The United States Life Insurance Company in the City of New York New York, New York A member company of American International Group, Inc.

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2 The United States Life Insurance Company in the City of New York New York, New York A member company of American International Group, Inc. Received $ from in connection with application for conversion of Group Life or Wholesale insurance to Individual insurance under Policy No. Certificate No. The Conversion of the insurance shall be subject to the provisions of the Group or Wholesale policy referred to. If the provisions have been fully complied with, the insurance applied for shall take effect when: (a) (b) the full first premium has been paid and the proposed insured s insurance under the Group or Wholesale policy has been terminated. Date Agent

3 HOW TO COMPLETE THE LIFE CONVERSION APPLICATION A) Group or Wholesale Policy Number: This enables The United States Life Insurance Company in the City of New York to properly maintain your individual insurance records. B) Issued To: Please write in the name of your group. C) Certificate No.: It is not necessary to answer this question. Please proceed to question 1. 1) Full Name: First name, middle name (if any), and last name. 2a) Date of Birth: Month, day, year. 2b) Age nearest birthday: Effective date of your life conversion is 31 says after group insurance ends. If your last birthday is within 6 months of the effective date, please use your present age. If the effective date is within 6 months of your next birthday, you would use the age you will be on your next birthday. 3) Residence Address: Where you currently live. 4) How many hours per week did you work for the above employer? This question should be answered only if you terminated employment, and the group plan remains in force. 5a) Date of termination of Group Insurance: This is the date in which you were last covered for group insurance. 6) Present Occupation: What you currently do. 7) Send Premium Notices to Owner: Please indicate where the premium statements are to be sent. If the premium statements are to be sent to the business, please fill in item #8. 8) Business Address: This is only completed if the premium statements are to be sent to the insured s business. 9, 10 & 11) It is necessary that these items are completed. The insured does not have to provide insurability, and this plan is not medically underwritten. This does not affect the eligibility of the life conversion. 12a) Plan of Insurance: Name of plan that you elect for life conversion. All life conversion plans are non-participating, which means that they do not pay dividends. 12b) Amount of Insurance: You can convert up to the amount of insurance you had while covered under the group plan. 13) Automatic Premium Loan: This is not available on the life conversion plan. If this loan provision became available in the future, would you like to exercise that option? 14) Premium Payable: You can be billed for your premiums either quarterly, semi annually or annually. 15) Amount of Premium: Please be sure that the amount of premium enclosed corresponds to the mode billing selected in item #14. 16) Beneficiary: This is the person who is entitled to the benefit on death of the insured. The primary beneficiary is the first person selected to receive the death benefit. The contingent beneficiary is the person selected to receive the death benefit only upon death of BOTH the insured and primary beneficiary. 17) Owner: This is the person responsible for the payment of premiums. If the owner is someone other than the insured. please complete this section. Special Requests: This is answered only if you want The United States Life Insurance Company in the City of New York to do something which is not listed on the application. Amendments: The home office uses this space. Do not fill in.

4 NON-SMOKING DECLARATION Proposed Insured s Name (Please print) Proposed Spouse s Name (Please print) For group life insurance to be issued or continued at a discounted premium, I declare that: Employee Spouse 1. I have not smoked cigarettes during the past 12 months. True False True False 2. I do not currently smoke pipes or cigars. True False True False This declaration is true to the best of my knowledge and belief. Signature of Proposed Insured Signature of Proposed Spouse Date of Signature Signed at: City State American General Life Companies Group Benefits and Financial Institutions Distributing products issued by: AIG Life Insurance Company*, All American Life Insurance Company*, American General Assurance Company*, American General Indemnity Company*, American General Life Insurance Company*, American General Life Insurance Company of Pennsylvania*, American General Life Insurance Company of New York, American International Life Assurance Company of New York, Delaware American Life Insurance Company*, North Central Life Insurance Company*, The United States Life Insurance Company in the City of New York Member companies of American International Group, Inc Route 66 Neptune, NJ *This Company does not solicit business in New York.

5 CONFIRMATION OF GROUP LIFE INSURANCE This form must be completed by your former employer and must be submitted with your application. DATE: GROUP POLICY NUMBER: NAME: Please have your Benefit Administrator complete the following information and return this form with your application for individual insurance: 1. TERMINATION DATE: MONTH: DAY: YEAR: REASON FOR TERMINATION: 2. DATE GROUP LIFE INSURANCE BEGAN: MONTH: DAY: YEAR: 3. AMOUNT OF LIFE INSURANCE INFORCE AT TIME OF TERMINATION OF EMPLOYMENT: $ 4. STATE IN WHICH YOUR COMPANY S CORPORATE OFFICE IS LOCATED: GROUP BENEFIT ADMINISTRATOR: SIGNATURE: DATE: PLEASE FORWARD INFORMATION TO: The United States Life Insurance Company in the City of New York Attention: Group Customer Accounts 3-A 3600 Route 66 P O Box 1583 Neptune, NJ American General Life Companies Group Benefits and Financial Institutions Distributing products issued by: AIG Life Insurance Company*, All American Life Insurance Company*, American General Assurance Company*, American General Indemnity Company*, American General Life Insurance Company*, American General Life Insurance Company of Pennsylvania*, American General Life Insurance Company of New York, American International Life Assurance Company of New York, Delaware American Life Insurance Company*, North Central Life Insurance Company*, The United States Life Insurance Company in the City of New York Member companies of American International Group, Inc Route 66 Neptune, NJ *This Company does not solicit business in New York.