Individual Life Products. Agent Product & Rate Guide for. Point-of-Sale Guaranteed Increasing Whole Life. For Agent Use Only

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1 Individual Life Products Agent Product & Rate Guide for Point-of-Sale Guaranteed Increasing Whole Life For Agent Use Only

2 TABLE OF CONTENTS Point-of-Sale Guaranteed Increasing Whole Life... 1 Point-of-Sale Underwriting... 2 Sales Process... 3 Product Highlights... 6 Riders... 7 Claims... 7 Rates... 8 Guaranteed Cash Values Sample Application Life Insurance Replacement/Existing Coverage Forms Sample Marketing Materials Supply Order Form... 25

3 POINT-OF-SALE GUARANTEED INCREASING WHOLE LIFE Guaranteed Increasing Whole Life (GIWL) has been added to EMC National Life s suite of whole life insurance products. It features a unique underwriting process via a telephone interview that speeds up the underwriting decision. Underwriting eligibility is determined immediately at point-of-sale, while you are with the applicant. An underwriting decision is generally made within 20 minutes, and if the policy is approved, it is mailed within three to five business days after receipt of the completed application. GIWL is designed to help cover final expenses, such as the costs associated with funeral and burial expenses. In addition, GIWL can help cover other financial obligations that your client s family may incur at the death of their loved one, such as car loans, student loans or credit card debt. Your clients can have peace of mind knowing that the GIWL product provides multiple guarantees. Guaranteed increasing death benefit by 2.5% until it doubles (after the 29th year) Guaranteed level premiums Guaranteed cash values Guaranteed options (surrender value or reduced paid-up) Prospects Any individual who is Looking to cover funeral costs Looking to cover car loans, student loans or credit card debt A second generation buyer purchased term insurance only to realize he or she still has a need for life insurance Retiring and losing benefits through his or her employer Questions to Ask Who is going to pay for your funeral? How are they going to pay for your funeral? Do you want your loved ones to be burdened financially? Do you have minutes to help eliminate the financial worries of your loved ones? How to Make the Sale Explain the need for GIWL (start the conversation by asking the questions above) Pre-qualify the applicant Provide initial quote Complete the application Contact the Elite Sales Processing (ESP) call center for phone interview Submit the application Note: Whether you make the sale or not, we encourage you to offer your clients a copy of My Memorial Guide (EMK315). My Memorial Guide provides your clients with the assurance that everything is in order when a loved one dies. 1

4 POINT-OF-SALE UNDERWRITING The Guaranteed Increasing Whole Life product uses a unique underwriting process to provide faster underwriting decisions. Through this process, underwriting eligibility can be determined immediately at point-of-sale, while you are with the applicant. The underwriting process is conducted via telephone interview by Elite Sales Processing Inc. (ESP), a consumer-reporting agency with extensive life insurance experience and our underwriting business partner for Guaranteed Increasing Whole Life. Call center representatives give you approval or declination while on the phone call. Once you have pre-qualified the applicant by completing the medical questions on application form ICC11EAP014/EAP014 and obtained the required signatures, you will contact the ESP call center ( ) for an underwriting interview. This point-of-sale interview typically lasts 20 minutes or less. The ESP call center representative will ask similar questions to those you used during the pre-qualification. During the call, an MIB search* and a prescription drug database search** will be run in the background. If there is a discrepancy found due to an MIB report or a prescription history, the ESP call center representative may ask a question again in an attempt to clarify the difference in information. After the applicant has completed the interview, the ESP call center representative will provide you with an underwriting decision of either approved or not approved. The underwriting decision is communicated to you, the agent, not the applicant. After the ESP call center representative provides you with the policy number, please write the policy number at the top of each page of the application. Once you have completed the appointment, remember to fax or mail the application form and state specific Life Insurance Replacement/Existing Coverage Form (if required) to EMC National Life s Home Office. The signed application form must be submitted whether the applicant qualifies for coverage or not. Benefits of Point-of-Sale Underwriting The point-of-sale underwriting process makes it easy for you to do business with EMC National Life. Point-of-sale underwriting allows a high percentage of applications to be quickly approved for issue. Other benefits include Immediate underwriting decision provided by the end of the phone call with ESP No Attending Physician s Statement (APS) requirement No medical exam Speeds up policy delivery (policies approved are mailed within three to five business days after receipt of the completed application) * MIB Check MIB Group, Inc. is a membership corporation owned by Member life insurance companies in the United States and Canada. MIB maintains a database for Members to exchange confidential information of underwriting significance when an individual applies for life, health, disability income, long-term care or critical illness insurance. This information is maintained and safeguarded in a coded format that is accessible only to authorized personnel of a Member company to which the individual has applied for insurance and has authorized the company to use MIB as an information source. Underwriting personnel of the Member company reviews the application information provided by the individual applying for insurance and compares it to what is in the individual s MIB file. The information in the individual s MIB file is used only as an alert. No underwriting decision can be made solely on the basis of a coded report. The federal Fair Credit Reporting Act allows a consumer to request free disclosure of his or her consumer report once annually. Only an individual can request an MIB file on himself or herself. He or she should call MIB s toll-free telephone number to request disclosure of his or her file. ** Prescription History Check The Milliman IntelliScript system is similar to traditional methods for insurers to access medical records from a doctor, hospital, pharmacy or other medical facility no information is gathered or released without an individual s prior authorization. As part of its underwriting process, an insurance company sends Milliman IntelliScript an authorized request for prescription information for an individual. Within seconds, Milliman IntelliScript checks with its data sources (Pharmacy Benefit Managers) to see if any information is available and then returns a prescription history to the insurance company for that individual. An individual can obtain a copy of the prescription history report at no cost by contacting Milliman IntelliScript at Bluemound Road, Suite 100, Brookfield, WI or

5 SALES PROCESS The following steps will ensure a smooth underwriting process. Step 1 - Pre-Qualify the Applicant After reviewing the build chart (below) and confirming smoking status, pre-qualify the applicant by completing the medical questions on application form ICC11EAP014/EAP014. Applicant s Personal History What is the applicant s height and weight? Height (Review build chart to confirm qualification.) Weight In the last 12 months, has the applicant smoked cigarettes or used other nicotine based products, excluding pipes or cigars, snuff, or chewing tobacco? (If this question is answered Yes, the applicant would use tobacco rates.) Build Chart Height Minimum Weight Level 1 & 2 Maximum Weight Level 3 Maximum Weight Height Minimum Weight Level 1 & 2 Maximum Weight Level 3 Maximum Weight Applicants who do not meet the minimum weight requirement are not eligible for coverage under this plan of insurance. Applicant s Medical History (See application) 8. PERSONAL AND MEDICAL HISTORY Instructions: I. Section A If any question in Section A is answered Yes or if your height and weight exceed the Level 1 & 2 criteria, STOP. You are not eligible for coverage under this plan of insurance. If all questions in Section A are answered No and if your height and weight meet the Level 1 & 2 criteria, proceed to Sections B and C. II. Sections B and C If any question in Section B is answered Yes, you may qualify for a plan at Level 1 rates. If all questions in Section B are answered No, you may qualify for Level 2 rates. You may choose to proceed to Section D, Level 3 questions. You must complete Section C. III. Section D If any question in Section D is answered Yes or if your height and weight exceed the Level 3 criteria, you remain qualified for Level 2 rates. If all questions in Section D are answered No and if your height and weight meet the Level 3 criteria, you may qualify for Level 3 rates. 3

6 Definitions Chronic Kidney Disease: Chronic Kidney Disease (CKD), also known as Chronic Renal Disease, is a progressive loss in renal function over a period of months or years. CKD consists of five stages Stage 1 through Stage 5. All five stages are considered to be CKD. COPD/COLD (Chronic Obstructive Pulmonary Disease or Lung Disease): This health condition includes chronic bronchitis, emphysema, pulmonary fibrosis, pulmonary granulomatosis, pulmonary edema, active tuberculosis, pneumoconiosis (black lung, farmer s lung, asbestosis and silicosis), bronchietasis, pulmonary sarcoidosis, histoplasmosis and cryptococcosis. Asthma by itself is not considered COPD/COLD and is an acceptable risk factor. Heart Disease or Disorder: The following are considered diseases or disorders of the heart occurring or discovered within the last 24 months: heart attack, heart blocks, PVD (peripheral vascular disease), valvular surgery, pacemaker, cerebral vascular disease, arrhythmias, carditis, abnormal resting and exercise EKGs, cardiac ischemia, enlarged heart, angina, coronary artery aneurysm, coronary artery bypass grafting, heart replacement, murmurs of any kind, cardiomyopathy, heart failure and coronary artery disease of any type. Lou Gehrig s disease (ALS): ALS (Amyotrophic Lateral Sclerosis) is a rare fatal progressive degenerative disease characterized by increasing and spreading muscular weakness. Medication: If medication is not listed in the Pre-Qualification Questionnaire, then the following applies: Medication being taken for preventative or maintenance reasons for the listed impairments in the application question is acceptable. Organ Transplant: Organ transplant is the receipt by transplant of any of the following organs: heart, lung, kidney, pancreas, small intestine or bone marrow. Treatment: Treatment is defined as receipt of medical services, surgery or therapeutic care due to disease or injury. This does not include routine checkups. Uncontrolled Blood Pressure: If the applicant feels blood pressure is uncontrolled, he or she should answer the question Yes. If confident that it is controlled, he or she should respond No. The applicant can determine whether his or her blood pressure condition is controlled by what his or her doctor has told him or her. If the applicant is taking his or her medication and if the average reading does not exceed 155/92, he or she can consider his or her blood pressure under control. Step 2 - Provide Initial Quote If the applicant qualifies to apply for coverage, determine the amount of coverage based upon insurance needs and the level qualified. Calculate the rate and determine the method of payment. Step 3 - Complete the Application Complete the application form (ICC11EAP014/EAP014). Obtain the state specific Life Insurance Replacement/Existing Coverage Form (if required). 4

7 Step 4 - Contact ESP Call Center for Phone Interview EMC National Life has contracted with Elite Sales Processing Inc. (ESP), a consumer-reporting agency with extensive life insurance experience, to provide point-of-sale inspections. Interviewers are focused on providing excellent customer service. They are trained to accurately verify the information with you and the applicant in a non-threatening manner and to give you approval or declination while on the phone call. ESP will ask the Personal and Medical History questions taken from the application. During the call, an MIB search* and prescription drug database search** will be run in the background. If there is a discrepancy found due to an MIB report or a prescription history, the ESP call center representative may ask a question again in an attempt to clarify the difference in information. In order to help expedite the call, please have your client obtain a list of all his or her prescription drugs that he or she is currently taking or may have taken recently. ESP will also request your client s basic demographic information including name, date of birth, social security number, zip code and driver s license number. Telephone Number: The hours of operation are 8 a.m. - 9:30 p.m. CST, Monday through Thursday 8 a.m. - 5 p.m. CST, Friday During high call volume periods, you may reach a voice mail box. Leave a message and request to have the interview completed. An ESP call center representative will return your call within 10 minutes or will accommodate your specific date/time request for the return call during business hours. If the ESP call center is closed, you may leave a message and request to have the interview completed. An ESP call center representative will accommodate your specific date/time request for the return call during business hours. After the ESP call center representative provides you with the policy number, please write the policy number at the top of each page of the application. After the applicant has completed the interview, the ESP call center representative will provide you with an underwriting decision of either approved or not approved. The underwriting decision is communicated to you, the agent, not the applicant. Step 5 - Submit the Application Once you have completed the appointment, mail or fax ( ) the completed application, premium payment authorization and forms to EMC National Life. The signed application form must be submitted whether the applicant qualifies for coverage or not. * MIB Check MIB Group, Inc. is a membership corporation owned by Member life insurance companies in the United States and Canada. MIB maintains a database for Members to exchange confidential information of underwriting significance when an individual applies for life, health, disability income, long-term care or critical illness insurance. This information is maintained and safeguarded in a coded format that is accessible only to authorized personnel of a Member company to which the individual has applied for insurance and has authorized the company to use MIB as an information source. Underwriting personnel of the Member company reviews the application information provided by the individual applying for insurance and compares it to what is in the individual s MIB file. The information in the individual s MIB file is used only as an alert. No underwriting decision can be made solely on the basis of a coded report. The federal Fair Credit Reporting Act allows a consumer to request free disclosure of his or her consumer report once annually. Only an individual can request an MIB file on himself or herself. He or she should call MIB s toll-free telephone number to request disclosure of his or her file. ** Prescription History Check The Milliman IntelliScript system is similar to traditional methods for insurers to access medical records from a doctor, hospital, pharmacy or other medical facility - no information is gathered or released without an individual s prior authorization. As part of its underwriting process, an insurance company sends Milliman IntelliScript an authorized request for prescription information for an individual. Within seconds, Milliman IntelliScript checks with its data sources (Pharmacy Benefit Managers) to see if any information is available and then returns a prescription history to the insurance company for that individual. An individual can obtain a copy of the prescription history report at no cost by contacting Milliman IntelliScript at Bluemound Road, Suite 100, Brookfield, WI or

8 POINT-OF-SALE GUARANTEED INCREASING WHOLE LIFE PRODUCT HIGHLIGHTS The policy, the riders and their provisions may vary or be unavailable in some states. Refer to the state specific policy form ICC12ELP025/ELP025 and rider forms ELR246 and LP740 for all contractual provisions, benefits and limitations. GUARANTEED INCREASING DEATH BENEFIT Death benefit is guaranteed to increase by 2.5% until it doubles (after the 29th year) (benefit amount remains level thereafter) ADDITIONAL GUARANTEES Guaranteed level premiums Guaranteed cash values Guaranteed options (surrender value or reduced paid-up) ISSUE AGES (age last birthday) UNDERWRITING CLASSES/RATES Male/Female Tobacco/Nontobacco Level 1 Level 2 Level 3 (top underwriting class for this product) (nontobacco only) Continuous pay to age 121 Note: Nontobacco rates for cigar, pipe or tobacco chewers are available for Level 1 and Level 2 provided the applicant is forthcoming about his or her tobacco use. PREMIUM CALCULATIONS Annual premium rates are displayed on pages 8-10 in this agent guide. For annual premium: Annual Rate x (Face Amount/$1,000) + $25 Policy Fee = Annual Premium For modes other than annual: Annual Premium x Mode Factor = Mode Premium Mode Semiannual Quarterly Monthly Check Plan or Credit Card* Factor.52 round by rule of 5 up.265 round by rule of 5 up.089 round by rule of 5 up * Credit card payment is not accepted in MD, NC and PA. Annual payment mode is not available in ME. ILLUSTRATION A signed illustration is not required. ANNUAL POLICY FEE $25 (non-commissionable) MINIMUM INITIAL DEATH BENEFIT $2,000 MAXIMUM INITIAL DEATH BENEFIT $25,000 for Level 1 $150,000 for Level 2 and Level 3 6

9 RIDERS AVAILABLE The following riders are automatically available at no charge in states where approved. Accelerated Death Benefit Rider - ELR246 In the event the insured is diagnosed with a terminal illness, the policyowner can receive benefits up to 75% of the face amount to a maximum of $112,500. Not approved in PA, VT and WA. Seat Belt Benefit Rider - LP740 An additional benefit amount will be paid if the company receives satisfactory proof the insured died while driving or riding in a private passenger vehicle in a covered accident. The vehicle must be equipped with seat belt(s), and the seat belt(s) must have been in actual use by the insured at the time of the accident. The additional benefit amount will be 10% of the amount of insurance shown on the policy specification page up to a maximum of $10,000. Not approved in AK, CA, CT, DC, GA, HI, MD, MA, MT, OR, PA, TN, UT, VA and WA. POLICY LOANS Policy loans may be made at any time while the policy is in force. The loan value is the cash value less any previous loan and any unpaid premium for the current policy year. Interest in advance will be charged at the rate of 7.4% a year payable on each anniversary. CLAIMS The Claims Department is committed to building trust and confidence with our policyholders and agents through rapid, equitable and courteous claims administration. This is accomplished through a well qualified staff with years of experience in the insurance industry. Assistance to Beneficiaries in Applying for Death Benefits Please provide the Claims Department notice of death as soon as possible, so we can research the policy file to determine the current beneficiary. Include the full name of the insured, along with the date and cause of death. A letter along with the appropriate claim form will be sent to the beneficiary or representative of the estate. Claims Within the Contestable Period The point-of-sale phone interview process uses an electronic audio signature to complete the application process and provide the necessary authorization allowing the company to underwrite and issue a policy. This oral consent serves as the insured s electronic audio signature. The statements made in an application materially affect the company s acceptance of coverage, and if a claim should occur within two years of the effective date, the Claims Department will conduct a full review of medical history. If there has not been full disclosure of material facts, the company may void the contract as of the issue date and refund all premiums paid, placing the insured and the company in the same position as if a policy had never been issued. When the Claims Department is conducting a medical review, it is important that the policyholder or beneficiary complete medical history at time of claim. Delays in obtaining medical information normally occur with the medical provider, so it is important that we know of all medical providers at the onset of the claims process and not learn of additional providers as records are received and reviewed. The Claims Department is happy to assist agents with questions regarding how benefits are administered or how to submit a claim. You can trust EMC National Life to deliver claims management that builds value with our policyholders. Please contact us at if we can be of any assistance. 7

10 RATES POINT-OF-SALE GUARANTEED INCREASING WHOLE LIFE LEVEL 1 - MAXIMUM COVERAGE AMOUNT $25,000 ANNUAL RATES PER $1,000 (ADD $25 ANNUAL POLICY FEE*) Issue MALE FEMALE Age Nontobacco Tobacco Nontobacco Tobacco *Non-commissionable MT - use male rates for all applicants

11 RATES POINT-OF-SALE GUARANTEED INCREASING WHOLE LIFE LEVEL 2 ANNUAL RATES PER $1,000 (ADD $25 ANNUAL POLICY FEE*) Issue MALE FEMALE Age Nontobacco Tobacco Nontobacco Tobacco *Non-commissionable MT - use male rates for all applicants

12 RATES POINT-OF-SALE GUARANTEED INCREASING WHOLE LIFE LEVEL 3 ANNUAL RATES PER $1,000 (ADD $25 ANNUAL POLICY FEE*) Issue NONTOBACCO Age Male Female *Non-commissionable MT - use male rates for all applicants

13 CASH VALUES POINT-OF-SALE GUARANTEED INCREASING WHOLE LIFE LEVEL 1, 2 & 3 PER $1,000 OF INITIAL FACE AMOUNT Issue MALE NONTOBACCO FEMALE NONTOBACCO Age 10th Year 20th Year Age 65 10th Year 20th Year Age N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A , N/A N/A , N/A N/A , N/A N/A , N/A N/A , N/A N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A 11

14 CASH VALUES POINT-OF-SALE GUARANTEED INCREASING WHOLE LIFE LEVEL 1, 2 & 3 PER $1,000 OF INITIAL FACE AMOUNT Issue MALE TOBACCO FEMALE TOBACCO Age 10th Year 20th Year Age 65 10th Year 20th Year Age , , , N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A , N/A N/A , N/A N/A , N/A N/A , N/A N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A , N/A 12

15 emc NATIONAL LIFe COMPANY P.O. BOX 9144 DES MOINES, IA Policy Number TeLePhONe INTeRvIew APPLICATION FOR INdIvIduAL LIFe INsuRANCe 1. PROPOsed INsuRed First Name Middle Name Last Name Address City State Zip + 4 Digit Address Social Security Number q Female Date of Birth Birth State Age Telephone Number q Male ( ) Is the Proposed Insured a U.S. citizen? q Yes q No If no, provide details on a separate sheet and send copy of permanent resident visa card. 2. PRIMARY BeNeFICIARY Name (First, M.I., Last) Date of Birth Social Security Number Relationship % CONTINGeNT BeNeFICIARY Name (First, M.I., Last) Date of Birth Social Security Number Relationship % 3. PAYOR (specify one) q Insured q Other If other, provide below: Full Name Address/City/State/Zip Relationship 4. PLAN & FACe AMOuNT OF INsuRANCe q Continuous Pay Increasing Whole Life Face Amount of Insurance: $ SAMPLE 5. PReMIuM MOde & AMOuNT Mode: q Annual q Semiannual q Quarterly q Monthly (not available on Direct Bill) Form: q Check Plan q Direct Bill q Credit Card* q List Bill Premium: Planned Periodic $ Amount Paid with Application: $ *Not available in all states 6. does PROPOsed INsuRed have ANY existing LIFe/ANNuITY COveRAGe? q Yes q No will ThIs POLICY RePLACe ANY existing LIFe/ANNuITY COveRAGe? q Yes q No If yes to either above question, specify coverage below (including EMCNL coverage). Company Policy Number Life Amount To Be Replaced? Complete replacement form applicable to your state and send with the application. q Yes q Yes q Yes q No q No q No ICC11EAP014 (11-11) FST Page 1 of 6 13

16 Policy Number 7. PeRsONAL ANd MedICAL history Instructions: I. section A If any question in Section A is answered Yes or if your height and weight exceed the Level 1 criteria, STOP, you are not eligible for coverage under this plan of insurance. If all questions in Section A are answered No and if your height and weight meet the Level 1 criteria, proceed to Sections B and C. II. sections B and C If any question in Section B is answered Yes and if your height and weight meet the Level 2 criteria, you may qualify for a plan at Level 1 rates. If all questions in Section B are answered No and if your height and weight meet the Level 2 criteria, you may qualify for Level 2 rates. You may choose to proceed to Section D, Level 3 questions. You must complete Section C. II. section d If any question in Section D is answered Yes or if your height and weight exceed the Level 3 criteria, you may remain qualified for Level 2 rates. If all questions in Section D are answered No and if your height and weight meet the Level 3 criteria, you may qualify for Level 3 rates. section A (1) What is your height and weight? Height Weight SAMPLE ANSWER FOR PROPOSED INSURED (2) Do you have any impairment, whether physical or mental, for which you need or receive assistance or supervision in performing normal activities of daily living such as bathing, toileting, eating, dressing, taking medications, or moving without any type of physical assistance? q Yes q No (3) Have you ever: a) Been treated or hospitalized for insulin shock, diabetic coma, amputation due to diabetes, or have you taken insulin injections or by other methods prior to age 40, or diagnosed with diabetes prior to age 25? q Yes q No b) Had, or been medically advised to have, an organ transplant, or been diagnosed as having a terminal medical condition that is expected to result in death within the next 12 months, or are you currently hospitalized, confined to a bed or nursing facility, or receiving hospice care? q Yes q No c) Been medically diagnosed, treated, or taken medication for chronic kidney disease (including dialysis), kidney or liver failure, congestive heart failure, cardiomyopathy, organic brain syndrome, Alzheimer s, dementia, Lou Gehrig s disease (ALS), schizophrenia, bipolar disorder, or mental incapacity? q Yes q No d) Been medically treated or diagnosed by a medical professional as having Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or any immune deficiency related disorder or tested positive for the Human Immunodeficiency Virus (AIDS Virus)? q Yes q No e) Had more than one occurrence or any metastasis of any cancer in your lifetime (excluding basal or squamous cell skin cancer), or are you currently being treated for cancer or recurrence of cancer, or had an amputation caused by cancer? q Yes q No (4) Within the past 24 months, have you: a) Been declined or postponed for life or health insurance or reinstatement? q Yes q No b) Been convicted of a felony or are you currently on probation or parole? q Yes q No c) Been convicted of operating a vehicle while intoxicated or impaired? q Yes q No (5) Within the past 24 months, have you been medically diagnosed, treated for, or taken medication for: a) Internal cancer, leukemia, lymphoma, melanoma, Hodgkin s disease, Parkinson s disease, stroke, Transient Ischemic Attack (TIA), cirrhosis, liver disease, attempted suicide, alcohol abuse, or drug abuse? q Yes q No b) Chronic Obstructive Pulmonary or Lung Disease (COPD), emphysema, chronic bronchitis, or required oxygen to assist in breathing? q Yes q No ICC11EAP014 (11-11) FST Page 2 of 6 14

17 section A - (continued) Policy Number ANSWER FOR PROPOSED INSURED (6) Within the past 24 months, have you been diagnosed as having, been treated for, advised to have treatment for, or hospitalized for: a) Angina, heart disease, heart attack, uncontrolled high blood pressure, heart or vascular surgery (including heart transplant, coronary artery bypass, pacemaker or replacement pacemaker, heart valve replacement, abdominal aortic aneurysm, but excluding angioplasty or stent placement), or any procedure to improve circulation to the legs, heart, or brain? q Yes q No b) Neuromuscular or brain disease (including cerebral palsy, muscular dystrophy, multiple sclerosis, cystic fibrosis), systemic lupus (SLE), or paralysis of 2 or more extremities? q Yes q No section B SAMPLE ANSWER FOR PROPOSED INSURED (1) Within the past 48 months, have you been medically diagnosed, hospitalized for, treated for or taken medication for: a) Lymphoma, melanoma, leukemia, any internal cancer, Hodgkin s disease, Parkinson s disease, stroke, Transient Ischemic Attack (TIA), cirrhosis, or liver disease? q Yes q No (2) Within the past 36 months, have you been medically diagnosed, hospitalized for, treated, or taken medications for: a) Angioplasty, cardiac or vascular stent placement, angina, heart attack, heart or vascular surgery, or any procedure to improve circulation to the heart or brain? q Yes q No b) Chronic Obstructive Pulmonary or Lung Disease (COPD), emphysema, chronic bronchitis, or required oxygen to assist in breathing? q Yes q No c) Diabetic complications (including neuropathy, retinopathy, or uncontrolled blood sugar)? q Yes q No (3) Within the past 24 months, have you been confined 3 or more times to a hospital, nursing facility, convalescent care facility, or mental facility? q Yes q No section C If any question in Section C is answered Yes, it may not necessarily exclude you from coverage. ANSWER FOR PROPOSED INSURED (1) Are you taking medication for any impairment listed in Section A or B? q Yes q No (2) Have you applied for life insurance with any other insurance companies in the last two years? q Yes q No (3) In the last 12 months, have you smoked cigarettes or used other nicotine based products, excluding pipes, cigars, snuff, or chewing tobacco? q Yes q No (4) Proposed Insured s driver s license number: State: q None SECTION D - Level 3 Questions ANSWER FOR PROPOSED INSURED (1) Within the past 5 years, have you been diagnosed with high blood pressure, treated or untreated, that had a reading greater than or equal to 150/90? q Yes q No (2) Within the past 5 years, have you been diagnosed with high cholesterol, treated or untreated, that had a reading greater than or equal to 270 mg? q Yes q No (3) Within the past 3 years, have you had a driver s license suspended or revoked for any reason or had more than 2 moving violations? q Yes q No (4) In the last 12 months, have you used any tobacco or nicotine products, such as cigarettes, pipes or cigars, snuff, chewing tobacco, or a nicotine delivery device such as a patch, gum, or lozenge? q Yes q No (5) Within the past 5 years, have you been charged with or convicted of driving while intoxicated or under the influence of a controlled substance or reckless driving? q Yes q No (6) Are you a student or private pilot? q Yes q No ICC11EAP014 (11-11) FST Page 3 of 6 15

18 section d - (continued) Policy Number ANSWER FOR PROPOSED INSURED (7) Has any parent died prior to age 60 due to cancer, diabetes, or cardiovascular disease? q Yes q No (8) Within the last 7 years, have you received medical treatment or counseling for, or been advised by a physician to discontinue the use of alcohol or prescribed or non-prescribed drugs, or been a member of any self-help group such as Alcoholics Anonymous or Narcotics Anonymous? q Yes q No (9) Have you ever been diagnosed by a medical professional as having diabetes, coronary artery disease, Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, emphysema or internal cancer? q Yes q No (10) Have you been advised by a member of the medical profession to get specified medical care which was not completed, such as any hospitalization, surgery, or diagnostic test, except those tests related to the Human Immunodeficiency Virus (AIDS virus)? q Yes q No 8. SPECIAL REQUESTS 9. statements ANd AuThORIzATIONs Proposed Insured s Statement I understand all of the questions that I have read or that have been read to me on this application. I am not currently taking and I am not under the influence of any medications or drugs that would affect my ability to fully understand and to fully and accurately complete this application. All of the statements and answers in this application for life insurance are true and complete to the best of my knowledge and belief. I agree that this application will be the basis for, and will become part of, any policy that is issued by EMC National Life Company (the Company) and that no information about me will be considered to have been given to the Company unless it is stated in the application. I agree that any policy shall not be in effect until it has been issued by the Company and all premiums have been paid. I understand that the agent has no authority to approve the application, change the policy or waive any policy provisions. I understand no insurance will be effective until the date stated in the policy and all eligibility requirements are met. I am not being paid cash and have not been promised services as an inducement to enter into this application. The purpose of this application is not to sell or assign it to any type of viatical settlement, senior settlement or life settlement company. I acknowledge receipt of a copy of the Fair Credit Reporting Act and MIB, Inc. notices. Medical Authorization I authorize any physician, medical practitioner, hospital, medical care facility, the Veteran s Administration, insurance company, the MIB, Inc. (formerly known as the Medical Information Bureau), pharmacy benefit manager, pharmacy, insurance laboratory, a consumer reporting agency, my employer, or any other person or organization that has any record of information about me to give EMC National Life Company (the Company), its reinsurers or its authorized representatives information about my health, other insurance coverage, employment, age, general character, finances, participation in hazardous activities, medical care or advice about any physical or mental condition including information about drugs, alcoholism, or other information the Company requires to determine insurability or eligibility of benefits. I also authorize the Company or its reinsurers to make a brief report of my personal health information to MIB, Inc. I further authorize the sources listed above, except for MIB, Inc., to give such information to a consumer reporting agency acting on behalf of the Company. This authorization may be revoked; however, it may not be revoked during the contestability period of the policy or to the extent the Company has taken action in reliance on this authorization. Notice of revocation may be sent, in writing, to the Company at its administrative office address. I agree that a copy of this authorization is as valid as the original and I can obtain a copy on request. This authorization is valid for 24 months from the date signed. SAMPLE warning Fraud Notice Any person who knowingly submits a false statement in an application or files a claim containing false or deceptive statements may be guilty of insurance fraud and subject to penalties under state law. I understand and acknowledge this Fraud Notice that I have read or that has been read to me. Misrepresentation Notice If your answers to the questions in the application are incorrect or untrue, EMC National Life Company may deny coverage by voiding or canceling your policy and returning your premium payments to you or your estate. Be aware that voiding or canceling you policy may be an adverse impact to your intended beneficiary(ies). I understand and acknowledge this Misrepresentation Notice that I have read or that has been read to me. I agree that the information on this application will be relied on to determine insurability and that incorrect or untrue information may result in coverage being voided, subject to the Incontestability provision in the policy. x Proposed Insured s Signature Signed At City/State Date ICC11EAP014 (11-11) FST Page 4 of 6 16

19 Policy Number 10. AGeNT s statement To the best of my knowledge and belief, the Proposed Insured q does q does not have any existing life insurance or annuity coverage and the life insurance applied for q will q will not replace any existing life insurance or annuity coverage. I q did q did not see the Proposed Insured. If not, please explain: I certify to the best of my knowledge that the Proposed Insured or any person or entity is not being paid cash or promised services as an inducement to enter into this insurance transaction and that this insurance transaction will not be sold or assigned for any type of viatical settlement, senior settlement, life settlement or other secondary market. Additional certification when Agent did see the Proposed Insured: I certify that I have verified the personal information of the Applicant by viewing state issued driver s license, state issued I.D. card, military I.D. card, Permanent U.S. Resident Card (Green Card), passport or other government issued picture I.D. card. I further certify that the Proposed Insured appeared to me to be lucid and able to fully understand all of the questions on this application. Agent s Printed Name x Agent s Signature Agent s Contract # Commission % Date Commissions Split (if applicable): Agent Name Agent No. Commission % Mail Policy To: q Insured q Agent SAMPLE ICC11EAP014 (11-11) FST Page 5 of 6 17

20 Policy Number PO Box 9144 Des Moines, IA AuThORIzATION TO OBTAIN ANd disclose INFORMATION Life Insurance Application This Authorization Complies with the HIPAA Privacy Rule. I understand EMC National Life Company (EMCNL), its reinsurers, insurance support organizations, and their authorized representative, may obtain medical and other information in order to evaluate my application for insurance. I authorize any Medical Providers, as described below, to disclose or release Protected Health Information, as described below, to EMC National Life Company, P.O. Box 9144, Des Moines, Iowa or its authorized representative. Medical Providers: All physicians, medical or dental practitioners, hospitals, clinics, pharmacies, pharmacy benefit managers, other medical care facilities and all other providers of medical or dental services who have provided treatment or other health care services to me or on my behalf. Protected Health Information: Any and all records and health information within such Medical Person s possession such as medical history, entire medical records, mental, psychiatric (excluding psychotherapy notes) and physical condition, prescription drug records, tobacco, drug and alcohol use and any other protected health information concerning me. This includes information which may be considered to be a communicable or a sexually transmitted disease, which may include, but are not limited to diseases such as Hepatitis, Syphilis, Gonorrhea, the Human Immunodeficiency Virus (HIV) and the Acquired Immune Deficiency Syndrome (AIDS). In addition, I authorize the Veterans Administration, the MIB, Inc., my employer, consumer reporting agency, insurance company or other organization who possesses information, records or knowledge of me including information about drugs, alcoholism or mental illness, to furnish such information to EMCNL, its reinsurers and their authorized representative upon presenting this authorization. By my signature below, I acknowledge that any agreements I have made to restrict my Protected Health Information do not apply to this authorization and I instruct any Medical Provider to release and disclose my entire medical record without restriction. The purpose of the release of the above information is for EMCNL to evaluate and underwrite an application for insurance coverage, to determine the rates and terms that apply to such insurance coverage, and/or to resolve any issues of incomplete, incorrect or misrepresented information on the application which may arise during the processing of the application. I authorize EMC National Life Company or its reinsurers to make a brief report of my Protected Health Information to MIB, Inc. EMCNL or its reinsurers may make a brief report regarding me or my children to other insurance companies to whom I have applied or may apply. This authorization will remain in effect from the date signed below for a period of 24 months, and a copy of this authorization is as valid as the original. I understand that this authorization may be revoked at any time by sending written notice of such to EMCNL at the address above. The right to revoke this authorization is limited to the extent that EMCNL has taken action in reliance on the authorization or the law provides the Company with the right to contest a claim under the policy for which I have applied or to contest the policy itself. I understand that any information that is disclosed pursuant to this authorization may no longer be covered by federal rules governing privacy and confidentiality of health information, but it will not be redisclosed by the recipient except as authorized by me or as allowed by law. I understand that my Medical Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I further understand that if I refuse to sign this authorization, EMCNL may not issue the insurance coverage for which I am applying or if coverage has been issued may not be able to make any benefit payments. I understand that any Personal Representative or I will receive a copy of this authorization upon request. I authorize EMC National Life Company to obtain an investigative consumer report on me, if required. q I elect to be interviewed if any investigative consumer report is prepared in connection with this application. SAMPLE x Signature of Proposed Insured Printed Name Date ICC11EAP014 (11-11) FST Page 6 of 6 18

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