AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224

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1 AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) JACKSONVILLE, FLORIDA ENROLLMENT FORM c New Certificate c Change/Increase Certificate # Remarks: This box for AHL Home Office use only GENERAL INFORMATION Employee s Name (Last, First, M.I.) c M Social Security Number c F Residence Address City State Zip Date of Birth Phone Number Employer/Association/Union Date Hired Occupation Plant Or Division A Plus Benefits Primary Beneficiary s Full Name and Address City State Zip Relationship Phone Number Date of Birth Social Security Number Contingent Beneficiary s Full Name and Address City State Zip Relationship Phone Number Date of Birth Social Security Number COMPLETE THIS SECTION FOR PERSONS TO BE INSURED Last Name First Name Relationship Sex Date of Birth Social Security Number Tobacco Use* Employee Spouse ** ** *Has anyone to be insured used tobacco in the last 12 months? (**If applying for Critical Illness.) Are you changing any existing coverage due to a qualifying event such as marriage, birth, or adoption? Accident Indemnity Medical Critical Illness If Yes, please complete the following: Qualifying Event Date of Qualifying Event Current Certificate Number(s) Do you currently have any of the following individual coverages with American Heritage Life Insurance Company (AHL)? Accident Critical Illness Hospital Indemnity If you answered Yes to any of the coverages, please enter the Policy Number Do you wish to terminate this coverage? If Yes, please enter effective date of termination Premium/Billing Mode Account Number Employee ID Situs State Monthly Date of First Deduction Coverage Effective Date 01/01/2015 V6989 UT ABJ4580UT2 Page 1 of 3 (A Plus Benefits)

Or Division A Plus Benefits Primary Beneficiary s Full Name and Address City State Zip Relationship Phone Number Date of Birth Social Security Number Contingent Beneficiary s Full Name and Address

2 Accident (GVAP2) (Off the Job Accident) Base Units Benefit Enhancement Rider Units 2 ENROLLMENT FORM SELECTION OF COVERAGE (Answer Yes or and complete for each coverage selected) Total Monthly Premiums Employee Only c $11.64 Employee+Spouse c $17.04 Employee+Child(ren) c $23.50 Family c $29.38 Home Office Use Only 1 Outpatient Physician s Rider Units 2 Critical Illness (GVCIP2) Cancer Critical Monthly Premiums n-tobacco Tobacco nd Event Initial Critical Home Office Use Only Basic Benefit Amount $10,000 If covered, Basic Benefit amount for spouse or other dependents is 50 of the employee s. Wellness Option Units 2 Employee Employee Employee Age Only + Spouse + Child(ren) Family c $ 5.08 c $ 8.63 c $ c $ c $ c $ c $ 7.55 c $ c $ c $ c $ c $ nd Event Cancer Critical c $ 8.23 c $ c $ c $ c $ c $ c $ c $ c $ c $ c $ c $ c $ 5.08 c $ 8.63 c $ c $ c $ c $ c $ 7.55 c $ c $ c $ c $ c $ c $ 8.23 c $ c $ c $ c $ c $ c $ c $ c $ c $ c $ c $ For AHL Home Office use only Group. Account Location Dep Code Smoker Issue State Effective Date E S C F EE Y or N SP Y or N Indemnity Medical II Total Monthly Premiums Employee Only Employee+Spouse Employee+Child(ren) Family c $17.68 c $39.65 c $30.55 c $52.52 ABJ4580UT2 Page 2 of 3 (A Plus Benefits)

38 Home Office Use Only 1 Outpatient Physician s Rider Units 2 Critical Illness (GVCIP2) Cancer Critical Monthly Premiums n-tobacco 18-29 30-39 40-49 50-59 60-63 64+ Tobacco 18-29 30-39 40-49 50-59

3 ELECTRONIC ACCEPTANCE (Please check YES or NO) By checking the "Yes" box, I elect electronic delivery of my certificate(s) of insurance, including all documents accompanying my certificate(s) of insurance. If electronically delivered, I understand that I will receive instructions at the address I have provided on how to receive my certificate and accompanying documents at: By checking the "Yes" box, I elect electronic delivery of all contractual, regulatory and administrative correspondence (correspondence) regarding my certificate(s) of insurance, to include claim correspondence, explanations of benefits, periodic notices (such as privacy notices) and other correspondence. If electronically delivered, I understand that I will receive instructions at the last address I have provided on how to receive correspondence at: I understand and agree that to receive electronic delivery, I must have a computer with internet access, a web browser that is Microsoft Internet Explorer version 5.0 or greater, an account, and the ability to download PDF files using Adobe Acrobat Reader version 5.0 or higher and a printer or other device to download and print or save any documents I wish to retain. I understand and I agree that my consent is valid while I remain covered. At any time, I may withdraw my consent for any reason and receive future correspondence in paper to include a paper copy of my certificate(s) of insurance, free of charge, by calling toll-free: ; or by writing to: Customer Care Center, American Heritage Life Insurance Company, 1776 American Heritage Life Drive, Jacksonville, Florida, ACCEPTANCE/AUTHORIZATION: I hereby request all coverage(s) checked yes above for which I am or may become eligible under the group coverages issued by AHL. I AUTHORIZE my employer to deduct from my salary or wages, if applicable, the necessary premium for the coverages requested. EFFECTIVE DATE: I understand that the effective date of my elected coverages will be the effective date recorded on my Certificate, not the date this Enrollment form is signed. WAIVER/DECLINATION: I understand that if I refuse any coverage for which I am eligible (by checking no above), satisfactory proof of insurability may be required, at my own expense, should I desire to apply for it at a later date. Any such application may be declined on the basis of such proof. Date Signed Employee s Signature Producer s Statement. I certify that to the best of my knowledge and belief the information on this form is complete, accurate and correctly recorded. Signature of Soliciting Producer Print Soliciting Producer Name To be completed by home office or producer, prior to issue: Producer Name Producer Number National Producer Percentage Credit Number (NPN) Servicing Producer: Soliciting Producer: ABJ4580UT2 Page 3 of 3 (A Plus Benefits)

4 AMERICAN HERITAGE LIFE INSURANCE COMPANY HOME OFFICE: JACKSONVILLE, FLORIDA (904) A Stock Company IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when it pays: Hospital or medical expenses up to the maximum stated in the policy Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: Hospitalization Physician services Outpatient prescription drugs if you are enrolled in Medicare Part D Other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIIP). AWD5262-1

It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

5 AMERICAN HERITAGE LIFE INSURANCE COMPANY HOME OFFICE: JACKSONVILLE, FLORIDA (904) A Stock Company IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS This is not Medicare Supplement Insurance This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when: any expenses or services covered by the policy are also covered by Medicare Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice outpatient prescription drugs if you are enrolled in Medicare Part D other approved items and services Before You Buy This Insurance Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIIP). AWD6301-1

AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224

AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) JACKSONVILLE, FLORIDA 32224 ENROLLMENT FORM Remarks: c New Certificate c Change/Increase Certificate # This box for AHL Home Office use only Employee s Name