A Guide to Life Insurance New Business Forms

Transcription

1 A Gide to Life Insrance New Bsiness Forms This gide is divided in 7 sections which inclde the form name and nmber, whether state variations exist, a description of the form, when needed and whether or not signatres are reqired. The first section contains the forms yo will always need when filling ot a life insrance application. The remaining sections contain forms that may be needed based on riders or for specific prodcts, age and amont reqirements, specific cstomers, beneficiary/owner designations and if there is replacement is involved. I. Reqired Forms in All Cases This section contains the forms yo will always need when completing a life insrance application. Form State Specific* Description When Needed Signatres Reqired Application for Life Insrance ENB-7-07 ENB-7-09-DC ENB-7-13-MD ENB-7-13-ME Do t Use with the Tele-Application process: yor case will be declined. Use Express Order ticket (see Section IV) Always Need, except for Tele- Application cases. Athorization EAUTH-13 Release of information to comply with the Health Insrance Portability and Accontability Act (HIPPA). Reqired for all Proposed Insreds. Always Need * A second EAUTH-13 is needed for Life 2 when applying for a LASUL. Life Insrance Byer s Gide EBG - or - EBG1 A gide to assist consmers in making informed decisions when considering the prchase of life insrance. Always Need ne, present to client Privacy tice ECPN-14 ECPN-14-NY Describes how we obtain and treat information we collect abot any Proposed Insred. Reqired to be presented to every client. Always Need ne, present to client Prodcer Identification & Certification EPID EPID NY Prodcer s statements regarding disclosres to the client. Reqired to completed on all applications. Always Need, except for Tele- Application cases., Agency Management Compensation Disclosre tice Reqired for all life policies. Provides an Always Need overview of prodcer/wholesaler compensation. ne, present to client COMPDISC-ID COMPDISC-ID-NY * t applicable for life brokers or non-metlife employees. Personal Financial Information EFIN (NH Only) EFIN Form sed to obtain information abot income, assets and liabilities of the Proposed Insred or Insreds. To be completed for all variable life applications; for ages when the amont of coverage is $2,000,001 or higher and for ages 70 and older when the amont of coverage is $500,001 or higher. Reqired in Maryland and Pennsylvania FORMSGUIDE (01/15) 1 Fs

2 II. Forms Yo May Need This section contains the forms yo may need when completing a life insrance application. Form State Specific* Description When Needed Signatres Reqired Athorization to Obtain and Disclose Information EGAAUTH-05 Release of personal information to the Enterprise GA and one or more of the listed companies. Enterprise GA sbmission * A second EGAAUTH needed for Life 2 when applying for a LASUL. Athorization to Release Health Related Information to the Prodcer INSRELTOAGT Athorization to allow client to contest to the disclosre of certain nderwriting information to their prodcer. To disclose nderwriting info to Prodcer * A second INSRELTOAGT is needed for Life 2 when applying for a LASUL. EGA: tice to the Proposed Insred EGANOTICE Client disclosre that provides a general description of the information practices of the Enterprise GA. Enterprise GA sbmission ne, present to client Medical Spplement EMED EMED MD Medical qestions regarding the health of any proposed insred. Paramedical/Medical Exam not reqired * A second EMED form is needed for Life 2 when applying for a LASUL. Reqired in Maryland and Pennsylvania *NOTE: Completion is optional if a Fll Paramedical/Medical Exam is reqired. For faster processing, always complete. Paramedical-Medical Exam EMED Medical qestions regarding the health of any proposed insred. Reqired if a Paramedical/Medical exam is needed. Pages 1 and 2 can also be sed by Prodcers in place of a medical spplement after the application has been signed. Temporary Insrance Agreement & Receipt ETIA-8-07 Explains the conditions and limitations of Temporary Insrance and serves as a receipt for the Proposed Policy Owner Insred for monetary consideration given. Collected at least 1/12 of the annal premim with application Prodcer only te: If yo have not collected an advance payment with the application (which mst eqal at least 1/12 of the annal premim), do not leave this form with the client. Temporary Insrance Agreement & Receipt for Tele-Application or Tele-Interview ETIAET ETIAET MD Explains the conditions and limitations of Temporary Insrance and serves as a receipt for the Proposed Policy Owner Insred for monetary consideration given. Complete at the time a Tele-Application or Tele-Interview is reqested if money is collected, or if fnds are athorized to be collected. FORMSGUIDE (01/15) 2 Fs

3 Important tice: Replacement of Life Insrance or Annities EREPLDIS-NAIC Provides information on what constittes a replacement and the other implications to the client. Reqired if the Proposed Insred or Owner has any existing life insrance or annity, even if replacement is not involved. Reqest for transcript of tax retrn IRS Form 4506-T Reqest for transcript of tax retrn. Completion is sggested whenever a Personal Financial Spplement is reqired. This form will need completion if reqested by the nderwriter. III. Forms Yo May Need Specific to Prodct/Riders This section contains the forms yo may need based on prodct and/or rider. Form Acceleration of Death Benefit Rider (ADBR) Smmary and Disclosre Statement EP Acceleration of Death Benefit De to Chronic Illness Rider (aka Enhanced Care Benefit) EN State Specific* Description When Needed A brief description of the important featres of the rider inclding benefits, limitations and exclsions. A brief description of the important featres of the rider inclding benefits, limitations and exclsions. If ADBR applied for If ECB rider applied for or illstrated Signatres Reqired Child Rider Spplement ECHILD ECHILD MD Application for Child Rider benefit. Mst be completed for each child. If Child Term Rider applied for ne Asset Allocation Qestionnaire ASSETALLOCQUEST Complete to determine applicant s risk tolerance and to assist in choosing the appropriate fnding options. Optional when applying for a VUL bt if sed in the sale, it mst be sbmitted. Variable Life Spplement UFND UFND Reqired when applying for a Variable Applications for Variable Life Life Policy with MetLife. Used to designate policies investment objectives and risk tolerance and to determine the appropriateness of the prodct. ne Riders With Premim or Cost of Insrance Charge Spplement MNCR NY Acknowledgment or refsal of desired rider(s): Acceleration of Death Benefit Rider, Acceleration of Death Benefit De to Chronic Illness Rider. Reqired with all New York applications for whole life prodcts pls any other prodct where the Acceleration of Death Benefit rider is available - Riders With Premim or Cost of Insrance Charge Spplement. FORMSGUIDE (01/15) 3 Fs

4 IV. Forms Yo May Need Specific to Age and/or Amont This section contains the forms yo may need based on age and/or amont. Form State Specific* Description When Needed Signatres Reqired Life Express Order Ticket LIFE-EOT-9-08 For se with the Tele-Application. Complete with Owner and Proposed Insred to provide information concerning Owner, Proposed Insred and proposed coverage. Tele-Application, by Prodcer, Agency Manager, Principal, and GA/MGA/BGA tice and Consent for HIV-Related Testing EHIV-04 EHIV-07-GA EHIV-07-ME EHIV-07-VT Use the applicable form by state of residence. Reqired at $100,000 w/ a fll blood; 18 and older at $50,001 in DC, DE, FL, GA, MD, NJ, NY, PR and SC. * A second EHIV-04 or EHIV-07 is needed for Life 2 when applying for a LASUL. Statement of Owner Intent Spplement EIOLI EIOLI Form that contests that the application is not being applied for with the intention of selling in the secondary market. To be completed and signed by the Proposed Insred(s) and Owner(s) applying for a life insrance policy for: face amonts of $500,000 and over AND Isse age of any Proposed Insred 67 and above; OR pon the reqest of the Underwriter * In the State of Ohio only: Applies to all ages; $50,000 and over or at the reqest of the Underwriter V. Forms Yo May Need Based on Cstomer This section contains the forms yo may need based on the cstomer. Form State Specific* Description When Needed Signatres Reqired Additional Insreds Spplement EAINS EAINS MD Application for life insrance for additional insreds. Applying for Life 2, Spose, Person to be covered nder Applicant Waiver of Premim and the Garanteed Srvivor Pls Prchase Option. The additional proposed insred applying on this form signs on the base application Athorization to Release Psychotherapy Treatment Records and tes Release of Psychotherapy treatment records/ notes in accordance with the reqirements of HIPAA. Reqired if there is a medical history of Psychotherapy. EPAUTH-05 EPAUTH-07-ME FORMSGUIDE (01/15) 4 Fs

5 Aviation Risk Spplement EAVI EAVI MD Used to disclose flying details and flying history if the proposed insred has flown in a plane other than as a passenger on a commercial flight. Reqired when the proposed insred has flown in a plane other than as a passenger on a commercial flight. ne Avocation Risk Spplement EAVO Form that is sed to obtain information related to any avocation in which the proposed insred engages in. Reqired when the proposed insred is involved in any avocation. ne Electronic Payment Accont Agreement DEBITAUTH-05 Agreement to participate in monthly electronic payments. Needed when monthly electronic payment is the selected mode of payment. Bank Draft Disclosre DEBITDISC Disclosre given to client when Electronic Payment is selected as the mode of payment. Provides important information regarding the atomatic debit process. Electronic payment is selected as mode of payment. ne Grop Conversion Spplement MGC Used for grop conversions only or for a new bsiness policy with grop conversion as an alternative. To be completed when converting from a grop policy to an individal policy. ne Consolidated Package for Tax Qalified Pension or Profit Sharing Plan PENSPACK-ID Pension Packages for Individal Distribtion. Consolidated Package for Tax Qalified Pension or Profit Sharing Plan PENSPACK-TPD Pension Packages for third Party Distribtion. If life insrance is owned by a tax qalified Pension or Profit Sharing Plan. Important Information for Members of the Military DISCMILITARY Disclosre needed for Military members and their dependents Before completing an application for Life Insrance with a member of the military services or his or her dependent or dependents, the prodcer mst provide the prospective prchaser with this disclosre form. ne VI. Forms Yo May Need Based on Beneficiary and Owner Designations This section contains the forms yo may need based on Beneficiary and Owner Designations. Form State Specific* Description When Needed Signatres Reqired Bsiness Entities EBUS-05 EBUS-05-NY Form that provides bsiness details, names of associates, prpose of the insrance and financial information of a bsiness that is named as owner/beneficiary. Complete when a bsiness is named as owner or beneficiary. ne Co-owner /Contingent Owner and UTMA Designations EOWN Co-owner spplement Complete when there is a Co- Owner or Contingent Owner, or when a Uniform Transfer to Minors Act (UTMA) or Uniform Gift to Minors Act (UGMA) is sed for a Beneficiary or Ownership designation. ne FORMSGUIDE (01/15) 5 Fs

6 Charity Designation as Beneficiary/Owner ECHARITY ECHARITY-NY Employer Owned Life Insrance EOLI Charity designation spplement Complete when a charity is named as owner or beneficiary. Employer Owned Life Insrance spplement Complete whenever an employer will be the owner of a Life Insrance policy. ne Trst Certification ETRUSTCERT-05 ETRUSTCERT-05-NY ETRUSTCERT-05-PR Form is sed in sitations where the trst is the owner of the life insrance policy. VII. Forms Yo May Need If a Replacement Is Involved This section contains the forms yo may need if Replacement is involved. To be completed by the Trstee(s) when a Trst is the owner or beneficiary of a life insrance policy. (Trstee) Form State Specific* Description When Needed Signatres Reqired Athorization for Life to Life: 1035 Exchange Form needed when completing a life to life 1035 exchange Life to Life 1035 exchange E1035EXCH te: A separate form mst be completed for each existing financial instittion. Important tice: Replacement of Life Insrance or Annities / Replacement Qestionnaire EREPLDIS tice regarding replacement which provides information on the implications of replacement to the client. Additional forms may be reqired depending on the facts of the case. Reqired in the 39 states that have adopted the new combined Important notice/ Replacement Qestionnaire. To be completed when canceling or altering an existing policy or contract in conjnction with an application for a new policy or contract in the 39 states that have adopted the new combined Important tice/ Replacement Qestionnaire. tice Regarding Replacement EREPLDIS tice regarding replacement which provides information on the implications of replacement to the client. Additional forms may be reqired depending on the facts of the case in the states that have not approved the combination EREPLDIS form. To be completed when canceling or altering an existing policy or contract in conjnction with an application for a new policy or contract. Replacement Qestionnaire EREPL Disclosre notice to be signed by the applicant when replacement is proposed. Additional forms may be reqired depending on the facts of the case. To be completed when canceling or altering an existing policy or contract in conjnction with an application for a new policy or contract. Sales Material Disclosre Form for the Replacement of Life Insrance or Annities EREPLSMDIS Disclosre notice sed to identify pre-printed or electronically presented MetLife sales material related to specific life policy or annity contract prchased. Reqired for states who have adopted the NAIC Replacement Model. Reqired for states who have adopted the NAIC Replacement Model. * State variations of some forms may exist, and some forms may not be available in all states. Additional forms may also be reqired in certain states and for certain types of sales. For a comprehensive inventory of state-specific forms, refer to or eforms website available on imetlife. FORMSGUIDE (01/15) 6 Fs

7 Compensation Disclosre tice MetLife and its affiliated insrance companies and broker-dealers are committed to helping yo select an appropriate prodct based on yor financial needs and stated investment objectives. Yor MetLife sales representative ("Representative") is an employee of a MetLife Company. Yor Representative is athorized to offer and sell prodcts to yo that are either issed or distribted by Metropolitan Life Insrance Company or certain of MetLife's affiliated insrance companies, or offered throgh one of MetLife's affiliated entities that is registered as a broker-dealer with whom yo have an accont relationship (each, a "MetLife Company" and, together, the "MetLife Companies").* Prodcts from the MetLife Companies inclde fixed life insrance and annities, property, casalty, and health insrance, variable annities, and variable life insrance ("MetLife Prodcts"). Yor Representative also may be athorized to offer yo certain prodcts, inclding insrance, annities, and mtal fnds, issed by companies other than the MetLife Companies ("non-metlife prodcts"). Yor Representative acts on behalf of the MetLife Companies in connection with the offer and sale of MetLife Prodcts to yo. He or she acts on behalf of a company other than MetLife in connection with the sale of non-metlife prodcts. Yor Representative also may service yor mtal fnds, secrities or insrance prodcts on behalf of the company issing the prodct. Yor Representative is compensated by a MetLife Company for sale, renewal and servicing of MetLife Prodcts and certain athorized non-metlife prodcts. This compensation incldes base commissions and other forms of compensation that may vary from prodct to prodct and by the amont of the prchase payment made by yo. Yo shold be aware that the amont of his or her compensation may increase in part based pon the relative amont of MetLife Prodcts and certain non-metlife prodcts that he or she sells dring a set period. He or she also is eligible for additional cash compensation (sch as medical, retirement and other benefits) and non-cash compensation (sch as conferences and sales spport services) based on his or her sales of MetLife Prodcts, certain athorized non-metlife prodcts, and overall sales and prodctivity. Yor Representative may also receive compensation for the sale, renewal and servicing of athorized non-metlife prodcts directly from the issing company. In some instances, MetLife Companies may also pay for expenses incrred by Representatives in connection with events for clients and prospects, training and edcation opportnities, and other miscellaneos expenses. MetLife receives compensation for non-metlife Prodcts sold by yor Representative. This compensation will vary based pon an agreement between a MetLife Company and the issing company and may inclde a bons featre or a marketing allowance, which may be sed in some instances to offset expenses associated with condcting de diligence on the company and its prodcts, and hosting training and edcation, or recognition, conferences. Additionally, sales management is compensated for MetLife Prodcts and approved non-metlife Prodcts that are sold by yor Representative throgh MetLife. Generally, this compensation is aligned with that of yor Representative, as noted above. The services provided by yor Representative may inclde: Discssing yor crrent financial condition, goals and objectives; Gathering relevant financial information; Analyzing yor financial sitation (inclding among other things yor needs, goals, risk tolerance, investment experience and time horizon) in order to determine appropriate strategies and recommendations of sitable investment or insrance prodcts; Making recommendations regarding asset allocation; Making recommendations involving investment repositioning; Implementing these recommendations; and Reviewing yor progress against yor financial goals and objectives. These services are not investment advisory or financial planning services sbject to the Investment Advisors Act of If yo are interested in sch services, ask yor Representative. Either yor Representative or another MetLife Representative may be able to provide investment advisory or financial planning services. Before receiving those services, however, yo will be provided with an additional disclosre and enter into a separate written agreement regarding those services as reqired by the Investment Advisors Act of In addition to yor Representative, certain independent brokers and agents sell prodcts throgh an association with a MetLife sales office. They are compensated by a MetLife Company for the sale, renewal and servicing of MetLife Prodcts. Those brokers and agents may receive increased compensation based pon the amont of MetLife Prodcts sold dring a set period. If yo prchased yor MetLife Prodct throgh the MetLife Ato & Home Grop Insrance Program we may also pay an agent or broker representing the employer/organization participating in the Grop Insrance Program for the sale and renewal of MetLife Prodcts. We may also pay yor employer or association or a third party acting on their or or behalf for the administration and service they provide related to the Grop Insrance Program. Administration and services may inclde payroll administration. * The following are the MetLife Companies whose prodcts yor Representative may be athorized to sell: Metropolitan Life Insrance Company, Metropolitan Property and Casalty Insrance Company, Metropolitan Casalty Insrance Company, Metropolitan General Insrance Company, Metropolitan Direct Property and Casalty Insrance Company, Metropolitan Grop Property and Casalty Insrance Company, Metropolitan Lloyds Insrance Company of Texas, Economy Fire & Casalty Company, Economy Preferred Insrance Company, Economy Premier Assrance Company, First MetLife Investors Insrance Company, MetLife Insrance Company USA, New England Life Insrance Company, General American Life Insrance Company, and MetLife Secrities, Inc. For more information, please refer to LEAVE WITH APPLICANT 1 of 1 COMPDISC-ID (01/15) Fs

8 Policy Nmber Personal Financial Information Spplement Company (Check the appropriate ONE.) Metropolitan Life Insrance Company The Company indicated in this section is New England Life Insrance Company referred to as "the Company". MetLife Insrance Company USA General American Life Insrance Company Metropolitan Tower Life Insrance Company This spplement will be attached to and become part of the application with which it is sed. First Name: Last Name: Identity Type: (Check all Insred that apply.) Owner SECTION I - Income SECTION II - Assets Annal Earned Income (in US dollars as reported to the IRS) Assets (in US dollars) Salary or Draw $ Cash/Cash Eqivalents $ Bons/Commissions $ Real Estate $ Other Earnings $ Bsiness Eqity $ Sorce (If government assistance, please provide Stocks $ details.) Total Earned Income $ Bonds $ Spose's Income $ Annities $ Mtal Fnds $ Annal Unearned Income (in US dollars as reported to the IRS) CD/Money Markets $ Dividends/Interest $ Foreign Assets (te: if more than 20% of Net Rentals $ total assets are otside the US, spporting docmentation may be reqested.) $ Other Unearned Income $ Sorce (If government assistance, please provide details.) Total Unearned Income $ SECTION III - Liabilities Liabilities (in US dollars) Mortgages $ Personal Loans $ Other $ Total Liabilities $ SECTION V Net Worth (Total Assets mins Total Liabilities) $ Tax Bracket (%) Frad Warning Signatre Signatre Signatre reqired for all sbmissions. Other Assets (Artwork and other personal property mst have written appraisals available.) $ Total Assets $ SECTION IV - Expenses Payor Expenses Annal Recrring Expenses (e.g., rent mortgage, long-term debts, tilities, alimony or child spport, etc.) $ "Special Expenses" (if any) (e.g., ftre, non-recrring expenses, sch as home prchase/ remodeling, car prchase or repairs, edcation, medical expenses, etc.) (Blank fields for Special Expenses will be assmed to be $0.) $ Timeframe for Special Expenses (within how many years) (e.g., 1 year for home remodeling, 4 years for edcation, etc.) Liqid Net Worth (The amont of cash (inclding checking, savings, etc.), and assets that can be trned into cash qickly and easily. Inclde the amont of the initial premim payment and/or lmp sm payment for this coverage. Exclde personal property, personal residence, real estate, bsiness eqity, home frnishings, atos and assets sbject to sbstantial penalties/sales charges.) $ Any person who knowingly and with intent to defrad any insrance company or other person files an application for insrance or statement of claim containing any materially false information or conceals for the prpose of misleading, information concerning any fact material thereto commits a fradlent insrance act, which is a crime and sbjects sch person to criminal and civil penalties. Date Signed at City, State 1 of 1 EFIN PA-1 (11/14) Fs

9 Application for Life Insrance Policy Nmber Company (Check the appropriate ONE.) Metropolitan Life Insrance Company General American Life Insrance Company The Company indicated in this section is referred to as "the Company". New England Life Insrance Company MetLife Insrance Company USA SECTION I - Abot the Proposed Insred For Additional Insreds please complete the Additional Insreds Spplement form. First Name Middle Name Last Name Permanent Address City State Zip Contry of Legal Residence Date of Birth Address Primary Phone Nmber Alternate Phone Nmber Preferred Time to Call From AM PM To AM PM Sex Place of Birth Social Secrity or Tax ID Nmber Earned Annal Income Net Worth Male Female U.S. Driver's License If not licensed, please indicate other form of ID: Passport Government Issed Photo ID Isser of ID ID Nmber Isse Date (if any) Expiration Date (if any) Name of Employer Employer City State ZIP Position/Dties NON U.S. CITIZENS ONLY - Contry of Citizenship Green Card/Visa Type Expiration Date Contry of Permanent Residence ID Nmber Years in the U.S. SECTION II - Abot the Owner Complete ONLY if the Owner is NOT the Proposed Insred. OWNER - TRUST / BUSINESS ENTITY - Name of Entity Tax ID Nmber Trstee / Owner State Trst Bsiness Entity Charity Qalified Pension Plan 2 Complete the appropriate reqired form(s). OWNER - OTHER INDIVIDUAL First Name Middle Name Last Name Permanent Address City State Zip Contry of Legal Residence Citizenship Social Secrity or Tax ID Nmber Date of Birth Phone Nmber Address Earned Annal Income Net Worth Relationship to Proposed Insred Please indicate form of ID: U.S. Driver's License Passport Government Issed Photo ID Isser of ID ID Nmber Isse Date (if any) Expiration Date (if any) Check if ownership shold revert to Insred pon Owner and Contingent Owner s deaths. ENB-7-07-PA 1 of 7 (11/14) ef

10 SECTION III - Abot the Beneficiary / Beneficiaries Check here if the Owner is the Primary Beneficiary. For Primary or Contingent Beneficiaries who are NOT the Owner, complete the table below. Beneficiary Type Primary Name (First, Middle, Last) For additional Beneficiaries, se Section IX - Additional Information. Date of Birth Relationship to Proposed Insred Social Secrity Nmber (Optional) Percentage of Proceeds (if not eqal) Primary Contingent Primary Contingent Check here to inclde all living and ftre natral or adopted children of the Proposed Insred as Contingent Beneficiaries. (Name all living children above.) 2 If a Cstodian is acting on behalf of a minor Beneficiary listed above, please se Co-Owner/Contingent Owner and UTMA Designations Spplement form. Federal law states that if someone with special needs has assets over $2,000, they may lose eligibility for government benefits. SECTION IV - Abot Proposed Coverage Check the desired coverage(s). Adjstable Life Variable Life 2 Whole Life Term Life Prodct Name Prodct Name Prodct Name Face Amont* Face Amont* Face Amont* Riders and Details Riders and Details Riders and Details Coverage Contination (UL only) Disability Waiver: Specified Premim Monthly Dedction (VUL only) Death Benefit Option Definition of Life Insrance: Gideline Premim Test Cash Vale Accmlation Test Planned Premim Year 1 Years 2 to Years to (UL only) Disability Waiver Dividend Options: Paid-Up Additions Other, please specify: Atomatic Premim Loan Reqested Disability Waiver: Convertible n-convertible i For a fll list of riders and options, please conslt with yor Prodcer. te: Some riders may reqire spplement forms to be completed. 2 For Variable Life prodcts, please complete the Variable Life Spplement form. * If Face Amont is eqal to or exceeds $1,000,000, please complete the Personal Financial Information form. ADDITIONAL OPTIONS One Time (Single) Payment Amont 1035 Exchange Amont Reqested Policy Date Save Age POLICY OPTIONS Alternate Policy: Prodct, Face Amont and Details Additional Policy: Prodct, Face Amont and Details Grop Conversion Only Grop Conversion Alternative } 2 Please complete the Grop Conversion Spplement form for either choice. ENB-7-07-PA 2 of 7 (11/14) ef

11 SECTION V - Abot Existing or Applied for Insrance Does the Proposed Insred or Owner have any existing or applied for life insrance or annities with this or any other company? Proposed Insred Owner If YES, please provide details of any existing or applied for Life Insrance on the Proposed Insred only. Company Amont of Insrance Year of Isse Existing Existing Existing Existing Stats Applied For Applied For Applied For Applied For In connection with this application, has there been, or will there be with this or any other company any: srrender transaction; loan; withdrawal; lapse; redction or redirection of premim/consideration; or change transaction (except conversions) involving an annity or other life insrance? 2 If YES, complete Replacement Qestionnaire AND any other state reqired replacement forms or 1035 exchange forms. If Proposed Insred is financially dependent on another individal, indicate individal providing spport: Spose Child Parent Other Amont of insrance on individal providing spport. Existing Insrance Insrance Applied For If Proposed Insred is a minor, are all siblings eqally insred? If NO, please provide details: SECTION VI - Abot Payment Information PREMIUM PAYOR Proposed Insred Owner (If NOT the Proposed Insred.) Other (Complete the box below.) Other Premim Payor Name Social Secrity or Tax ID Nmber Relationship to Proposed Insred or Owner Reason this Person is the Payor Permanent Address City State Zip PAYMENT MODE (Check the appropriate ONE.) Billing Mode: Annal Semi-Annal Qarterly Monthly Draft per Debit Athorization (See next page.) Monthly Draft per Existing Electronic Payment Nmber Special Accont: Government Allotment Salary Dedction List Bill If Special Accont, provide Employer Grop Nmber (EGN) or List Bill Nmber INITIAL PAYMENT Amont Collected with Application Method of Collection: Initial Premim by Electronic Fnds Transfer (Mst be at least a monthly amont.) Check (Mst be at least 1/12 of an annal premim.) SOURCE OF CURRENT AND FUTURE PAYMENTS (Check ALL that apply.) Earned Income Mtal Fnd/Brokerage Accont Money Market Fnd Savings Loans Certificate of Deposit Use of Vales in another Life Insrance/Annity Contract Other ENB-7-07-PA 3 of 7 (11/14) ef

12 DEBIT AUTHORIZATION Available only if the bank accont holder is the Owner and/or Proposed Insred. 2 All others please complete the Electronic Payment (EP) Accont Agreement form. The ndersigned ( I ) hereby athorize the Company with whom I am completing this application to initiate debit entries throgh Metropolitan Life Insrance Company to the deposit accont designated below, at the Financial Instittion named below, sing the Atomated Clearing Hose. I athorize: 1. Monthly recrring debits; AND 2. Debits made from time to time, as I athorize. This athorization is to remain in fll force and effect ntil the Company has received written notification from me of its termination at sch time and in sch manner as to afford the Company and the Financial Instittion a reasonable opportnity to act on it. Monthly Debit Date: Isse Date of the Policy Debit Date on the of each month Bank Accont Type: Checking Savings Bank Roting Nmber Bank Accont Nmber Name of Financial Instittion i te: Please attach a voided check or deposit slip to Section IX - Additional Information. We cannot establish banking services from starter checks, cash management, brokerage, or mtal fnd checks. We cannot establish banking services from foreign banks UNLESS the check is being paid in U.S. Dollars throgh a U.S. correspondent bank (the U.S. correspondent bank name mst be on the check). SECTION VII - General Risk Qestions Use Section IX - Additional Information if necessary. 1. Within the past three years has the Proposed Insred flown in a plane other than as a passenger on a commercial airline or does he or she have plans for sch activity within the next year? 2 If YES, please complete a separate Aviation Risk Spplement form for the Proposed Insred. 2. Within the past three years has the Proposed Insred participated in or does he or she plan to participate in any of the following? Underwater sports - SCUBA diving, hard hat, skin diving, snorkeling or cave diving Racing sports - motorcycle, ato or motor boat Sky sports - skydiving, hang gliding, parachting, ballooning, ltra lights, para sailing or para skiing Rock ice or moain climbing Bngee jmping 2 If YES, please complete a separate Avocation Risk Spplement form for the Proposed Insred. 3. Has the Proposed Insred traveled or resided otside the U.S. or Canada within the past two years; or does he or she plan to travel or reside otside the U.S or Canada within the next two years? If YES, please provide details. Past Ftre Dration (weeks) Cities and Contries Prpose 4. Has the Proposed Insred EVER sed tobacco or nicotine prodcts in any form (e.g., cigars cigarettes, cigarillos, pipes, chewing tobacco, nicotine patches, or nicotine gm)? If YES, please provide details. Prodct(s) Freqency / Amont Date Last Used ENB-7-07-PA 4 of 7 (11/14) ef

13 5. Has the Proposed Insred EVER had a driver's license sspended or revoked, been convicted of DUI or DWI, or in the last five years had any moving violations? If YES, please provide date(s) and violation(s). 6. Has the Proposed Insred EVER had an application for life, disability income or health insrance declined, postponed, rated or modified or reqired an extra premim? If YES, please provide details. 7. In the past 10 years, has the Proposed Insred been convicted of or pled Gilty or Contest to a felony? If YES, list type of felony, state, and date of occrrence. 8. Is the Proposed Insred actively at work performing the sal dties of his or her occpation? If NO, please provide details. SECTION VIII - Personal Physician Check here if Proposed Insred does not have a personal physician. Physician Name Name of Practice or Clinic Street Address City Zip State Phone Nmber Date Last Conslted Reason Findings/Treatment Given/Medication Prescribed SECTION IX - Additional Information If more space is needed, attach additional sheet(s). ENB-7-07-PA 5 of 7 (11/14) ef

14 Certification / Agreement / Disclosre Was a sales illstration provided for the life insrance policy as applied for? A. If, please choose one of the following: An illstration was signed and matches the policy applied for. It is inclded with this application. An illstration was shown or provided bt is different from the policy applied for. An illstration conforming to the policy as issed will be provided no later than at the time of policy delivery. The sale was made sing an illstration with Accelerated Payment. If illstration was only shown on a compter screen, check and complete the details in the box below. An illstration was displayed on a compter screen. The displayed illstration matches the policy applied for bt no printed copy of the illstration was provided. An illstration conforming to the policy as issed will be provided no later than at the time of policy delivery. The illstration on the screen inclded the following personal and policy information: 1. Gender (as illstrated) Male Female Unisex 2. Age 3. Rating Class (e.g. Standard n-smoker) n-smoker Smoker 4. Prodct Name (e.g. GAUL) 5. Face Amont 6. Dividend Option (Whole Life only) B. If, please choose one of the following: Prodcer certifies that a signed illstration is not reqired by law or the policy applied for is not illstrated in this state. illstration conforming to the policy as applied for was shown or provided prior to or at the time of this application. An illstration conforming to the policy as issed will be provided no later than at the time of policy delivery. Agreement / Disclosre I have read this application for life insrance inclding any amendments and spplements and to the best of my knowledge and belief, all statements are tre and complete. I also agree that: My statements in this application and any amendment(s), paramedical/medical exam and spplement(s) are the basis of any policy issed. This application and any amendment(s), paramedical/medical exam, and spplement(s) to this application will be attached to and become part of the new policy. information will be deemed to have been given to the Company nless it is stated in this application, paramedical/medical exam, amendment(s), or any spplement(s). Only the Company s President, Vice-President or Secretary may: (a) make or change any contract of insrance; (b) make a binding promise abot insrance; or (c) change or waive any term of an application, receipt, or policy. Except as stated in the Temporary Insrance Agreement and Receipt, no insrance will take effect ntil a policy is delivered to the Owner and the fll first premim de is paid. It will only take effect at the time it is delivered if: (a) the condition of health of each person to be insred is the same as stated in the application; and (b) no person to be insred has received any medical advice or treatment from a medical practitioner since the date of the application. If I have reqested a rider that provides an acceleration of death benefit, I have received the appropriate disclosre form. I nderstand that paying my insrance premims more freqently than annally may reslt in a higher yearly ot-of-pocket cost or different cash vales. If I intend to replace existing insrance or annities, I have so indicated in the appropriate section of the application. I have received the Company s Privacy tice and the Life Insrance Byer s Gide. If I was reqired to sign a tice and Consent for HIV Testing, I have received a copy of that tice. 6 of 7 ENB-7-07-PA (11/14) ef

15 Frad Warnings Any person who knowingly and with the intent to defrad any insrance company or any other person files an application for insrance or statement of claim containing any materially false information, or conceals for the prpose of misleading information concerning any fact material thereto, commits a fradlent insrance act which is a crime and sbjects sch person to criminal and civil penalties. Taxpayer Identification Nmber Certification Under penalties of perjry, I, the Owner, certify that: The nmber shown in this application is my correct taxpayer identification nmber, and I am not sbject to backp withholding becase: (a) I have not been notified by the IRS that I am sbject to backp withholding as a reslt of a failre to report all interest or dividends; or (b) the IRS has notified me that I am not sbject to backp withholding. (If yo have been notified by the IRS that yo are crrently sbject to backp withholding becase of nder reporting interest or dividends on yor tax retrn, yo mst cross ot and initial this item.) I am a U.S. citizen or a U.S. resident alien for tax prposes. (If yo are not a U.S. citizen or a U.S. resident alien for tax prposes, please cross ot this certification and complete form W-8BEN). i Please note: The Internal Revene Service does not reqire yor consent to any provision of this docment other than the certifications reqired to avoid backp withholding. Signatres If not witnessing all signatres, witness shold initial next to signatre being witnessed and sign below. Signatre(s) of all Proposed Insred(s) Date Signed at City, State (age 18 or over) 2 Please complete the Additional Insreds Spplement or Child Rider Spplement form(s) if applicable. Signatre(s) of all Owner(s) (If NOT the Proposed Insred.) Date Signed at City, State (age 18 or over) i If the Owner is a firm or corporation, inclde Officer's title with signatre. 2 If Co-Owner or Cstodian, please complete the Co-Owner/Contingent Owner and UTMA Designations Spplement form. Signatre of Parent or Gardian Date Signed at City, State (If Owner or Proposed Insred is nder 18, sign here. If not sign above.) Witness to Signatres Licensed Prodcer Print Name of Prodcer ENB-7-07-PA 7 of 7 (11/14) ef

16 Temporary Insrance Agreement and Receipt Company (Check the appropriate ONE.) The Company indicated in this section is referred to as "the Company". Metropolitan Life Insrance Company New England Life Insrance Company General American Life Insrance Company MetLife Insrance Company USA SECTION I - What Does Temporary Insrance Provide? For those eligible, Temporary Insrance provides for a death benefit pon receipt of proof of death of the Proposed Insred(s). The Temporary Insrance death benefit will be for the amont of insrance (inclding riders) applied for on the life of the deceased Proposed Insred(s) named on the application bearing the date of this Receipt and the spplement(s) to that application (collectively the "Application"). The total death benefit nder this Receipt and all other receipts issed by all the companies listed above will not be more than $1,000,000 for any Proposed Insred(s) ($2,000,000 for srvivorship life policies).* However, there will be no death benefit provided for the first death on a srvivorship policy, or if death is by sicide. The death benefit will be paid to the person who wold have received payment nder the policy, had it been issed. If the health or insrability of the Proposed Insred(s) changes once Temporary Insrance has started, the Company will consider the health of the Proposed Insred(s) as of the date Temporary Insrance began in deciding whether to isse the policy applied for. If the Proposed Insred(s) shold have a material change in health or insrability while Temporary Insrance is in effect, the total amont of insrance which may be issed nder this Receipt and all other receipts will not be more than $1,000,000 ($2,000,000 for srvivorship life policies).* If there is a person to be insred nder an applicant waiver of premim rider or benefit (an "Applicant"), this benefit or rider will be inclded in the policy issed on the life of the Proposed Insred(s) if an Applicant dies: 1. Other than by sicide; 2. Before the rider or benefit is declined by the Company; and 3. While Temporary Insrance is in effect on the life of the Proposed Insred(s). Premims nder the policy will be waived nder the terms of the rider or benefit applied for. *Shold there be more than one application or receipt for any person to be insred, the share for each application will be in the ratio that the amont applied for on that application bears to the total amont of insrance applied for nder all sch applications. SECTION II - Who is Eligible for Temporary Insrance? The Proposed Insred(s) nder the policy applied for is/are eligible for Temporary Insrance, if EACH of the following is tre: 1. The Application, its spplements and paramedical/medical exam; do not inclde any material misrepresentation. AND 2. The Proposed Insred(s) has/have never received medical treatment for or been diagnosed with: cancer; Hman Immnodeficiency Virs (HIV); Acqired Immne Deficiency Syndrome (AIDS); coronary artery disease; stroke; alcohol se; or drg se. AND 3. The Proposed Insred(s) is/are at least 14 days old. SECTION III - When Does Temporary Insrance Start? Coverage starts on the later of the date of this Receipt or (if reqired at the time the Application was completed by the Company's nderwriting rles) the date of any medical examination of the Proposed Insred(s) provided that one of the following is satisfied on the date of the Application: 1. Payment by check of an amont of at least 1/12 of an annal premim; or 2. Payment of Initial Premim Draft per Electronic Fnds Transfer; or 3. Properly completed MetLife salary dedction plan form(s); or 4. Properly completed government allotment form(s); or 5. If the life insrance applied for with the Application is to be part of a Qalified Plan nder the Employee Retirement Income Secrity Act of 1974 ERISA (e.g. a Pension Plan, Profit Sharing Plan, or a 401(k) Plan) and the Proposed Owner is the trstee of the Qalified Plan and the Employer Grop Nmber (EGN) assigned by the Company is entered in the appropriate space on the Application, and a copy of the Commission Disclosre forms is provided to the Proposed Owner. If a check or draft is retrned for insfficient fnds it will not constitte payment and Temporary Insrance will not be in effect. Temporary Insrance will be in effect, if it has not already ended nder the terms of this Receipt, if a Proposed Insred dies: from an accident; within 30 days from the date of this Receipt; before the reqired medical exam described above is completed; and one of the above 5 items was received on the date of the Application. 1 of 2 ETIA-8-07 (11/14) ef

17 SECTION IV - When Does Temporary Insrance End? Temporary Insrance will end on the earliest of the following: 1. When coverage nder a policy issed by the Company as a reslt of the Application takes effect. 2. When a policy issed by the Company as a reslt of the Application is not accepted. 3. When the Company offers to refnd any payment received nder this Receipt. 4. When the Company refnds any payment received nder this Receipt. 5. The date the Proposed Insred(s) or an Applicant learns that either the Application has been declined or the Company has decided to terminate the Temporary Insrance, or five days from the date the Company mails to the Proposed Insred(s) or an Applicant, at the address on the Application, a notice that the Application has been declined. 6. If the Application is for a Qalified Plan nder ERISA, the Proposed Owner learns that either the Application has been declined or the Company has decided to terminate the Temporary Insrance, or five days from the date the Company mails to the Proposed Insred(s) or an Applicant, at the address on the Application, a notice that the Application has been declined. 7. One hndred and twenty (120) days from the date of this Receipt. If no policy takes effect, any payment received will be refnded when Temporary Insrance ends. SECTION V - Limitations on Athority one bt the President, Vice-President or the Secretary of the Company may change or waive the terms of this Receipt. Signatres All Premim Checks mst be made payable to the Company checked on top of page 1. DO NOT MAKE CHECK PAYABLE TO THE AGENT. DO NOT LEAVE THE CHECK PAYEE BLANK. Amont Collected Method of Collection: Check (Mst be at least 1/12 of an annal premim.) Initial Premim by Debit Athorization in application (Mst be at least a monthly amont.) Initial Premim by EP Accont Agreement form (Mst be at least a monthly amont.) Or receipt of: MetLife Salary Dedction Plan form(s) Government Allotment form(s) Qalified Plan form(s) is acknowledged in connection with the Application made on this date in which the Proposed Insred(s) is/are: and the plan of insrance is: from company Receipt Date: Title: Sales Office: Prodcer Signatre: Date Signed at City, State Metropolitan Life Insrance Company New York, NY New England Life Insrance Company Boston, MA Timothy Ring, Secretary MetLife Insrance Company USA Wilmington, DE Tyla Reynolds, Secretary General American Life Insrance Company St. Lois, MO Jacob M. Jenkelowitz, Secretary Tyla Reynolds, Secretary te: If yo have not heard from the Company within 120 days from the date of this Receipt, please contact the Company's representative. 2 of 2 ETIA-8-07 (11/14) ef

18 Athorization Company (Check the appropriate ONE.) The Company indicated in this section is referred to as "the Company". Metropolitan Life Insrance Company New England Life Insrance Company MetLife Insrance Company USA General American Life Insrance Company Metropolitan Tower Life Insrance Company This form was designed to comply with the reqirements of the Health Insrance Portability and Accontability Act (HIPAA). For nderwriting and claim settlement prposes regarding me or any child(ren) nder the age of 18 named below, I athorize: Any medical practitioner; any medical facility; any other medical entity; any pharmacy or pharmacy-related service organization; any insrer; any consmer reporting agency; and the MIB Grop, Inc. (MIB) to give the Company information abot me or sch child(ren), inclding: - personal information and data; - entire medical file for the last ten (10) years, inclding medical information, records and data (sch as: office visits; patient treatment; hospitalization; drgs prescribed; medical test reslts; information abot sexally transmitted diseases and other similar information); - information related to alcohol and drg abse and treatment; - information, records and data relating to Acqired Immne Deficiency Syndrome (AIDS) or AIDS related conditions, inclding Hman Immnodeficiency Virs (HIV) test reslts; and - information, records and data relating to mental illness. The Company to redisclose information received prsant to this Athorization as athorized by me in writing or as otherwise permitted by applicable law. The Company, or its reinsrers, to make a brief report of my personal health information to MIB. The Company to reqest and obtain: consmer; investigative consmer; or motor vehicle reports. Any employer, bsiness associate, financial instittion, or government agency to give the Company any information or data that it may have abot: occpations; avocations; driving record; finances; character; reptation; and aviation activities. I nderstand that: Information, records and data that the Company receives prsant to this Athorization will be sed and maintained by the Company as described in the Company s Privacy tice, a copy of which was given to me. All or part of the information, records and data that the Company receives prsant to this Athorization may be disclosed to MIB. Sch information may also be disclosed to and sed by: any reinsrer; Signatres Print Name of Proposed Insred First Middle Last any Company employee; or any affiliate or independent contractor who performs a bsiness service for the Company on the insrance applied for or on existing insrance with the Company. Information may also be disclosed as otherwise reqired or permitted by applicable laws. Information related to alcohol and drg abse that has been disclosed to the Company may be protected by Federal Reglations 42 CFR Part 2. This information may be redisclosed as provided in this Athorization. Medical information, records and data disclosed may have been sbject to federal and state laws or reglations, inclding federal rles issed by Health and Hman Services, 45 CFR Parts These rles set forth standards for the se, maintenance and disclosre of sch information by health care providers and health plans. Once disclosed to the Company, this information may no longer be sbject to those laws or reglations. Information obtained prsant to this Athorization abot me or sch child(ren) may be sed, to the extent permitted by law, to determine the insrability of other family members. Information relating to HIV test reslts will only be disclosed as permitted by applicable law. If nderwriting determines that an investigative consmer report is needed, I will be contacted by the consmer reporting agency and interviewed in connection with its preparation. I am not reqired by law to sign this Athorization, bt if I do not, the Company will not be able to nderwrite my application for life insrance. Health care provider(s) or health care plan(s) asked to release information prsant to this Athorization cannot condition treatment or payment for treatment or other benefits on my signing it. This Athorization will end 24 months from the date on this form or sooner if prescribed by law. I may revoke it at any time by writing to the Company, Privacy Office, PO BOX 489, Warwick, RI and advising it that I have revoked this Athorization. Any action taken before the Company has received my revocation will be valid. I have a right to receive a copy of this form. A photocopy of this form is as valid as the original form. Date of Birth If Proposed Insred is nder 18, the Parent or Gardian is to sign on line for sch child. Signatre of Proposed Insred Date Signed at City, State As witness, I attest to having observed all parties sign in my presence. Witness to Signatre EAUTH-13 1 of 1 (11/14) Fs

19 Proposed Insred: First Name Middle Name Last Name tice And Consent For HIV-Related Testing Company Copy Company (Check the appropriate ONE.) The Company indicated in this section is referred to as "the Insrer". Metropolitan Life Insrance Company General American Life Insrance Company 200 Park Avene, New York, NY Tesson Ferry Road, St. Lois, MO New England Life Insrance Company MetLife Insrance Company USA One Financial Center, Boston, MA Orange Street, Wilmington, DE Metropolitan Tower Life Insrance Company 200 Park Avene, New York, NY THE HIV VIRUS AND AIDS To evalate yor insrability, it is reqested that yo provide a blood or other bodily flid sample for testing for the presence of HIV antibodies or antigens, as well as for other tests sch as cholesterol, diabetes and immne disorders. The antibody test will determine the presence of antibodies to the hman immnodeficiency virs (HIV), the virs associated with Acqired Immnodeficiency Syndrome (AIDS), a life-threatening disorder of the immne system. The HIV antigen test directly identifies AIDS viral particles. These tests are not tests for AIDS; AIDS can only be diagnosed by medical evalation. By signing and dating this form, yo agree that testing may be performed and that nderwriting decisions will be based on the test reslts. Yo may refse to be tested; however, sch refsal may be sed by the insrer as a reason to deny coverage. COUNSELING/ANONYMOUS TESTING Many pblic health organizations have recommended that before sbmitting to an HIV test, a person seek conseling to better nderstand the implications of the test. Yo may wish to consider conseling, at yor expense, prior to being tested or to conslt with yor physician or local health department. Yo may also wish to be anonymosly tested. See next page for conseling information. For yor information, HIV is transmitted: by sexal contact with an infected person; from an infected mother to her newborn infant; or by exposre to infected blood (as in needle sharing dring intravenos drg se). HIV is not spread throgh casal contact, sch as eating with, toching or kissing a person infected with the virs. Persons at high risk of contracting AIDS inclde: males who have had sexal contact with another male; intravenos drg sers; hemophiliacs; and sexal contacts of any of these persons. A person may remain free of symptoms for years after becoming infected. It is thoght that persons have a 25-50% chance of developing AIDS within 10 years of becoming infected. THE TEST: PURPOSE AND ACCURACY The HIV antibody test is a medically accepted three-test series which is extremely accrate and reliable and is performed by a licensed laboratory. It is not error free. Possible errors inclde: a. False positives: the test may give a positive reslt, even thogh yo are not infected. This happens only rarely and is more common in persons who have not engaged in high-risk behavior. Retesting shold be done to help confirm the validity of a positive test. b. False negatives: the test may give a negative reslt, even thogh yo are infected with HIV. This happens most commonly in recently infected persons; it takes at least for to 12 weeks for a positive test reslt to develop after a person is infected. MEANING OF POSITIVE HIV TEST RESULT A positive HIV test reslt does not mean that yo have AIDS bt that yo are at a significantly increased risk of developing problems with yor immne system inclding AIDS or AIDS-related conditions. Federal athorities consider persons who are HIV antibody/antigenpositive to be infected with the AIDS virs and capable of infecting others. If yo test positive, yo shold seek a follow-p visit with yor personal physician and/or a pblic health clinic or an AIDS information organization. Yo may want to consider frther independent testing. SIDE EFFECTS A positive HIV test reslt may case yo significant anxiety, and may also reslt in ninsrability for life, health, or disability insrance policies yo may apply for now or in the ftre. Althogh prohibited by law, discrimination in hosing, employment or pblic accommodations may reslt if yor test reslts were to become known to others. A negative reslt may create a false sense of secrity. CONFIDENTIALITY All test reslts will be treated confidentially. They will be reported by the laboratory to the Insrer. The test reslts may be disclosed: to the proposed insred; to the person legally athorized to consent to the test; to a licensed physician, medical practitioner, or other person designated by the proposed insred; if yor HIV test is other than normal, to the Medical Information Brea (MIB), a national insrance data bank, sing a non-specific code, indicating only an abnormal test, to assre confidentiality; for statistical reports that do not disclose the identity of any particlar proposed insred; to employees, reinsrers, or contractors of the Insrer who have the responsibility to make nderwriting decisions on behalf of the Insrer; and to Insrer s legal consel who needs sch information to represent the Insrer effectively in matters concerning the proposed insred. Reslts will not otherwise be disclosed except as allowed by law or as athorized by yo. Reslts will not be disclosed to yor agent or broker. Yo may reqest by notice to the Insrer the names of the specific individals or organizations that: will have access to yor file; will receive a copy of yor reslts; or will keep the test information in a data bank or other file. 1 of 3 EHIV-04-PA (11/14) ef

20 NOTIFICATION If yor test reslts are negative, no rotine notification will be sent to yo nless yo complete the following: Name to whom to disclose negative test reslts: Address: If yor HIV test reslts are other than normal, the Insrer will notify a physician or organization that yo designate to receive the reslts directly. If yo do not name a physician to receive these reslts, the Insrer will notify the health department who will then notify yo. It is reqired that yo designate a physician, local health department, or local commnity-based AIDS/HIV organization to receive the test reslts becase a trained person shold deliver the information so that yo can nderstand the meaning of the test reslts. tify my physician Name Address PREVENTION Persons who have a history of high-risk behavior shold modify these behaviors to prevent getting or giving AIDS, regardless of whether or not they are tested. Specific important changes in behavior inclde safe sex practices (inclding latex condom se) and not sharing needles. HEALTH DEPARTMENT CONTACTS If yo want one of the following local health departments to notify yo of the test reslts, initial here: organization. and check the applicable PA DEPARTMENT OF HEALTH Goodwin Obiri Division of HIV/AIDS, Room 911 Attn: Insrance Information Section Health and Welfare Bilding 625 Forster Street Harrisbrg, PA ALLEGHENY COUNTY Tim Crges Allegheny Conty Health Department Insrance tification Information 3441 Forbes Avene Pittsbrgh, PA ALLENTOWN CITY Stephen Krtz Commnicable Disease Manager Allentown Health Brea 245 rth Sixth Street Allentown, PA BETHLEHEM CITY Jose Crz AIDS Prevention Coordinator Bethlehem Brea of Health 10 East Chrch Street Bethlehem, PA BUCKS COUNTY Shrita Washington Bcks Conty Department of Health Conseling & Testing Section Health Bilding 12 Almshose Road Neshaminy Manor Center Doylestown, PA CHESTER COUNTY Elizabeth Walls or Sandra Schwartz Chester Conty Health Department Brea of Personal Health Services 601 Westtown Road, Site 180 PO Box 2747 West Chester, PA ERIE COUNTY Darlene Scavona Erie Conty Department of Health 606 West Second Street Erie, PA EHIV-04-PA (11/14) ef 2 of 3