CSA FRATERNAL LIFE A Fraternal Benefit Society P.O. Box 249, Lombard, Illinois Application for Life Insurance

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1 FOUNDED MARCH 4, 1854 Personal Information 1. Full name of Proposed Insured: Lodge Name: CSA FRATERNAL LIFE A Fraternal Benefit Society P.O. Box 249, Lombard, Illinois Application for Life Insurance Lodge No.: PLEASE PRINT/TYPE IN DARK INK ONLY Last First Middle 11. Total Annual Premium: $ Sex: M F 12. Requested Effective Date: Social Security No. (required) Application Date Other Date 4. Date of Birth: 5. Age: Note: Coverage can only become effective on the 1st through 28th of 6. Citizen of : a month. A requested effective date cannot be earlier than the application date and no later than 30 days afterward. All checks are deposited 7. Driver s License No: upon receipt of the application. 8. Residence Address: 13. Dividend Option not a guarantee of future dividends. Street Cash Accumulated at Interest Paid-Up Additions City State Zip Home Telephone No. Business Telephone No. Cell Telephone No. 9. Billing Address and Name of Payor (if other than insured): Selection of Coverage Non-nicotine Nicotine Base Plan of Insurance Ultimate Face Amount Full Name Street Level Benefit Lifetime Pay $ City State Zip 10. Do you currently have any existing life insurance policies or annuity contracts in force? Yes No Will the proposed insurance replace or change in whole or in part any in force insurance or annuities? Yes No If yes, give name of company, amount and policy number your state may require a replacement form. Insurance Company Amount Policy No. Do not cancel any in force insurance or annuities until this proposed life insurance is approved in writing by CSA Fraternal Life. Level Benefit Single Pay $ Increasing Benefit $ Graded Benefit $ Modified Benefit $ Rider (available only on level and increasing benefit plans) Accidental Death $ Amount of Rider (Face Amount) DESCRIPTION OF DEATH BENEFITS OTHER THAN ACCIDENTAL DEATH* Level 100% of Ultimate Face Amount Graded * Certificate Year 1 30% of Ultimate Face Amount Increasing Death benefit increases 4% per year starting in 2 nd year Certificate Year 2 70% of Ultimate Face Amount Ultimate Face Amount is 2 times original face amount Certificate Years 3 and after 100% of Ultimate Face Modified* Certificate years 1 and 2 120% of premiums paid; after Amount 2 years 100% of Ultimate Face Amount * For accidental death, the Ultimate Face Amount is paid in years 1 and 2 for all plans. OWNER INFORMATION (if other than Proposed Insured) 1. Full name of Owner: 1A. Relationship to Proposed Insured: Sex: M F Last First Middle Social Security No. (required) 4. Date of Birth: 5. Age: 5. Residence Address: Street City State ZIP Home Telephone No. Business Telephone No. Cell Telephone No. 1

2 GENERAL HEALTH QUESTIONS TO BE COMPLETED BY ALL APPLICANTS PART A Yes No 1. Have you been diagnosed by a medical professional as having a life expectancy of 12 months or less? Have you been diagnosed, received treatment, advice or consultation or been prescribed medication by a medical professional for: A. Human immunodeficiency virus (HIV) infection, acquired immune deficiency syndrome (AIDS) or AIDS related complex (ARC)?... B. Amyotrophic lateral sclerosis (ALS)? Have you had or been advised by a medical professional to have an organ or tissue transplant other than corneal? Are you currently hospitalized, bedridden, confined to a nursing or rehabilitation facility or receiving hospice or home health care?. IF ALL QUESTIONS IN THIS PART HAVE BEEN ANSWERED NO, PLEASE PROCEED IN COMPLETING THE REMAINDER OF THIS APPLICATION. IF ANY OF THE QUESTIONS IN THIS PART HAVE BEEN ANSWERED YES, COVERAGE CANNOT BE PROVIDED AND THE REMAINDER OF THIS APPLICATION SHOULD NOT BE COMPLETED. PART B IF ANY QUESTIONS IN THIS PART ARE ANSWERED YES A MODIFIED PLAN MAY BE ISSUED. FOR ALL YES ANSWERS, PLEASE CIRCLE THE APPROPRIATE CONDITIONS. 5. Have you ever been diagnosed, received treatment, advice or consultation or been prescribed medication by a medical professional for Alzheimer s disease, dementia or organic brain disorder?.. 6. In the past five (5) years, have you been diagnosed, received treatment, advice or consultation for or been prescribed medication by a medical professional for:... A. Internal cancer, malignant or benign brain tumor, malignant melanoma, leukemia, lymphoma or Hodgkin s disease?.. B. Coronary artery disease (CAD), cardio-vascular heart disease, heart attack, angina or chest pain, congestive heart failure, heart valve disease, cardiomyopathy, aneurysm, carotid artery disease, peripheral artery disease or any heart or cardio-vascular disease or disorder that required surgery?. C. Stroke or transient ischemic attack (TIA)?... D. Emphysema, chronic obstructive pulmonary disease (COPD), respiratory distress syndrome or any respiratory or pulmonary disease or disorder that required the use of oxygen?. E. End stage renal disease, chronic renal failure or any kidney disease or disorder that required dialysis?.. F. Alcoholism, drug or alcohol abuse or addiction?. G. Any disease or disorder that required an amputation?. 7. Are you confined to a wheelchair?... PART C IF ANY QUESTIONS IN THIS AREA ARE ANSWERED YES, A GRADED PLAN MAY BE ISSUED. FOR ALL YES ANSWERS, PLEASE CIRCLE THE APPROPRIATE CONDITIONS. 8. In the past five (5) years, have you been diagnosed, received treatment, advice or consultation or been prescribed medication by a medical professional for: A. High blood pressure or other heart or circulatory disease or disorder not previously listed on this application? If yes for high blood pressure, please provide the latest blood pressure reading: / B. Cirrhosis or hepatitis?... C. Epilepsy or seizure disorder?... D. Parkinson s disease, Huntington s chorea, myasthenia gravis, muscular dystrophy or multiple sclerosis?.. E. Lupus erythematosus, dermatomyositis, polyarteritis or scleroderma?. F. Sickle cell or aplastic anemia?. G. Insulin or non-insulin dependent diabetes? H. Bi-polar disorder, schizophrenia or psychosis?. 2

3 9. Do you require assistance with the activities of daily living such as eating, bathing, dressing, etc.? Do you use a walker or other mobility aid? Have you been advised by a medical professional to have surgery that has yet to be performed?. If yes, please provide details: 12. Are you currently taking any prescription medication?. If yes, please list the names of the prescription medications being taken: Yes No 13. In the past five (5) years, have you had life insurance declined, rated-up or rescinded?... If yes, please provide details: IF MULTIPLE QUESTIONS HAVE BEEN ANSWERED YES OR MULTIPLE CONDITIONS HAVE BEEN CIRCLED IN PARTS B AND C, MODIFIED COVERAGE MAY BE ISSUED OR COVERAGE MAY NOT BE PROVIDED. PART D IF ANSWERED YES, NICOTINE RATES WILL APPLY. 14. Have you used tobacco in any form or nicotine cessation/replacement products in the past 12 months?. BENEFICIARY INFORMATION List full name, address, date of birth, relationship and social security number 1. Primary beneficiary(ies): 2. Contingent beneficiary(ies): 3

4 CERTIFICATION AND SIGNATURE I hereby declare that the statements and answers made by me on this application are complete, correct and true to the best of my knowledge and belief and that no material information has been withheld or omitted. I understand CSA Fraternal Life will individually underwrite this application relying on the responses contained on the application. I agree that the completed application, the certificate issued to me upon this application and the Constitution and Bylaws of CSA Fraternal Life, the medical examinations of the questions and my answers thereto concerning my insurability and all amendments of such documents, shall together constitute the entire contract of insurance between me and CSA Fraternal Life. I further agree that the same shall in no way be affected or modified by any statements or information given by or to any person soliciting or taking this application or by or to any other person or by any information possessed by such person. I further agree, for myself and my beneficiary (ies), to abide by said Bylaws. I hereby apply for membership in CSA Fraternal Life. If accepted, I agree to abide by the Articles of Incorporation and Bylaws of CSA Fraternal Life and the rules and regulations of said Lodge, all as the same now exist or are hereafter amended. I further agree to pay the required membership dues. I hereby authorize any licensed physician, medical practitioner, hospital, clinic, medical or medically related facility or other health care provider, insurance or reinsuring company, consumer reporting agency or other organization, institution or person, having any records or knowledge of my health, to give to CSA Fraternal Life or its reinsurers any such information it may require to determine eligibility for insurance or any subsequent benefit payment. I hereby authorize CSA Fraternal Life to use one of its approved vendors to check my usage of prescription medication. This authorization will be valid for 24 months from the date the authorization is signed and may be revoked at any time. A photographic copy of this authorization shall be as valid as the original. I understand that I (or my authorized representative) am entitled to a copy of this authorization. I also acknowledge receipt of the NOTICE OF INFORMATION PRACTICES. I understand that there may be a follow-up telephone call in conjunction with this application. I KNOW THAT ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD AN INSURER SUBMITS AN APPLICATION FOR INSURANCE CONTAINING FALSE OR DECEPTIVE STATEMENTS MAY BE GUILTY OF INSURANCE FRAUD. Signed at: Date: (city and state) Signature of Proposed Insured: Signature of Owner (if other than Proposed Insured): AGENT S STATEMENT 1. Did you give Notice of Information Practices, Receipt of Premium and Notice of Underwriting form to the Proposed Insured? 2. What other agent receives commission on this application? What percent? 3. Does the Proposed Insured wish to be mailed the CSA Journal? Yes No 4. To the best of your knowledge, is insurance replacement involved in this transaction? Yes No 5. I certify that I do not have any knowledge concerning the Proposed Insured s medical information other than the information contained on this application. I have not advised the Proposed Insured to omit or inaccurately report any information requested on the application. I understand that I do not have the right to bind coverage and I have advised the Proposed Insured that no amount of life insurance will become effective prior to being approved in writing by CSA Fraternal Life. Comments: Cash received with application $ for month s premium Agent Name: Agent No. Business Telephone No. Business Address: City State ZIP Yes No Signature of Agent: 4

5 AUTHORIZATION TO HONOR CHECKS DRAWN BY CSA FRATERNAL LIFE Gentlemen: As a convenience to me, I hereby request and authorize you to pay and charge to my account checks drawn on my account by and payable to CSA Fraternal Life, provided there are sufficient collected funds in my account to pay such checks upon presentation. I agree that your rights in respect to each such check shall be the same, as if it were a check drawn on you and signed personally by me. This authority is to remain in effect until revoked by me in writing, and until you actually receive such notice. I agree that you shall be fully protected in honoring any such check. I further agree that if any such check is dishonored, whether with or without cause and whether intentionally or inadvertently, then you shall have no liability whatsoever, though such dishonor results in the forfeiture of insurance. Bank Name: Branch: Street: City: State: ZIP: Bank Account Number: Bank Routing Transit Number: Name(s) of Depositor(s), as shown on bank account: Signature(s): X X IF YOU ARE PAYING FOR MORE THAN ONE POLICY, PLEASE LIST IN THE BOX TO THE RIGHT. PREMIUM CERTIFICATE NO. PLEASE ATTACH A VOIDED CHECK OR DEPOSIT FORM Checking Savings AGREEMENT: As a convenience to me, I request and authorize CSA Fraternal Life to draw Pre-Authorized Checks (PAC) on my account maintained at the bank named on this form. It is agreed that: 1. Checks shall be drawn to CSA Fraternal Life for premiums and/or policy loan repayment as directed by me. 2. CSA Fraternal Life shall incur no liability by reason of dishonor of any such check. 3. Any requirement for giving notice of premiums due shall be waived so long as this PAC plan is in effect for the payment of premiums; the cancelled check shall constitute a receipt, but no payment shall be deemed to have been made unless and until CSA Fraternal Life receives actual payment at its Home Office. Use of the PAC plan shall in no way alter or amend the provisions of the certificates as to premium payment. Request by me that such checks be drawn on other than the premium due date or the grace period provisions in connection herewith. 4. If a check drawn by CSA Fraternal Life on my account includes the premium for more than one certificate and/or includes loan repayments, I understand and agree that no premium shall be deemed paid not shall a loan repayment be deemed made until CSA Fraternal Life receives actual payment of the full amount of such check at its Home Office. 5. I understand that checks drawn under this PAC plan for loan repayments, upon being charge to my account by the bank, shall be my receipt for the payment as designated. Should any check not be honored by said bank upon presentation, then it is understood that such payment shall be charged back to the certificate or certificates. 6. I agree that I shall be liable to reimburse CSA Fraternal Life for any and all bank fees incurred by CSA Fraternal Life due to nonpayment. 7. This agreement can be terminated by either party upon 30 days written notice. It may be extended by mutual consent to cover premiums and/or loan repayments on additional certificates. TO THE BANK ADDRESSED ABOVE: INDEMNIFICATION AGREEMENT In consideration of your honoring Pre-Authorized Checks drawn against depositors of your bank for the payment of amounts to CSA Fraternal Life we agree that no liability or responsibility shall attach to your bank as a result of honoring or dishonoring such checks. We further agree to hold you harmless from and reimburse you for any loss resulting as a consequence of your actions taken pursuant to your agreement to honor such checks. We shall defend any action brought against you by any of your depositors or any other person because of your compliance with this Pre-Authorized Check plan. Executive Secretary/Treasurer Notice to Bank: We have intentionally omitted any reference to certificate numbers, amounts or the frequency of the payment to save you the time, trouble and expense of verifying this information before honoring a check for clearance. 5

6 NOTICE OF INFORMATION PRACTICES This application is the major source of information about you which we use in evaluating your application and reviewing your certificate. As part of our routine underwriting procedure, we will occasionally obtain an investigative consumer report which will provide applicable personal information concerning character, general reputation, personal characteristics and mode of living. This information may be obtained through other parties, including personal interviews with your family members, friends, neighbors and associates. (None of the information collected concerning the sexual orientation of the Proposed Insured will be used to determine eligibility for insurance.) In some circumstances, this information may be disclosed to third parties without your specific authorization, but only for certain limited purposes related to the conduct of our business with respect to this application. You have the right to access and correction with respect to all personal information collected, and a full notice of your rights will be furnished upon request. CSA Fraternal Life A Fraternal Benefit Society PO Box 249, Lombard IL RECEIPT OF PREMIUM AND NOTICE OF UNDERWRITING Received from this day of 20, the sum of $, as first premium for the application relating to (Proposed Insured) subject to the following terms and conditions. It is understood that CSA Fraternal Life will individually underwrite this application for life insurance relying upon the responses contained on the application. No amount of life insurance will become effective prior to being approved in writing by CSA Fraternal Life. No agent of CSA Fraternal Life is authorized to waive these terms and conditions. Signature of Agent Agent No. Date Signature of Proposed Insured Date Signature of Owner (if other than Proposed Insured) Date 6

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