Group Life Insurance Amounts. Basic $ Voluntary $ Group Life Insurance Amounts. Spouse Effective Date: Child(ren) Effective Date:

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1 DIRECTIONS: CONVERSION KIT GROUP LIFE INSURANCE (MONTANA) 1. Complete a separate Conversion Kit for each applicant. 2. Complete all sections below and the attached conversion application. 3. Mail the completed form below, the completed application, the signed Important Information About Your Life Insurance Conversion, initial premium and bank draft form to the above address within 31 days of the date your group insurance terminates. Checks or Money Orders should be made payable to Texas Life Insurance Company. In accordance with and subject to all the terms and conditions of the conversion privilege contained therein, I make application to Texas Life Insurance Company to convert my insurance under said Group Policy to an individual plan issued by Texas Life Insurance Company, such policy to be used in accordance with the following requests and statements of fact: Name of Employer: TO BE COMPLETED BY EMPLOYEE Group Policy Number: Name of Employee (Last, First, Middle): Employee s Social Security Number: Present Occupation: Date and Reason for Termination: Employee: Basic $ Voluntary $ Name of Employer: Group Life Insurance Amounts Spouse: Basic $ Voluntary $ TO BE COMPLETED BY EMPLOYER Child(ren): Basic $ Voluntary $ Group Policy Number: Employee Ineligible for Coverage: Date: Employee Effective Date: Group Policy Terminated: Date: Group Life Insurance Amounts Spouse Effective Date: Child(ren) Effective Date: Basic $ Voluntary $ Employee Date: Basic $ Voluntary $ Date Coverage Terminated Spouse Date: Basic $ Voluntary $ Child(ren) Date: Name of Person Authorized to Certify for Group Policyholder (please print) Telephone Number Signature of Person Authorized to Certify for Group Policyholder Date Signed *For rates under age 17 and over age 70, please contact Texas Life Insurance Company at (800) , ext. 6819

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3 Important Notice Regarding Your Accelerated Death Benefits Important Notice The Insurance proceeds, cash values and loan values will all be reduced to zero and will no longer be payable and Texas Life s obligation under the contract will terminate if Texas Life pays you the Accelerated Death Benefit under this Rider. Important Tax Notice The Accelerated Death Benefit under this rider is intended to qualify for favorable tax income treatment under the Internal Revenue Code of 1986 (as amended by Public Law in Washington state). If the Accelerated Death Benefit qualifies for such favorable tax treatment, the benefit will be excludable from your income and not subject to federal income taxation. Tax laws relating to acceleration of life insurance benefits are complex. You should consult a qualified tax or legal advisor to determine the effect on you. Neither Texas Life nor its agents are authorized to give tax or legal advice. Public Assistance Notice Receipt of the Accelerated Death Benefit may affect your, your spouse s or your family s eligibility for medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), supplementary social security income (SSI), and drug assistance programs. You should consult a qualified tax or legal advisor and social services agencies concerning how receipt of such payment will affect you, your spouse s, and your family s eligibility for public assistance. Rider Mechanics The policy includes an Accelerated Death Benefit Due to Terminal Illness Rider, Form ICC11-ULABR-11 in states which are members of the Interstate Insurance Compact (ICC*) and Form ULABR-11 in non-icc states. If the insured becomes terminally ill you may elect to claim an accelerated death benefit while the insured is still alive in lieu of the insurance proceeds otherwise payable at death. The single sum benefit is 92.6% (92% in AR, AZ, CA, CT, FL, DE, MT, ND, OR, and SD) of the insurance proceeds less an administrative fee of $150 ($100 in Florida and $150 premium in Montana). This is not a long term care benefit. Terminal illness is an injury or sickness diagnosed and certified by a qualifying physician that, despite appropriate medical care, is reasonably expected to result in death within 12 months (See your rider for additional detail regarding the certification of terminal illness). A 90 day exclusion period applies in AZ, AR, CA, DE, DC, FL, MT, ND, and SD (30 days in CT) unless the terminal illness results from accidental bodily injury. Other conditions and limitations apply. The right to accelerate benefits under this rider does not extend to any Family Term Life Insurance Rider. However, if the Accelerated Benefit is paid, The Family Term Life Insurance Rider results in coverage becoming paid-up as if the Insured had died. Payment of the Accelerated Death Benefit terminates the policy and all other optional benefit/riders without further value. In AZ, AR, CA, CT, DE, DC, FL, MT, ND, OR and SD, this rider cannot be reinstated after a policy lapses. So, pay your premiums faithfully.

4 Instructions for Completing Application 1. On the Individual Life Insurance Application, complete all highlighted areas. (complete only the highlighted areas) 2. Print your Last Name, First Name, Middle Initial, Sex (M/F), Social Security Number, Birth Date, and your age as of the 1 st of the month following the completion of this application. If completing this application for a minor child (under the age of 18), please provide their information instead of your own. 3. Answer the tobacco question Yes if you have used any form of tobacco within the last 12 months and No if you have not. 4. Print your mailing address, daytime phone number, evening phone number and address in the boxes provided. This will only be used in the processing of this application and the ongoing administration of this plan. 5. Print the full name and relationship of your beneficiary in the boxes provided. 6. Use the attached rate sheet to select your face amount and the monthly premium. Locate your age as of the 1 st of the month following the completion of this application and follow across to the appropriate face amount and the applicable tobacco usage column. This will be your monthly bank draft premium. If your requested face amount is not listed on the rate sheet, see attached instructions on calculating your premium. 7. Record the face amount (not to exceed the lesser of your Group Life insurance amount or $150,000), premium and total premium in the boxes provided. 8. If you would like to include the Automatic Contract Loan provision, check the appropriate box. You may choose to include an Automatic Contract Loan provision which pays any unpaid premiums for a policy that has sufficient cash value when the premium is overdue 30 days or more. 9. Turn to the back of the application; review the appropriate disclosure notices and then sign the application as the Proposed Insured. For applicants under the age of 18, the application must be signed by the legal guardian, making them the owner of the policy. Date the signature with the current date, and then add the City and State where the application was signed. 10. Attach a check or money order made payable to Texas Life Insurance Company to the application for the 1 st month s premium. Your initial premium will be the bank draft premium amount. See step 9 for all subsequent premiums. Your application is incomplete without the 1 st premium attached. 11. Read and sign the Important Information About Your Life Insurance Conversion form that follows the application. Your application is incomplete without this form being signed. 12. Please complete the attached bank draft form, attach a voided check or deposit slip and mail with your completed application. If you choose not to complete the bank draft form, you will receive a monthly bill which will include a $2.00 monthly billing fee. 13. Use the attached postage paid envelope to mail the completed cover sheet, completed application, signed Important Information About Your Life Insurance Conversion, initial premium and bank draft form to the address below within 31 days of the date your group insurance terminates: Texas Life Insurance Company Conversion Application New Business P. O. Box 830 Waco, TX For assistance with your conversion application, please call , ext and ask for LifeMap Conversion Expert assistance.

5 INDIVIDUAL LIFE INSURANCE APPLICATION FOR HOME OFFICE USE ONLY 1 st Deduction Date: Employer: LifeMap Conversion Policy Number: Proposed Insured Personal Information Last Name First Name SSN Birth Date Age (1) MI Sex Hire Date Tier 1 Within the last 12 months have you used tobacco in any form? Yes Are you at work on a full-time basis, performing your usual duties?... Yes No No Street/PO Box City State Zip Phone: Day Evening Beneficiary Name : Relationship: Will proposed coverage replace or change any existing insurance or annuity policy? Yes No (if Yes identify and complete replacement form.) Company Policy Number Do you have existing insurance or annuities (including coverage with Texas Life)? Yes No If Yes complete the Existing Insurance Form even if replacement is not contemplated. Face Amount (2) Premium Rider Premium Total Premium Coverage Information Plan of Insurance: SOLUTIONS Series 121 Select Riders to be Added: Family Term Rider Accidental Death (3) Waiver Premium (3) Payroll is per: Weekly Bi-Weekly Semi-Monthly Monthly Skip I elect the Automatic Contract Loan provision to pay a premium overdue 30 days or more, if my policy has sufficient cash value. Tier 2 Questions (If answered Yes no coverage is offered, except as available under Tier 1 questions) During the last 24 months have you been treated for, been prescribed medication for, or been diagnosed by a member of the medical profession as having, any of the following: Yes No a. Cancer (excluding non-melanoma skin cancer? b. Heart attack, coronary artery or valve disease, heart failure or cardiomyopathy? c. Alcohol or drug abuse? d. Diabetes for which the recommended treatment is insulin? e. Chronic obstructive pulmonary disease (COPD), emphysema or other chronic lung disease (excluding asthma)? f. Stroke or transient ischemic attack (TIA)? g. Chronic kidney disease or kidney failure (excluding kidney stones)? h. Parkinson s disease or paralysis? i. Cirrhosis of the liver or hepatitis (excluding Hepatitis A)? j. Acquired Immune Deficiency Syndrome or tested positive for the Human Immunodeficiency Virus (HIV) or its antibodies? (1) Age on Issue Date (2) or Face Amount purchased by premium shown, if less (3) Proposed insured (employee) issue ages Form: 11M009 R 12-11

6 Additional Statements For residents of AL, DC, IN, and OR: I received a summary description of the accelerated death benefit and Important Notice regarding Accelerated Death Benefit. For residents of Arkansas: Any person who knowingly and with intent to defraud any insurance company or other person files an application 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. For residents of Washington, DC: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment, and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. REPRESENTATIONS: I believe to the best of my knowledge and belief that all statements and answers in this application are complete, true and correctly recorded, and are made as a consideration for the insurance applied for. I understand that Texas Life Insurance Company will rely on my statements and answers as being true and complete in deciding whether to issue insurance on the proposed insured. Insurance is effective under the policy only when it is delivered to the owner and the full first premium is paid in cash. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Proposed Insured (Owner) Signature X Date City State Agent Only: To the best of my knowledge the insurance applied for is is not to replace existing insurance or annuity. I have delivered to the Proposed Insured the applicable forms and information described in Additional Statements above. Enroller Print Signature X Regence Coordinated Services Inc Enroller Name Agent # _LM18721 Interim Insurance Interim insurance will be in force on the application date if these conditions are met: (1) the insurance is purchased through payroll deduction or through your membership in a union or association; (2) you sign a Salary Deduction Authorization or Bank Draft Authorization Form (union and association members only); and, (3) you are insurable at standard rates under Our rules and usual practice. Interim insurance remains in effect until the earlier of: (a) the Policy Date; (b) the date We decline the application; (c) the date We notify you that you are ineligible for interim insurance; or, (d) the 180 th day after the application date. In Kansas, clauses (3) and (d) do not apply, and clauses (b) and (c) apply only when We refund all premiums. Form: 11M009 R 12-11

7 Important Information About Your Life Insurance Conversion You have decided to convert the life insurance coverage you had under the LifeMap Assurance Company (LifeMap) Group Life Insurance Policy (Group Policy) that you acquired through your former employer, to an individual life insurance policy (individual policy), to be issued by Texas Life Insurance Company (Texas Life), a Texas domestic insurance company which is authorized to do business in all states other than New York. Texas Life has a financial strength rating of A (Excellent) from AM Best Company. A Best s Financial Strength Rating is an independent opinion of an insurer s financial strength and ability to meet its ongoing insurance policy and contract obligations. It is based on a quantitative and qualitative evaluation of a company s balance sheet strength, operating performance and business profile. As part of the conversion process, Texas Life wants to make you aware of the following important items. 1. Coverage under the Group Policy extends for 31 days past the date you ceased to be eligible for such coverage. Should the insured die within that time period, life insurance coverage will still be provided by the Group Policy and not by Texas Life. If the insured dies during the conversion process only one death benefit will be paid; either through the Group Policy or by the Texas Life policy 2. The Interim Insurance provision set out on the back of the Texas Life application form does not apply to your Texas Life policy because its terms do not apply to a conversion. Instead, the following Interim Insurance provision will apply. Interim Insurance Interim Insurance will be in force on this application to convert the applicant s group policy voluntary coverage beginning on the first day after the applicant no longer has coverage under the Group Policy if these conditions are met: (1) the applicant submits an application to Texas Life for such conversion in accordance with the attached instructions; and (2) the first month s premium for the policy as shown on the enclosed monthly premium chart is paid. Interim Insurance will remain in effect until the Policy Date so long as all premiums therefore are paid. 3. Your Group Policy provides that any time period the insured was covered by the Group Policy will apply to any contestability or suicide exclusion provisions contained in the converted policy. Even though the Individual Policy that will be issued to you by Texas Life contains specific contestability period and suicide exclusion provisions, the time period that you were covered under the Group Policy will be considered in determining the incontestability or suicide exclusion time period under the Individual Policy issued to you by Texas Life. 4. The Individual Policy is issued by Texas Life rather than LifeMap. Your rights and remedies will be against Texas Life rather than LifeMap. Texas Life makes no representation or warranties as to any differences as may arise by virtue of the foregoing. I hereby acknowledge receipt of this information. Signature Printed Name Date

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9 Face Amount Age Monthly Premiums Monthly Premiums $10,000 $15,000 $25,000 $30,000 PAID UP At Attained Age Use the rate sheet to select your face amount and the monthly premium. Locate your age as of the 1 st of the month following the completion of this application and follow across to the appropriate face amount and the applicable tobacco usage column. This will be your monthly bank draft premium and the amount of your initial premium sent with your application. If your requested face amount is not listed on the rate sheet, see attached instructions on calculating your premium

10 Face Amount Age Monthly Premiums $50,000 $75,000 $100,000 $150,000 PAID UP At Attained Age , , , , , , , , Use the rate sheet to select your face amount and the monthly premium. Locate your age as of the 1 st of the month following the completion of this application and follow across to the appropriate face amount and the applicable tobacco usage column. This will be your monthly bank draft premium and the amount of your initial premium sent with your application. If your requested face amount is not listed on the rate sheet, see attached instructions on calculating your premium.

11 Age Monthly Premium per 1,000 for - users Monthly Premium per 1,000 for users Calculating Monthly Premium Instruction for Calculating Premium 17 $0.54 $ Record Face Amount Requested (not less than 18 $0.57 $0.70 $5,000, not greater than $150,000) 19 $0.57 $0.71 Ex. $10,000 $ 20 $0.59 $ $0.60 $ Determine what your age will be on the first of the 22 $0.62 $0.78 month following the completion of the application. 23 $0. $0.81 Ex $0.66 $ $0.68 $ Find your age on the table to the left, follow 26 $0.72 $0.90 across to the appropriate non-tobacco or tobacco 27 $0.75 $0.94 column (whichever applies to you) and record the 28 $0.79 $0.98 monthly premium per 1, $0.83 $1.03 Ex. $4.00 (non-tobacco) $ 30 $0.85 $ $0.91 $ Record the number of units you are purchasing (1 32 $0.97 $1.20 unit = 1,000) ex. $10,000 Face Amount = 10 units 33 $1.02 $1.27 Ex $1.05 $ $1.10 $ Multiply number of units times monthly premium 36 $1.17 $1.49 per 1, $1.25 $1.58 Ex. $40.00 $ 38 $1.32 $ $1.44 $1.80 Policy Fee $ $1.50 $ $1.60 $ Add $3.00 policy fee to your total in step 5 42 $1.69 $2.17 Ex. $43.00 $ 43 $1.79 $ $1.93 $ Total monthly premium for bank draft 45 $2.07 $2.69 equals the total in step 6 46 $2.16 $2.82 Ex. $43.00 $ 47 $2.26 $2.95 If you choose not to complete the bank draft form, there 48 $2.37 $3.09 will be a monthly billing fee added to your premium. $ $2.49 $ $2.58 $ Add $2.00 monthly billing fee if you wish to be 51 $2.69 $3.45 billed monthly direct 52 $2.81 $3.60 Ex. $45.00 $ 53 $2.94 $ $3.08 $ $3.14 $ $3.26 $ $3.45 $ $3.62 $ $3.76 $ $4.00 $ $4.23 $ $4.45 $ $4.66 $ $4.95 $6.48 $5.21 $ $5.56 $ $5.91 $ $6.32 $ $6.76 $ $7.24 $ Total monthly premium for monthly direct bill equals the total in step 8 Ex. $45.00 $ The initial premium sent in with your application will be the bank draft premium in step #7. To obtain premium rates for ages under 17 and over 70, contact Texas Life Insurance Company

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13 Automatic Bank Draft Form A convenient payment option for you. Three easy steps: 1. Read and complete each item on the Automatic Bank Draft Form. 2. Include either a voided check or deposit slip as required. 3. Mail with your completed application to Texas Life Insurance Company, P.O. Box 830, Waco, TX Please enter all Texas Life policy numbers you want drafted with this authorization: Texas Life will begin drafting your account for the current or any outstanding premiums due immediately. Future drafts will be drawn on the policy date each month, which is typically the 1 st of the month. Please check the appropriate box: [ ] Checking Account Include a check with Void written on it. [ ] Savings Account Include a deposit slip with Void written on it. Work Number ( ) Home Number ( ) Mobile Number ( ) Drafts are submitted to the bank and should clear your account within 2-3 days. If your draft date falls on a weekend or holiday, it will leave our office on the next business day. As a convenience to me, I hereby request and authorize you to pay and charge to my account drafts drawn on my account by and payable to the Texas Life Insurance Company, Waco, Texas provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that your rights in respect to each such draft shall be the same as if it were a draft drawn on you and signed personally by me. The payment of premium under this plan may be discontinued by the Company or the undersigned. You shall be under no obligation to determine the correctness of the amount of any draft drawn under this authority. I further agree that if any such draft be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in forfeiture of insurance. Signature of Bank Account Holder Date