INSTRUCTIONS: FOR SIMPLIFIED ISSUE LIFE INSURANCE APPLICATION (ICC115045/5045)

Transcription

1 INSTRUCTIONS: FOR SIMPLIFIED ISSUE LIFE INSURANCE APPLICATION (ICC115045/5045) This application is for: Sage Lapse Universal Life Issue Ages with Face Amounts of $25,000 to $249,999, (except West Virginia, where the minimum face amount is $25,001) Sage 10/15/20 Term Issue Ages with Face Amounts of $50,000 to $399,999 (20 Year Term all Tobacco Maximum Issue Age is 55) Paper Applications - MRS Tele-Underwriting Interview Phone Number: PLEASE OBSERVE THE FOLLOWING TO ENSURE SUBMITTING AN APPLICATION IN GOOD ORDER: If the Proposed Insured is under the age 18, a parent or legal guardian must sign the application on the Proposed Insured Signature line in Section 11. Complete in black/blue ink only use of correction fluid/tape is not permitted. All corrections (cross-outs) must be initialed by the Owner. All sections of the application must be complete and legible (print information). Incomplete/illegible applications will delay the New Business process. Submit all pages of the Accelerated Benefit Insurance Rider Disclosure Statement using the appropriate state version. Check or Money Order must be made payable to Sagicor Life Insurance Company and are the only acceptable forms of payment, except for electronic fund transfers (EFT). IMPORTANT REMINDERS: SECTION 2 Have the applicant read the questions in Section 2 carefully and answer them as accurately as possible. If an applicant s answer to any question in this Section is, the applicant does not qualify for the coverage available through the Simplified Issue underwriting process. SECTION 3 Proposed Owner Information (if not Proposed Insured) A Proposed Owner is eligible to own the Policy only if they are able to answer to at least one of the first three relationship questions. If the proposed owner is eligible, have the proposed owner respond to questions 4 and 5. SECTION 4 Payor Information (if not Proposed Insured or Owner) A person may be both the Payor and a beneficiary only if they are able to answer to one of the three relationship questions. SECTION 7 If any question is answered, please list the information in the space provided within the Section. SECTIONS 9 & 11 Review these sections with your client, prior to completing the signature box in Section 11. SECTION 12 Complete in its entirety, sign, and submit with application. DISCLOSURE NOTICE Review and leave with your client. Do not return it with the application. CONDITIONAL RECEIPT If money will be submitted with the application, complete this page and leave it with your client. Checks must be made payable to Sagicor Life Insurance Company. EFT AUTHORIZATION FORM This form must be completed, dated and signed by the individual/entity (Payor) who will be paying the premium. A void check is not required if the financial institution information is accurately completed on the form. The information must be for the account from where the premiums are to be withdrawn. When EFT is selected as the method of payment, the initial premium will also be drafted from the designated account. Debit card numbers are not always the checking account number and premiums cannot be drafted using a debit card number. For premiums to be drafted from a savings account, the Payor must contact their financial institution for the appropriate routing number. A deposit slip does not provide the information required to setup the EFT. The routing number and savings account number must be added to the EFT form. For all Life Policies, the draft date must be equal to the effective date of the policy. The Payor may change the draft date once the policy is in force. S

2 INDIVIDUAL LIFE INSURANCE SIMPLIFIED ISSUE APPLICATION SECTION 1 Proposed Insured Information Name: Sex: Male Female Former Address: Address City State Zip Code (If at current address less than 2 years) City State Zip Code Date of Birth: Social Security Number: Marital Status: State of Birth if born in the U.S.: Country of Birth if born outside of U.S.: Telephone : Home: Other: Address: Government Issued Picture ID: Type: State: Number: Is the Proposed Insured a U.S. Citizen, or does the Proposed Insured have permanent resident (green card) status? (If, please complete a Foreign Travel and Residence Questionnaire) Employer s Name: Occupation: Annual Earned Income: $ Secondary Addressee Name: Secondary Addressee Address City State Zip Code SECTION 2 Initial Medical and Personal History Questions (If any question in Section 2 is answered, Proposed Insured is not eligible for insurance through this application.) 1. Does the Proposed Insured currently receive health care at home, or require assistance with activities of daily living such as bathing, dressing, feeding, taking medications or use of toilet? Proposed Insured 2. Is the Proposed Insured currently in a Hospital, Psychiatric, Extended or Assisted Care, Nursing facility? 3. Is the Proposed Insured currently in a Prison or Correctional facility due to a misdemeanor or felony conviction? 4. Has the Proposed Insured 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? 5. Has the Proposed Insured ever tested positive for or been diagnosed by a member of the medical profession as having Alzheimer s or Dementia, Cirrhosis, Emphysema or Chronic Obstructive Pulmonary Disease (COPD)? 6. Has the Proposed Insured: a) In the past 12 months been advised by a physician to be hospitalized or to have Diagnostic Tests, Surgery, or any medical procedure that has not yet been completed or for which the results are not yet available, except those tests related to the Human Immunodeficiency Virus (AIDS)? b) In the past 24 months been treated for or diagnosed by a licensed member of the medical profession as having any Cancer (other than Basal Cell Carcinoma), had a Heart Attack, Stroke or TIA (Transient Ischemic Attack), Alcohol or Drug Abuse? c) In the past 24 months had a Driver s License revoked or suspended, or been convicted of 2 or more moving violations, or been convicted of a violation for driving while intoxicated or under the influence, or for driving while ability impaired because of the use of alcohol and/or drugs? 5045FL Page 1 of 10 BC N. Scottsdale Rd. #300, Scottsdale, AZ 85251/ T (888) / F (800) S

3 SECTION 3 Proposed Owner Information (Complete if Proposed Owner is different than Proposed Insured) Check box if the Proposed Owner is a company or trust. Name: Check box if the Proposed Owner s address is the same as the Proposed Insured. Social Security/Tax Identification Number: 5045FL Page 2 of 10 Date of Birth: Address City State Zip Code Telephone : Home: Other: Address: Government Issued Picture ID: Type: State: Number: Is the Proposed Owner a U.S. Citizen, or does the Proposed Owner have permanent resident (green card) status? (If, please complete a Foreign Travel and Residence Questionnaire) 1. Does the Proposed Owner have one of the following relationships with the Proposed Insured: Spouse, Child, Parent, Grandchild, Grandparent, Brother, or Sister? If, Relationship: 2. If to the above question, is the Proposed Insured a legal dependent, under Federal tax law, of the Proposed Owner or is the Proposed Owner the legal guardian of the Proposed Insured? 3. If to both of the above questions, does the Proposed Owner have a lawful and material economic interest in having the life of the Proposed Insured continue? 4. Has the Proposed Owner received or been promised any incentive to participate in this transaction? 5. Does the Proposed Owner have any intention, within the next 2 years, to transfer ownership of any of the policy issued as a result of this application to a third party who, as an owner, would not be able to answer to either question 1,2 or 3 above? NOTICE: State insurance law may prohibit the owner of a life insurance policy from entering into an agreement to sell, transfer, or assign a life insurance policy prior to the date the policy was issued, or within a period of time specified by state law after the date the policy was issued. You should consult with legal advisors if you have any questions about these matters. SECTION 4 Proposed Payor Information (Complete if Proposed Payor is different than Proposed Insured or Proposed Owner) Check box if the Proposed Payor is a company or trust. Name: Check box if the Proposed Payor s address is the same as the Proposed Insured. Social Security/Tax Identification Number: Date of Birth: Address City State Zip Code Telephone : Home: Other: Address: Government Issued Picture ID: Type: State: Number: Is the Proposed Payor a U.S. Citizen, or does the Proposed Payor have permanent resident (green card) status? (If, please complete a Foreign Travel and Residence Questionnaire) Will the Proposed Payor be a beneficiary on the policy? (if, please answer the 3 questions below) 1. Does the Proposed Payor have one of the following relationships with the Proposed Insured: Spouse, Child, Parent, Grandchild, Grandparent, Brother, or Sister? If, Relationship: 2. If to the above question, is the Proposed Insured a legal dependent, under Federal tax law, of the Proposed Payor or is the Proposed Payor the legal guardian of the Proposed Insured? 3. If to the above questions, does the Proposed Payor have a lawful and material economic interest in having the life of the Proposed Insured continue?

4 SECTION 5 Beneficiary Information (If there are Additional Beneficiaries, attach information on a separate sheet of paper.) Check box if the Beneficiary is a company or trust. Percentage: Primary Beneficiary Contingent Beneficiary Beneficiary Name: Relationship: Check box if the Beneficiary s address is the same as the Proposed Insured. Address City State ZIP Code Social Security/Tax Identification Number: Date of Birth: Check box if the Beneficiary is a company or trust. Percentage: Primary Beneficiary Contingent Beneficiary Beneficiary Name: Relationship: Check box if the Beneficiary s address is the same as the Proposed Insured. Address City State ZIP Code Social Security/Tax Identification Number: Date of Birth: Check box if the Beneficiary is a company or trust. Percentage: Primary Beneficiary Contingent Beneficiary Beneficiary Name: Relationship: Check box if the Beneficiary s address is the same as the Proposed Insured. Address City State ZIP Code Social Security/Tax Identification Number: Date of Birth: Check box if the Beneficiary is a company or trust. Percentage: Primary Beneficiary Contingent Beneficiary Beneficiary Name: Relationship: Check box if the Beneficiary s address is the same as the Proposed Insured. Address City State ZIP Code Social Security/Tax Identification Number: Date of Birth: Check box if the Beneficiary is a company or trust. Percentage: Primary Beneficiary Contingent Beneficiary Beneficiary Name: Relationship: Check box if the Beneficiary s address is the same as the Proposed Insured. Address City State ZIP Code Social Security/Tax Identification Number: Date of Birth: 5045FL Page 3 of 10

5 SECTION 6 Coverage Selection Plan: Face Amount Applied For: $ Tobacco Rates Accidental Death Benefit $ Waiver of Monthly Deductions (Universal Life) Universal Life Elections (select one for each) Guideline Premium Test OR Cash Value Accumulation Test Death Benefit Option A OR B n-tobacco Rates Waiver of Premium Automatic Premium Loan Option (select one) (Whole Life Only) Will the premiums for this policy be from a loan, or otherwise financed by an individual(s) or entity other than the Proposed Insured? (If YES, identify all parties involved and provide copies of all financing agreements or promissory notes and related side agreements and schedules.) Premium Class Quoted: (Policy will be issued in the premium class quoted unless advised otherwise.) Premium Collected with Application: $ Transfer/1035 Exchange: Amount: $ Planned Modal Premium: $ Draft Initial Premium: Mode: Annual Semi-Annual Quarterly Monthly EFT (Complete an Electronic Funds Transfer (EFT) Authorization) SECTION 7 In Force/Replacement Information 1. Does the Proposed Insured have any other life insurance or annuity in force? (If YES, a replacement form may have to be completed. Please visit and check your state s requirements.) 2. Will any life insurance or annuity of this or any other company be replaced or changed as a result of this application? (If YES, please complete a Replacement Form.) 3. Does the Proposed Insured have any application (including reinstatement) for life insurance now pending? (If YES, please list information below.) 4. Has the Proposed Insured applied for any life insurance in the last ninety (90) days? (If YES, please list information below.) Company Policy # Amount Issue Date Plan Type Applied For (A), Existing (E), or Replacing (R) 5045FL Page 4 of 10

6 SECTION 8 A Additional Medical and Personal History Questions (Please respond to the best of your knowledge and belief. Record details to answers in Section 8B below) Proposed Insured 1. In the past 24 months have you used any form of tobacco or nicotine products including cigarettes, cigars, pipes, chewing tobacco, snuff, nicotine patches or gums? 2. Your Current Height (feet & inches) Weight (pounds) a) Have you lost more than 20 pounds in the past 12 months (other than diet or following pregnancy)? 3. Are you currently disabled and/or receiving disability benefits? 4. In the past 10 years, have you consulted or been given medical advice by a member of the medical profession for: a) Cancer (other than Basal Cell or Squamous Cell skin cancer), Malignant Tumor, Lymphoma or Leukemia? b) Heart Disease including Coronary Artery Disease, Heart Attack, Heart Failure and Irregular Heartbeat, or Vascular Disease involving the Arteries? c) Stroke, Transient Ischemic Attack (TIA)? 5. In the past 5 years, have you consulted or been given medical advice by a member of the medical profession for: a) Parkinson s Disease, Cerebral Palsy, Seizures, Paralysis, Multiple Sclerosis, or any Loss of Memory or Mental Capacity? b) Kidney Disease? c) Any Lung or Breathing Disorder including Asthma, Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, and Sleep Apnea? d) Depression, Bipolar Disorder, Anxiety or any other Psychiatric Disorder? e) Rheumatoid Arthritis (not Osteoarthritis), Systemic Lupus (SLE), Progressive Systemic Sclerosis (PSS or Scleroderma), or Polymyositis? f) Hepatitis or other Liver Disorder, Crohn s Disease, Ulcerative Colitis, or a Disorder of the Pancreas? g) High Blood Pressure (Hypertension)? h) Diabetes, Immune System Disorder (other than related to HIV infection) or Blood Disorder? 6. In the past 5 years, have you used illegal drugs, consulted a member of the medical profession or been treated, hospitalized, or taken medication for abuse of alcohol or drugs (including prescription drugs)? 7. In the past 5 years, have you been convicted of a felony? SECTION 8 B Details To All Answers Above: 5045FL Page 5 of 10

7 SECTION 8 C Family History and Aviation/Avocation Questions (Please respond to the best of your knowledge and belief.) 8. Family Member Living Cause of Death Age of Death Mother Father Sister(s) Brother(s) 9. In the past 24 months have you participated in Parachuting, Ballooning, Hang Gliding, Motorized Racing, Rock Climbing, Mountaineering, Rodeo, or Scuba Diving? 10. In the past 24 months have you flown, or in the next 24 months do you intend to fly as a pilot, student pilot, or crew member on any aircraft, (other than scheduled commercial flights)? SECTION 9 Fraud Warning Any person who knowingly and with the 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 of the third degree. SECTION 10 Additional Information/Special Request or Instructions 5045FL Page 6 of 10

8 SECTION 11 Authorization and Acknowledgement I understand that I am applying for life insurance coverage issued by Sagicor Life Insurance Company ( Sagicor ). I understand and consent that this application, and information obtained pursuant to this authorization may be used by Sagicor to evaluate my eligibility for life insurance. I authorize the release to Sagicor of all information requested about me. This information may be released to Sagicor s authorized representatives. Authorized representatives include any consumer reporting agency acting on their behalf. Each of the following may be a source of information: the Medical Information Bureau, Inc. ( MIB ); my employer; physician, medical practitioner, hospital, clinic, or medically related facility; insurance or reinsuring company; consumer reporting agency; any other organization or insurance support organization; and a Pharmacy Benefit Manager. Information means facts about me. Those facts include, but are not limited to; information about mental or physical health; other insurance coverage; use of drugs or alcohol; motor vehicle records; avocations; employment; prescription drug records; hazardous activities; character; general reputation; mode of living; finances; vocation; and other personal traits. I understand and agree that Sagicor may disclose all or some of my information to its insurance administrators, its reinsurance companies, the producer who solicited my application and his or her principals, the MIB, and other persons or organizations performing business or legal services in connection with my application. I authorize Sagicor Life Insurance Company, or its reinsurers, to make a brief report of my personal health information to MIB. This authorization shall be valid for 24 months. I understand that I or my authorized representative may receive a copy of the authorization upon request. I agree that a photographic copy of this authorization shall be as valid as the original. I understand that I may revoke this authorization at any time by sending written notice to Sagicor s home office. I understand that any information that is disclosed pursuant to this authorization may be re-disclosed and no longer covered by federal rules governing privacy and confidentiality of health information. I understand that my right to revoke this authorization is limited to the extent that Sagicor has not already taken action in reliance on the authorization. To the best of my knowledge and belief, the statements and answers given on this application are true, complete, and correctly recorded. I understand that a policy does not go into effect and no liability exists for Sagicor until the policy is delivered and accepted by the Owner, the first full premium is paid, there has been no change in the health of the Proposed Insured that would change any of the answers in this application, and Sagicor has received an executed copy of this application. I understand and agree that no producer may accept risks or pass upon insurability, make or modify contracts, or waive any of Sagicor s rights or requirements. I have received a copy of the Disclosure tice to Proposed Insured, and when applicable, the Accelerated Benefit Insurance Rider Disclosure Statement. To help the government fight the funding for terrorism and money laundering activities, federal law requires all financial institutions obtain, verify, and record information that identifies each person who opens an account. What this means for you: prior to your signing of this life insurance application, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We will also ask to see your driver s license or other government issued photo identification. If you wish to have more detailed explanation of our information practices, please write to: Sagicor Life Insurance Company; Attention: Client Service Department; PO Box 52121; Phoenix, AZ Under the penalties of perjury, by my signature on this application, I certify that: (1) the Social Security number shown on this application is my correct taxpayer identification number and, (2) I am not subject to back-up withholding either because I have not been notified by the IRS that I am subject to back-up withholding as a result of a failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to back-up withholding. Signed: City State Date Signed: Proposed Insured Signature Proposed Owner s Signature (If a minor, signature of parent or guardian) (if other than Proposed Insured) Writing Producer s Signature Writing Producer s Name (Please Print) Writing Producer s Florida License Number 5045FL Page 7 of 10

9 SECTION 12 This section should be completed by the Producer. For questions about this application or requirements, contact our Underwriting Department. Producer Name (Please Print) Producer ID Number % Split Each licensed Producer will share equally unless otherwise indicated. 1. Have you delivered the consumer protection notices to the Proposed Owner and Proposed Insured? 2. If premium was accepted, was the Conditional Receipt completed and delivered to the Proposed Owner? 3. Does the Proposed Insured: a) Have any other life insurance or annuity in force? b) Have any application (including reinstatement) for life insurance or annuity now pending? 4. Will any annuity or life insurance presently in force be replaced or changed by this policy that is being applied for? (If YES, and if required by state regulation, any Replacement Comparison, tice, or Statement must accompany this application.) 5. Is this a 1035 Exchange? (If YES, attach all required forms.) If YES, is the 1035 Exchange Internal or External? 6. Are there any other Sagicor Life Insurance Company applications associated with this application? 7. Has the Proposed Insured applied for any life insurance or annuity in the last ninety (90) days? 8. What is the purpose of this insurance purchase? 9. Do you know the: Proposed Insured? Proposed Owner? 10. Are you related to the Proposed Insured? Proposed Owner? If YES, how are you related? 11. Did you personally meet with the Proposed Owner and Proposed Insured, obtain their Social Security Number(s) and view for each a Government issued photo ID? (If YES, specify the type of ID & number. If NO, please explain why.) 12. Does the Proposed Insured understand and speak English? Proposed Owner? If NO, please explain: 13. Was any other person present to answer questions? If YES, who was present and why? 14. Do you know of anything not disclosed in this application that may affect the risk of this life insurance purchase? If YES, please explain: 15. Sagicor is responsible for ordering all medical requirements. If the requirements are ordered by the producer, please indicate the requirements ordered and the company. Paramed Company: Date Ordered: Blood Profile MD Exam Treadmill EKG EKG Paramedical Exam Producer s Certification I certify that unless indicated otherwise in response to questions 9 and 11, I saw and know the Proposed Owner and Proposed Insured to be the person(s) described in this application, and have reviewed the appropriate documentation, and have truly and accurately recorded the information supplied by the Proposed Owner and Proposed Insured, that I know of no condition affecting the insurability of the applicant not fully set forth in the application, and that I have made no declaration, representation, or waiver regarding coverage or the provisions or terms of the application or policy. I further certify that I am licensed in the state in which this application was completed and have delivered all required notices and disclosures and fully complied with all privacy and replacement regulations. I also assume full responsibility for the delivery of the policy and the submission of the first premium. Signed (Writing Producer): Date Signed: Phone Number: Fax Number: Address: 5045FL Page 8 of 10

10 Disclosure tice to Proposed Insured Leave with the Proposed Insured Investigative Consumer Report tice You are our most important source of information, but personal information may also be collected from other sources. Such information may, in certain circumstances, be disclosed to third parties without your authorization. An investigative consumer report may be prepared in which information is obtained from public records and through personal interviews with: your neighbors, friends, employers, business associates, financial sources, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living. You may request to be interviewed as part of the report. Upon written request to Sagicor, further information on the nature and scope of the report will be provided. Information Practices Personal information we obtain during the underwriting process is private and confidential. We will not disclose such information to other persons or organizations without your written authorization, except to the extent necessary to conduct our business, as permitted by law, or as required by law. You have the right to be told about and obtain access to certain items or personal information in our files. You also have the right to request correction of information you believe to be inaccurate. If you would like to receive a more detailed explanation of our information practices, please write to: Sagicor Life Insurance Company Attention: Client Service Department P.O. Box Phoenix, AZ Medical Information Bureau (MIB) tice Information regarding your insurability will be treated as confidential. Sagicor or its reinsurers may, however, make a brief report thereon to the Medical Information Bureau (MIB). The MIB is a non-profit membership organization of life insurance companies which operates an information exchange on behalf of its members. If you apply to another MIB member company for life insurance or health insurance coverage, or a claim for benefit is submitted to such a company, MIB, upon request, will supply such company with the information in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. If you question the accuracy of information in MIB s file, you may contact MIB and seek a correction in accordance with the Fair Credit Reporting Act. The address of MIB s information office is 50 Braintree Hill, Suite 400, Braintree, MA MIB s toll free number is or TTY Website Sagicor Life Insurance Company or its reinsurers may also release information in its file to other life insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted N. Scottsdale Rd. #300, Scottsdale, AZ / T (888) / F (800) FL Page 9 of 10

11 Conditional Receipt ( Receipt ) Detach and leave this page with the Proposed Owner if premium is submitted with the application. payment may be accepted with the application, if, within the past three (3) years, any Proposed Insured has been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession concerning heart disease, stroke, cancer, HIV or AIDS. Make all checks payable to: Sagicor Life Insurance Company. Do not make checks payable to the producer or leave the payee blank. Do not pay with cash. Received from as the Proposed Owner, the sum of $, for the insurance application dated, with as the Proposed Insured. The policy you applied for will not become effective unless and until a policy is delivered to you, and all other conditions of coverage are met. Conditional insurance under the terms of the policy applied for may become effective as of the date the Proposed Insured completes the application in its entirety (the Effective Date ). Such conditional insurance is subject to the conditions and limitations of this Receipt. Such conditional insurance will take effect as of the Effective Date, so long as all of the following requirements are met: 1. The Proposed Insured is found to have been insurable as of the Effective Date, exactly as applied for in accordance with Sagicor s underwriting rules and standards, without any modifications as to plan, amount, or premium rate; 2. As of the Effective Date, all of the Proposed Insured s statements and answers given in the application are true; 3. The payment accompanying the application is not less than the full initial premium for the mode of payment chosen in the application and is received at Sagicor s Home Office within the lifetime of the Proposed Insured; and 4. The following items have been signed and received at Sagicor s Home Office: the application and any required supplemental application, questionnaire(s), addendum, and/or amendment to the application. The aggregate amount of conditional coverage provided under this Receipt, if any, and any other conditional receipt(s) issued by Sagicor shall be limited to the lesser of the amount(s) applied for or $250,000 of life insurance. There is no conditional coverage for riders or any additional benefits, if any, for which you have applied. There will be no conditional insurance coverage and the Company s liability will be limited to returning any premium submitted to the Company with this Receipt if any of the following occurs: (a) the Proposed Insured does not complete the application in its entirety; (b) one or more of the Receipt s conditions have not been met exactly; (c) the Proposed Insured dies by suicide; or (d) the Company does not approve and accept the application for insurance within ninety (90) days of the date the Proposed Insured completes the application in its entirety, thus deeming the application rejected by the Company. Any conditional coverage provided by this Receipt will terminate on the earliest of: (a) ninety (90) days from the date the Proposed Insured completes the application in its entirety; (b) the date Sagicor either mails a notice to the Proposed Owner rejecting the application and/or mails a refund of any amount paid with the application; (c) the date the insurance applied for goes into effect under the terms of the policy applied for; or (d) the date Sagicor offers to provide insurance on terms that differ from the insurance for which you have applied. This Receipt is not valid unless all blanks are completed above and this Receipt is signed by the producer. This Receipt does not provide any conditional insurance until all of the conditions and requirements are met as outlined above. Dated at on City State Date Producer s Signature 4343 N. Scottsdale Rd. #300, Scottsdale, AZ / T (888) / F (800) FL Page 10 of 10

12 ACCELERATED BENEFIT INSURANCE RIDER DISCLOSURE STATEMENT You should consult with a personal tax advisor if You are considering electing an Accelerated Benefit payment. Benefits as specified in Your Policy will be reduced upon receipt of an Accelerated Benefit payment. Receipt of Accelerated Benefit payments may be taxable or may affect Your eligibility for benefits under state or federal law. This Rider is not intended to provide coverage primarily for confinement in a Nursing Home Facility or long term care benefits. DESCRIPTION OF BENEFITS An Accelerated Benefit is the advance of a portion of the Death Benefit Amount prior to the Covered Person's death due to a Terminal Condition. The amount of the Accelerated Benefit you may receive is the lesser of 50% of the Initial Term Policy Benefit Amount, or $300,000; less a one time administrative fee of the lesser of $100 or the maximum allowed by law in the state in which this rider was issued. RIDER PREMIUM AND CASH VALUE There is no premium, cash value or loan value associated with this Rider. ACCELERATED BENEFIT DUE TO A TERMINAL CONDITION We will pay to You the Accelerated Benefit Amount when We receive, In Writing, proof that the Covered Person has a Terminal Condition. Terminal Condition means an imminent death is expected in 12 months or less, as a result of a non-correctable medical condition that with reasonable medical certainty will result in a drastically limited life span of the Covered Person. This Accelerated Benefit will be paid in a lump sum. EFFECT ON YOUR POLICY Upon payment of the Accelerated Benefit, Your coverage will remain In Force; however, the total Benefit Amount and premium of the Policy will be reduced. The Benefit amount and premiums for the Policy will be reduced by the same percentage that was applied to the calculation of the Accelerated Benefit payment. A revised Policy Data Page showing the reduced Benefit Amount and premium will be provided. EXAMPLE An example of the effect of a Terminal Condition Accelerated Benefit on a policy is shown below: Death Benefit Amount before Terminal Condition Accelerated Benefit Pay Out: $[100,000.00] Total Annual Premium Amount before Terminal Condition Accelerated Benefit Pay Out: (Includes $ policy fee) $[ ] Accelerated Benefit Payment ($50,000.00) less $ activation fee: $[ 49,750.00] Death Benefit Amount after Terminal Condition Accelerated Benefit Pay Out: $[ 50,000.00] Total Annual Premium Amount after Terminal Condition Accelerated Benefit Pay Out: (Includes $ policy fee) $ [ ] 6015FL 1 White Copy Home Office Yellow Copy Proposed Owner S410307

13 I ACKNOWLEDGE RECEIPT OF THIS DISCLOSURE Signature of Agent Date Signature of Owner Date Print Name of Agent Agent Number Print Name of Owner 6015FL 2 White Copy Home Office Yellow Copy Proposed Owner

14 NOTICE TO APPLICANT REGARDING REPLACEMENT OF LIFE INSURANCE A decision to buy a new policy and discontinue or change an existing policy may be a wise choice or a mistake. Get all the facts. Make sure you fully understand both the proposed policy and your existing policy or policies. New policies may contain clauses which limit or exclude coverage of certain events in the initial period of the contract, such as the suicide and incontestable clauses which may have already been satisfied in your existing policy or policies. Your best source for facts on the proposed policy is the proposed company and its agent. The best source on your existing policy is the existing company and its agent. Hear from both before you make your decision. interest. This way you can be sure your decision is in your best If you indicate that you intend to replace or change an existing policy, Florida regulations require notification of the company that issued the policy. Florida regulations give you the right to receive a written Comparative Information Form which summarizes your policy values. Indicate whether or not you wish to receive a Comparative Information Form from the proposed company and your existing insurer or insurers by placing your initials in the appropriate box below. YES NO DO NOT TAKE ACTION TO TERMINATE YOUR EXISTING POLICY UNTIL YOUR NEW POLICY HAS BEEN ISSUED AND YOU HAVE EXAMINED IT AND FOUND IT ACCEPTABLE. I have read this notice and received a copy of it. APPLICANT'S SIGNATURE AGENT'S SIGNATURE AGENT' 'S NAME (PRINTED OR TYPED) AGENT' 'S ADDRESS ( PRINTED OR TYPED) AGENT'S COMPANY (PRINTED OR TYPED) DATE DATE Information on Policies which may be replaced: Company Name Policy Number Name of Insured BC S N. Scottsdale Rd., Ste 300 / Scottsdale, AZ / T (888) / F (800) REP (FL) Original Replacing Insurer Yellow Copy Existing Insurer Pink Copy Applicant

15 PO Box Phoenix, Arizona Ph: (888) / Fax: (480) ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION OWNER AND PAYOR INFORMATION Complete Name of Owner (First, Middle, Last) Complete Name of Payor (If different from Owner) Policy Number TYPE OF REQUEST New Business Application (Please include a voided check OR complete the Payor s Financial Institution section below) Initial Request for EFT Add to existing EFT under policy number: Existing Policy Changes (Please include a voided check AND complete the Payor s Financial Institution Section below) Change of bank and/or account number (Allow 15 days for change processing) Change from direct billing to EFT Add to existing EFT under policy number: Please allow a supplementary draft(s) of my account, other than the scheduled draft, to bring my policy(ies) current. WITHDRAWAL DATE AND MODE Initial EFT and any additional EFTs necessary to bring the policy current will be withdrawn based on the Policy Effective Date. Requested withdrawal day of the month for subsequent withdrawals (1 st 28 th only): Requested Mode: Monthly Quarterly Semi-Annually Annually Insured Name(s) POLICY(IES) TO BE INCLUDED IN EFT Policy Number(s) AUTHORIZATION AND ACCEPTANCE I hereby request and authorize Sagicor Life Insurance Company ( Sagicor ) to make electronic funds transfers from my financial institution as indicated below. This authorization will remain in effect until revoked by me or by Sagicor upon thirty (30) days written notice. I understand that if a fund transfer is not honored by the financial institution, Sagicor will consider the premium unpaid. Any fund transfer returned due to insufficient funds may be re-drafted by Sagicor at its sole discretion. I further agree that if any such fund transfer is not honored, whether with or without cause, Sagicor shall be under no liability whatsoever, even though such dishonor results in the lapse of insurance. Sagicor reserves the right to revoke this authorization without notice in the event of two (2) consecutive returned fund transfers or a cumulative total of three (3) returned funds transfers in a twelve (12) month period. If this authorization is revoked by Sagicor, it is not eligible to be reinstated for a twelve (12) month period. You must contact Sagicor and request that this authorization be reinstated. Payor/Financial Institution Account Owner Signature Date Financial Institution Name PAYOR S FINANCIAL INSTITUTION INFORMATION Financial Institution Account Number: Street Address of Financial Institution Transit/ABA Number: City State ZIP Financial Institution Telephone Number: ACCOUNT TYPE Checking (Please include a voided check and/or complete the Payor s Financial Institution Information section) Saving (Please include a letter from your bank with your routing & account numbers a deposit slip is not acceptable) NOTE: Debit and Credit Card account numbers are not acceptable BC EFT SL550713A