Family Life Insurance Company LBS. Living Benefit Series. Critical Choice LBS. Living Benefit Series. Agent Guide AGT-VL/VCC 0314

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1 Family Life Insurance Company LBS Living Benefit Series Critical Choice LBS Living Benefit Series AGT-VL/VCC 0314 Agent Guide

2 Table of Contents Product Specifications - Viva Life Life Insurance Benefit Return of Premium Benefit Rate Chart Sample Viva Life On-line Application Sample Viva Life Application Product Specifications - Viva Critical Choice Critical Illness Benefit Life Insurance Benefit Return of Premium Benefit Rate Chart Sample Critical Choice On-line Application Sample Critical Choice Application

3 Viva Life Life Benefit This Benefit provides level term insurance for 20 years. Issue Amount Plan A - 25,000 Plan B - 50,000 Plan C - 100,000 Policy Fees Fully commissionable $60 policy fee on base policy. Premium Rates Unisex Tobacco Non-tobacco Underwriting Simplified underwriting $25,000 - $100,000 Standard to Table 4. See new business and underwriting guidelines. Answer only 4 medical questions Application, MIB and Prescription Drug check. Paying Premiums Monthly payments are available through pre-authorized bank draft. Draft days 29, 30 and 31 are not available draft days. Quarterly, semi-annual, and annual payments are available through direct billing and subject to direct bill minimums. List bill is also available for three or more participants in a group. Renewal This benefit is renewable to age 95. Any renewal will be for a one-year term period without evidence of insurability. Conversion On or before the earlier of the tenth policy anniversary or the insured s 70th birthday, this benefit may be exchanged for a new policy on the life of the insured. The new policy may be on any form of life insurance, other than term insurance, then being issued by us. No evidence of insurability will be required. The premium for the new policy will be at our rates in use on the date of conversion at the insured s attained age and in the same premium class as the initial policy was issued in. The death benefit under the new policy may not exceed the death benefit of the original policy on the date of exchange. Termination This benefit will automatically end: At the end of the initial term period, unless renewed; On the policy anniversary at which the age of the insured is 95; If the premium is not paid by the end of the grace period; When the policy is converted or any nonforeiture provision of the policy takes effect; or At any premium due date, upon written request from the policyowner. Page 1

4 Viva Life Return of Premium Benefit The Return of Premium Benefit provides a cash value that is payable at the end of the initial term period if the insured is alive. The cash value at the end of the initial term period will be equal to the total of all premiums paid. A partial Return of Premium benefit is available if the policy is surrendered prior to the end of the initial term period. The Partial Return of Premium benefit is a percentage of the total premiums paid based on the issue age and the number of years the policy has been inforce as indicated in the Schedule of Cash Values. At the end of the initial term period, the Return of Premium benefit will be paid. The life benefit can be renewed for one-year term periods without proof of insurability up to age Year Term No Tobacco Use Last 12 Months Issue Age End of Policy Year 1 0% 0% 0% 0% 0% 0% 0% 0% 2 0% 0% 0% 0% 0% 0% 0% 7% 3 0% 0% 0% 0% 6% 15% 21% 24% 4 6% 6% 9% 16% 24% 30% 33% 36% 5 22% 22% 24% 30% 35% 39% 41% 44% 6 33% 33% 35% 39% 43% 46% 47% 49% 7 42% 42% 43% 47% 50% 52% 52% 52% 8 49% 49% 50% 53% 55% 56% 56% 56% 9 55% 55% 56% 58% 60% 60% 60% 59% 10 61% 61% 61% 63% 64% 64% 64% 63% 11 65% 65% 66% 67% 68% 68% 68% 66% 12 70% 70% 70% 71% 71% 71% 71% 70% 13 74% 74% 74% 75% 75% 75% 75% 74% 14 78% 78% 78% 79% 79% 79% 78% 77% 15 82% 82% 82% 82% 82% 82% 81% 80% 16 86% 86% 86% 86% 86% 86% 85% 84% 17 89% 89% 89% 89% 89% 89% 89% 89% 18 93% 93% 93% 93% 93% 93% 93% 93% 19 97% 97% 97% 97% 97% 97% 97% 96% % 100% 100% 100% 100% 100% 100% 100% 20 Year Term Tobacco Use Last 12 Months Issue Age End of Policy Year 1 0% 0% 0% 0% 0% 0% 0% 0% 2 0% 0% 0% 0% 0% 5% 9% 11% 3 1% 1% 3% 10% 19% 24% 25% 26% 4 21% 21% 22% 26% 32% 35% 37% 37% 5 33% 33% 34% 37% 41% 43% 44% 44% 6 42% 42% 42% 45% 47% 49% 49% 48% 7 49% 49% 49% 51% 52% 53% 53% 52% 8 55% 55% 55% 56% 57% 57% 57% 55% 9 60% 60% 60% 60% 61% 61% 59% 57% 10 65% 65% 64% 64% 64% 64% 63% 59% 11 69% 69% 68% 68% 68% 68% 66% 63% 12 73% 73% 72% 72% 72% 71% 69% 70% 13 76% 76% 76% 75% 75% 74% 73% 76% 14 80% 80% 79% 79% 79% 78% 76% 82% 15 83% 83% 83% 82% 82% 81% 79% 88% 16 87% 87% 86% 86% 86% 85% 83% 90% 17 90% 90% 90% 89% 89% 89% 88% 92% 18 94% 94% 93% 93% 93% 93% 92% 94% 19 97% 97% 97% 97% 97% 96% 96% 97% % 100% 100% 100% 100% 100% 100% 100% *The information given here is based on the generic policy form and may vary by state. Page 2

5 Viva Life Monthly Bank Draft Non-Tobacco Tobacco Age $25,000 $50,000 $100, $10.55 $15.71 $ $10.64 $15.89 $ $10.78 $16.16 $ $10.98 $16.56 $ $11.18 $16.97 $ $11.43 $17.46 $ $11.81 $18.22 $ $12.22 $19.04 $ $12.76 $20.11 $ $13.39 $21.38 $ $14.15 $22.90 $ $14.81 $24.21 $ $15.59 $25.79 $ $16.52 $27.63 $ $17.51 $29.61 $ $18.77 $32.13 $ $20.05 $34.70 $ $21.47 $37.53 $ $23.02 $40.64 $ $24.75 $44.10 $ $26.71 $48.02 $ $28.62 $51.84 $ $30.71 $56.03 $ $33.03 $60.66 $ $35.57 $65.75 $ $38.50 $71.60 $ $41.83 $78.26 $ $45.70 $85.99 $ $50.15 $94.91 $ $55.10 $ $ $60.64 $ $ Age $25,000 $50,000 $100, $16.06 $26.73 $ $16.06 $26.73 $ $16.18 $26.96 $ $16.36 $27.32 $ $16.67 $27.95 $ $17.15 $28.89 $ $17.69 $29.97 $ $18.34 $31.28 $ $19.17 $32.94 $ $20.14 $34.88 $ $21.31 $37.21 $ $22.75 $40.10 $ $24.55 $43.70 $ $26.60 $47.79 $ $28.96 $52.52 $ $31.70 $58.01 $ $34.74 $64.08 $ $38.07 $70.74 $ $41.40 $77.40 $ $45.79 $86.18 $ $50.20 $94.99 $ $53.84 $ $ $57.80 $ $ $62.06 $ $ $66.67 $ $ $71.71 $ $ $77.42 $ $ $83.81 $ $ $91.06 $ $ $98.84 $ $ $ $ $ Page 3

6 For assistance, please contact: Family Life Insurance Co NW Fwy Houston, TX Viva Life A 20 year Life Insurance policy with Return of Premium. As easy as Get a Quote 2. Complete the Application 3. Apply online Answer these questions Applicant s Information Viva LIfe Sample On-line Application Birth Date: Age: Gender: m Female m Male Tobacco User?: m Yes m No State: Effective Date: Plan Name: Monthly Premium: m Plan A - $25,000 $12.22 m Plan B - $50,000 $19.04 m Plan C - $100,000 $30.24 Name: SSN: Marital Status: Height: Weight: lb Address: City: State: Zip: Telephone: Employer s Name: Occupational/Duties: Premium Payor q (Check if other than applicant). Name: Address: City: State: Zip: Telephone: Page 4

7 Viva LIfe Sample On-line Application Beneficiary Primary: Name: SSN: Relationship: Billing Payment By: m Bank Account m Credit Card Representation & Questions Is this insurance intended to replace any other life insurance now in force? m Yes m No If Yes, give name of Company and Policy Number: 1. Has any proposed insured used tobacco in any form? m Yes m No 2. In the past seven (7) years, has any person to be insured been diagnosed by a doctor as having heart trouble, stroke, cancer lung disease or disorder, diabetes, liver or kidney disease, organ transplant, paralysis, loss of 2 or more limbs, blindness, AIDS, AIDS related complex, or immune deficiency, mental illness requiring medication, treatment for alcoholism or drug abuse or has been hospitalized or advised to have any diagnostic tests or surgery for any condition? m Yes m No 3. In the last seven (7) years have any of the proposed insured s used narcotics, cocaine, hallucinogens, barbiturates, heroin, marijuana or any other drugs not prescribed by a physician? m Yes m No 4. Have you ever been denied insurance due to health reasons? m Yes m No Mail Policy To: m Agent m Policy Holder Authorization and disclose information: Family Life Insurance Company and its reinsurers may obtain medical and other information in order to evaluate my application for insurance. This may be disclosed by any physician, practitioner, hospital, clinic, medically related facility, the Veterans Administration, the Medical Information Bureau, Inc., or any consumer reporting agency, or any insurance company. The information may involve me, or any care, treatment or advice of me. This includes information relating to alcohol or drug abuse, mental disease or information which may be considered a communicable or venereal disease which may include, but are not limited to, diseases such as Hepatitis, Syphilis, Gonorrhea and the Human Immunodeficiency Virus, also known as Acquired Immune Deficiency Syndrome (AIDS). Family Life may report such information to the Medical Information Bureau or to other insurance companies to which I have or may apply. This authorization will be valid for 2 years. A photocopy of this will be as valid as the original. I, or my authorized representative may receive a copy of this authorization upon request. If applicable, I also have the right to receive notice of the reason for any adverse underwriting decision. Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of criminal offense under state law. I agree that no insurance shall be in effect until: (a) a policy has been issued; and (b) the first premium is paid while my insurability remains unchanged and then only if I am actually in the state of health represented in this application. I state that the answers set forth above, are full, complete and true to the best of my knowledge and belief. The answers are to be the basis of any insurance issued. I also acknowledge that I have received the Investigative Consumer Reports notification and the MIB Notice attached to this application. All Statements made by or on behalf of the insured or annuitant shall be deemed to be representations and not warranties. By submitting your Mother s maiden name you are electronically signing the application thereby giving us authorization to obtain information as well as agreeing the terms and conditions. Mother s maiden name: Submit Page 5

8 Viva Life Sample Application (This is the generic application, state variations may apply to your state) Page 6

9 Viva Life Sample Application (This is the generic application, state variations may apply to your state) Page 7

10 Critical choice Critical Illness Benefit This Benefit provides for an accelerated payment of life insurance proceeds. Death benefits will be reduced if a benefit is paid. Benefit Amount Plan A - 12,500 Plan B - 25,000 Plan C - 50,000 Waiting Period Number of days that must pass after this Benefit is issued before the critical illness first occurs.* Life threatening cancer 90 days Non-invasive cancer 90 days Other critical illness 30 days When a partial benefit is paid, the face amount of the life benefit will be reduced by the amount of the benefit paid. Partial payments will also reduce any future benefits under this benefit. The premium will be reduced to reflect the reduction. The reduction will not be prorata because the policy premium includes a policy fee which does not vary with the face amount and which will not be reduced. If the full death benefit is paid, the policy will terminate with no further benefits. If a reduced benefit has been paid, the death benefit will be reduced by the amount paid. Benefits A benefit will be payable for the first occurrence of one of the following conditions. That benefit will be 50% of the Life Benefit amount. Life threatening cancer; Heart attack; Major organ transplant; Paralysis; Renal failure; or Stroke A reduced benefit will be payable for coronary by-pass surgery, heart valve surgery, or aortic surgery. This benefit will be one-fourth of the amount payable for the six conditions listed above. This benefit is payable only once. A reduced benefit will be payable for angioplasty surgery or cancer in situ. This benefit will be one-tenth of the amount payable for the six conditions listed above. This benefit is payable only once. Eligibility for Benefit Payment of any benefit is subject to the following conditions: The policy is in force; You have furnished due proof of the occurrence of a covered condition; The policy has not been assigned; and The waiting period must elapse before the critical illness first occurs. First Occurrence Date For heart attack or stroke, the date of diagnosis; For life-threatening cancer, the date of diagnosis; For major organ transplant, the date of the transplant surgery; For renal failure, the earlier of the date regular dialysis begins, or the date renal transplantation takes place; For major heart surgery or angioplasty, the date surgery takes place. *The information given here is based on the generic policy form and may vary by state. Page 8

11 Critical choice Critical Illness Benefit This benefit provides for an accelerated payment of life insurance proceeds. Death benefits will be reduced if an accelerated benefit is paid. Exclusions and Limitations* This benefit does not cover any critical illness resulting from: War, declared or undeclared, or any act of war, riot or insurrection; An intentionally self-inflicted injury or an attempted suicide; The covered insured committing or attempting to commit a felony or being engaged in an illegal occupation; The covered insured being under the influence of alcohol or drugs, excluding those drugs that were prescribed by a physician and taken in the dosage and manner prescribed; Cosmetic surgery, other than from a cosmetic surgery for the reconstruction or repair of damage from an injury or illness; The covered insured operating, riding in or descending from any aircraft. This does not apply while the covered insured is a passenger on a licensed, commercial, non-military aircraft regularly offered over an established passenger route; The covered insured participating in hazardous activities such as parachuting, hang gliding sports, bungee jumping, rock climbing, or any motorized race or speed contest; or A critical illness that occurs during the waiting period. Premiums We have a right to change the premium rates for all insureds in the same class in the covered insured s state for this benefit. This change can take place on any premium due date on or after the first policy anniversary. We will provide at least 60 days prior written notice of any change in premium rates. If critical illness first occurs for a covered insured during the waiting period, all premiums paid for the critical illness benefit will be returned. The rider will terminate for the covered insured. Reinstatement If coverage is reinstated, we will only cover a critical illness that first occurs after the date of reinstatement. A new waiting period will apply. Termination Coverage for a covered insured under this benefit will terminate on the earlier of: Any premium due date upon written request by the owner; The date the critical illness benefit for the covered insured expires; The date a critical illness benefit has been paid for the covered insured; The date a critical illness has first occurred during the waiting period; The date of the covered insured s death; or The date a premium for the covered insured under this rider is not paid within the grace period. *The information given here is based on the generic policy form and may vary by state. Page 9

12 Critical choice Life Benefit This Benefit provides level term life insurance for 20 years, for ages term life is 15 years. Issue Amount Plan A - 25,000 Plan B - 50,000 Plan C - 100,000 Policy Fees Fully commissionable $60 policy fee on base policy. Premium Rates Unisex Tobacco Non-tobacco Underwriting Simplified underwriting $25,000 - $100,000 Standard to Table 4. See new business and underwriting guidelines. Answer only 4 medical questions Application, MIB and Prescription Drug check. Paying Premiums Monthly payments are available through pre-authorized bank draft and credit card. Draft days 29, 30 and 31 are not available draft days. Quarterly, semi-annual, and annual payments are available through direct billing and subject to direct bill minimums. List bill is also available for three or more participants in a group. Renewal This benefit is renewable to age 95. Any renewal will be for a one-year term period without evidence of insurability. Conversion On or before the earlier of the tenth policy anniversary or the insured s 70th birthday, this benefit may be exchanged for a new policy on the life of the insured. The new policy may be on any form of life insurance, other than term insurance, then being issued by us. No evidence of insurability will be required. The premium for the new policy will be at our rates in use on the date of conversion at the insured s attained age and in the same premium class the initial policy was issued in. The death benefit under the new policy may not exceed the death benefit of the original policy on the date of exchange. Termination This benefit will automatically end: At the end of the initial term period, unless renewed; On the policy anniversary at which the age of the insured is 95; If the premium is not paid by the end of the grace period; When the policy converted or any non-foreiture provision of the policy takes effect; or At any premium due date, upon written request from the policyowner. Page 10

13 Critical choice (optional) Return of Premium Benefit The Return of Premium Benefit provides a cash value that is payable at the end of the initial term period if the insured is alive. The cash value at the end of the initial term period will be equal to the total of all premiums paid, less any amounts paid under the policy. A partial Return of Premium benefit is available if the policy is surrendered prior to the end of the initial term period. The Partial Return of Premium benefit is a percentage of the total premiums paid based on the issue age and the number of years the policy has been inforce as indicated in the Schedule of Cash Values, less any amount paid under the policy. At the end of the initial term period, the Return of Premium benefit will be paid. The life benefit can be renewed for one-year term periods without proof of insurability up to age Year Term No Tobacco Use Last 12 Months Issue Age End of Policy Year % 0% 0% 0% 0% 0% 0% 0% 0% 2 0% 0% 0% 0% 5% 13% 18% 20% 21% 3 16% 16% 18% 24% 30% 35% 36% 37% 37% 4 35% 35% 36% 40% 44% 46% 49% 49% 48% 5 47% 47% 48% 50% 53% 55% 57% 57% 56% 6 56% 56% 56% 58% 60% 62% 63% 63% 61% 7 63% 63% 63% 64% 66% 67% 67% 67% 65% 8 69% 69% 69% 70% 71% 71% 71% 71% 69% 9 74% 74% 74% 75% 75% 75% 75% 74% 72% 10 79% 79% 79% 79% 80% 80% 79% 77% 75% 11 84% 84% 83% 84% 84% 84% 83% 82% 80% 12 88% 88% 88% 88% 88% 88% 87% 87% 85% 13 92% 92% 92% 92% 92% 92% 92% 91% 90% 14 96% 96% 96% 96% 96% 96% 96% 96% 95% % 100% 100% 100% 100% 100% 100% 100% 100% 15 Year Term Tobacco Use Last 12 Months Issue Age End of Policy Year % 0% 0% 0% 0% 0% 0% 0% 0% 2 0% 0% 0% 0% 0% 0% 6% 14% 17% 3 0% 0% 0% 7% 17% 25% 30% 34% 36% 4 20% 20% 22% 28% 35% 41% 44% 47% 48% 5 36% 36% 38% 42% 47% 51% 54% 56% 56% 6 48% 48% 49% 52% 55% 58% 61% 62% 62% 7 57% 57% 57% 60% 62% 64% 67% 67% 67% 8 64% 64% 65% 66% 68% 70% 71% 71% 71% 9 70% 70% 71% 72% 74% 75% 75% 75% 74% 10 76% 76% 76% 77% 79% 79% 79% 79% 77% 11 82% 82% 82% 82% 83% 83% 83% 83% 82% 12 87% 87% 87% 87% 88% 88% 88% 88% 87% 13 91% 91% 91% 92% 92% 92% 92% 92% 91% 14 96% 96% 96% 96% 96% 96% 96% 96% 96% % 100% 100% 100% 100% 100% 100% 100% 100% 20 Year Term No Tobacco Use Last 12 Months Issue Age End of Policy Year % 0% 0% 0% 0% 0% 0% 0% 2 0% 0% 0% 0% 0% 0% 0% 6% 3 0% 0% 0% 0% 4% 13% 19% 23% 4 3% 3% 6% 14% 21% 28% 31% 34% 5 19% 19% 21% 27% 33% 37% 39% 42% 6 31% 31% 32% 37% 41% 44% 45% 47% 7 40% 40% 41% 44% 47% 49% 50% 51% 8 47% 47% 48% 50% 53% 54% 54% 54% 9 53% 53% 53% 56% 57% 58% 58% 57% 10 58% 58% 59% 60% 62% 62% 62% 61% 11 63% 63% 64% 65% 66% 66% 66% 64% 12 68% 19% 21% 27% 33% 37% 39% 42% 13 72% 72% 72% 73% 73% 73% 73% 71% 14 76% 76% 76% 77% 77% 77% 76% 75% 15 81% 81% 80% 81% 81% 81% 80% 78% 16 85% 85% 84% 85% 85% 84% 84% 82% 17 89% 89% 88% 88% 88% 88% 88% 87% 18 92% 92% 92% 92% 92% 92% 92% 92% 19 96% 96% 96% 96% 96% 96% 96% 96% % 100% 100% 100% 100% 100% 100% 100% *The information given here is based on the generic policy form and may vary by state. 20 Year Term Tobacco Use Last 12 Months Issue Age End of Policy Year 1 0% 0% 0% 0% 0% 0% 0% 0% 2 0% 0% 0% 0% 0% 4% 8% 10% 3 0% 0% 1% 8% 17% 23% 19% 23% 4 19% 19% 20% 24% 30% 33% 35% 35% 5 31% 31% 31% 35% 38% 40% 42% 42% 6 40% 40% 40% 42% 45% 46% 46% 46% 7 47% 47% 47% 48% 50% 51% 51% 50% 8 53% 53 52% 53% 54% 55% 55% 52% 9 58% 58% 57% 58% 58% 58% 58% 55% 10 62% 62% 62% 62% 62% 62% 61% 57% 11 67% 67% 66% 66% 66% 66% 64% 61% 12 71% 71% 70% 70% 70% 69% 68% 65% 13 74% 74% 74% 74% 73% 73% 71% 69% 14 78% 78% 78% 77% 77% 76% 75% 72% 15 82% 82% 81% 81% 81% 80% 78% 75% 16 86% 86% 85% 85% 84% 84% 82% 80% 17 89% 89% 89% 89% 88% 88% 87% 85% 18 93% 93% 93% 92% 92% 92% 92% 90% 19 97% 97% 97% 96% 96% 96% 96% 95% % 100% 100% 100% 100% 100% 100% 100% Page 11

14 Critical Choice (Without Return of Premium) Nonsmoker Monthly Bank Draft 20 Year Term Age $25,000 $50,000 $100, $10.55 $15.71 $ $10.66 $15.93 $ $10.82 $16.25 $ $11.09 $16.79 $ $11.40 $17.40 $ $11.77 $18.14 $ $12.26 $19.10 $ $12.80 $20.21 $ $13.46 $21.54 $ $14.22 $23.04 $ $15.09 $24.77 $ $15.93 $26.46 $ $16.85 $28.31 $ $17.88 $30.36 $ $18.98 $32.56 $ $20.27 $35.15 $ $21.64 $37.89 $ $23.19 $40.97 $ $24.87 $44.33 $ $26.77 $48.15 $ $28.91 $52.43 $ $31.24 $57.08 $ $33.77 $62.15 $ $36.55 $67.70 $ $39.54 $73.69 $ $42.84 $80.27 $ $46.49 $87.58 $ $50.52 $95.65 $ $54.98 $ $ $59.83 $ $ $65.08 $ $ Year Term 56 $62.11 $ $ $67.02 $ $ $72.36 $ $ $78.25 $ $ $84.71 $ $ Smoker Monthly Bank Draft 20 Year Term Age $25,000 $50,000 $100, $15.33 $25.27 $ $15.38 $25.36 $ $15.54 $25.68 $ $15.79 $26.17 $ $16.27 $27.14 $ $16.94 $28.46 $ $17.73 $30.06 $ $18.71 $32.02 $ $19.88 $34.35 $ $21.23 $37.06 $ $22.79 $40.16 $ $24.54 $43.70 $ $26.50 $47.61 $ $28.64 $51.89 $ $31.07 $56.75 $ $33.82 $62.24 $ $36.89 $68.38 $ $40.33 $75.27 $ $44.01 $82.62 $ $48.54 $91.67 $ $53.40 $ $ $58.39 $ $ $63.79 $ $ $69.64 $ $ $75.94 $ $ $82.74 $ $ $90.19 $ $ $98.28 $ $ $ $ $ $ $ $ $ $ $ Year Term 56 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Page 12

15 Critical Choice (With Return of Premium) Nonsmoker Monthly Bank Draft 20 Year Term Age $25,000 $50,000 $100, $15.04 $24.69 $ $15.24 $25.09 $ $15.58 $25.77 $ $16.05 $26.71 $ $16.64 $27.88 $ $17.34 $29.27 $ $18.26 $31.11 $ $19.27 $33.15 $ $20.52 $35.64 $ $21.95 $38.50 $ $23.58 $41.76 $ $25.16 $44.91 $ $26.87 $48.36 $ $28.82 $52.22 $ $30.86 $56.32 $ $33.29 $61.18 $ $35.88 $66.36 $ $38.76 $72.11 $ $41.93 $78.46 $ $45.50 $85.59 $ $49.49 $93.58 $ $53.88 $ $ $58.62 $ $ $63.83 $ $ $69.46 $ $ $75.65 $ $ $82.49 $ $ $90.04 $ $ $98.40 $ $ $ $ $ $ $ $ Year Term 56 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Smoker Monthly Bank Draft 20 Year Term Age $25,000 $50,000 $100, $23.98 $42.57 $ $24.08 $42.77 $ $24.36 $43.32 $ $24.85 $44.31 $ $25.73 $46.06 $ $27.01 $48.60 $ $28.50 $51.59 $ $30.33 $55.27 $ $32.52 $59.65 $ $35.08 $64.76 $ $38.01 $70.60 $ $41.30 $77.20 $ $44.98 $84.56 $ $49.01 $92.61 $ $53.54 $ $ $58.67 $ $ $64.44 $ $ $70.88 $ $ $77.77 $ $ $86.26 $ $ $95.41 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Year Term 56 $ $ $1, $ $ $1, $ $ $1, $ $ $1, $ $ $1, Page 13

16 Critical choice Sample On-line Application Critical Choice Insure Brighter Tomorrows As easy as For assistance, please contact: Family Life Insurance Co NW Fwy Houston, TX Answer Questions 2. Get a Quote 3. Apply online Answer these questions Birth Date: Age: Gender: m Female m Male Tobacco User?: m Yes m No State: Effective Date: Payment Mode: Plan Name: Monthly Premium: Applicant s Information m Plan A - $12,500 $19.27 Critical Illness/$25,000 Term Life m Plan B - $25,000 $33.15 Critical Illness/$50,000 Term Life m Plan C - $50,000 $58.46 Critical Illness/$100,000 Term Life q Add Return of Premium Name: SSN: Marital Status: Height: Weight: lb Address: City: State: Zip: Telephone: Employer s Name: Occupational/Duties: Page 14

17 Critical choice Sample On-line Application Beneficiary Primary: Name: SSN: Relationship: Billing Payment By: m Bank Account m Credit Card Representation & Questions Is this insurance intended to replace any other life insurance now in force? m Yes m No If Yes, give name of Company and Policy Number: 1. Has any proposed insured used tobacco in any form? m Yes m No 2. In the past seven (7) years, has any person to be insured been diagnosed by a doctor as having heart trouble, stroke, cancer lung disease or disorder, diabetes, liver or kidney disease, organ transplant, paralysis, loss of 2 or more limbs, blindness, AIDS, AIDS related complex, or immune deficiency, mental illness requiring medication, treatment for alcoholism or drug abuse or has been hospitalized or advised to have any diagnostic tests or surgery for any condition? m Yes m No 3. In the last seven (7) years have any of the proposed insured s used narcotics, cocaine, hallucinogens, barbiturates, heroin, marijuana or any other drugs not prescribed by a physician? m Yes m No 4. Have you ever been denied insurance due to health reasons? m Yes m No Mail Policy To: m Agent m Policy Holder Authorization and disclose information: Family Life Insurance Company and its reinsurers may obtain medical and other information in order to evaluate my application for insurance. This may be disclosed by any physician, practitioner, hospital, clinic, medically related facility, the Veterans Administration, the Medical Information Bureau, Inc., or any consumer reporting agency, or any insurance company. The information may involve me, or any care, treatment or advice of me. This includes information relating to alcohol or drug abuse, mental disease or information which may be considered a communicable or venereal disease which may include, but are not limited to, diseases such as Hepatitis, Syphilis, Gonorrhea and the Human Immunodeficiency Virus, also known as Acquired Immune Deficiency Syndrome (AIDS). Family Life may report such information to the Medical Information Bureau or to other insurance companies to which I have or may apply. This authorization will be valid for 2 years. A photocopy of this will be as valid as the original. I, or my authorized representative may receive a copy of this authorization upon request. If applicable, I also have the right to receive notice of the reason for any adverse underwriting decision. Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of criminal offense under state law. I agree that no insurance shall be in effect until: (a) a policy has been issued; and (b) the first premium is paid while my insurability remains unchanged and then only if I am actually in the state of health represented in this application. I state that the answers set forth above, are full, complete and true to the best of my knowledge and belief. The answers are to be the basis of any insurance issued. I also acknowledge that I have received the Investigative Consumer Reports notification and the MIB Notice attached to this application. All Statements made by or on behalf of the insured or annuitant shall be deemed to be representations and not warranties. By submitting your Mother s maiden name you are electronically signing the application thereby giving us authorization to obtain information as well as agreeing the terms and conditions. Mother s maiden name: Submit Page 15

18 Critical choice Sample Application (This is the generic application, state variations may apply to your state) Page 16

19 Critical choice Sample Application (This is the generic application, state variations may apply to your state) Page 17

20 Family Life Contact Information Mailing Address: Family Life Insurance Company Northwest Freeway Houston, Texas 77092, U.S.A. Phone: New Business: Fax: Customer Service: Policy Administration Northwest Freeway Houston, Texas

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