Greek Catholic Union of the U.S.A Tuscarawas Road, Beaver, PA Phone: FAX: Authorization

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5 Greek Catholic Union of the U.S.A. A Fraternal Benefit Society 5400 Tuscarawas Road, Beaver, PA Phone: FAX: Authorization For Blood Testing and Disclosure of Results I do hereby authorize blood to be drawn from me for laboratory tests. I understand that: 1. The tests performed will be those required by the Insurer to determine my eligibility for the insurance I have applied for; 2. I have the right to refuse to have blood drawn and that, in such event, the Insurer will decline to accept my application; and 3. The tests preformed shall include, but are not limited to, tests for: I further authorize: a. Cholesterol and related blood lipids; glucose; liver or kidney disorder; or the presence of medication, drugs, nicotine or metabolites; and b. Immune disorders; or T-Helper to T-Suppressor ratio with total T-cell count. 1. The laboratory to disclose the test results to the Insurer; 2. The Insurer to disclosed the test results, including any abnormal results, to its reinsurer, provided such reinsurer is involved in the determination of my eligibility for insurance; and 3. The Insurer to make a brief, coded report to the Medical Information Bureau (MIB) in the manner described in the MIB Notice I received as a part of my application process. I understand that the test results will be confidential. No one will have access the test results except: as I have authorized; as I may later authorize; or, as may be required by law. Name of Proposed Insured (Please Print) Address Signature of Proposed Insured Witness (Signature) (Printed Name) Date GCUBloodAuth092011

6 Greek Catholic Union of the USA 5400 Tuscarawas Road Beaver, PA (724) Addendum to Application 1. Will the insurance now applied for replace or change any insurance or annuities? _ Yes_ No 2. Did you ask each question in the Application as stated in the Application? _ Yes_ No 3. Are the answers to the questions in the Application recorded exactly as made to you? _ Yes_ No 4. Are you aware of any information not disclosed in this Application which might have a bearing on the Insurability (including health, occupation, avocations, habits or reputation) of the Proposed Insured? _ Yes _ No If yes, explain below or in a separate letter. Remarks: _ Dated at: this: day of:, 20 Sponsor/Agent: _ Form ADD-APP

7 AUTHORIZATION TO OBTAIN, RELEASE AND DISCLOSE MEDICAL INFORMATION I hereby authorize any: medical practitioner, physician, hospital, clinic, pharmacy benefit manager, or other medical related facility, insurance company, insurance support organization, business partner, pharmacy, government agency, group policy holder, employer, benefit plan administration, the MIB, Inc., the Department of Motor Vehicle Registration, and paramedical facility to provide to THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU), or to any agent, attorney, consumer reporting agency or independent administration, including medical record retrieval services or pharmaceutical services, acting on THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU), or its reinsurers behalf, information concerning advice, care, or treatment sought by or provided to me and/or any other applicant for coverage, including information relating to medical history, medical conditions, treatment, hospitalizations or confinements, ailments, pharmacy prescription drugs, and/or drug, alcohol or tobacco usage of the applicant(s) THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU). It is understood that THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU) underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation, or in response to litigation, summons, or subpoenas. I understand that after this information is disclosed, the recipient may re-disclose it resulting in loss of protection by federal regulations. I understand that: such information will be used by THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU) for underwriting and insurability determinations; I may refuse to sign this authorization and that my refusal to sign will affect my ability to obtain life insurance coverage; A picture copy or photocopy of this authorization shall be as valid as the original; and Any authorized representative of the proposed insured is entitled to receive a copy of this authorization upon request. This authorization is valid from the date signed for a duration of 24 months. I understand I may revoke the authorization at any time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Life Underwriting Department of THE GREEK CATHOLIC UNION OF THE U.S.A. (GCU), 5400 Tuscarawas Road, Beaver, PA I may inspect or copy any information used or disclosed under this authorization, if signed. Date Proposed Insured (Please print) Signature of Proposed Insured (or parent if Proposed Insured is under age 18) Birthdate Additional Proposed Insured (Please print) Signature of Additional Person Proposed for Insurance Birthdate Personal Representative designated by signature above is hereby authorized to execute this instrument based on: Power of attorney, guardian-in-fact, guardian, payee, representative, other (Circle one) HIPPA A