Senior Tribute Life Insurance NEW YORK

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1 Senior Tribute Life Insurance from American Progressive Life & Health Insurance Company of New York, a member of the Universal American family of companies. NEW YORK PR-STL-APPK 09 NY Rev. 1/2011

2 Senior Tribute can give you and your family peace of mind. Final expenses Final expenses do not have to create an unexpected financial burden for your family or loved ones. You can relax knowing that when they are faced with the inevitable expenses such as your Funeral and Administrative and Probate fees, you have provided for them. Whole Life Insurance Policy Form Series PR-LDBWL 09 Graded Death Benefit Whole Life Insurance Policy Form Series PR-GDBWL 09 Features - Level Death Benefit Age Amount $2,500 - $35, $2,500 - $25, $2,500 - $10,000 Level Death Benefit Immediate, Full Death Benefit Features - Graded Death Benefit Age Amount $2,500 - $25, $2,500 - $10,000 Over 75 Not Available Graded Death Benefit Modified Death Benefit (as shown) If death occurs during the first three years of the policy, the death benefit will equal all the premium paid plus 10% interest. Should death occur as a result of an accident, the full death benefit will be paid. Premiums Your premium is specifically designed for Males, Females, Tobacco Users and Non Tobacco Users. Guarantees are important! You can relax with Senior Tribute knowing your premiums are guaranteed NEVER TO INCREASE; your coverage is guaranteed NEVER TO DECREASE! This is all part of the Senior Tribute promise to you. There is more. Your cash values are accumulated on a tax-deferred basis. And, when the death benefit is ultimately paid to your beneficiary, it is Federal Income Tax-Free! You have the option to double or even triple your death benefit. Should you choose our Accidental Death Rider, we will Double your death benefit if death occurs as a result of an accident. Your benefits are Tripled if that accident results from riding as a passenger in a bus or a plane or any other public conveyance being operated by a common carrier transporting passengers for hire. Accidental Death Benefit Rider Form Series PR-ADB 09 This policy excludes suicide for the first two years. The optional Accidental Death Rider has further limitations and exclusions. For complete explanation of benefits, limitations and exclusions, please refer to the policy and optional rider. Simplified Underwriting No medical examination is required to obtain this valuable coverage. Just answer a few simple medical questions to determine the coverage for which you may qualify. LEAVE WITH APPLICANT

3 What are final expenses? Funeral Home Minister Cemetery Plot Medical Plot Casket Music Vault Transportation Medical Cash Needs Probate Other* Administrative Total *Proceeds from this life insurance policy may be used for any purpose. Calculate your own premium Use this handy calculation worksheet to estimate your Final Expenses. Annual Rate per 1,000 (1)$ Accidental Death Rate per 1,000 (2)+ [1+2] Total rate: (3) Number of 1,000 s (4)x [3x4] Premium: (5) Annual Policy Fee (6)+ [5+6] Total Premium: (7) Modal Factor** (if other than annual) (8)x Modal Premium: $ (Calculated premium may vary slightly due to rounding.) ** You may submit your premium using payment methods other than Annually. To determine your modal premium, multiply the corresponding modal factor times the Total Premium (7). Modal Factor Direct Annual Direct Semi-Annual Direct Quarterly Monthly Bank Draft/PAC Credit Card* Semi-Annual Credit Card* Quarterly Credit Card* Monthly * Visa and MasterCard Only LEAVE WITH APPLICANT

4 FAIR CREDIT REPORTING ACT PRE-NOTIFICATION FORM Thank you for considering American Progressive Life & Health Insurance Company of New York as your insurance carrier. Your application will be processed as quickly as possible. Public Law requires that we advise you that an investigative consumer report may be made in connection with this application. It will provide applicable information concerning character, general reputation, personal characteristics and mode of living. The information obtained in such investigative consumer report will not be used to make a determination of your sexual preference. The information for this report may be obtained through personal interviews with friends, neighbors and associates. Upon written request you will be informed whether or not an investigative consumer report was requested and if such report was requested, you will be furnished with the name and address of the consumer reporting agency to whom the request was made. You may inspect and receive a copy of the report by contacting the agency. NOTICE TO APPLICANT FOR INSURANCE Information regarding your insurability will be treated as confidential. American Progressive Life & Health Insurance Company of New York or its reinsurer(s) may; however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another Bureau member company for life and health insurance coverage, or a claim for benefits is submitted to such a company, the Bureau, upon request from you, will arrange disclosure of any information it may have in your file. (Medical information will be disclosed only to your attending physician.) If you question the accuracy of information in the Bureau s file, you may contact the Bureau and seek a correction in accordance with the procedure set forth in the Federal Fair Credit Reporting Act. The address of the Bureau s information office is 50 Braintree Hill, Suite 400, Braintree, MA , telephone number , TTY American Progressive Life & Health Insurance Company of New York or its reinsurer(s) may also release information in its file to other life insurance companies to whom you may also apply for life or health insurance, or to whom a claim for benefits may be submitted. Notice of Insurance Information Practices To evaluate your application, we will need some personal information about you. It may be necessary to obtain some of that information from sources other than yourself. For your protection, you have a qualified right to learn what information we obtain about you. You also have the right to request correction of any erroneous information. All information obtained will be kept confidential. We will furnish a more detailed summary of our information practices upon request. CONDITIONAL RECEIPT NO INSURANCE WILL BECOME EFFECTIVE PRIOR TO POLICY DELIVERY UNTIL EACH AND EVERY CONDITION CONTAINED IN THIS RECEIPT IS MET. NO AGENT OR BROKER OF THE COMPANY IS AUTHORIZED TO ALTER OR WAIVE ANY OF THE FOLLOWING CONDITIONS: Received from the sum of $ which represents a premium in connection with the application for Life Insurance with American Progressive Life & Health Insurance Company of New York. The conditions under which insurance, for which payment above is intended, may become effective prior to policy delivery, are as follows: 1. The proposed insured must be, on the Effective Date as hereafter defined, a risk acceptable to the Company under its rules, standards and practices for the exact policy and premium applied for, without modification. 2. The amount of payment taken with the application must be equal to the amount of the full first premium according to the mode of premium payment selected. 3. The policy is issued exactly as applied for within 90 days from the date of application. If each and every one of the above conditions shall have been fulfilled, then insurance as provided by the terms and conditions of the policy applied for will become effective, prior to policy delivery. The total amount of insurance (life insurance, accidental death benefits) which may become effective prior to policy delivery shall not exceed $25,000. If one or more of the conditions is not met, the liability of the Company will be limited to the return of the sum received. Effective Date (coverage begins) as used herein means the later of: (a) the date the application is signed or (b) the Requested Policy Date shown on the application. Applicant s/owner s Signature Agent s Signature Received from this day of, ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO THE COMPANY. DO NOT MAKE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK. LA-014 (1/09) NY LEAVE WITH APPLICANT

5 HOME OFFICE: Rye Brook, New York Administrative Office: P.O. Box , Lake Mary, FL (800) APPLICATION FOR INSURANCE Proposed Complete only if Owner is not Proposed Insured Insured Owner Address Relationship Birth date Address City State Zip City State Zip Social Security Number Social Security/Tax ID Number Birth Date Age Birth State Sex Marital Status Occupation Height Weight Phone: Day ( ) Evening ( ) Secondary Addressee Information When the insured or owner is age 64 or older, a copy of any notification of possible lapse will be sent to this person. Name & Address: Send premium notices to: o Proposed Insured o Owner o Other (Give name/address in Special Requests) Face Amount $ Plan Accidental Death o Yes o No Automatic Premium Loan Beneficiary of the Proposed Insured (If split, please indicate percentages) Primary Birth Date Relationship Contingent Birth Date Relationship Does the applicant own existing, in-force policies or contracts on the Proposed Insured? If yes, complete the required replacement form. Do you now or have you within the last year used tobacco products in any form? If Yes, please explain: Section 1 - No Coverage Available Modal Premium: o Annual o Semi-Annual o Quarterly o PAC o Credit Card o Visa o MC (Check one) Modal Premium Amount $ o Yes o No Yes o If the applicant answers Yes to any question in this section, the Proposed Insured is not eligible for coverage. 1. Is the Proposed Insured currently: a) hospitalized, bedridden, confined to a nursing facility, receiving hospice or home health care, confined to a wheel chair or awaiting an organ transplant?... b) diagnosed with or being treated for a terminal illness? Has the Proposed Insured ever been diagnosed with, treated for or been advised by a physician to be treated for: a) Alzheimer s Disease or other Dementia? Has the Proposed Insured ever or been diagnosed as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) by a member of the medical profession? In the past 5 years, has the Proposed Insured been diagnosed with, treated for or been advised by a physician to be treated for: a) Congestive Heart Failure?... b) Internal Cancer, Malignant Melanoma, or Leukemia? In the past 12 months, has the Proposed Insured been diagnosed with, treated for or been advised by a physician to be treated for: a) Heart Attack, Angina (chest pain), Heart Surgery, Stroke, Aneurysm?.... b) Kidney Dialysis, Alcohol or Drug Dependency Has the Proposed Insured had an application for life insurance declined in the past 6 months? No o Special Requests PR-GLDBAPP (1/09) NY (Please complete reverse side) Administrative Office Use Only: RETURN TO COMPANY

6 Section 2 - Modified Death Benefit Available If the answer is Yes to any question in this section, the Proposed Insured is eligible for the modified death benefit. 1. Has the Proposed Insured ever been diagnosed with, treated for or been advised by a physician to be treated for: a) Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Chronic Asthma, Chronic Bronchitis or any other Chronic Respiratory Disorder?... b) Parkinson s Disease, Kidney Disease, Kidney Failure, Cirrhosis, or other Liver Disease? In the past 2 years, has the Proposed Insured been diagnosed with, treated for or been advised by a physician to be treated for: a) Heart Attack, Angina (chest pain), Stroke, Aneurysm or other Heart or Circulatory disorder? b) Alcohol or Drug Dependency?... c) Diabetes requiring insulin or Diabetic Coma? Is the Proposed Insured currently Paralyzed or has the Proposed Insured had an Amputation due to disease or disorder? In the past 12 months has the Proposed Insured used Oxygen Therapy to assist in breathing? RETURN TO COMPANY If the answers are No to all questions in Section 1 & 2, the Proposed Insured is eligible for level death benefit. I hereby apply for the insurance indicated above and I am submitting the first premium. The statements on the application are true to the best of my knowledge and belief. I understand that my policy will be effective on the date it is issued by the company except as stated in the conditional receipt. I personally completed the questions in Section 1 & 2 above. I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medically related facility, insurance company, the Medical Information Bureau, a pharmaceutical database or any other organization, institution, or person that has any records or knowledge of me or my health to give to American Progressive Life & Health Insurance Company of New York or its reinsurers any such information. A photographic copy of the authorization shall be valid as the original. This authorization is valid for 24 months from the date of signature. It may be revoked at any time by sending written request to the Administrative Office of American Progressive Life & Health Insurance Company of New York. Revocation is subject to the rights of any person that acted in reliance on the authorization prior to receiving the revocation. This application will be attached to and made part of the policy. I the undersigned applicant acknowledge that I have read, or had read to me, the completed application. Cash paid with application $. Dated at, this day of,. If you are not healthy enough to qualify for the level death benefit policy and a modified or graded death benefit policy is issued, with minimal medical underwriting, the premium rate charged includes an extra mortality risk charge. For insurance policies issued for face amounts of $25,000 or less or with little or no underwriting, the premiums are often relatively expensive in relationship to the death benefit provided. For insurance purchases, as with any other types of purchases, it may be to your advantage to compare products and prices from a number of sources. X X Signature of Owner (if other than Proposed Insured) Signature of Proposed Insured Graded Death Benefit Policies - If you have applied for the Graded Death Benefit policy, please note that the death benefit in the first 3 years is equal to the premiums plus interest. Also, an accidental death benefit is in effect during those 3 years. Instructions to agents - This statement must be completed with application. 1. Submit all applications and business transmittals within 7 days of application date. 2. Do not solicit business on any individual currently hospitalized or confined to a nursing home. 3. Do not solicit business on any individual you have reason to believe is suffering from a terminal illness. 4. All premium checks must be made payable to American Progressive Life & Health Insurance Company of New York. 5. The full initial premium must be submitted with application. Agent s Statement By signing below, I the agent, hereby certify that all the information contained on this application has been truly and accurately recorded as supplied by the Proposed Insured. To the best of my knowledge all the answers are complete and true, and the applicant is not currently hospitalized or confined to a nursing home, nor do I have reason to believe the applicant is suffering from a terminal illness. The applicant has read or had read to him/her the entire application. To the best of my knowledge and belief the applicant does o does not o own existing, in-force policies or contracts on the Proposed Insured. I personally did see o did not see o the applicant at the time of the application. Agent Printed Name Agent Signature Agent Number: Agent State ID Number: PR-GLDBAPP (1/09) NY

7 Point of Sale Telephone Interview #: Issue Age Senior Tribute Level Death Benefit Graded Death Benefit Female Male Female Male Non Tobacco Tobacco Non Tobacco Tobacco Non Tobacco Non Tobacco All Tobacco Tobacco 45 $20.00 $28.00 $28.00 $39.00 $ Graded Benefit Available for Age Only Age Only Ω Annual rates per $1000 Graded Benefit Available for Ω Add $36 annual policy fee Acc. Death Benefit Rider RETURN TO COMPANY

8 AMERICAN PROGRESSIVE LIFE & HEALTH INSURANCE COMPANY OF NEW YORK Home Office: Administrative Office: Phone: BANK CHECK PREMIUM PAYMENT PLAN AMERICAN PROGRESSIVE LIFE & HEALTH INSURANCE COMPANY OF NEW YORK X EXACTLY PRE-AUTHORIZATION FORM For Recurring Payment with Credit Card X RETURN TO COMPANY

9 USA PATRIOT Act Customer Identification Program (CIP) Notification and Identification Form American Progressive Life & Health Insurance Company of New York respects and protects the confidentiality of our customer s information. To help the government fight the funding of terrorism and money laundering activities, Section 326 of the USA PATRIOT Act requires all financial institutions, including insurance companies, to obtain, verify, and record information that identifies each person who applies for, and is insured under an insurance policy and/or an annuity contract. As part of this program, we require our representative to review and verify a current governmental issued photo ID for each Insured/Owner/Trustee associated with the specified insurance policy or annuity contract. This verification process may include our use of a Credit Reporting Agency to verify the information you have provided to us. Applicant s name Taxpayer identification number (SSN) Applicant #2 s name Taxpayer identification number (SSN) Residential street address City State Zip code Identification Verified: (One for each Insured/Owner/Trustee. Use additional forms if necessary.) The type of identification used (one required) number and expiration date must be recorded below. Document ID Number Driver s License State ID Card Military ID Card Passport US Alien Registration Card Other: Country/State of Origin Date of Birth Expiration Date Applicant #2 Identification Verified: (One for each Insured/Owner/Trustee. Use additional forms if necessary.) The type of identification used (one required) number and expiration date must be recorded below. Document ID Number Driver s License State ID Card Military ID Card Passport US Alien Registration Card Other: Country/State of Origin Date of Birth Expiration Date Agent Attestation: I attest to the fact that I have viewed the above identified documentation. I also attest that the documents did not appear to be altered and the picture identification provided appeared to be that of the Insured/Owner/Trustee. Agent printed name Date Agent signature American Progressive PAT-CIP 0406 RETURN TO COMPANY

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11 HIPAA AUTHORIZATION ADDENDUM American Progressive Life & Health Insurance Company of New York Home Office: Rye Brook, NY Administrative Office: P. O. Box 13547, Pensacola, Florida Phone: (800) This authorization is designed to satisfy the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The purpose of this disclosure is to evaluate my application for insurance or claim benefits. I authorize any health care provider, including any physician, practitioner, pharmacy, hospital or medically-related facility, and any insurance company, MIB, Inc., Pharmaceutical Database, employer, or, except in AZ and WI, any other organization, institution or person that has my records or knowledge of me or my dependent(s) to disclose to American Progressive Life & Health Insurance Company of New York (The Company) and its reinsurers, or its authorized representative, any and all such records or information. Records or information may include medical records in their entirety, which may contain mental health records (excluding psychotherapy notes), prescription drug records, records of use of alcohol, or use of controlled or prohibited substances, driving records, financial and employment records. Such records or information will be used by The Company personnel to determine eligibility for life and/or health insurance and life and/or health insurance benefits. The Company may disclose such information to its reinsurer(s), precertification firm, individual benefits management firms or any other organization which performs services in connection with the insurance relationship, including, but not limited to, the insurance agent, or as lawfully required. I further authorize The Company, and its reinsurers, to disclose information to MIB, Inc., a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. The information may be disclosed by The Company to MIB, Inc., who, upon request, may also disclose such information about you in its file to another member company with whom you apply for life or health insurance or to whom a claim for benefits may be submitted. There may be certain circumstances under which the information received may be disclosed to third parties who are not subject to the regulations under federal health privacy law. We contractually require such persons to agree to protect the confidentiality of the information. I understand that I have the right to request access to all personal information collected and, upon written request, I may ask The Company to correct, amend or delete any incorrect personal information. A copy of The Company s Notice of Privacy Practices is available upon request. This authorization shall be valid for a period of two (2) years from the date signed, one (1) year in Kansas. A photocopy of this authorization shall be as valid as the original. I understand that I, or my authorized representative, may receive a copy of this authorization upon request. This authorization may be revoked at any time subject to the rights of anyone who acted in reliance upon the authorization prior to notice of its revocation. This authorization may be revoked upon submission of a written notice to The Company s Home Office. If this authorization was obtained as a condition of obtaining insurance coverage, your right to revoke is also subject to the rights of The Company under any law granting The Company the right to contest a claim under the policy or the policy itself. Revocation or failure to sign the authorization may be a basis for denying an application or eligibility for benefits. Patient s Name: First Middle Last Other Names Used: Date of Birth: Social Security Number: Signature of Applicant: Date: (Signature of Parent or Legal Guardian required if child is under 18) Signature of Spouse: Date: (If applying for coverage) Signature of Authorized Representative: Relationship: Date: Authorized Representative s Address: Authorized Representative s Phone Number: PR HIPAA 4/10 RETURN TO COMPANY

12 AMERICAN PROGRESSIVE LIFE AND HEALTH INSURANCE COMPANY OF NEW YORK RYE BROOK, NEW YORK INSURANCE DEPARTMENT OF THE STATE OF NEW YORK DEFINITION OF REPLACEMENT In order to determine whether you are replacing or otherwise changing the status of existing life Insurance policies or annuity contracts, and in order to receive the valuable information necessary to make a careful comparison if you are contemplating replacement, the agent is required to ask you the following questions and explain any items that you do not understand. As part of your purchase of a new life insurance policy or a new annuity contract, has existing coverage been, or is it likely to be: 1. Lapsed, surrendered, partially surrendered, forfeited, assigned to the insurer replacing the life insurance policy or annuity contract, or otherwise terminated?..... YES 2. Changed or modified into paid-up insurance; continued as extended term insurance or under another form of nonforfeiture benefit; or otherwise reduced in value by the use of nonforfeiture benefits, dividend accumulations, dividend cash values or other cash values? YES 3. Changed or modified so as to effect a reduction either in the amount of the existing life insurance or annuity benefit or in the period of time the existing life insurance or annuity benefit will continue in force? YES 4. Reissued with a reduction in amount such that any cash values are released, including all transactions wherein an amount of dividend accumulations or paid-up additions is to be released on one or more of the existing policies? YES 5. Assigned as collateral for a loan or made subject to borrowing or withdrawal of any portion of the loan value, including all the transactions wherein any amount of dividend accumulations or paid-up additions is to be borrowed or withdrawn on one or more existing policies? YES 6. Continued with a stoppage of premium payments or reduction in the amount of premium paid? YES If you have answered YES to any of the above questions, a replacement as defined by New York Insurance Department Regulation No. 60 has occurred or is likely to occur and your agent is required to provide you with a completed Disclosure Statement and the IMPORTANT Notice Regarding Replacement or Change of Life Insurance Policies or Annuity Contracts. Signature of Applicant: Signature of Applicant: Date: Date: AGENT S STATEMENT To the best of my knowledge, a replacement is involved in this transaction YES Signature of Agent: Date: RPL-DEF-NY (11/98) Rev White Copy Home Office Yellow Copy Leave with Applicant RETURN TO COMPANY

13 AMERICAN PROGRESSIVE LIFE AND HEALTH INSURANCE COMPANY OF NEW YORK RYE BROOK, NEW YORK INSURANCE DEPARTMENT OF THE STATE OF NEW YORK DEFINITION OF REPLACEMENT In order to determine whether you are replacing or otherwise changing the status of existing life Insurance policies or annuity contracts, and in order to receive the valuable information necessary to make a careful comparison if you are contemplating replacement, the agent is required to ask you the following questions and explain any items that you do not understand. As part of your purchase of a new life insurance policy or a new annuity contract, has existing coverage been, or is it likely to be: 1. Lapsed, surrendered, partially surrendered, forfeited, assigned to the insurer replacing the life insurance policy or annuity contract, or otherwise terminated?..... YES 2. Changed or modified into paid-up insurance; continued as extended term insurance or under another form of nonforfeiture benefit; or otherwise reduced in value by the use of nonforfeiture benefits, dividend accumulations, dividend cash values or other cash values? YES 3. Changed or modified so as to effect a reduction either in the amount of the existing life insurance or annuity benefit or in the period of time the existing life insurance or annuity benefit will continue in force? YES 4. Reissued with a reduction in amount such that any cash values are released, including all transactions wherein an amount of dividend accumulations or paid-up additions is to be released on one or more of the existing policies? YES 5. Assigned as collateral for a loan or made subject to borrowing or withdrawal of any portion of the loan value, including all the transactions wherein any amount of dividend accumulations or paid-up additions is to be borrowed or withdrawn on one or more existing policies? YES 6. Continued with a stoppage of premium payments or reduction in the amount of premium paid? YES If you have answered YES to any of the above questions, a replacement as defined by New York Insurance Department Regulation No. 60 has occurred or is likely to occur and your agent is required to provide you with a completed Disclosure Statement and the IMPORTANT Notice Regarding Replacement or Change of Life Insurance Policies or Annuity Contracts. Signature of Applicant: Signature of Applicant: Date: Date: AGENT S STATEMENT To the best of my knowledge, a replacement is involved in this transaction YES Signature of Agent: Date: RPL-DEF-NY (11/98) Rev White Copy Home Office Yellow Copy Leave with Applicant LEAVE WITH APPLICANT

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16 Administrative Office Senior Health Service Center P.O. Box Pensacola, FL Policyholder Services & Claims: Universal American (NYSE: UAM), through our family of healthcare companies, offers benefit plans designed to promote collaboration among our members and their healthcare professionals. This Healthy Collaboration SM improves the health and well-being of over two million people with Medicare every day. American Progressive is a member of the Universal American family of companies. American Progressive offers a portfolio of products to America s seniors, including supplemental health insurance and life insurance.

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