A Fraternal Benefit Society Corrections must be initialed by Applicant Military Street P.O. Box 5020 Port Huron M PART 1

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1 Application for Membership and Single Premium Whole Life Insurance or Annuity Print carefully in Black Ink Woman's Life Insurance Society A Fraternal Benefit Society Corrections must be initialed by Applicant Military Street P.O. Box 5020 Port Huron M PART Fax Section A Name (First, Middle, and Last) Social Security Number Proposed Insured Current Age I Date of Birth (Mo/DayNr) I City and State of Birth lsex Marital Status OM OF Married Divorced Home Address (Street, City, State and Zip) Single 0 Widowed o Separated Occupation IDriver's License or State 10 No. State Home Telephone ( ) Best Time to Call AM PM Work Telephone ( ) Best Time to Call AM PM Is the Proposed Insured a member of this Society? o Yes ONo If "Yes", give Certificate Number(s): Section B Plan of Insurance Face Amount of Insurance 31 Accelerated Benefit Rider Plan of Single Premium (ABR) Insurance Whole Life Insurance Single Premium Amount 31 o Yes ONo and Premium Rate Class Applied for Amount Submitted with Application (If face amount Dividend Option Information exceeds $100,000 or current age is greater than 70, o Nontobacco Paid Up Additions submit C.O.D.) 31 o Cash o Tobacco o Check 0 Electronic Funds Transfer o Accumulate at Interest Section C Owner Name (First, Middle and Last) Relationship to Insured Owner (Complete if Owner is other Owner's Address (Number, Street, City, State and Zip) Home Telephone than person ( ) proposed for insurance in Age I Date of Birth (Mo/DayNr) Isex Isocial Security Number Work Telephone Part 1 Section A.) OM OF ( ) Section D Are the Proposed Insured and Owner, if other than Proposed Insured, citizens or permanent residents of Citizenship the United States? 0 Yes 0 No If "No", (1) Please state how long the Proposed Insured and/or Owner has lived in the U.S.A., and (2) Provide visa numbers and/or type of permanent alien registration card and numbers. Section E Primary Beneficiary Name(s) and Address(es) Age Relationship to Insured Beneficiary Contingent Beneficiary Name(s) and Address(es) Age Relationship to Insured If trust is named as beneficiary, provide date of trust and trustee's name. Date of Trust Trustee's Name Unless otherwise indicated: The certificate proceeds shall be divided equally between the Primary Beneficiaries who survive the Insured. If no Primary Beneficiary survives the Insured, the proceeds shall be divided equally between the Contingent Beneficiaries who survive the Insured. A300-RO-05 M14/07 1

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14 Modified Endowment Contract Disclosure Woman s Life Insurance Society A Fraternal Benefit Society 1338 Military Street PO Box 5020 Port Huron MI Fax Under the terms of the Technical and Miscellaneous Revenue Act (TAMRA), if the premiums paid on a life insurance certificate are in excess of the limits established by Congress, the certificate is classified as a MODIFIED ENDOWMENT CONTRACT (MEC). Distribution from a MEC, including certificate loans, may be taxable and will be reported to the Internal Revenue Service as taxable income. Also, if the distribution occurs prior to the taxpayer s age 59½, the distribution may be subject to a 10% tax penalty. A life insurance certificate that is a MEC will always be subject to MEC treatment. If a MEC is subsequently exchanged for a life insurance contract that standing alone would not be a MEC, the new contract will be subject to MEC tax treatment. Any single premium whole life insurance certificate issued to you on your application to Woman s Life Insurance Society will be a MEC. I have read the above and understand that, if issued, the single premium whole life insurance certificate for which I am applying will be classified as a Modified Endowment Contract as described above. I acknowledge that I have received a copy of this form. Signature of Owner Date Name of Owner (Please Print) Signature of Witness (Representative) A MEC Applicant s Copy

15 Modified Endowment Contract Disclosure Woman s Life Insurance Society A Fraternal Benefit Society 1338 Military Street PO Box 5020 Port Huron MI Fax Under the terms of the Technical and Miscellaneous Revenue Act (TAMRA), if the premiums paid on a life insurance certificate are in excess of the limits established by Congress, the certificate is classified as a MODIFIED ENDOWMENT CONTRACT (MEC). Distribution from a MEC, including certificate loans, may be taxable and will be reported to the Internal Revenue Service as taxable income. Also, if the distribution occurs prior to the taxpayer s age 59½, the distribution may be subject to a 10% tax penalty. A life insurance certificate that is a MEC will always be subject to MEC treatment. If a MEC is subsequently exchanged for a life insurance contract that standing alone would not be a MEC, the new contract will be subject to MEC tax treatment. Any single premium whole life insurance certificate issued to you on your application to Woman s Life Insurance Society will be a MEC. I have read the above and understand that, if issued, the single premium whole life insurance certificate for which I am applying will be classified as a Modified Endowment Contract as described above. I acknowledge that I have received a copy of this form. Signature of Owner Date Name of Owner (Please Print) Signature of Witness (Representative) A MEC Home Office Copy

16 Modified Endowment Contract Disclosure Woman s Life Insurance Society A Fraternal Benefit Society 1338 Military Street PO Box 5020 Port Huron MI Fax Under the terms of the Technical and Miscellaneous Revenue Act (TAMRA), if the premiums paid on a life insurance certificate are in excess of the limits established by Congress, the certificate is classified as a MODIFIED ENDOWMENT CONTRACT (MEC). Distribution from a MEC, including certificate loans, may be taxable and will be reported to the Internal Revenue Service as taxable income. Also, if the distribution occurs prior to the taxpayer s age 59½, the distribution may be subject to a 10% tax penalty. A life insurance certificate that is a MEC will always be subject to MEC treatment. If a MEC is subsequently exchanged for a life insurance contract that standing alone would not be a MEC, the new contract will be subject to MEC tax treatment. Any single premium whole life insurance certificate issued to you on your application to Woman s Life Insurance Society will be a MEC. I have read the above and understand that, if issued, the single premium whole life insurance certificate for which I am applying will be classified as a Modified Endowment Contract as described above. I acknowledge that I have received a copy of this form. Signature of Owner Date Name of Owner (Please Print) Signature of Witness (Representative) A MEC Representative s Copy

17 Single Premium Whole Life Suitability Questionnaire Woman s Life Insurance Society A Fraternal Benefit Society 1338 Military Street PO Box 5020 Port Huron MI Fax In order to help us determine that you have carefully considered whether or not the life insurance for which you are applying is right for you, please answer the following questions and sign and date this form. If you have not considered any of the factors addressed in the questions, please discuss them thoroughly with your agent. 1. Name of Applicant: 2. Major purpose of the life insurance for which application is made: 3. Do you anticipate any future need to take a loan or loans from or surrender the life insurance for which you are applying? Yes No If Yes, please explain, 4. Can you reasonably acknowledge that the funds used to purchase this life insurance are not needed to support your daily needs? Yes No If No, please explain, 5. Total annual income (from all sources): $ Will there be any foreseeable reduction in this income in future years? Yes No If Yes, please explain, 6. Current Savings and Investment Distribution: Circle any that will not be renewed or that will be closed, sold, or liquidated to pay for this life insurance: Savings Accounts...$ Money Market Funds... $ Annuities...$ Treasuries... $ CD s...$ Stocks, Bonds, Mutual Funds... $ Other (Specify)... $ 7. Identify and explain any other source of funds not indicated above that will be used to pay the premium for this life insurance. 8. Amount of premium paid annually for other life insurance: $ 9. If another person or entity will fund the single premium, please indicate name, address and relationship to the proposed insured/applicant. I acknowledge that I have reviewed each of the above questions and that the answers to the questions are accurate to the best of my knowledge. I understand that any outstanding loans will change the death benefit and may result in adverse tax consequences. Date Signature of Applicant Based upon information received from the applicant concerning the applicant s financial needs and status, it is my opinion that the life insurance for which application is made is suitable for the applicant. Date Signature of Representative A300-INS-Q SPWL

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19 Customer Identification Verification Name of Proposed Insured: Woman s Life Insurance Society A Fraternal Benefit Society 1338 Military Street PO Box 5020 Port Huron MI Fax I have verified the identity of the Proposed Insured, Spouse (if Spouse Rider requested), Applicant/Owner (if other than Proposed Insured) and Parent signing (if junior application) by examining the following specified state or federal issued picture identification. If the individual is a permanent legal resident of the United States, I have examined his/her Resident Alien ID (Green Card). Proposed Insured Citizen of the United States or Canada Driver s License Passport Other (Describe) Child Under 15 Permanent Legal Resident of United States and Citizen of Resident Alien ID (Green Card) Name as printed on ID Date of Birth on ID Number on ID State/Country on ID Expiration Date on ID Military Status: Active Member of United States Armed Forces Yes No If yes and application is for life insurance provide, forms W-169 DISC 7/09 and W /06. Proposed Spouse Insured or Parent, if Junior Application Citizen of the United States or Canada Driver s License Passport Other (Describe) Permanent Legal Resident of United States and Citizen of Resident Alien ID (Green Card) Name as printed on ID Date of Birth on ID Number on ID State/Country on ID Expiration Date on ID Military Status: Active Member of United States Armed Forces Yes No If yes, provide form W-169 DISC 7/09. Also provide form W /06 if Proposed Spouse Insured. Applicant/Owner (Answer for any case in which the Applicant is not the Proposed Insured or Parent.) (Individual, Officer, Partner, LLC Manager or Trustee) Citizen of the United States or Canada Driver s License Passport Other (Describe) Permanent Legal Resident of United States and Citizen of Resident Alien ID (Green Card) Name as printed on ID Date of Birth on ID Number on ID State/Country on ID Expiration Date on ID Military Status: Active Member of United States Armed Forces Yes No If yes, provide form W-169 DISC 7/09. Entity Verification In addition to the above, for an Entity Ownership (Corporation, Partnership, LLC, or Trust), please check the documentation you viewed in order to gain first-hand knowledge of the existence of a legitimate business. A copy of the portion of the documentation that identifies the entity and establishes the authority of the applicant must be submitted along with this form. Articles of Incorporation Partnership Agreement Other (Describe) LLC Operating Agreement Trust Documents Date Signature of Representative A-06 CIDV 8/09 Representative Name (print)

20 Information Box: A-1035 E INST 10/11 Woman s Life Insurance Society A Fraternal Benefit Society 1338 Military Street P.O. Box 5020 Port Huron MI EXTERNAL 1035 EXCHANGES ONLY INSTRUCTIONS FOR REPRESENTATIVE (Please make sure the Insured/Annuitant carefully reads and understands Form A-1035 E 10/11) Policy or Contract No(s).: List Policy No(s). from one company only. Multiple companies require multiple A-1035 E 10/11 forms. Insured/Annuitant under Old Policy(ies): Must be the owner of the contract as well as Insured/Annuitant. Any third party owner must release (or assign back) the ownership to the Insured/Annuitant prior to the execution of Form A-1035 E 10/11 and the application for the New Certificate. Type of Policy(ies): Check each type that applies. Verify that each of the Old Policies is of the type that qualifies for a 1035 Exchange into the New Certificate by referring to the following list: Old Policy New Certificate Life Insurance Life Insurance, Annuity Endowment Annuity Annuity Annuity Woman s Life offers the above types of transactions that, if done properly, should qualify under Section 1035 of the Internal Revenue Code. If an Old Policy is a modified endowment contract, please note this fact on Form A-1035 E 10/ Please indicate type of exchange. If a full exchange, enclose all Old Policy(ies) and check the box indicating they are enclosed. If an Old Policy cannot be enclosed because it is lost or destroyed, please check the box indicating this. The Insured/Annuitant will be certifying to that fact if the box is checked. (Both boxes might be checked in some instances.) The Annual Statement for an Old Policy is not a Policy for this purpose. If a partial exchange of annuity contracts, indicate the amount or percentage of the account value that is being assigned for surrender. Do not fill in both blanks. Partial exchange can only be used if the old and new contracts are annuities. 2. Assigns, to Woman s Life, the portion of the Old Policy(ies) to be surrendered. 3. Certifies that the Insured/Annuitant is the owner at the time of this assignment and that no legal action is pending against him/her. 4. a) Insured/Annuitant is responsible for tax treatment of the transaction. Recommend to him/her to seek advice from a personal tax advisor. b) If full exchange/surrender of Old Policy(ies), make sure that Insured/Annuitant completely understands this Subsection. By placing his/her initials in the box, he/she elects to have Woman s Life surrender the Old Policy(ies) upon delivery of the New Certificate, if it is issued as applied for. (See * below.) By choosing to NOT place his/her initials in the box, he/she chooses to have Woman s Life wait for the Free Look Period to elapse, as defined in the Form, before surrendering the Old Policy(ies). (See * below.) If the New Certificate is issued other than as applied for, Woman s Life will wait for the Free Look Period to elapse before surrendering the Old Policy(ies) even if initials are placed in the box. (See * below.) * If an annuity or a single premium whole life is applied for, Woman s Life may surrender the Old Policy(ies) as early as upon approval of issue of the New Certificate as or other than as applied for. Please stress: No coverage exists under the Old Policy(ies) after its surrender date. c) If partial exchange of annuity contracts, make sure that the Annuitant completely understands this Subsection. If the New Certificate is issued as or other than as applied for, Woman s Life will immediately request partial surrender of the Old Policy(ies). Special reference should be made to the 3 rd paragraph of Section 4(a) of the form. The 1035 transaction should not be entered into if the owner intends withdrawal from or surrender of the Old Policy(ies) or the New Certificate during the 180 days beginning on the date that Woman s Life receives the proceeds from the partial surrender of the Old Policy(ies). Such withdrawal or surrender will negate 1035(a) treatment. d) Sets forth conditions when the assignment becomes null and void, and the Old Policy(ies) will be reassigned back to the Insured/Annuitant. e) Insured/Annuitant is responsible for payment of premiums on Old Policy(ies), if he/she wishes it to remain in force prior to its surrender by Woman's Life. Please stress: Woman s Life is not responsible for these premium payments. f) This Assignment does not create insurance or an annuity. The money received as a result of the 1035 transaction will not be considered part of the first full premium for the New Certificate if the New Certificate is life insurance. The first full premium for the New Certificate (full single premium if the New Certificate is a single premium whole life or single premium deferred annuity) must be paid at or by the time the New Certificate is delivered. The cash surrender value of the Old Policy(ies) will not be considered part of premium for the New Certificate until received by Woman s Life at its Home Office. Questions: Contact the Woman's Life New Business Administration Department at THESE INSTRUCTIONS ARE NOT PART OF AND DO NOT AMEND THE ABSOLUTE ASSIGNMENT TO EFFECT SECTION 1035(a) EXCHANGE FORM.

21 Policy or Contract No(s).: Woman s Life Insurance Society A Fraternal Benefit Society 1338 Military Street P.O. Box 5020 Port Huron MI ABSOLUTE ASSIGNMENT TO EFFECT SECTION 1035(a) EXCHANGE [hereafter called Old Policy(ies) ]. Insured/Annuitant and Owner under Old Policy(ies) (must be the same):. Insurer under the Old Policy(ies):. Phone Number: Address: Type of Old Policy(ies): Life Insurance Endowment Annuity Contract 1. Type of Exchange Full Exchange (must check one) I have enclosed the Old Policy(ies). I certify that the Old Policy(ies) are lost or destroyed. Partial Exchange of Annuity Contracts $ or % of Account Value 2. Absolute Assignment of Old Policy(ies) to Effect Section 1035(a) Exchange For good and sufficient consideration, I hereby assign the above specified portion of my rights, title and interest in the Old Policy(ies) to Woman's Life Insurance Society of Port Huron, Michigan, (hereafter called Woman s Life ), including the right to receive and receipt for the cash surrender value. The purpose of this assignment is to effect an exchange, under Section 1035(a) of the Internal Revenue Code, of the above identified Old Policy(ies) for a new life insurance or annuity certificate as described in the application to Woman s Life which accompanies this assignment (hereafter called New Certificate ). This assignment shall not be effective unless accepted by Woman s Life and such acceptance is evidenced by being recorded on this form. 3. Ownership of Old Policy(ies) In making the assignment under Section 2 above, I represent, warrant and certify that: a) I have not previously assigned or pledged the Old Policy(ies) for any purpose whatsoever or that such assignment or pledge has been released. b) No proceedings of either a legal or equitable nature (including proceedings in bankruptcy) have been instituted or are pending against the undersigned. 4. I Understand and Agree that: a) Acknowledgment of Responsibility for Tax Consequences Woman s Life is furnishing this form and participating in this transaction at my specific request and as an accommodation to me. I am not relying on Woman s Life, its agents or employees for any tax advice whatsoever with regard to this transaction. Woman s Life assumes no responsibility or liability for the validity or effect of this assignment or the tax treatment of the undersigned in connection with this transaction. I assume any and all risk with regard to the accomplishment of a valid Section 1035 exchange under the Internal Revenue Code. If there is an outstanding policy loan under the Old Policy(ies) at the time of exchange, the transaction may not be characterized as tax-free and any gain may be taxed to the extent of such outstanding policy loan. If this is a partial exchange of annuity contracts, I understand that pursuant to IRS Revenue Procedure , any amount (other than an amount received as an annuity for a period of 10 years or more or during one or more lives) that is received under the Old Policy(ies) or the New Certificate during the 180 days beginning on the date that Woman s Life receives the proceeds from partial surrender of the Old Policy(ies) will negate treatment of this partial exchange as tax free under IRC 1035(a). I have been directed to consult my tax or legal advisor. b) Full Exchange/Surrender of Old Policy(ies) If this is a full exchange and Woman's Life accepts the assignment of the Old Policy(ies), and: (Note: Please see (iii) of this Subsection b if the New Certificate is a SINGLE PREMIUM WHOLE LIFE or an ANNUITY.) Initial only after reading this section (Subsection b) carefully. i) Approves the issue of the New Certificate as applied for and I have placed my initials in the box in this Subsection b; then Woman s Life will surrender the Old Policy(ies) for its(their) cash surrender value immediately after the New Certificate is delivered to me and paid for; and apply the surrender value of the Old Policy(ies), if any, when received, as additional premium to the New Certificate. ii) Approves the issue of the New Certificate other than as applied for and/or I have not placed my initials in the box in this Subsection b; then Woman s Life will surrender the Old Policy(ies) for its(their) cash surrender value after the elapse of the 30 day right to examine period under the 30 Day Right to Examine Notice accompanying the New Certificate or the elapse of the right to examine period specified in the New Certificate, if longer, (the period used will hereafter be called the Free Look Period ); and apply the surrender value of the Old Policy(ies), if any, when received, as additional premium to the New Certificate. A-1035 E 10/11 Page 1 of 2

22 iii) Approves the issue of the New Certificate as or other than as applied for and the New Certificate is a SINGLE PREMIUM WHOLE LIFE or an ANNUITY, then Woman s Life may (items (i) and (ii) of this Subsection b notwithstanding) surrender the Old Policy(ies) for its(their) cash surrender value as early as when issue of the New Certificate is approved by Woman s Life; and apply the surrender value of the Old Policy(ies), if any, when received, as premium to the New Certificate. iv) The Surrender Date shall be the date that Woman s Life mails or otherwise sends its first request to surrender the Old Policy(ies) for its(their) cash surrender value; v) After the Surrender Date, if I refuse delivery of the New Certificate or return it under the Free Look Period, there will be no coverage of any kind under either the Old Policy(ies) or the New Certificate and I will receive the surrender value of the Old Policy(ies), if any, which may have income tax consequences to me; vi) On or after the Surrender Date, the Old Policy(ies) cannot be returned to me and no death benefit will be paid under it(them) if I die; and vii) Nothing in this assignment waives or alters any of the terms of the New Certificate, including but not limited to the suicide and incontestability clauses. c) Partial Exchange of Annuity Contracts If this is a partial exchange of annuity contracts and Woman s Life approves issue of the New Certificate as or other than as applied for, it will immediately request partial surrender of the Old Policy(ies) in an amount or portion specified in Section 1 and apply the partial surrender proceeds, if any, when received, as premium to the New Certificate. The Surrender Date shall be the date that Woman s Life mails or otherwise sends its first request for partial surrender of the Old Policy(ies). After the Surrender Date, if I refuse delivery of the New Certificate or return it under the Free Look Period, the New Certificate will be void and I will receive the partial surrender proceeds of the Old Policy(ies), if any, which may have income tax consequences to me. d) Reassignment of Old Policy(ies) If Woman s Life declines to issue the New Certificate (as or other than as applied for) pursuant to my application, I refuse to accept the New Certificate BEFORE the Surrender Date, or I die BEFORE the Surrender Date AND written notice of my death is received by Woman s Life in its Home Office BEFORE the Surrender Date, then, this Assignment shall be null and void, and Woman s Life shall reassign the Old Policy(ies) to me or my legal representative. If a rehabilitation, liquidation or other insolvency proceeding or action is commenced against the issuer of an Old Policy which results in the inability of Woman s Life to surrender such Old Policy for its cash surrender value, then this Assignment shall be null and void as to such Old Policy and Woman s Life shall reassign such Old Policy to me or my legal representative. Upon this assignment becoming null and void as to any of the Old Policies, Woman s Life shall have no further obligation with respect to such Old Policy. e) Woman s Life Will Not Pay Premiums on the Old Policy(ies) Woman s Life is not obligated to and will not make any premium payments on any of the Old Policies. I agree for myself, my heirs and assigns that Woman s Life is not liable if an Old Policy lapses for nonpayment of premiums. f) No Insurance or Annuity Created by This Assignment This assignment creates NO INSURANCE or ANNUITY. If I receive a Conditional Receipt with the application for the New Certificate, such Conditional Receipt defines the effective date of coverage, if any, BEFORE delivery of the New Certificate to me. The first full premium for the New Certificate (full single premium if the New Certificate is a single premium whole life or single premium deferred annuity) must be paid at or by the time the New Certificate is delivered to me. If the New Certificate is life insurance, the surrender value of the Old Policy(ies) will not be applied to pay part or all of the first full premium for the New Certificate or be applied under the terms of the Conditional Receipt. The cash surrender value of the Old Policy(ies) will not be considered part of premium for the New Certificate until received by Woman s Life at its Home Office. g) Photocopy A photocopy of this form shall have the same force as the original. Signed this day of, 20. Signature of Witness Signature of Insured/Annuitant Soc. Sec. No. Signature of Witness Signature of Spouse (if required)* Soc. Sec. No. * Signature of Spouse required in all community property states. To be completed by Home Office. Woman's Life hereby accepts the assignment and ownership of the Old Policy(ies) specified above. Date:, 20 Authorized Signature/Title A-1035 E 10/11 Page 2 of 2

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