CONVERSION OF GROUP TERM LIFE INSURANCE. Subject to the terms of the Group Policy, as described in your group insurance certificate:

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1 CONVERSION OF GROUP TERM LIFE INSURANCE Subject to the terms of the Group Policy, as described in your group insurance certificate: (1) you may apply for an individual, permanent life insurance policy for conversion of your expiring group term life insurance; and (2) the individual policy may be for the same amount which you are losing by termination of your group insurance, or for a lesser amount, depending upon the circumstances of your termination. No medical examination will be required, as long as your application and payment for the first modal premium are received by Harleysville Life within 31 days of the termination date of your Group Term Life Insurance. Premiums may be paid annually, semi-annually, quarterly, or monthly via preauthorized check (PAC). Before sending your conversion request be sure you have: Included a check for the first modal premium, even if monthly Preauthorized check (PAC) was selected. Completed and signed the Application for Conversion of Group Term Life Insurance, application form LFUL-412. In Florida, use application form LFUL-412 (FL). A witness must sign the application, and be sure to include relationship to the beneficiary designated. Have the employer/plan sponsor complete page 2 of this form. If payment option is monthly, completed the Pre-Authorized Check Plan form (LFOA- 126B), a check is still necessary for first modal premium. WHERE TO SEND YOUR APPLICATION Please send your completed application, Notice of Eligibility Statement, and check or money order to: Harleysville Life Insurance Company, Group Administration Department, P.O. Box 253, Harleysville, PA, Be sure the NOTICE OF ELIGIBILITY STATEMENT (included in this packet) has been fully completed. If you have any questions, please call Your application and payment of the first modal premium must be made within the time limit shown in your certificate or policy. LFUL-41 (2)(FL) (Ed ) Page 1 of 4

2 GROUP TERM LIFE CONVERSION NOTICE OF ELIGIBILITY STATEMENT To be completed by an authorized representative of the Employer or Plan Sponsor 1. Name of Plan Sponsor: 2. Group Policy Number: 3. Name of insured converting coverage: 4. Insured s classification: Employee/Participant Spouse Dependent Child 5. Insured s Social Security Number: 6. If Insured is a Spouse or Dependent Child, provide name of Employee or Member, herein called the Participant : 7. Participant occupation or member status: 8. If Participant was an employee, please indicate number of hours worked per week: 9. Participant s date of hire or membership: 10. Date Insured s life insurance began under the group policy: 11. If participant was an employee, was the employee actively at work on their initial effective date? Yes No 12. Last day of employment or membership status: 13. Date eligibility for group life insurance terminated: 14. Amount of insurance cancelled: 15. Reason for cancellation of Insured s Group Insurance: 16. If reason for cancellation was disability, please provide the date the Insured became totally disabled: 17. Please state specific cause for total disability: 18. Date written notice of conversion right given to Participant: 19. Participant or Insured s home telephone number: Date Signature Authorized Representative of Employer / Plan Sponsor and Job Title Phone Name (Please Print) If you have any questions, please call LFUL-41 (2)(FL)(Ed ) Page 2 of 4

3 HOW TO CALCULATE YOUR PREMIUM 1. Select the annual rate per $1,000 from Appendix A for your age as of your last birthday. 2. Multiply this rate by the number of thousands of insurance for which you are applying. This is your annual premium. 3. If you wish to pay premiums semi-annually, quarterly, or monthly by preauthorized check (PAC), follow the steps below: Payment Options: Semi-annual... = multiply your annual premium by.515 Quarterly... = multiply your annual premium by.270 Monthly by preauthorized check (PAC)... = multiply your annual premium by.084 Example: Male, age 55, $20,000 death benefit Rate per thousand = $58.82 Thousands requested = 20 ($20,000 / $1,000) Annual premium = $58.82 x 20 = $1, Premium payment = $1, x.27 (quarterly) = $317.63/Quarter Your Premium Calculations: Rate per thousand... $ Thousands requested... x Annual premium... $ Payment option rate... x Semi-annual =.515 Quarterly =.270 Monthly by preauthorized check (PAC) =.084 (Please complete the PAC authorization form in this packet) Premium payment... $ Now that you have obtained your premium payment amount, please complete the enclosed application. Return the application and Notice of Eligibility with your personal check or money order made out to Harleysville Life Insurance Company. Please mail to: Harleysville Life Insurance Company Attn: Group Administration Department P.O. Box 253 Harleysville, PA If you have any questions, please call LFUL-41 (2)(FL)(Ed ) Page 3 of 4

4 Harleysville Life Insurance Company Whole Life Rates for Group Term Conversions ANNUAL PREMIUM RATE PER $1,000 OF INSURANCE Age Age Female Male Female Male Rates are effective 1/1/2011 LFUL-41 (2)(FL)(Ed ) Page 4 of 4

5 APPLICATION FOR CONVERSION OF GROUP TERM LIFE INSURANCE I hereby apply for a policy of insurance upon my life in accordance with the provisions of Group Policy Number insuring my life as an employee/participant 1. Proposed Insured (Print Name-First, Initial, Last) Male Date of Birth (Mo.-Day-Yr.) Place of Birth Female 2. Residence (No., Street, City, County, State, Zip) Social Security Number 3. a. Date employment/eligibility or covered class terminated with above employer/plan sponsor? - - b. Was employee/participant disabled when employment/eligibility terminated? If yes, provide date of disability c. Name of new employer Date of Hire d. Amount of group life benefit with new employer Effective Date 4. Plan - Whole Life A. Amount of insurance (Must not exceed state maximum or amount of term insurance when employment/eligibility terminated.) $ B. Premium Payable Annual Semi-Annual Quarterly PCP (Preauthorized Checking Plan) C. Automatic Premium Loan Yes No D. Amount of Premium submitted $ No insurance will be effective until the entire first premium for the policy is paid within 31 days from the date coverage under the group policy terminated during the lifetime of the proposed insured. ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO THE INSURANCE COMPANY - DO NOT MAKE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK. 5. Premium Notices to be sent: Insured at Residence Other: 6. a. Beneficiary (Name and Relationship to Proposed Insured): Primary Contingent Unless otherwise requested herein, payment is to be made to primary beneficiaries who survive the Insured, equally, or, if none survives, to contingent beneficiaries who survive, equally, or if none survives, to Insured's estate. b. Policyowner Unless otherwise requested, Proposed Insured is to be Policyowner. 7. ADDITIONAL INFORMATION (Refer to specific question number). 8. Is the policy intended to replace or change any existing life or annuity contract? Yes No If "Yes," please provide the following information: Company Name Policy Number Warning For Applications signed in: Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. IT IS MUTUALLY AGREED THAT: (1) The statements and answers made herein are complete and true to the best of my knowledge and belief; (2) issuance of the policy applies or shall be exchanged for all privileges and benefits with respect to the full amount of term insurance on my life under the Group Policy; (3) no person other than an officer of Harleysville can make, modify or discharge a contract or waive any of Harleysville s rights or requirements. Signed at on (City, State) (Mo.-Day-Yr.) X X Witness Signature of Proposed Insured NOTICE: If you do not hear from the Company concerning the X proposed insurance within 60 days, please notify Harleysville Signature of Applicant (if other than Proposed Insured) Life at Signature of Licensed Florida Agent Date Agency Name and Code Tax ID Number _ TO BE COMPLETED BY AGENT To the best of your knowledge, does the insurance applied for replace any existing life insurance? Yes No If Yes, complete any required replacement forms. Agent: Date: LFUL-412 (FL) (Ed. 8-03)

6 PREAUTHORIZED CHECK (PAC) INFORMATION FORM HARLEYSVILLE LIFE INSURANCE COMPANY The company above will withdraw the premiums from the specified account. This company will be referred to hereafter as Company. You, your, I and me refer to the bank account owner whose name appears below. How automatic bank draft works: Automatic bank draft is a debit service that offers a convenient way to pay life insurance premiums. The company will collect the life insurance premiums from your bank account electronically you do not need to write checks or mail in any payments. Premium withdrawals will appear on your bank statement, and your statements will be your receipts for payment of your premium. [Draft date will be 7-10 days from the date the application is received by Harleysville Life Insurance Company.] Automatic Bank Draft Agreement I hereby authorize and request the company to initiate electronic or other commercially accepted-type debits against the indicated bank account in the financial institution named for the payment of monthly premiums and other indicated charges due on the insurance policy, and to continue to initiate such debits in the event of a conversion, renewal, or other change to any such contract(s). I hereby agree to indemnify and hold the Company harmless from any loss, claim or liability of any kind by reason or dishonor of any debit. I understand that this authorization will not affect the terms of the contract(s), other than the mode of payment, and that if premiums are not paid within the applicable grace period, the contract(s) will terminate, subject to any applicable nonforfeiture provision. I acknowledge that the debit appearing on my bank statement shall constitute my receipt of payment, but no payment is deemed made until the Company receives actual payment. I agree that this authorization may be terminated by me or the Company at any time and for any reason by providing written notice of such termination to the non-terminating party and may be terminated by the Company immediately if any debit is not honored by the financial institution named for any reason. This must be dated and signed by the bank account owner(s) as his/her name appears on the bank records for the account provided on this authorization. Financial Institution Name: Financial Institution Address: City: State: Zip: Routing Number: Account Number: This agreement authorizes: A new monthly transfer A change in existing transfer amount A change in financial institution Type of Account: Checking Savings Credit Union Yes No Name of Primary Insured: Policy Number(s): Preferred Monthly Withdrawal Date (1st 28th): Universal Life, Term Only* Preferred Monthly Withdrawal Date (10th or 25th): Whole Life, Annuities Only Print Bank Account Owner(s) Name: Insured s Relationship to Bank Account Owner(s): NOTE: As part of HLIC s money laundering prevention program, a Bank Account Owner must have a specific relationship to the insured/policyowner, such as a parent, grandparent, spouse, guardian, child or employer. If this relationship does not exist, HLIC may refuse to establish the Bank Draft or may terminate the payment of funds to the policy. Signature(s) of Bank Account Owner(s): *if changing PAC information on a Universal Life or Term six digit policy number, a withdrawal date of the 10th or 25th is only available. FORM MUST BE COMPLETED IN FULL, ACCOMPANIED BY A VOIDED CHECK AND SENT TO HARLEYSVILLE LIFE INSURANCE COMPANY AT THE ADDRESS ABOVE. LFUL-412 (Ed. 8-03) IM-026 (Ed.02-10) Page 2 of 2