay dividends. Acquisition costs for the old policy may have been paid, you will incur costs for the new one. What surrender charges do the policies have? What expenses and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage? INSURABILITY: If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down. You may need a medical exam for a new policy. Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage. IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY: How are premiums for both policies being paid? How will the premiums on your existing policy be affected? Will a loan be deducted from death benefits? What values from the old policy are being used to pay premiums? IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT: Will you pay surrender charges on your old contract? What are the interest rate guarantees for the new contract? Have you compared the contract charges or other policy expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS: What are the tax consequences of buying the new policy? Is this a tax free exchange? (See your tax advisor.) Is there a benefit from favorable grandfathered treatment of the old policy under the Federal tax code? Will the existing insurer be willing to modify the old policy? How does the quality and financial stability of the new company compare with your existing company? CG-LIFE-REPLACE

13 OFFICIAL RECEIPT UNLESS ACH FORM IS USED A CHECK OR MONEY ORDER MUST ACCOMPANY APPLICATION Received of this day of (M) / (Y), an application for a Form Policy and Check or Money order for Dollars. Should the Company decline to issue the insurance applied for, the Company herby agrees to return the above sum to the applicant. Agent If the full premium is paid with the application and so recorded in the application and the Company shall be satisfied after investigation that the applicant was acceptable for the insurance applied for at the time the application was signed according to the underwriting rules of the Company the policy will be dated and effective according to its terms at 12:01 A.M. the day the application was dated or the date on which the premium was paid, whichever is later. CGI /15/08