SUPPLEMENTAL DISABILITY INCOME PROTECTION PLAN

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1 SUPPLEMENTAL DISABILITY INCOME PROTECTION PLAN PROPOSED FOR: Company Name PREPARED BY: AGENT NAME ADDRESS 1 ADDRESS 2 CITY, STATE ZIP PHONE, FAX DATE UC 619 (12/03)

2 PROPOSAL OF SUPPLEMENTAL DISABILITY INCOME PROTECTION FOR SELECT EMPLOYEES OF ABC COMPANY Based on the information that you have provided us, we have calculated the level of coverage your employees now have. To provide each employee with a higher level of protection, we have calculated the amount of coverage for which each employee is eligible. Based on a study of your current program, we have determined the following conditions exist: Your LTD plan insures XX percent of covered compensation. Your LTD plan has a maximum benefit of $X,XXX. There are employees who earn bonus or other incentive income that is not protected by your LTD plan. There are employees whose total incomes exceed the maximum level protected by your LTD plan. Your LTD plan is employer-paid, resulting in taxable benefits to a disabled employee. Included in this proposal is an offer of Guaranteed Issue coverage for the selected employees, which includes the terms under which we offer individual disability income policies. These policies are designed to supplement your existing LTD plan and will provide a higher level of protection for your key employees. Also included is an illustration that shows the level of protection each employee will receive under this program as well as its cost.

3 The Union Central Life Insurance Company 1876 Waycross Road P.O. Box Cincinnati, OH (800) Date Name Address City, State Zip Dear Union Central is pleased to extend this offer of disability insurance coverage to the eligible participants of ABC Company. The offer is based on the following: Requirements for Eligibility: 70 US-based vice presidents and executives earning at least $100,000 Underwriting requirements: below age 65 must be actively at work full-time and for past 180 days 100 percent of those eligible and meeting the underwriting requirements must participate. Our Plan Design: LTD plan design is 60 percent to $10,000, taxable. We guarantee to issue on a standard basis up to a maximum of $5,000 of individual disability insurance base coverage. The definition of disability for the base coverage is Own Occupation to 65 and Non-engaged. The riders included in the plan specifically designed for ABC Company are: Long Term Residual Rider availability follows normal underwriting guidelines regarding age and occupation class. The elimination period is 90 days. The benefit period is to Age 65. The occupational classes of the participants will be based upon their actual job duties on the effective date of coverage for each insured. The premium basis is unisex. Securities offered through affiliate Ameritas Investment Corp., member NASD/SIPC, 1876 Waycross Road, Cincinnati, Ohio Telephone number (800)

4 Payment of Premiums: Premiums will be paid entirely by the employer using a list bill covering all eligible participants. The mode of premium payment is monthly. Discount: 25 percent Basis of Issue: The basis of issue is Guaranteed Standard Issue (GSI). This means that the policy will not be rated or ridered for medical reasons for basic amounts up to the maximum amount shown above. The amount of GSI for which a participant is eligible has been determined using the Issue and Participation Limits for the GSI program and an underwriting assessment of general risk factors associated with ABC Company less any other individual or group coverage applied for or in-force. Benefit amount is calculated for each participant by using 75 percent of that participant s current salary less the LTD benefit. In no event will GSI coverage in excess of the maximum stated above be issued. Any amounts purchased above the maximum basic amounts noted above or with a benefit configuration other than that described in the Plan Design section of this correspondence will be considered outside of the terms of this offer. Such policies will be issued pursuant to normal rules for fully underwritten business. Earned income verification will be required as a basis for coverage. However, as a provision of this program, we will waive our normal requirements for tax forms if we receive a census on the employer s letterhead signed by a duly authorized officer of the company. The census for each eligible participant should include name, date of birth, sex, smoker status, job duties, salary (two years, if possible), bonus (two years, if possible), commission (two years, if possible), and employee contribution to retirement plan. Policies will be issued to all employees eligible on the effective date of coverage. Newly eligible employees must apply within 60 days of coverage. When additional employees become eligible, the same requirements will apply to them. Offer Acceptance: This offer is valid until Date. No applications will be processed until written acceptance of this offer is received in our Home Office. We reserve the right to modify or withdraw this offer at any time. Factors such as, but not limited to, experience, availability of contract or rider types, nonadherence to offer terms or a change in our marketing direction could make this necessary. No communication to participants of this offer or its terms should be distributed without prior review by an appropriate member of our legal department.

5 Application Process: All applications must be received within 90 days of the acceptance of this offer. If all applications have not been received by this date, the offer will be void. The short form application UC4348 must be used for all insureds under this offer. A copy of this offer letter must be attached to the applications. Offer Renewal: Any redefinition of the eligible group will result in a reevaluation of the existing offer. This offer may be renewed each year based on the mutual agreement of ABC Company and Union Central. In order to consider the renewal of the offer, we need to receive a census current as of the renewal date that includes data consistent with that originally provided. Name, we are very excited to have this opportunity to provide GSI disability coverage to eligible participants of ABC Company. If you have questions about any of the above, or anything not covered by this offer, please do not hesitate to call me at (800) (ext. 2814). Please indicate the acceptance of this offer by returning a copy of this letter signed by an authorized representative of ABC Company and yourself. Sincerely, Cathy Howe Multi-Life Underwriter On behalf of ABC Company, I accept the offer outlined in this correspondence and understand that these specifications are only available pursuant to the requirements stated herein and only through the producer to whom this letter is addressed. (Signature) (Signature) (Title) (Producer) (Date) (Date