In life you can count on one thing. Things

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1 The GeoCare Benefits Group 10-Year Level Term Life Insurance Plan Underwritten by New York Life Insurance Company In life you can count on one thing. Things rarely go according to plan. That s why the GeoCare Benefits Group 10-Year Level Term Life Insurance Plan is so important. It s the plan that helps you plan for your family s future financial security, because your benefits and your premiums remain the same for the initial 10-year term. Financial Planners Agree. Life Insurance is an Important Part of Any Sound Financial Plan. The Group 10-Year Level Term Life Insurance Plan Can Help You With benefits of up to $1 million available to members, and coverage equal to yours available to your spouse at exceptionally affordable group rates the 10-Year Level Term Life Insurance Plan offers you and your family outstanding Plan for Your Family s Future, with Coverage Up to $1 Million, Spouse Coverage, Affordable Group Rates and Exceptional Personal Service. value. You may also benefit from discounts on higher levels of coverage. It all adds up to a great value in term life insurance. 1

2 Eligibility Requirements: Under Age 65? Your Eligibility is Guaranteed Members of AAPG, AAPL, AEG, AIPG, COPAS, EEGS, GSW, SEG (Society of Economic Geologists), SEG (Society of Exploration Geophysicists), and SEPM under age 65 living in the United States, who are in good health and are actively performing the normal, everyday activities commonly associated with someone of like age, are eligible to apply for coverage. Certain state restrictions may apply. Due to state regulations, the Plan is not available in SD. Please note that filing approval is pending for WA. Call the Administrator at for status of approval. You can also apply for coverage for your lawful spouse or domestic partner (under age 65) and any unmarried, dependent children ages 15 days to 25 years. A dependent that is also a member is eligible for either member or dependent coverage, but not both. If both spouses/ domestic partners are covered as members, neither may insure the other as spouse/ domestic partner and only one may insure eligible children. Schedule of Coverage: Coverages of $100,000 to $1,000,000 Are Available Coverage is available for members, spouses or domestic partners and children. Member: With benefits of $100,000 to $1,000,000 available to members, in increments of $10,000, you can tailor your coverage to meet your family s specific needs. Coverage is available to all members under the age of 65. Spouse or Domestic Partner: Spouses or domestic partners age 65 and under are eligible for coverage, not to exceed the member s level of coverage, in increments of $10,000. Children: Your dependent children age 15 days to 25 years are eligible for coverage of up to $5,000. Please note: The maximum amount of life insurance in force for combined New York Life Insurance group policies may not exceed $1,000,000 per insured association member. 10-Year Level Premiums: Lock in Your Premiums... and Your Benefit...They Stay the Same for Ten Years...a Great Way to Plan Your Future The idea behind the GeoCare Benefits Group 10-Year Level Term Life Insurance Plan is simple take term life insurance coverage and add a premium feature to keep rates level for the initial term of 10 years. The benefit to you? There are no costly savings or investment features, and, best of all, rates don t move up or down, so you ll know exactly how your life insurance can fit into your family s financial plan. Your Coverage Continues: After the Initial 10-Year Period, Your Coverage Will Remain in Force At the end of your initial ten-year coverage period, if you and your spouse are under age 65, you may apply for a new ten-year period of coverage at the ten-year level term rates appropriate to your ages and health histories at that time. If you or your spouse is not approved for a subsequent 10-year term or do not apply, coverage will continue in force on a nonguaranteed rate basis with increasing premiums as the insured ages. You may exchange your coverage under the Policy for an equal or lesser amount of coverage under the GeoCare Benefits traditional Group Term Life Policy. Effective Date: When Does Your Coverage Begin? Coverage for you and any dependents who applied for this Plan becomes effective on the date it is approved by New York Life Insurance Company, provided your first contribution is paid within 31 days after the date you are billed and you and any of your approved dependents are in good health and performing the normal activities of a person of like age on the date of approval. (Residents of MD and NC: Any reference to performing normal activities of a person in good health of like age is replaced by the requirement that the health status of any proposed insured person remain the same as stated in your application.) When Coverage Ends: Your Coverage Terminates at Age 75 Coverage ends when the insured member becomes age 75 (25 for insured children), or earlier if: a) premium is not paid within the 31 day grace period following the due date, b) the Policy ends or is changed to end insurance for the group of insureds to which the insured belongs, c) the insured member ceases to be a member of the Association or d) the insured requests in writing to cancel the insurance. Coverage for dependent children will terminate when the child ceases to be an eligible dependent. 2

3 Insurance Amounts $100,000-$249,000 The cost of this life insurance is based upon the member and spouse s gender*, amount of insurance requested, usage of tobacco/nicotine products, health status, and attained age on the date coverage is issued. Non-smokers meeting the highest underwriting standards may qualify for the Preferred premium rates. Other non-smokers may qualify for higher Select or Standard rates. Upon approval of your application you will be notified of the rate classification for each approved person. Current Annual Premium Contribution Per $1,000 of Benefit Amount as of January 1, 2011 MALE FEMALE Issue Age Preferred Select Standard Preferred Select Standard All eligible children: $5,000 for $6.00 annually *Male rates apply to all Montana residents, regardless of a person s sex. The premium contributions shown above reflect the current rate and benefit structure for an initial 10-year term. Premiums are guaranteed to remain level for the first 10 years of coverage. Then, if still eligible, you may reapply for the 10-year level rates in effect for a subsequent 10-year term; rates for the subsequent term would be determined based on your then current age, health, and smoking status and guaranteed for 10 years. If you re not approved for a subsequent 10-year term of guaranteed rates, or do not apply for a subsequent 10-year term, coverage will continue in force on a non-guaranteed rate basis with increasing premiums as the insured ages. An alternative at the end of a 10-year period would be to request an exchange to enter into the GeoCare Traditional Term Life Policy. Please call the Administrator for details. Premiums will be billed semi-annually June 1 and December 1. A $2.00 administrative charge is added for the convenience of semi-annual billing. Premiums may be paid annually to eliminate the $2.00 charge. 3

4 Insurance Amounts of $250,000-$499,000 The cost of this life insurance is based upon the member and spouse s gender*, amount of insurance requested, usage of tobacco/nicotine products, health status, and attained age on the date coverage is issued. Non-smokers meeting the highest underwriting standards may qualify for the Preferred premium rates. Other non-smokers may qualify for higher Select or Standard rates. Upon approval of your application you will be notified of the rate classification for each approved person. Current Annual Premium Contribution Per $1,000 of Benefit Amount as of January 1, 2011 MALE FEMALE Issue Age Preferred Select Standard Preferred Select Standard All eligible children: $5,000 for $6.00 annually *Male rates apply to all Montana residents, regardless of a person s sex. The premium contributions shown above reflect the current rate and benefit structure for an initial 10-year term. Premiums are guaranteed to remain level for the first 10 years of coverage. Then, if still eligible, you may reapply for the 10-year level rates in effect for a subsequent 10-year term; rates for the subsequent term would be determined based on your then current age, health, and smoking status and guaranteed for 10 years. If you re not approved for a subsequent 10-year term of guaranteed rates, or do not apply for a subsequent 10-year term, coverage will continue in force on a non-guaranteed rate basis with increasing premiums as the insured ages. An alternative at the end of a 10-year period would be to request an exchange to enter into the GeoCare Traditional Term Life Policy. Please call the Administrator for details. Premiums will be billed semi-annually June 1 and December 1. A $2.00 administrative charge is added for the convenience of semi-annual billing. Premiums may be paid annually to eliminate the $2.00 charge. 4

5 Insurance Amounts of $500,000-$1,000,000 The cost of this life insurance is based upon the member and spouse s gender*, amount of insurance requested, usage of tobacco/nicotine products, health status, and attained age on the date coverage is issued. Non-smokers meeting the highest underwriting standards may qualify for the Preferred premium rates. Other non-smokers may qualify for higher Select or Standard rates. Upon approval of your application you will be notified of the rate classification for each approved person. Current Annual Premium Contribution Per $1,000 of Benefit Amount as of January 1, 2011 MALE FEMALE Issue Age Preferred Select Standard Preferred Select Standard All eligible children: $5,000 for $6.00 annually *Male rates apply to all Montana residents, regardless of a person s sex. The premium contributions shown above reflect the current rate and benefit structure for an initial 10-year term. Premiums are guaranteed to remain level for the first 10 years of coverage. Then, if still eligible, you may reapply for the 10-year level rates in effect for a subsequent 10-year term; rates for the subsequent term would be determined based on your then current age, health, and smoking status and guaranteed for 10 years. If you re not approved for a subsequent 10-year term of guaranteed rates, or do not apply for a subsequent 10-year term, coverage will continue in force on a non-guaranteed rate basis with increasing premiums as the insured ages. An alternative at the end of a 10-year period would be to request an exchange to enter into the GeoCare Traditional Term Life Policy. Please call the Administrator for details. Premiums will be billed semi-annually June 1 and December 1. A $2.00 administrative charge is added for the convenience of semi-annual billing. Premiums may be paid annually to eliminate the $2.00 charge. 5

6 Your Beneficiary: You Decide Who Your Beneficiary Should Be Your beneficiary can be anyone you choose. You may change your beneficiary at any time by written request. You are the automatic beneficiary for your covered spouse and children. If you wish to name another beneficiary for spouse insurance, please contact the Administrator for the appropriate forms. Accelerated Death Benefit: An Accelerated Death Benefit Pays Benefits When an Insured Needs Them Most A terminal illness can be emotionally devastating and financially draining. The last thing you and your family need to worry about is how to pay your bills. The Group 10-Year Level Term Life Insurance Plan has a special provision that pays up to 50% of your (or an insured dependent s) life insurance benefit if a terminal illness has been diagnosed. Full premiums continue to be payable. For terms, conditions and limitations, please see the Certificate of Insurance. The Accelerated Death Benefit is not available to residents of Massachusetts. Discounted Premium Rates: You May Be Eligible for Discounts on Higher Amounts of Coverage Volume discounts are included for coverage amounts of $250,000 to $499,000. Even greater discounts are available for coverage of $500,000 to $1,000,000. Certificate of Insurance This brochure is only a partial description of the provisions of this insurance coverage. When you become insured, you will be sent a Certificate of Insurance as evidence of coverage underwritten by New York Life Insurance Company, 51 Madison Avenue, New York, NY under the Group Policy on Policy Form GMR-G29195/FACE. Refer to the Certificate of Insurance for all benefits, costs, eligibility, limitations and exclusions. 30-Day Free Look: Take Up to 30 Days to Review Your Coverage Please read your Certificate thoroughly when it arrives and contact the Administrator with any questions. If you are not completely satisfied with the terms of your Certificate, you may return it, without claim, within thirty days for a full premium refund. No questions asked. How to Apply for Coverage 1. Complete, sign, and date the enclosed 10-Year Term Life Plan Application. 2. Send no money now. You will be billed when your coverage goes into effect. 3. Mail your completed Application to: GeoCare Benefits Insurance Program P.O. Box 9159 Phoenix, AZ Residents of New York: Please contact the Administrator for an application specific to New York State. IMPORTANT NOTICE: How New York Life Obtains Information and Underwrites Your Request for Group 10- Year Level Term Life Insurance Information regarding insurability will be treated as confidential. In considering your request for insurance, we will rely on the medical information you provide, and on the information you authorize us to obtain from your physician, other medical practitioners and facilities, other insurance companies to which you have applied for insurance and MIB, Inc. (formerly known as Medical Information Bureau). MIB and other insurance companies may also furnish New York Life, its subsidiaries or the plan administrator with non-medical information (such as driving records, past convictions, hazardous sport or aviation activity, use of alcohol or drugs, and other application for insurance). The information provided may include information that may predate the time frame stated on the medical questions section, if any, on this application. This information may be used during the underwriting and claims processes, where permitted by law. Your AUTHORIZATION may be used for a period of 24 months from the date you signed the application, unless sooner revoked. The AUTHORIZATION may be revoked at any time by notifying the Administrator in writing at the address provided. Your revocation will not be effective to the extent New York Life or any other person already has disclosed or collected information or taken other action in reliance on it, or to the extent that New York Life has a legal right to contest a claim under an insurance certificate or the certificate itself. The information New York Life obtains through your AUTHORIZATION may be come subject to further disclosure. For example, New York Life may be required to provide it to insurance, regulatory or other government agencies. In this case, the information may no longer be protected by the rules governing your AUTHORIZATION. New York Life may release this information to the plan administrator, MIB, other insurance companies to whom you may apply for insurance, or to whom a claim 6

7 for benefits may be submitted and to others whom you authorize in writing. However, this will not be done in connection with information concerning Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV). New York Life will not disclose such information to anyone except those you authorize or where required or permitted by law. We may make a brief report to MIB; however, we will not disclose our underwriting decision. Information in our files may be seen by New York Life and Plan Administrator employees, but only on a need to know basis in considering your request. Upon receipt of all requested information, we will make a determination as to whether your request for insurance can be approved. MIB is a not-for-profit organization of insurance companies, which operates an information exchange on behalf of its members. When you apply for insurance or submit a claim for benefits to a MIB member company, medical or nonmedical information may be given to the Bureau, which may then be furnished to member companies. If we cannot provide the coverage you requested, we will tell you why. If you feel our information is inaccurate, you will be given a chance to correct or complete the information in our files. Upon written request to New York Life or MIB, you will be provided with non-medical information. Generally, medical information will be given either directly to the proposed insured or to a medical professional designated by the proposed insured. Your request is handled in accordance with the Federal Fair Credit Reporting Act procedures. If you question the accuracy of the information provided by MIB, you may contact MIB and seek a correction. MIB s information office is: MIB, Inc., 50 Braintree Hill Park, Suite 400, Braintree, MA , telephone (866) (TTY ). For Canadian residents, the address is: MIB Information Office, 330 University Avenue, Suite 501, Toronto, Ontario, Canada M5G 1R7, telephone (416) Information for consumers about MIB may be obtained on its website at For NM Residents: PROTECTED PERSONS 1 have a right of access to certain CONFIDENTIAL ABUSE INFORMATION 2 we maintain in our files and they may choose to receive such information directly. You have the right to register as a PROTECTED PERSON by sending a signed request to the Administrator at the address listed on the application. Please include your full name, date of birth and address. 1 PROTECTED PERSON means a victim of domestic abuse: who has notified us that he/she is or has been a victim of domestic abuse; and who is an insured person or prospective insured person. 2 CONFIDENTIAL ABUSE INFORMATION means information about: acts of domestic abues or abuse status; the work or home address or telephone number of a victim of domestic abuse; or the status of an applicant or insured as family member, employer or associate or a victim of domestic abues or a person with whom an applicant or insured is known to have a direct, close, personal, family or abuse-related relationship. New York Life Insurance Company 2.09 ed. The Group 10-Year Level Term Life Insurance Plan is underwritten by New York Life Insurance Company, 51 Madison Avenue, A Quality Life Insurance Plan to Help Protect Your Family s Financial Security. New York, NY under Group Policy Form GMR, Policy No. G /FACE. Founded in 1845 and a recognized leader in the association group insurance field, it is one of the largest and most respected life insurance companies in the nation. It has received the highest ratings for financial strength from the leading independent ratings services: A.M. Best (A++), Fitch Ratings (AAA), Standard and Poor s (AAA), and Moody s Investor Services (Aaa). Source: Individual Third Party Ratings Reports (as of 7/7/10) The Broker of Record is: F. Michael Strunk P. O. Box Punta Gorda, FL Phone: CA License # 0C30823 Residents of Florida: F. Michael Strunk is a licensed Florida agent for service of Florida residents. The Association incurs certain administrative expenses in connection with this sponsored program. To provide and maintain this valuable membership benefit, it is reimbursed for such expenses. 10YR2011 7

8 GeoCare Benefits Group 10-Year Level Term Life Insurance Plan Worksheet and Rates How much life insurance should you and your family consider? For years, financial planners have recommended 5 to 8 times your annual income.* But these days, with more mobile and two-income families, life insurance needs can vary widely. So, how do you determine how much coverage your family needs? Completing the simple worksheet below can give you a better idea of your family s unique life insurance needs. Add the following expenses: Final Expenses $ (Medical bills, funeral costs, attorney, probate or estate planning fees, also any estate taxes) Debt $ (Credit cards, auto loans, your mortgage(s), home equity loans/property taxes due) Living Expenses $ (Food, clothing and other day-to-day living expenses and home maintenance, child care expenses, college costs) Subtotal of Your Financial Needs $ -PLUS- -PLUS- -SUBTRACT- Current Financial Assets $ (Savings, cash, investments, any equity in your home, IRAs, any life insurance you already have) Life Insurance Needs $ (Your financial responsibilities and needs minus your current assets equal life insurance you may need) *Insurance Information Institute: 8

9 Group 10-Year Level Term Life Insurance Plan Application For Members of the GeoCare Benefits Group Insurance Trust Not for Residents of New York State Please print in ink or type all answers. Do not use correction fluid or gel pens. Initial and date any changes you make. 1 Member s Full Name and Information: Name LAST FIRST MIDDLE Street Address City State (or Province) Zip Code - Request for Group Insurance from New York Life Insurance Company 51 Madison Avenue, NY, NY Social Security #: Applying Is Easy. Here s How: 1. Complete and Sign This Form in Ink. 2. Send No Money Now. You Will Be Billed Once Coverage is Approved. 3. Mail Completed Form to: GeoCare Benefits Insurance Program P.O. Box 9159, Phoenix, AZ Have a Question or Need Additional Information? Please Call or City State (or Province) Home Phone: ( ) AREA CODE NUMBER Business Phone: ( ) AREA CODE NUMBER Address Marital Status: Married Divorced Single Widowed Civil Union* or Domestic Partner* *As applicable only where jurisdictional law so mandates. Call the Administrator for Declaration of Domestic Partnership Form, complete, and return with application. (Not applicable in OR.) Are you presently insured under any other GeoCare Life Plans? Yes No If Yes, indicate which Plan(s) and provide details below (person insured and amount of insurance) Term Life First-to-Die Life 10-Year Level Term Life Details: Date of Birth Height Weight Sex Mo. Day Yr. Lbs. Member: / / ft. in. M F Member s Date of Birth Required if Requesting Only Spouse Coverage Spouse* or Domestic Partner* / / ft. in. M F Name if Proposed for Insurance Child(ren)*: / / ft. in. M F Name if Proposed for Insurance / / ft. in. M F Name if Proposed for Insurance If more than two children are proposed for insurance, attach a separate sheet. Please sign and date the additional sheet. *See Plan Information for definition of eligible dependents. In the next 12 months, does any person if proposed for insurance intend to reside outside the U.S. or Canada? Member Yes No Country(ies) Spouse Yes No Country(ies) 2 Membership Affiliation Are you now a member of the GeoCare Benefits Group Insurance Trust? Yes No The GeoCare Benefits Group Insurance Trust covers members in the following associations. Please check your affiliation(s) and provide your membership number(s), if available. American Association of Petroleum Geologists American Association of Professional Landmen Association of Environmental and Engineering Geologists Membership in AAPG or a cooperating society is required for participating in this plan. American Institute of Professional Geologists Council of Petroleum Accountants Societies Environmental and Engineering Geophysical Society Geological Society of Washington Society of Economic Geologists Society of Exploration Geophysicists SEPM Society for Sedimentary Geology 3 Insurance Requested Refer to brochure for eligibility, options and coverage description. A. I Hereby Apply For the Following Group 10-Year Level Term Life Insurance Coverage: Member Insurance Requested: $ I Also Request Coverage For My Eligible Children** Yes No Spouse* Insurance Requested: $ *Spouse coverage cannot exceed member s coverage. **Member coverage must be in force to request child coverage. B. Tobacco/Nicotine Use: Have you or your spouse (if proposed for coverage) used tobacco or any Member Spouse nicotine substitute in any form (including nicotine patches and nicotine chewing gum)? Yes No Yes No If Yes, please state when you last used tobacco or nicotine products and specify the product used. Member: Spouse: MM/YYYY Product MM/YYYY Product C. I Wish to Pay: Annually Semiannually Please note: A $2.00 administrative fee is added for billing modes other than annual. G Form GMA-PRS1 Continued next page.

10 3 Insurance Requested (Continued) Refer to brochure for eligibility, options and coverage description. D. Insurance Replacement Member Spouse Is the insurance applied for intended to replace, discontinue or change an existing policy? Yes No Yes No Do you have other life insurance in force? If Yes, total amount in all companies: Member $ E. Spouse Do you have other life insurance applications pending? If Yes, indicate amount and company: $ Member: $ Company Spouse: $ Company Beneficiary Designation Insert name, relationship and address. I hereby make the following beneficiary designation with respect to all the insurance on my life under this Group 10-Year Level Term Life Insurance Plan and, if I am already covered under the Plan, I hereby revoke any prior beneficiary designation. The beneficiary for dependent coverage shall be the insured member as provided in the Group Policy. (If you wish to name a different beneficiary for spouse coverage, contact the Administrator.) 1.) If naming more than one beneficiary, please note if each is to be primary and/or secondary, and also indicate the percentage of death proceeds to be distributed to each. 2.) If naming a trust, please indicate the full name and date of the trust. (Attach a separate sheet if necessary, then sign and date it.) Primary Secondary % Beneficiary Name Beneficiary s Relationship to Member Beneficiary s Social Security # Street Address City State Zip Code Primary Secondary % Beneficiary Name Beneficiary s Relationship to Member Beneficiary s Social Security # Street Address City State Zip Code 5 Statement of Health (Please initial and date any changes you make to this form) To the best of your knowledge and belief, please answer the following questions as they apply to you and all dependents to be insured. Yes No A. Are you or any other person to be insured disabled or receiving any disability or workers compensation benefits or on waiver of premium for life or health insurance? B. Are you or any other person to be insured now ill or receiving medical attention or surgical treatment? C. During the past five years, has any person to be insured consulted any physician or other medical care practitioner other than for a routine physical examination, or check up, or been hospitalized or had an operation or had any illness, disease or injury? D. Are you or any person to be insured taking any kind of medication or, so far as you know, in impaired physical or mental health? E. Is any person to be insured now pregnant? F. During the past five years, has any person to be insured ever been medically diagnosed by a physician as having been treated for: Yes No 1. Heart or circulatory trouble, high blood pressure, pain or pressure in chest? 2. Arthritis, back trouble, bone or joint disorder? 3. Fainting spells, convulsions, or epilepsy? 4. Sugar, blood, albumin or pus in urine? 5. Diabetes, kidney trouble, ulcers or digestive disorder? 6. Disorder of breasts or reproductive organs or functions? 7. Nervous or mental disorder, emotional condition or psychiatric care? 8. Cancer, tumor or cyst? 9. Varicose veins, hemorrhoids or hernia? Yes No 10. Disorder of eyes, ears, nose or sinuses? 11. Thyroid, liver or respiratory disorder? 12. Alcoholism or drug habit? 13. Disorder of the blood? 14. Other health or physical impairment including: (i). Being medically diagnosed as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex (ARC)? (ii). Chronic cough, persistent diarrhea, enlarged lymph glands, chronic fatigue, in the past five years? (iii). Any other impairment? Yes No G. (This question does not apply to residents of Maryland.) Have you or has your spouse had a parent, brother or sister who, prior to age 60, was medically diagnosed by a physician as having, or being treated for, cancer, stroke, paralysis, hypertension, diabetes, heart disease, kidney disease, or neuromuscular or mental illness? H. Within the past two years have you or has your spouse (if proposed for insurance) participated in, or do either of you within the next two years plan to participate in: aircraft flying other than as a passenger, scuba diving, ultralight flying, ballooning, parachuting, mountaineering, organized motorcycle racing, rodeo riding, snowmobiling, any type of motorized racing, hang-gliding, parasailing or bungee jumping? I. Driver s License No.: Member Spouse State in Which Issued: Member Spouse Have you or has your spouse (if proposed for insurance) had driver s license suspended or revoked, or had any moving violations, within the past five years? J. Except for residents of CT and MN, in the last seven years, have you or your spouse (if proposed for insurance) been convicted of a crime or served time in prison because of a conviction, or have an arrest pending? For residents of CT and MN only, in the last seven years have you and/or your spouse (if proposed for insurance) been convicted of a crime or served time in prison because of a conviction or been arrested and convicted for any reason? G Form GMA-PRS1 Please be sure to complete and sign the following page.

11 IF YOU HAVE ANSWERED ANY QUESTIONS YES, GIVE COMPLETE DETAILS BELOW: (If you need more space, use a signed and dated separate sheet. Please avoid the use of such terms as etc., various, or miscellaneous. ) Question Letter/No. Name(s) of Proposed Insured Illness or Condition Date of Onset Duration Treatment Operations Degree of Recovery and Date Name and Address of Physicians or Other Medical Care Practitioners and Hospitals Where Confined or Treated FRAUD NOTICE For Residents of all states except those listed below and NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. RESIDENTS OF CO, the following also applies: Any insurance company or agent who defrauds or attempts to defraud an insured shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. RESIDENTS OF AR/LA/MD/RI: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FOR RESIDENTS OF D.C., WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. RESIDENTS OF FL: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. RESIDENTS OF KS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of insurance fraud as determined by a court of law. RESIDENTS OF ME: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. RESIDENTS OF NJ: WARNING: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. RESIDENTS OF OK: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. RESIDENTS OF PUERTO RICO: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years. RESIDENTS OF TN/WA: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. RESIDENTS OF VA: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statements may have violated state law. G Form GMA-PRS1 Continued next page.

12 Authorization and Signature I understand that New York Life has the right to require additional information and, if necessary, an examination by a physician. I ask New York Life to rely on all such statements made on this form, and any supplements to it, while considering this request. I also understand that the coverage afforded will be in consideration of the answers and statements set forth above. AUTHORIZATION: I authorize any physician, medical practitioner, hospital, medical or medically related facility, laboratory, insurance company or MIB, Inc. to release information, including prescription drug records, maintained by physicians, pharmacy benefit managers, and other sources of information to New York Life Insurance Company, its subsidiaries or the plan administrator about the physical and mental health of any persons proposed for insurance, including significant history, findings, diagnosis and treatment, but excluding psychotherapy notes. A photocopy of this AUTHORIZATION and request form shall be as valid as the original. In all circumstances, my authorized agent or I may request a copy of this AUTHORIZATION. This AUTHORIZATION may be used for a period of 24 months from the date signed, unless sooner revoked as stated in the IMPORTANT NOTICE. By signing and dating this application, the member requests the insurance indicated; and the member and any person proposed for insurance consent to authorize the disclosure of information to and from the providers noted in the IMPORTANT NOTICE; and attest to having read the IMPORTANT NOTICE and Fraud Notices indicated above, including how information is exchanged with MIB, and that to the best of his/her knowledge and belief, the answers provided to the questions are true and complete. Member s Signature X (PLEASE SIGN AND DATE IN INK) DATE Spouse s Signature X (NECESSARY ONLY IF SPOUSE COVERAGE IS REQUESTED) DATE Owner Information, required if owner is other than the member (if Owner is a Trust, please submit a copy of the document with this application). Full Name Relationship to Proposed Insured LAST FIRST MIDDLE INITIAL Mailing Address STREET CITY STATE ZIP CODE Tax ID# Date of Birth / / Social Security #: - - Owner s Signature X (NECESSARY ONLY IF OTHER THAN MEMBER) DATE G Form GMA-PRS1 4/10 ed. 4/10