Buying A New Life Insurance Policy?

Transcription

1 New Business Applications and Supporting Documents FOR USE IN: Alabama Arkansas Louisiana Mississippi Ohio Virginia Point of Sale Support: Enhanced POS Interviews Mon. - Fri. 8:00am-10:00pm E.T , Opt. 2 Sat. 9:00am-2:00pm E.T. After 8:00 P.M. M-F and on Sat calls will be answered by MRS New Business Partner Support: , Option 3 Medical Follow-Up Calls , Opt. 4 New Applications Fax: S-APPKIT-A

2 Packet Contents: Fax Cover Sheet Gold, Silver, Bronze Application (Form # ICC14 S-2300) Notice & Receipt (Form # S-4622) Disclosure Statement for Accelerated Benefit Rider (Form # S-4620) Replacement Notice S-700A-MODEL Replacement Notice S-700B-MODEL Product Summary (Form # S-4600 PS (Rev )) Silver II Application (Form # ICC14 S-2300S2) Instructions for use: Complete appropriate application form (Gold/Silver/Bronze or Silver II). Review and sign Accelerated Benefit Rider (Form # S-4620). Complete form S-700A-MODEL if: 1. Replacing an existing policy. Entire form must be completed & signed. OR 2. If applicant has existing insurance and the new Settlers Life policy will not replace the existing policy. Complete questions 1 & 2 and signature section. One copy is submitted with application; duplicate copy is left with the applicant. Complete form S-700B-MODEL only if Settlers Life policy will replace an existing policy. Notice of Insurance Information Practices/Premium Receipt and Product Summary should ALWAYS be left with the applicant. Call , Opt. 2 to conduct the EPOS interview. Applicant should review form S-4622 prior to the EPOS call. Submit required forms to Settlers Life.

3 FAX COVER SHEET FOR SUBMITTAL OF SETTLERS LIFE APPLICATIONS To: Underwriting Support Team From: Fax: Pages: (Including Cover Sheet) Phone #: Agent #: Address: Date: Checklist 1. Applications 2. Forms 3. Voided Check PLEASE TAPE A VOIDED CHECK HERE IF THE CHECK IS LARGER THAN THIS SPACE, PLEASE ATTACH IT ON A SEPARATE PAGE. Form: U-112 (Rev )

4 A Member of the NGL Insurance Group A. Proposed Insured SETTLERS LIFE INSURANCE COMPANY Madison, Wisconsin Administrative Office: P.O. Box 8600 Bristol, Virginia Policy Number Individual Whole Life Insurance Application Faxed App: Use this application for the Bronze, Silver and Gold life insurance plans. Please complete sections per underwriting guide. First, MI, Last Name, Maiden, Suffix: Sex: Male Female DOB: Backdate to Save Age: Yes No Birth State: Birth Country: SSN: Address: Residential Address: Mailing Address: Phone Number (Day) Phone Number (Evening): Best time to Call: US Driver s License #or Other I.D. State Issued: Expiration Date: Is an assignment of ownership being made to NGL Trust? No Yes (check one): FET EPT B. Policy Owner (if other than Proposed Insured) First, MI, Last Name, Suffix: Mailing Address: Phone Number : Address: Date of Birth: SSN or TIN: Relationship to Insured: C. Policy Co-Owner (if any) First, MI, Last Name, Suffix: Mailing Address: Phone Number : Address: Date of Birth: SSN or TIN: Relationship to Insured: D. Beneficiary (if other than NGL Trust) First, MI, Last Name, Suffix: Residential Address: Phone Number : Address: Date of Birth: SSN or TIN: Relationship to Insured: E. Contingent Beneficiary (if other than NGL Trust) First, MI, Last Name, Suffix: Residential Address: Phone Number : Address: Date of Birth: SSN or TIN: Relationship to Insured: ICC14 S-2300

5 F. Physician Information Primary Physician s Name and Phone Number: Physician s Address: G. Health Questions for Bronze, Silver, Gold Plans 1. Is the Proposed Insured currently hospitalized, bedridden due to disease, confined to a nursing facility, or receiving hospice or home health care? Has the Proposed Insured been diagnosed by a member of the medical profession with AIDS (Acquired Immune Deficiency Syndrome), ARC (AIDS Related Complex), or tested positive for HIV (Human Immunodeficiency Virus)? H. Health Questions for Silver, Gold Plans 1. Has the Proposed Insured used any form of tobacco in the past 12 months other than chewing tobacco or snuff? 2. Is the Proposed Insured currently required to receive personal assistance with activities of daily living such as bathing, dressing, eating, taking medications, toileting or moving about? Has the Proposed Insured ever had or been recommended by a member of the medical profession to have an Organ Transplant? In the past two years has the Proposed Insured been diagnosed by a member of the medical profession: i. with diabetes requiring insulin, been prescribed or used insulin for the treatment of diabetes, or been diagnosed with or treated for complications of diabetes, including Insulin Shock, Diabetic Coma, Retinopathy, Neuropathy, Amputation, or Kidney disorder? ii. as requiring or undergone surgery for Heart Disease (including heart bypass), Angioplasty, Stent Placement, Peripheral Vascular Disease, or Amputation due to disease?. iii. as requiring or been prescribed oxygen to assist with breathing?.. 5. In the past two years has the Proposed Insured been diagnosed by a member of the medical profession with, treated for or prescribed medication for: Angina, Coronary Artery Disease, Heart Attack, Congestive Heart Failure, Cardiomyopathy, Atrial Fibrillation, Chronic Asthma, Chronic Bronchitis, Black Lung, Cystic Fibrosis, Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Alzheimer s, Dementia, Progressive Memory Loss, Aneurysm, Multiple Sclerosis, Parkinson s Disease, Stroke, Systemic Lupus, Sickle Cell Anemia, Kidney Failure, Kidney Disease, Liver Disease, Hepatitis, or any form of cancer other than basal cell skin cancer?. 6. In the past two years has the Proposed Insured used illegal drugs or marijuana, or received or been advised by a member of the medical profession to receive counseling or treatment for excessive use of alcohol or prescription drugs? If the Proposed Insured is under the age of 25, has the Proposed Insured ever been diagnosed by a member of the medical profession with: Cerebral Palsy, Down Syndrome, Diabetes requiring insulin, Mental Retardation, Muscular Dystrophy or Spina Bifida?.. I. Health Questions for Gold Plan 1. Please state the Proposed Insured s: Height and Weight. 2. In the past five years has the Proposed Insured been diagnosed by a member of the medical profession as requiring or undergone surgery for Heart Disease (including heart bypass), Angioplasty, Stent Placement, Peripheral Vascular Disease, or Amputation due to disease? 3. In the past five years has the Proposed Insured been diagnosed by a member of the medical profession with, treated for or prescribed medication for: Angina, Coronary Artery Disease, Heart Attack, Congestive Heart Failure, Cardiomyopathy, Atrial Fibrillation, Chronic Asthma, Chronic Bronchitis, Black Lung, Cystic Fibrosis, Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Alzheimer s, Dementia, Diabetes, Progressive Memory Loss, Bipolar Disorder, Schizophrenia, TIA (mini-strokes), Rheumatoid Arthiritis, Aneurysm, Multiple Sclerosis, Parkinson s Disease, Stroke, Systemic Lupus, Sickle Cell Anemia, Kidney Failure, Kidney Disease, Liver Disease, Hepatitis, or any form of cancer other than basal cell skin cancer? 4. In the past five years has the Proposed Insured used illegal drugs or marijuana, or received or been advised by a member of the medical profession to receive counseling or treatment for excessive use of alcohol or prescription drugs? Has the Proposed Insured ever been diagnosed by a member of the medical profession with: Cerebral Palsy, Down Syndrome, Mental Retardation, Muscular Dystrophy or Spina Bifida?.. J. Applicant Replacement Questions (If Yes complete required replacement forms.) Does the Applicant have any existing life insurance policies or annuity contracts?.. Will the insurance applied for replace, discontinue, or change any insurance or annuity now or recently in force? ICC14 S-2300

6 K. Insurance Plans and Riders Applied For Bronze Plan (Modified Whole Life) Benefits reduced during first two years for death by natural causes Silver Plan (Immediate Benefit Whole Life) Gold Plan (Immediate Benefit Whole Life) Accidental Death Benefit Rider (As defined in the policy, full benefits may be paid for accidental death) ICC14 S-2300 Ages 40 yr 80 yr $1,000 - $15,000 Ages 6 mo 85 yr $1,000-$25,000 (6 mo-65 yr) $1,000-$20,000 (66 yr-75 yr) $1,000-$15,000 (76 yr-85 yr) Ages 15 days 85 yr $2,500 - $50,000 (15 days-80yr) $2,500 - $20,000 (81yr-85yr) Max. Eligible Age: 70 yr Max. Coverage: $100,000 L. Premium Billing (Please answer all six items) 1. Premium Duration: Life-Pay 20-Year 10-Year Single-Pay 2. Premium Method: PAC (Collect 1 st premium) Direct Bill PAC (Draft 1 st premium) 1035 Exchange Direct Express List Bill 3. Premium Mode: Monthly Quarterly Semi-Annual Annual 4. Bill Day: No preference Match Existing Day of month (1 st 28 th ) On the (1 st 4 th ) (Mon Fri) of each month Amount of Insurance: $ An Accelerated Benefit Rider will be issued with all Silver and Gold policies at no additional cost if the face amount of the base policy is $5,000 or more. This Rider is not available on policies with face amounts less than $5,000. A Child/Grandchild benefit (at the lesser of the base policy face or $5,000) will be included within all Silver and Gold policies. Amount of Accidental Death Benefit Insurance $ 5. Modal Premium Amount..$ (Add premium for Accidental Death Benefit Rider) 6. Premium Collected....$ Where premium not submitted with application: If selected Bill Day is no more than 7 days prior to application approval and not in the previous month, the policy will bill immediately upon approval. Otherwise, the policy will first bill on the upcoming Bill Day. M. Applicant s Statement Fraud Warning Statement: 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. I have read or had read to me the application and fraud warning statement. All the information is true and complete to the best of my knowledge and belief. The statements and answers in this application are the basis for any policy issues. No information will be considered to have been given unless it is on this application. The agent does not have the authority to accept risk, pass on insurability, or make void, waive or change any conditions or provisions of the application or policy. I acknowledge that the Notice of Insurance Information Practices, the Protected Health Information Authorization, the MIB, Inc. Disclosure Notification, and the Prescription History Authorization were read by me or to me. I specifically endorse the Protected Health Information Authorization and the Prescription History Authorization. The policy will not take effect until all eligibility requirements have been met and not until the effective date stated in the policy, and only if the policy is issued during the lifetime of the Proposed Insured. If I am the Owner for insurance on the life of the Proposed Insured, I certify that I have insurable interest in his or her life. Signature of Proposed Insured Signature of Owner (If Other than Proposed Insured) Signature of Co-Owner (If Other than Proposed Insured) Date Date Date Application Signed At: City State N. Agent s Statement Does the Applicant have any existing life insurance policies or annuity contracts?... Will the insurance applied for replace, discontinue, or change any insurance or annuity now or recently in force?... Are you related to the Applicant? If Yes, indicate relationship. No Yes Was a telephone interview conducted? NO POS EPOS Date and time completed: I certify that any information recorded by me on this application is true and accurate to the best of my knowledge. Agent s Name-Please Print Signature of Agent Agent Number Date

7 O. Agent s Remarks P. Policy Payor Check here if Policy Payor is: Proposed Insured Owner Other (If other, complete the following) First, MI, Last Name, Suffix: Mailing Address: Phone Number : Address: Date of Birth: SSN or TIN: Relationship to Insured: Q. Premium Withdrawal Authorization Accountholder Name: Financial Institution Name, City, and State: Checking Savings Direct Express Routing # (lower left corner of check) Bank Account # (middle of check) Direct Express Card Account Number / Expiration Date I authorize Settlers Life Insurance Company to make automatic withdrawals from my bank account or Direct Express account, as identified above, for premiums according to the amount, mode, duration, and timing set forth in the life insurance application to which this authorization is attached. I acknowledge that the actual date of withdrawal can vary due to holidays, weekends and is dependent on my Financial Institution. In the event a withdrawal is not honored, Settlers Life has the right to resubmit the transaction. I agree Settlers Life shall not be responsible for any charges for submitting an account withdrawal request consistent with this authorization. In the event a withdrawal is not paid upon presentation and any premiums due are not paid within the time stated in the policy, I acknowledge that the policy and its coverage may lapse or be terminated by Settlers Life Insurance Company. I agree that this authorization shall remain in effect until Settlers Life shall have received five (5) business days advance written notice of revocation from me. If the above identified account is replaced by another account or with an account from a different bank, this authorization shall apply to the successor account or bank. Printed Name: Accountholder Signature: Date: ICC14 S-2300

8 Notice & Receipt Form and State Specific Forms

9 THIS PAGE TO BE LEFT WITH THE APPLICANT NOTICE OF INSURANCE INFORMATION PRACTICES In the course of underwriting your insurance application, we will rely primarily on personal and health information provided by the proposed owner and/or insured. However, with your authorization, we may also share and seek personal and health information, including medical records and prescription drug records, from and by way of persons other than the proposed owner and/or insured, including persons such as Optum, MIB, Inc., and Management Research Services. Rarely, and only in compliance with applicable law, we may disclose some or all of such information to third parties without your or the insured s specific authorization. Information prepared by an insurance support organization such as Management Research Services may be retained by it and disclosed to third parties. You and/or the insured have the right to access any such information and to seek correction of any portions you believe to be inaccurate. If you would like to receive a more detailed explanation of these practices, please send a written request to Director of Underwriting, Settlers Life Insurance Company, P.O. Box 8600, Bristol, VA PROTECTED HEALTH INFORMATION AUTHORIZATION My signature to the Policy Application authorizes Settlers Life Insurance Company to make a brief report of my protected health information to MIB, Inc. and authorizes any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, MIB, Inc. or other organization, institution, or person, that has any records or knowledge of me or my health, to give any such information to Settlers Life Insurance Company. A photographic copy of this authorization shall be as valid as the original. MIB, INC. DISCLOSURE NOTIFICATION Information regarding your insurability will be treated as confidential. Settlers Life Insurance Company or its reinsurers may, however, make a brief report thereon to the MIB, Inc. (MIB), a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its Members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits 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. Please contact MIB at If you question the accuracy of the information in MIB s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB s Information Office is 50 Braintree Hill Park, Suite 400, Braintree, MA Settlers Life, or its reinsurers, may also release information in its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at PRESCRIPTION HISTORY AUTHORIZATION My signature to the Policy Application authorizes any pharmacy or pharmacy benefit manager that possesses prescription history about me to provide such health information to Settlers Life Insurance Company for the purpose of evaluating my application for life insurance. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on obtaining this authorization. I understand that my information may be subject to redisclosure by the recipient and may not be protected by federal privacy regulations. This authorization shall be valid for two years from this date and may be revoked by submitting written notice to the Director of Underwriting, Settlers Life Insurance Company, P.O. Box 8600, Bristol, VA 24203; however, if I revoke the authorization it will not have any effect on (1) actions taken in reliance upon the authorization prior to revocation, or (2) if applicable, during a contestability period. APPLICATION / PREMIUM RECEIPT ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO SETTLERS LIFE INSURANCE COMPANY. DO NOT MAKE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE PORTION BLANK. Cash Check Received From: $ By (check one) Money Order in connection with an application for life insurance dated. It is understood that the insurance applied for will NOT be effective unless issued by the Company and will NOT be effective until the Effective Date stated in the Policy. The Company is NOT responsible for any loss sustained prior to the Effective Date stated in the Policy, and is thereafter liable only as stated in the Policy. No agent has the authority to change the terms of this receipt. If, for any reason, the application is not accepted and no Policy is issued, the Company s liability will be limited to the return of all premium paid. When you provide us with a check as payment, you authorize us to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day we receive your check, and you will not receive your check back from your financial institution. Agent s Name-Please Print Signature of Agent Agent Number Date Settlers Life Insurance Company Administrative Office P. O. Box 8600 Bristol, VA (276) S-4622

10 THIS PAGE TO BE LEFT WITH THE APPLICANT DISCLOSURE STATEMENT FOR ACCELERATED BENEFIT RIDER (Note: This Disclosure only applies where the base policy has a face value of $5000 or greater, in which case the Accelerated Benefit Rider is provided free of any additional premium charge.) A. What is an accelerated benefit? An accelerated benefit is a portion of the death benefit paid because the insured is diagnosed with a Terminal Condition which results in the insured having a life expectancy of six months or less or the insured is diagnosed as requiring Continuous Confinement in an Eligible Nursing Home and is expected to remain there until death. B. What payment options are available? Up to a maximum of 75% of the face amount if the insured is diagnosed with a Terminal Condition which results in the insured having a life expectancy of six months or less or the insured is diagnosed as requiring Continuous Confinement in an Eligible Nursing Home and is expected to remain there until death. The minimum benefit that may be requested is $1,000. This amount will be paid as a lump sum. The company may apply a portion of the accelerated death benefit to repay an outstanding policy loan but only up to the amount of the outstanding policy loan multiplied by the percentage of the policy death benefit that has been accelerated. There is an administrative fee of $100 to use this benefit. C. What is the premium for the Accelerated Benefit Rider? No additional premium is charged for an Accelerated Benefit Rider. Policy premiums are still due after taking the accelerated benefit unless premiums are waived under another policy provision. D. How will taking an accelerated benefit affect my policy? The cash value, premium, and death benefits will be reduced by the same percentage as the accelerated benefit is to the face amount of the policy. An example is as follows: Values Prior to Acceleration Face Amount $10, Premium Cash Value 1,000 Loan Balance % Acceleration Calculation: Face amount = $10,000 Maximum benefit available = 75% of face amount = $7,500 Minus 75% of outstanding loan = $7, = $7,350 Minus administration fee = $7,350 - $100 = $7,250 = accelerated benefit amount paid After Receiving 75% Acceleration Net Face Amount Remaining 2, Premium Cash Value Loan Balance The net face amount remaining at the insured s death will be paid to the named beneficiary at the insured s death if the policy is in force at that time. Upon a request to accelerate the policy death benefits and upon the payment of the accelerated death benefit, specific information about the effect of an accelerated benefit on policy values, death benefit, premium and loans will be provided to the policyowner and any irrevocable beneficiary. An amended policy schedule page will then be provided to the policyowner to reflect changes in death benefit and policy values as a result of any accelerated benefit payment. E. Are there any limitations on the use of the accelerated benefit proceeds? There are no restrictions or limitations. F. Are the accelerated benefit proceeds taxable? Unlike conventional life insurance proceeds, accelerated benefits may be taxable. Consult a personal tax advisor. Receipt of accelerated benefit proceeds may adversely affect the recipient s eligibility for Medicaid or other governmental benefits or entitlements. The accelerated benefit proceeds do not and are not intended to qualify as long-term care insurance. G. Is the exercise of the rider voluntary? You are not required to exercise the Accelerated Benefit and have the right to waive this benefit. Owner s Signature: Date: Agent s Signature: Date: Settlers Life Insurance Company Administrative Office P. O. Box 8600 Bristol, VA (276) S-4620

11 Settlers Life Insurance Company 1969 Lee Highway P.O. Box 8600 Bristol, Virginia Ph: (800) Fax: (888) A Member of the NGL Insurance Group 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 or 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 NUMBER 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. I certify that the responses herein are, to the best of my knowledge, accurate: Applicant s Signature and Printed Name Date Producer s Signature and Printed Name Date I do not want this notice read aloud to me (Applicants must initial only if they do not want the notice read aloud.) 1st Copy - Administrative Office Form S-700A-MODEL (Rev ) - Page 1 of 2-2nd Copy - Applicant

12 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: POLICY VALUES: INSURABILITY: 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? 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 expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage? 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? Form S-700A-MODEL (Rev ) - Page 2 of 2 -

13 Settlers Life Insurance Company 1969 Lee Highway P.O. Box 8600 Bristol, Virginia Ph: (800) Fax: (888) A Member of the NGL Insurance Group 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 or 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 NUMBER 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. I certify that the responses herein are, to the best of my knowledge, accurate: Applicant s Signature and Printed Name Date Producer s Signature and Printed Name Date I do not want this notice read aloud to me (Applicants must initial only if they do not want the notice read aloud.) 1st Copy - Administrative Office Form S-700A-MODEL (Rev ) - Page 1 of 2-2nd Copy - Applicant

14 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: POLICY VALUES: INSURABILITY: 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? 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 expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage? 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? Form S-700A-MODEL (Rev ) - Page 2 of 2 -

15 A Member of the NGL Insurance Group Settlers Life Insurance Company 1969 Lee Highway P.O. Box 8600 Bristol, Virginia Ph: (800) Fax: (888) Proposed Insured: Date of Application IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES B TO BE COMPLETED FOR AL, AZ, AR, CO, CT, IN, IA, KS, KY, LA, ME, MD, MS, MO, MT, NE, NC, NH, NJ, NM, OH, OK, RI, SC, SD, TX, VA, VT, WI AND WV ONLY: (Complete the following only if an existing policy is being replaced with this contract) I certify that only company approved sales materials were used in conjunction with this sale, and I have left a copy of all sales materials used in conjunction with this sale with the applicant. The following lists the materials used (check, and complete, as applicable): Description Form Number Brochure Product Summary Other: Agent s Signature Agent s Printed Name Agent Number Date Form S-700B-MODEL (Rev )

16 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: POLICY VALUES: INSURABILITY: 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? 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 expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage? 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? Form S-700A-MODEL (Rev ) - Page 2 of 2 -

17 Settlers Life Insurance Company offers plans to fit every individual. Because we exist to pay claims, you can have peace of mind that your loved ones will be cared for. A Settlers Life policyholder receives: a permanent policy with lifetime coverage coverage that never decreases level premium rates that never increase, even as age increases accumulation of cash value an Accelerated Benefit Rider for Gold, Silver, and Silver II Plans at no additional cost for face amounts of $5,000 or more Gold Plan [2014 Series WLP2300] Has your health been good for the past five years? Immediate Benefit Whole Life Insurance Policy (Full death benefits are paid beginning with the first day of coverage.) Eligible ages 15 days-85 years Face amounts from $2,500-$50,000 Maximum amounts available: 15 days - 80 yrs. - $50, yrs yrs. - $20,000 Silver Plan [2014 Series WLP2300] Has your health been good for the past two years? Immediate Benefit Whole Life Insurance Policy (Full death benefits are paid beginning with the first day of coverage.) Eligible ages 6 months-85 years Face amounts from $1,000-$25,000 Maximum amounts available: 6 mos yrs. - $25, yrs yrs. - $20, yrs yrs. - $15,000 Silver II Plan [2014 Series WLP2300] Have you had some health problems but you are taking care of yourself? Immediate Benefit Whole Life Insurance Policy (Full death benefits are paid beginning with the first day of coverage.) Eligible ages Face amounts from $1,000 - $15,000 Available for non-smokers Bronze Plan [2014 Series IMWLP300] Do you have current health difficulties? Modified Whole Life Insurance Policy (Provides a reduced death benefit for deaths due to natural causes in the first two years - total of premiums paid plus 10%. Full death benefits are paid beginning with third year of coverage. Full death benefit paid in first two years for deaths due to an accident, as defined in the policy.) Eligible ages Face amounts from $1,000 - $15,000 S-4600 PS (Rev )

18 Child/Grandchild Benefit One-time benefit for death of child or grandchild. Benefit is equal to the lesser of $5,000 or the benefit amount of the base policy. Included with all Gold, Silver, and Silver II policies. No additional forms required at time of application. NO ADDITIONAL COST. Accidental Death Benefit Rider This rider provides additional coverage - up to a maximum of $100,000 - if your death is caused by an accident, as defined in the policy. Maximum eligible age for all plans is 70 years. Coverage terminates at age 80. Benefit amounts greater than $25,000 (up to a maximum of $100,000) are available for insureds 40 years of age or older who request base coverage of at least $10,000. Accelerated Benefit Rider Available with Gold, Silver, and Silver II Plans. Provides you with accelerated benefits before your death to help you manage your costs and final expenses. This rider is added to all Gold, Silver, and Silver II policies with a face amount of $5,000 or greater at NO ADDITIONAL COST. Allows you to apply for an accelerated benefit of up to 75% of your current policy death benefit if (i) you are diagnosed by a physician with a Terminal Condition with a life expectancy of six months or less; OR (ii) as requiring Continuous Confinement in an Eligible Nursing Home with the expectation that you will remain there until death. If the policy funds are payable through this rider, the benefits paid under this rider may be taxable. Receipt of these funds may also affect the eligibility for Medicaid and other government benefits. A minimum available accelerated benefit of $1,000 is required. An administrative fee of $100 will be deducted from your benefit payment. Life Insurance Presentation Summary Name: DOB: Sex: Final Expense Plan Gold Silver Insurance Amount Non-Smoker Silver II Bronze Premium (Requested) 1. (Optional) 2. (Optional) 3. (Optional) 4. Premium Mode: PAC Smoker MD Q SA A Your Agent: Agent Number: Date: Phone Number: Settlers Life Insurance Company Toll Free (800) Administrative Office: 1969 Lee Hwy P.O. Box 8600 Bristol, VA

19 Silver II Application

20 I A Member of the NGL Insurance Group A. Proposed Insured SETTLERS LIFE INSURANCE COMPANY Madison, Wisconsin Administrative Office: P.O. Box 8600 Bristol, Virginia Silver II Individual Whole Life Insurance Application Use this application for the Silver II life insurance plan. Please complete sections per underwriting guide. Policy Number Faxed App: First, MI, Last Name, Maiden, Suffix: Sex: Male Female DOB: Backdate to Save Age: Yes No Birth State: Birth Country: SSN: Address: Residential Address: Mailing Address: Phone Number (Day) Phone Number (Evening): Best time to Call: US Driver s License #or Other I.D. State Issued: Expiration Date: Is an assignment of ownership being made to NGL Trust? No Yes (check one): FET EPT B. Policy Owner (if other than Proposed Insured) First, MI, Last Name, Suffix: Mailing Address: Phone Number : Address: Date of Birth: SSN or TIN: Relationship to Insured: C. Policy Co-Owner (if any) First, MI, Last Name, Suffix: Mailing Address: Phone Number : Address: Date of Birth: SSN or TIN: Relationship to Insured: D. Beneficiary (if other than NGL Trust) First, MI, Last Name, Suffix: Residential Address: Phone Number : Address: Date of Birth: SSN or TIN: Relationship to Insured: E. Contingent Beneficiary (if other than NGL Trust) First, MI, Last Name, Suffix: Residential Address: Phone Number : Address: Date of Birth: SSN or TIN: Relationship to Insured: ICC14 S-2300S2

21 F. Physician Information Primary Physician s Name and Phone Number: Physician s Address: G. Health Questions for Silver II Plan 1. Please state the Proposed Insured s: Height and Weight. 2. In the past 12 months has the Proposed Insured used any form of tobacco other than chewing tobacco or snuff? 3. Before the age of 50, was the Proposed Insured diagnosed by a member of the medical profession with diabetes requiring insulin, or been prescribed or used insulin for the treatment of diabetes?. 4. Has the Proposed Insured been informed by a member of the medical profession that they have had a heart attack in the past 6 months or more than one heart attack in their lifetime? 5. In the past two years has the Proposed Insured been diagnosed by a member of the medical profession as requiring or undergone surgery for: Heart Disease, Pacemaker or Defibrillator Placement, Angioplasty with or without stent placement, Peripheral Vascular Disease, Carotid Artery Disease, or Amputation due to disease? 6. Has the Proposed Insured ever had or been recommended by a member of the medical profession to have an Organ Transplant or more than one procedure to unblock two or more arteries? 7. In the past two years has the Proposed Insured been diagnosed by a member of the medical profession with, treated for or prescribed medication for: a. Black Lung, Cystic Fibrosis, or Chronic Obstructive Pulmonary Disease (COPD), including Emphysema or Chronic Bronchitis, but not including Asthma? b. Alzheimer s, Dementia, or Progressive Memory Loss? c. Multiple Sclerosis, Parkinson s Disease, or Systemic Lupus? d. Kidney (renal) Failure, Kidney (renal) Disease, Liver Disease, or Hepatitis? e. Sickle Cell Anemia? f. Angina, Aneurysm, Congestive Heart Failure, Stroke, Cardiomyopathy, or Atrial Fibrillation? g. Complications of Diabetes, including Insulin Shock, Diabetic Coma, Retinopathy, Neuropathy, Amputation due to Diabetes, or Kidney (renal) disorder? h. Any form of cancer other than basal cell skin cancer? 8. Is the Proposed Insured currently hospitalized, bedridden due to disease, confined to a nursing facility, or receiving hospice or home health care? 9. In the past two years has the Proposed Insured been prescribed oxygen by a member of the medical profession to assist with breathing? 10. Is the Proposed Insured currently required to receive personal assistance with activities of daily living such as bathing, dressing, eating, taking medications, toileting or moving about? 11. Has the Proposed Insured been diagnosed by a member of the medical profession with AIDS (Acquired Immune Deficiency Syndrome), ARC (AIDS Related Complex), or tested positive for HIV (Human Immunodeficiency Virus)? 12. In the past two years has the Proposed Insured used illegal drugs or marijuana, or received or been advised by a member of the medical profession to receive counseling or treatment for excessive use of alcohol or prescription drugs? H. Applicant Replacement Questions ( If Yes complete required replacement forms.) Does the Applicant have any existing life insurance policies or annuity contracts?.. Will the insurance applied for replace, discontinue, or change any insurance or annuity now or recently in force? ICC14 S-2300S2

22 I. Insurance Plans and Riders Applied For Silver II Plan Ages 50 yr 75 yr $1,000 - $15,000 Amount of Insurance $ An Accelerated Benefit Rider will be issued at no additional cost if the face amount of the base policy is $5,000 or more. This Rider is not available on policies with face amounts less than $5,000. A Child/Grandchild Benefit (at the lesser of the base policy face or $5,000) will be included within all Silver II policies. Accidental Death Benefit Rider (As defined in the policy, full benefits may be paid for accidental death) Max. Eligible Age: 70 yr Max. Coverage: $100,000 J. Premium Billing 1. Premium Duration: Life-Pay 20-Year 10-Year Single-Pay 2. Premium Method: PAC (Collect 1 st premium) Direct Bill PAC (Draft 1 st premium) 1035 Exchange Direct Express List Bill 3. Premium Mode: Monthly Quarterly Semi-Annual Annual 4. Bill Day: No preference Match Existing Day of month (1 st 28 th ) On the (1 st 4 th ) (Mon Fri) of each month Amount of Accidental Death Benefit Insurance $ 5. Modal Premium Amount..$ (Add premium for Accidental Death Benefit Rider) 6. Premium Collected....$ Where premium not submitted with application: If selected Bill Day is no more than 7 days prior to application approval and not in the previous month, the policy will bill immediately upon approval. Otherwise, the policy will first bill on the upcoming Bill Day. K. Applicant s Statement Fraud Warning Statement: 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. I have read or had read to me the application and fraud warning statement. All the information is true and complete to the best of my knowledge and belief. The statements and answers in this application are the basis for any policy issues. No information will be considered to have been given unless it is on this application. The agent does not have the authority to accept risk, pass on insurability, or make void, waive or change any conditions or provisions of the application or policy. I acknowledge that the Notice of Insurance Information Practices, the Protected Health Information Authorization, the MIB, Inc. Disclosure Notification, and the Prescription History Authorization were read by me or to me. I specifically endorse the Protected Health Information Authorization and the Prescription History Authorization. The policy will not take effect until all eligibility requirements have been met and not until the effective date stated in the policy, and only if the policy is issued during the lifetime of the Proposed Insured. If I am the Owner for insurance on the life of the Proposed Insured, I certify that I have insurable interest in his or her life. Signature of Proposed Insured Signature of Owner (If Other than Proposed Insured) Signature of Co-Owner (If Other than Proposed Insured) Date Date Date Application Signed At: City L. Agent s Statement Does the Applicant have any existing life insurance policies or annuity contracts?... Will the insurance applied for replace, discontinue, or change any insurance or annuity now or recently in force?... ICC14 S-2300S2 State Are you related to the Applicant? If Yes, indicate relationship. No Yes Was a telephone interview conducted? NO POS EPOS Date and time completed: I certify that any information recorded by me on this application is true and accurate to the best of my knowledge. Agent s Name-Please Print Signature of Agent Agent Number Date