Group Administration Manual

Group Administration Manual Welcome To Greater Georgia Life Insurance Company THANK YOU... for selecting Greater Georgia Life Insurance Company to provide benefits for your employees. We at Greater Georgia Life Insurance Company want to make the administration of your plan a successful experience. This manual has been designed to supplement the personal attention you will receive from your Personal Service Representative. This manual is not a part of the policy and should not be viewed as such. The coverage provided under this plan is governed at all times by the terms of your policy, and you should refer to your Group Insurance Policy and Certificate for rate amounts and plan provisions. You have selected Greater Georgia Life Insurance Company to provide benefits for your most important asset... your employees. We are dedicated to that commitment. Greater Georgia Life Insurance Company, Inc. is a wholly owned subsidiary of Blue Cross and Blue Shield of Georgia, an Independent Licensee of the Blue Cross Blue Shield Association. Registered Mark of the Blue Cross Blue Shield Association.

TABLE OF CONTENTS SECTION DESCRIPTION PAGE Section A. CONTACT INFORMATION 3 Section B. BILLING - General Information 4 Section C. SAMPLE GROUP BILLING STATEMENT 5 Section D. ELIGIBILITY 16 D1. New Enrollments D2. Late Enrollees D3. Changes D4. Employee Terminations D5. Conversions Section E. TERMINATING THE GROUP POLICY 22 Section F. LIFE CLAIMS 23 F1. Life and Dependent Claims F2. Beneficiary Designations F3. Accidental Death and Dismemberment Claims F4. Accelerated Death Benefit Claims F5. Waiver of Premium Claims Section G. SHORT TERM AND LONG TERM DISABILITY CLAIMS 27 G1. Short Term Disability Claims G2. Long Term Disability Claims Section H. FORMS 30 H1. Member Enrollment Forms H2. Member Change Forms H3. Claim Forms 2

Section A. CONTACT INFORMATION LIFE and AD&D CLAIMS Topic: Phone: Fax: Claims - Customer Service, Life and AD&D Claims, Absolute Assignment, Waiver of Premium (800) 552-2137 ((770) 438-9712 Mailing Address: Greater Georgia Life Insurance Company - Life Claims Service Center P.O. Box 724767, Atlanta, GA 31139-1767 SHORT TERM and LONG TERM DISABILITY CLAIMS Topic: Phone: Fax: Claims - Customer Service (800) 232-0113 (770) 801-9393 (800) 850-0017 Mailing Address: Greater Georgia Life Insurance Company Disability Service Center P.O. Box 723058, Atlanta, GA 31139-0058 MEMBERSHIP, BILLING and GENERAL LIFE & DISABILITY QUESTIONS Topic: Phone: Fax: Membership/Billing (678) 443-5200 OR (800) 851-8544 (678) 443-5299 Mailing Address: Greater Georgia Life Insurance Company P.O. Box 4445 Atlanta, GA 30302 4445 Payment Address: Greater Georgia Life Insurance Company P.O. Box 281487 Atlanta, GA 30384-1487 3

Section B. BILLING - General Information B1. What is included on the group bill? The group billing statement provides the total amount due for all Greater Georgia Life Insurance Company (GGL) coverages included in your policy. B2. When will I receive the bill? Approximately ten days before each billing due date, you will receive a group billing statement that identifies the total amount due. B3. When is payment due? Payment is due on the first day of the billing period, which for customers billed monthly would be the first of each month. For example, the premium for March 1 to April 1 billing period is due on March 1. If premium is not received prior to the expiration of your grace period (31 days), your policy will lapse. B4. What do I return with the payment? Along with your remittance check made payable to Greater Georgia Life, you should include a copy of the group billing statement. All enrollment application and change request forms should be mailed to the billing address in Section A Membership. B5. How are new enrollments and changes reflected on the bill? A signed enrollment application form or an enrollment change form is necessary to ensure proper coverage for your members. These forms may be submitted at any time during the month and should be mailed to the address shown in Section A - Membership. GGL s membership and billing department will review and determine the eligibility of new enrollments and change requests. Approved membership changes processed between billing periods will be recapped in the Eligibility Adjustments section of your bill. Check your statement carefully to ensure all eligible employees are included on the statement and that benefits are correct. B6. What is the Total Amount Due? Your monthly premium payment should always equal the Total Amount Due as shown on your group billing statement. There is no need to adjust or recalculate your monthly bill. Any adjustments due to eligibility changes to the Total Amount Due will be made on a future billing statement. B7. Whom do I call for help? Your billing statement will include the name of the Personal Service Representative assigned to your group. Your assigned representative can be contacted at 1-800-851-8544 and is available to answer any questions you may have regarding your membership records or your group billing statement. For specific claim related questions, please contact either the Life Claims Service Center or the Disability Service Center by using the numbers provided in Section A - Contact Information. 4

Section C. SAMPLE GROUP BILLING STATEMENT C1. Overview The group billing statement includes the following three (3) sections: Cover Page Product Summary Billing Detail - Eligibility Adjustments - Manual Adjustment Detail - Membership Detail C2. Cover Page The Cover Page is a summary of all of the billing and payment activity that has occurred since your last month s billing statement. It gives pertinent information regarding the following: - your prior billed and paid amounts - a premium subtotal of any eligibility adjustments submitted and processed since your last bill - a premium subtotal of any manual adjustments made since your last bill - a premium subtotal of all membership for the current billing period - a total amount due for the bill The Cover Page is designed to be folded in half and placed in the remittance window envelope and returned along with your premium payment. To help us identify the payment when returned, your group name, bill entity number, billing period, and due date are displayed on this page. C3. Product Summary Page The Product Summary page displays the contract count totals for all product types, the current month s charges, current volume, any retroactive adjustments and the rate for each product. This provides you with a detailed breakdown of the total amount due for each product. C4. Billing Detail (a) Eligibility Adjustments This section recaps the eligibility changes that were received and processed since the last billing statement was prepared, and details retroactive premium charges and credits. We recommend that you check this section carefully each month to ensure that all eligibility changes you requested were processed accurately. However, remember that new enrollments and eligibility changes received after the 5 th of the month will most likely be reflected on your next billing statement. (b) Manual Adjustment Detail This section identifies any manual adjustment that was made to your Total Amount Due. A reason and a brief description of the adjustment are provided, along with the amount of the adjustment. (c) Membership Detail The Membership Detail section lists all of the subscribers enrolled on your group coverage for the current billing period. This listing is usually in alphabetical order by the subscriber s last name. User's Guide to the Group Billing Statement The following pages provide a field-by-field explanation of the group billing statement. It will help you read and understand your monthly statement. 5

USER'S GUIDE TO THE GROUP BILLING STATEMENT Section C2: COVER PAGE TOP HALF - This section provides a recap of the prior and current month s billing amounts/totals. Ref Field Name Description 1 Prior Bill Amount The total amount due for the previous billing. 2 Amount Paid The total premium payment applied toward the prior month s billing. 3 Prior Balance Due Premium discrepancy amount (debit or credit) after last month s billing was reconciled. 4 Eligibility Adjustment Subtotal This amount represents the net total (debit or credit) for all retroactive membership changes processed after the last month s billing was prepared. 5 Manual Adjustment Subtotal An amount will only appear here if a manual adjustment is processed (e.g., reinstatement fees) 6 Membership Detail Subtotal This amount represents the net premium total for the "current billing period only". 7 Total Amount Due The sum of the prior balance due, eligibility adjustment, manual adjustment and the membership detail. LOWER HALF - This section includes pertinent address and billing information. When mailing your payment, it is important to write the amount of your check in the field Enter Amount Paid. (Field 14) Ref Field Name Description 8 Group Information The group s name and billing address. 9 Bill Entity No. The primary group number that consolidates all suffixes under one group number for billing purposes. 10 Invoice Number A unique invoice number will appear on your group billing statement each time a bill is issued for your group. 11 Billing Period The period of time for which you are being billed. 12 Date Billed The calendar date that your billing was generated. 13 Total Due The total premium due. 14 Enter Amount Paid The amount that you are remitting to GGL. 15 GGL Address Greater Georgia Life s remittance address. 16 Sys For internal use only. 17 Desk For internal use only. 18 Bill Entity The primary group number that consolidates all suffixes under one group number for billing purposes. 19 MBS Number For internal use only. 20 Due Date The date by which your premium payment should be received by Greater Georgia Life. 6

USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) COVER PAGE Invoice Number 000001628A Billing Entity No. GAA042C001 1 Prior Bill Amount $ 442.42 2 Amount Paid 442.42 3 Prior Balance Due $ 0.00 4 Eligibility Adjustment Subtotal 0.00 5 Manual Adjustment Subtotal 0.00 6 Membership Detail Subtotal 298.20 7 Total Amount Due $ 298.20 Please Return this Page With Your Check ------------------------------------------------------------------------------------------------------------------------------------------------------------------ Please Fold Here for Mailing GREATER GEORGIA LIFE P.O. BOX 281487 ATLANTA, GA 30384-1487 8 FAMILY TREE ENTERPRISES 9 Bill Entity No.: GAA042C001 21555 OXNARD ST. WOODLAND, GA 30612 10 Invoice Number: 000001628A 11 Billing Period: 04-01-03 To 05-01-03 12 Date Billed: 03-16-03 13 Total Due: $298.20 14 Enter Amount Paid,,. 15 Make Check Payable To: GREATER GEORGIA LIFE P.O. BOX 281487 ATLANTA, GA 30384-1487 16 17 18 19 20 BILL MBS SYS DESK ENTITY NUMBER Due Date 2 9007 GAA042C001 LSG00000 04-01-03 5812 7

USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) Section C3: PRODUCT SUMMARY The Product Summary section provides a detailed breakdown of the total amount due for each group/product. It displays the contract counts for all contract types, the current month s charges, current volume, any retroactive adjustments and the rate for each product. This gives you the opportunity to quickly determine the monthly charge for each of your products. Ref Field Name Description 1 Billing Entity Name The group s name. 2 Billing Entity No. The primary group number that consolidates all suffixes under one group number for billing purposes. 3 Invoice No. A unique invoice number will appear on your group billing statement each time a bill is issued for your group. 4 Page No. The page number of the bill. 5 Group Contact The first and last name of the person that Greater Georgia Life contacts when billing or reconcilement issues need to be resolved. 6 Personal Service The name of the personal service representative assigned to administer your account. Representative 7 Desk No. The desk number of the personal service representative (this is not an extension number). 8 Telephone The phone number of the personal service representative. 9 Billing Period The period of time for which you are being billed. 10 Date Billed The calendar date that your billing was generated. 11 Payment Due Date The date your premium payment is to be received by Greater Georgia Life. 12 Group/Product Contract Type Your group numbers/product names with the appropriate contract type codes within each product. 13 Current Count The subscriber counts within each contract type. 14 Current Volume Current total volume for all products billed. 15 Billing Charges The premium charges being billed, by contract type, for the current month only. 16 Retro The premium charges being billed, by contract type, for retroactive changes only. 17 Total The total of all current month s premium plus retroactive amounts being billed. 18 Rate The rate for your group will be displayed by group suffix for each contract type. 19 Total The total for each group suffix, by the number of subscribers, current month charges, retroactive charges and the total premium due. 20 Subtotal/All Products The subtotal for all products. 21 Legend Description of all contract types. Note:The subtotal shown for current billing charges will also appear by the membership detail subtotal on the cover page. The subtotal shown for retroactive charges also appears by the eligibility adjustment subtotal on the cover page. 8

USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) PRODUCT SUMMARY 1 Billing Entity Name: FAMILY TREE ENTERPRISES 3 Invoice No.: 00001628A 2 Billing Entity No.: GAA042C001 4 Page No.: 1 5 Group Contact: FRANCES JONES 6 Personal Service Representative: SALLY SMITH 7 Desk No.: 9007 8 Telephone: (800) 851-8544 9 Billing Period: FROM 04-01-03 TO 05-01-03 10 Date Billed: 03-16-03 11 Payment Due Date: 04-01-03 12 13 14 15 16 17 18 Group/Product Current Current Billing Contract Type Count Volume Charges Retro Total Rate GAA042B001 AD&D - ACTIVE OFFERED BY GREATER GEORGIA LIFE LSUB 5 150,000 7.50 0.00 7.50 0.050*** 19 Total 5 150,000 7.50 0.00 7.50 GAA0042C001 BASIC LIFE TERM - ACTIVE OFFERED BY GREATER GEORGIA LIFE LSUB 1 30,000 7.80 0.00 7.80 0.260*** 19 Total 1 30,000 7.80 0.00 7.80 GAA042F001 LIFE WITH DEP - ACTIVE OFFERED BY GREATER GEORGIA LIFE LSUB 4 120,000 31.20 0.00 31.20 0.260*** LDEP 6.80 0.00 6.80 1.700**** 19 Total 4 120,000 38.00 0.00 38.00 GAA042L001 LONG TERM DISABILITY - ACTIVE OFFERED BY GREATER GEORGIA LIFE 00 24 0.00 0.00 0.00 0.550** 25 29 1 900 7.02 0.00 7.02 0.780** 30 34 0.00 0.00 0.00 1.070** 35 39 0.00 0.00 0.00 1.500** 40 44 3 7,300 153.30 0.00 153.30 2.100** 45 49 1 1,100 32.78 0.00 32.78 2.980** 50 54 0.00 0.00 0.00 4.030** 55 59 0.00 0.00 0.00 4.780** 60 64 0.00 0.00 0.00 4.780** 65 69 0.00 0.00 0.00 4.780** 70 99 0.00 0.00 0.00 4.780** GAA042W001 SHORT TERM DISABILITY - ACTIVE OFFERED BY GREATER GEORGIA LIFE LSUB 5 1,480 51.80 0.00 51.80 0.35* 19 Total 5 1,480 51.80 0.00 51.80 20 Subtotal/ALL Products 310,780 298.20 0.00 298.20 * Rate per $10 ** Rate per $100 *** Rate per $1000 **** Flat Rate 9

USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) Section C3: PRODUCT SUMMARY 21 LEGEND S = SUBSCRIBER ONLY 2P = TWO PARTY CONTRACT FAM = FAMILY CONTRACT DEP = ONE DEPENDENT DEPS =TWO OR MORE DEPENDENTS S+DEP = SUBSCRIBER + 1 DEPENDENT (NO SPOUSE) S+DEPS = SUBSCRIBER + 2 OR MORE DEPENDENTS (NO SPOUSE) LSUB = LIFE SUBSCRIBER LSPS = LIFE SPOUSE LCHD = LIFE CHILD LDEP = LIFE SPS AND CHILD(REN) 10

USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) CALCULATING PREMIUM To calculate the premium due for a particular coverage, please follow the formulas provided below. Please refer to your insurance contract to determine the coverage amounts for your employees. SHORT TERM DISABILITY (*) The cost of weekly income (or short term disability) insurance is calculated based on the actual benefit provided to the employee if that employee becomes disabled. Rates are per $10 of benefit. Use the formula below to calculate the cost of WI/STD coverage. BENEFIT AMOUNT X RATE = PREMIUM $10 EXAMPLE: (STD coverage for John Smith) According to the contract under which he is covered, John's benefit amount will be 60% of his weekly earnings. The maximum benefit allowed under this group plan is $250. 60% of John's weekly earnings : $285.09 Maximum Benefit Amount: $250 Cost of John's coverage: 250.00 = 25.00 x.44 = $11.00 10 LONG TERM DISABILITY INSURANCE (**) Traditional LTD rates are based on a per $100 of monthly covered payroll. However, the payroll rate must be converted to a monthly covered benefit rate and premium is calculated based on monthly benefit. Payroll rate.38 =.633 (benefit rate) Benefit percentage.60 Use this formula to calculate the cost of LTD coverage: MONTHLY BENEFIT X RATE = PREMIUM $100 EXAMPLE: (LTD insurance for Julie Johnson) According to the group contract, this plan will cover a 60% maximum per member's monthly benefit of $5,000 and has a rate of $.38 of monthly covered payroll. Julie's monthly earnings: $3,012 x.60 = 1,807.20 (Julie's benefits) Cost of Julie's coverage: 1,807.20 = 18.07 x.633 = $11.44 100 ** This applies to LTD coverage that was effective prior to June 1,2003. If you have any questions on your LTD premium calculation, please contact your personal service representative. BASIC LIFE/AD&D INSURANCE (***) Life and AD&D rates are per $1,000 of coverage, so premium should be calculated based on the actual benefit amounts provided to each employee. Use the formula listed below to calculate the cost: BENEFIT AMOUNT X RATE = PREMIUM $1,000 EXAMPLE: (Life insurance for John Smith) 25,000 = 25.00 x.55 = $13.75 1,000 DEPENDENT LIFE INSURANCE (****) Dependent life insurance rates are per family unit. The same rate is charged per family regardless of the actual number of dependents covered. Use the formula below to calculate the cost of dependent life insurance: FAMILY UNIT X RATE = PREMIUM EXAMPLE: (Dependent life insurance for John and Sarah Smith and children) EXAMPLE: (AD&D insurance for John Smith) 25,000 = 25.00 x.05 = $1.25 1,000 1 Family unit X 1.20 = $1.20 11

USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) Section C4: BILLING DETAIL a) ELIGIBILITY ADJUSTMENTS This section of the billing recaps all eligibility changes that were received and processed after the last billing statement was prepared. This section also details all retroactive premium charges. Ref Field Name Description 1 Cert. No. Subscriber s certificate number (generally the employee s social security number). 2 Subscriber Name The name of the subscriber. 3 Dept. No. Employee department number if group requests. 4 Group No. Each of the group numbers that were impacted by the subscriber s eligibility changes. 5 Prod Type Each of the product types that were impacted by the subscriber s eligibility changes. 6 Cont. Type The new contract code resulting from the membership change. 7 No Cvd. Number of members covered. 8 From Date The from date of the change*. 9 To Date The to date of the change*. 10 Mo/Da Indicates the number of months/days affected by the adjustment change. Zeros will be displayed for all changes made during the current billing period. 11 Calc. Rate The rate amount used to calculate retroactive premium (calculation rate) x (number of months/days). 12 Prem. Adj. Premium adjustments resulting from the membership change. The premium adjustment for changes processed as of the current billing period will display with zeros due. Premium amounts for the current billing period are shown in the membership detail section. Premium adjustment amounts shown here represents retroactive premiums only. 13 Code Short description of the membership change processed (See General Terms). 14 Eligibility Adjustment Subtotal The net subtotal of the eligibility adjustments. We recommend that you audit this section of the billing each month to ensure that all eligibility changes requested were processed accurately. * If the change is effective as of the current billing period, the " from" and "to" dates will be the same. If the change is effective retroactive to the current billing period, the effective date will be displayed in the "from date" column. b) MANUAL ADJUSTMENT DETAIL This section identifies any manual adjustment that had to be made to your Total Amount Due. A reason and a brief description of the adjustment are provided, along with the amount of the adjustment. Ref Field Name Description 15 Grp/Suf The group number to which the adjustment has been made. 16 Reason The reason for the adjustment. 17 Description A brief explanation of the adjustment. 18 From Date The from date of the change. 19 To Date The to date of the change. 20 Amount The dollar amount of the adjustment. 21 Manual Adjustment Subtotal The net subtotal of all the manual adjustments. 12

USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) BILLING DETAIL Billing Entity Name: FAMILY TREE ENTERPRISES Invoice No.: 00001628A Billing Entity No.: GAA042C001 Page No.: 2 Group Contact: FRANCES JONES Premium Specialist: SALLY SMITH Desk No.: 9007 Telephone: (800) 851-8544 Billing Period: FROM 04-01-03 TO 05-01-03 Date Billed: 03-16-03 Payment Due Date: 04-01-03 ELIGIBILITY ADJUSTMENTS * *Eligibility changes received after the 5 th of the month may be reflected on your next bill. 1 2 3 4 5 6 7 8 9 10 11 12 13 Dept Group Prod Cont No. From To Mo/ Calc Prem Cert No. Subscriber Name No. No. Type Type Cvd Date Date Da Rate Adj Code 14 Eligibility Adjustment Subtotal MANUAL ADJUSTMENT DETAIL 15 16 17 18 19 20 GRP/SUF Reason Description From Date To Date Amount 21 Manual Adjustment Subtotal 13

USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) c) MEMBERSHIP DETAIL This section of the group billing statement lists all of your subscribers who are enrolled for the billing period in your group plan. Ref Field Name Description 1 Cert. No. Subscriber s certificate number (generally the employee s social security number). 2 Dept. No. This area will remain blank unless your organization utilizes department numbers for billing purposes. 3 Emp. No. This area will remain blank unless your organization utilizes employee numbers for billing purposes. 4 Subscriber The name of the subscriber. Name 5 COBRA End Does not apply to Life benefits. Date 6 Group No. The group number(s) in which the subscriber is enrolled. /Suffix 7 Grp Type Group type associated with the group the subscriber is enrolled in (e.g. A=Active) 8 Prod Type A brief description of the benefit associated with each group suffix. Refer to the General Terms section for a complete list. 9 Cont Type Current contract type for each subscriber (i.e., S=Subscriber Only, FAM=Family) 10 No. Cvd Total number of members currently covered on the subscriber s contract. 11 Volume Product volume per subscriber. 12 Prem. Amt. Premium amount due for the current billing period for each subscriber. 13 Total The total number of subscribers. Subscribers 14 Volume Total The total volume for subscriber products for your group for the current billing period. 15 Membership The premium sub total amount due for the current billing period. Detail Subtotal 16 Total Amount Due The total amount due for any eligibility adjustments, any manual adjustments and all the membership detail. 14

USER'S GUIDE TO THE GROUP BILLING STATEMENT (continued) BILLING DETAIL Billing Entity Name: FAMILY TREE ENTERPRISES Invoice No.: 00001628A Billing Entity No.: GAA042C001 Page No.: 2 Group Contact: FRANCES JONES Premium Specialist: SALLY SMITH Desk No.: 9007 Telephone: (800) 851-8544 MEMBERSHIP DETAIL Billing Period: FROM 04-01-03 TO 05-01-03 Date Billed: 03-16-03 Payment Due Date: 04-01-03 1 2 3 4 5 6 7 8 9 10 11 12 Dept Emp. COBRA Group No. Grp Prod Cont No. Prem. Cert No. No. No. Subscriber Name End Date / Suffix Type Type Type Cvd Volume Amt. 123456780 ATON, VIVIAN GAA042B001 A ADD LSUB 30,000 1.50 GAA042F001 A LDEP LSUB 30,000 7.80 GAA042F001 A LDEP LDEP 1.70 GAA042L001 A LTD 40-44 5,000 105.00 GAA042W001 A STD LSUB 500 17.50 123456781 ANNT, XAVIER GAA042B001 A ADD LSUB 30,000 1.50 GAA042F001 A LDEP LSUB 30,000 7.80 GAA042F001 A LDEP LDEP 1.70 GAA042L001 A LTD 40-44 1,100 23.10 GAA042W001 A STD LSUB 250 8.75 123456782 HOOVER, YVONNE GAA042B001 A ADD LSUB 30,000 1.50 GAA042C001 A LBAS LSUB 30,000 7.80 GAA042L001 A LTD 25-29 900 7.02 GAA042W001 A STD LSUB 200 7.00 123456783 MMEL, ZEEK GAA042B001 A ADD LSUB 30,000 1.50 GAA042F001 A LDEP LSUB 30,000 7.80 GAA042F001 A LDEP LDEP 1.70 GAA042L001 A LTD 40-44 1,200 25.20 GAA042W001 A STD LSUB 280 9.80 123456784 SMITH, JOE GAA042B001 A ADD LSUB 30,000 1.50 GAA042F001 A LDEP LSUB 30,000 7.80 GAA042F001 A LDEP LDEP 1.70 GAA042L001 A LTD 45-49 1,100 32.78 GAA042W001 A STD LSUB 250 8.75 14 Volume Total 310,780 13 Total Subscribers: 5 15 Membership Detail Subtotal 298.20 16 Total Amount Due 298.20 15

Section D. ELIGIBILITY D1. New Enrollments (a) Who is eligible to enroll To obtain coverage under your group policy, an employee must meet the eligibility requirements as defined in your policy, reach an eligibility effective date as designated by the group policy probation period, and enroll by completing a Group Insurance Application or Member Enrollment Application Form. General eligibility requirements for coverage under your group policy include (actual eligibility provisions may vary - please refer to your group policy for details): Employees a. Must be full-time active employees working 30 hours or more per week. b. Must have completed the required probationary period. Dependents (Applicable to Life Only) a. Employee must complete the required probationary period. b. Must be a dependent of a member employee who has elected dependent coverage. Dependents include: - Legal spouse (only one spouse may be enrolled at one time) under the age AND not legally separated from the employee. - Unmarried children who are financially dependent upon the employee for support. Children are considered financially dependent if they qualify as dependents for Federal Income Tax purposes - Unmarried children who meet all the other unmarried children criteria AND who are enrolled as full-time students at an accredited secondary school, college or university. Please refer to your group policy for specifics pertaining to your group. - Age restrictions apply. Please see your policy for details. Notes: 1) An unmarried child may include the employee s natural child, stepchild, legally adopted child, and a child under custody pursuant to a court order or legal guardianship. (Note: Copies of the court documents are required.) 2) The term dependent does NOT include any person who: - is eligible as an employee - is a member of the armed forces of any country - is residing outside the United States and Canada (b) Employees who do not wish to enroll If an employee declines coverage, an application marked "refused" or the "Life/Disability Coverage Waiver Authorization Form" needs to be completed. This is necessary to document that the employee was given an opportunity to enroll through the group plan, but elected not to do so at that time. An employee who declines coverage when first eligible or who does not elect coverage for his eligible family members during the initial eligibility period may apply at a later date, but will be subject to medical underwriting. Refer to Section D2 -Late Enrollees for more information. 16

Section D: ELIGIBILITY (continued) (c) When may employees enroll Eligible employees may apply for coverage as a new hire within 31 days of employment or within 31 days of any group's specific employee probationary period. If an employee does not enroll for coverage by completing the enrollment application form within 31 days from his or her eligibility date, the employee and dependents become late enrollees and are subject to medical underwriting. Refer to Section D2 - Late Enrollees for more information. (d) How to enroll new employees Eligible employees may enroll by completing the Group Insurance Application or Member Enrollment Application Form. These forms are created to clearly convey information between you and GGL and it's parent and affiliates. Please take a moment to review and verify that all items have been completed accurately. Errors or missing information could cause a delay in processing and the application being returned. Important points to help your employees enroll: New employees should complete enrollment forms when hired. Applications must be submitted within 31 days from an employee s eligibility date, or the employee will be required to apply for coverage as a late enrollee. Having the form completed when the employee is hired will help in meeting the 31-day timeliness requirement in the event that you or the applicant are away from the office when eligibility occurs. Be sure that each employee indicates the exact coverage(s) desired. This is especially important when dependent term life insurance is desired. If the employee pays any portion of the premium for dependent term life insurance, the box for dependent term life insurance must be checked. If the box is not checked, the dependent life coverage will not be effective. Each member must name a primary beneficiary. (1) A primary beneficiary is the person(s) who will receive the death benefit upon the death of the member. If more than one primary beneficiary is named, be sure to indicate the percentage each person is to receive. If percentages are not indicated, the proceeds will be divided equally. (2) If no beneficiary is named or surviving at the member s death, benefits will be paid to the member s estate. (3) When designating children as beneficiaries, note that we cannot make payment to children under the age of 18. If the beneficiary is under 18, we will pay benefits to a court appointed guardian of property (conservator). (4) Use the full first and last name of the beneficiary; do not use initials only for the first name. (5) A member cannot name his/her employer as their beneficiary. (6) A member cannot name himself as beneficiary. However, a member can name his estate or a trust. When naming a trust as beneficiary, we will need both the name and date of the trust. (7) The employee is always the primary beneficiary in a dependent life claim. 17

Section D. ELIGIBILITY (continued) (e) Effective date of coverage If an employee applies for coverage when first eligible, the effective date of coverage will be as stipulated in accordance with the Eligibility section of the Group Term Life Insurance Master Application. Example 1: Assume that your Group Term Life Insurance Master Application provides that employees and their dependents become eligible for coverage on the first day of the month following 30 days of employment. Here is how coverage would begin for a new employee hired on August 15: 1. Date of hire 08/15 2. Date probationary period is completed (Hire date plus 09/14 term of probationary period as shown in the Group Policy) 3. Date coverage begins (as specified in your Group 10/01 Policy) 4. First billing period for which premiums must be paid 10/01-10/31 Example 2: Now let us see how coverage and the first premium payment would differ if the employee is hired on August 1 (rather than August 15): 1. Date of hire 08/01 2. Date probationary period is completed 08/31 3. Date coverage begins 09/01 4. First billing period for which premiums must be paid 09/01-09/30 18

Section D. ELIGIBILITY (continued) D2. Late Enrollees (a) Who is a late enrollee? Contributory Products (Employee and Employer Paid) Late enrollment rules apply to employees who elected not to apply when first eligible or who did not enroll prior to the expiration of the enrollment probationary period. Additionally, if an employee has existing coverage with GGL and initially declined dependent life coverage for dependents, but later elects to provide coverage for those dependents, a Member Enrollment Change Form and a Medical Questionnaire are required for the dependents. Non-Contributory Products (Employer Paid) Late enrollment rules do not apply. All employees should be enrolled during their initial eligibility period. Coverage will be effective as of the date first eligible. (b) How to enroll late enrollees Late enrollees may apply for coverage by completing the Group Insurance Application or the Member Enrollment Application and a Medical Questionnaire. The Medical Questionnaire is a self-explanatory form with clear instructions. A copy has been enclosed in this manual. Information on the form should be verified by the employee and the group administrator for completeness and accuracy to prevent a delay in processing. Our Underwriting department will review the application and medical questionnaire. For legal and audit purposes, please be sure the original forms are filled out in ink and are signed by the employee and spouse (if applying). The forms should be mailed immediately to the address in Section A Membership. Please note that applications with signatures more than 60 days old will not be accepted. In some instances, additional medical information may be required. The originals of all questionnaires are to be submitted to GGL; duplicates or facsimiles cannot be accepted. If such health evidence is required, GGL will not be liable for any of the costs related to acquiring the additional documents. It will take approximately 30 days to process the application and medical questionnaire. If approved, the effective date of coverage will be the first of the month following approval by our underwriting department. D3. Changes The Member Enrollment Change Form or Request for Change Form provides documentation that a member has made a change in beneficiary, dependent status (adding or deleting dependent life coverage) or a change in name. All of the appropriate sections of the form must be completed, signed and dated by the employee and must include the employee s certificate number and group number(s). Events that might occur after an employee is originally enrolled include the following: - Primary beneficiary dies Submit change form to specify a new primary beneficiary; otherwise, benefits will be paid to the contingent beneficiary, if one was named; if no contingent beneficiary was designated, benefits will be paid to the member s estate. 19

Section D. ELIGIBILITY (continued) - Spouse or dependent loses eligibility (divorce, spouse or dependent s death, dependent s attainment of policy s maximum age, dependent s marriage, etc.) Employee submits Member Enrollment Change Form within 31 days of the event for consideration. The effective date of the change will be the date of the event unless otherwise specified in your policy. Note that the loss of eligibility may also qualify the individual for a conversion policy. Refer to Section D6 - Conversions for more information. - Employee wishes to add a new spouse (marriage or change in employment status of spouse.) A Member Enrollment Change Form must be received within 31 days of the event; the coverage effective date will be the first of the month following the event. If not received within 31 days of the event, a Medical Questionnaire will also be required; the effective date of coverage will be the first of the month following medical underwriting approval. - Employee wishes to assign benefits An employee may request an assignment of benefits by submitting an Absolute Assignment of Group Life Insurance Form to GGL (form available from the Life Claims Service Center ). The request must be approved by GGL to be a valid assignment under the policy. To be valid, an assignment must also be absolute and irrevocable. GGL assumes no liability for its sufficiency. D4. Retroactivity Retroactivity is generally defined as any change affecting additions or terminations of a member or members with an effective date prior to the date received by GGL. The processing of all retroactive changes is solely at the discretion of GGL, and the following guidelines are in place: Non-Contributory Products: Retroactive terminations and changes will be processed for effective dates up to six months prior to GGL receipt. Retroactive additions will be added back to the date first eligible. Contributory Products: Retroactive terminations and changes that reduce benefits will be processed for effective dates up to 90 days prior to GGL receipt for billing purposes. Additions and changes that increase benefits must be applied for within 31 days of becoming eligible. Premium will be billed from the date first eligible. Additions and changes that increase benefits that are not applied for within 31 days of becoming eligible will require the submission of a medical questionnaire and will not be effective until the first of the month following underwriting approval. Requests for effective dates other than what would be provided using the above guidelines must be approved by the Underwriting Department. 20

Section D. ELIGIBILITY (continued) D5. Employee Terminations Written notification should be received by GGL when loss of eligibility occurs. Written notification may be provided on your group billing statement, a change form, or letter. This information should be provided as soon as the termination occurs and include the term effective date. If termination is due to death of an employee, please write deceased next to the employee s name along with the date of death. D6. Conversions Eligible employees or spouses may apply, without evidence of insurability, for an individual policy of life insurance when they have lost their eligibility to be covered under the group policy for the following reasons: a. termination of the employee s employment b. death of the employee c. loss of eligibility in a class under this policy Consult your group policy for additional reasons that may allow an eligible employee or spouse to apply for an individual policy. Note: Dependent children are not eligible for conversion. The steps to follow if an eligible employee or eligible dependent wishes to exercise his of her conversion option: a. The employer must complete Section I of the Request for Group Life Conversion Information Form. b. The employer forwards the request to the employee to complete Section II of the form and mail to the address at the bottom of the form. c. The employee will then be sent an application for life conversion, along with the rates for a conversion policy. The employee completes the application and returns it, along with appropriate premium, to the address designated on the form. NOTE: IN ORDER TO MEET THE CONVERSION PROVISIONS SET FORTH IN THE POLICY, THE COMPLETED CONVERSION APPLICATION AND APPROPRIATE PREMIUM MUST BE RECEIVED WITHIN 31 DAYS OF TERMINATION OF YOUR LIFE INSURANCE BENEFITS UNDER YOUR GROUP INSURANCE POLICY. 21

Section E. TERMINATING THE GROUP POLICY Termination of a group from GGL coverage can be initiated by a request from the group or by GGL. If the group requests cancellation of its policy, a letter signed by an authorized representative of the company is required. The letter must include the requested cancellation date and be received at least 30 days prior to the next premium due date. Your group policy will clearly outline all of the above in detail. Example: Next premium due date 06-01-2003 Letter must be received by GGL or the group must receive GGL's notice of termination no later than 05-01-2003 Cancellation of the group occurs on 06-01-2003 If no written notice is given, the policy renews under the same terms and conditions. If premium due for a group is not paid before the end of the grace period, GGL will cancel that policy as of the paid to date of the policy. Upon termination, it is the group s responsibility to notify its employees when GGL coverage is cancelled. 22

Section F. LIFE CLAIMS Life claims are processed by a claims unit that specializes in the administration and payment of life related claims. Please submit all Life, AD&D, Waiver of Premium, and Accelerated Death claims to the Life Claims Service Center. Our goal is to process all life claims with complete information within 5-7 days of receipt. For specific details regarding the benefits provided by your policy, please refer to the benefit provisions of your policy. Life Claims Contact Information Topic: Phone: Fax: Claims - Customer Service (800) 552-2137 (770) 438-9712 Mailing Address: Life Claims Service Center P.O. Box 724767 Atlanta, GA 31139-1767 F1. Life and Dependent Claims Life Claims require the following: Claims Submissions Beneficiary Claim Form Certified copy of death certificate Enrollment Form Any change of beneficiary designation, if applicable Employer provides payroll records for last period worked 23

F2. Beneficiary Designations In the event of a claim, the Group Administrator is responsible for providing copies of the enrollment form (with beneficiary information) plus any other beneficiary designation forms that the member completed. Valid beneficiary designations should include a name, social security number, relationship to member and birth date. In addition, the form must be signed and dated by the member. Multiple beneficiaries may be named on the same form. If percentages are not filled in, equal shares will be assumed. Primary and secondary beneficiaries may also be named on the form. If the primary beneficiary is not living at the time of the member's death, the secondary beneficiary will receive the benefit. If no beneficiary is living at time of death, or none is named, the benefit will be paid as shown in the certificate booklet. Standard wording would be..."benefits are payable to the executor or administrator of the estate. If there is no executor or administrator, we may at our option: - (a) pay benefit to the spouse if living; or - (b) if there is no living spouse, pay equal shares of the benefit to your children if living; or - (c) if there are no living children, pay the benefit in equal shares to the direct parents if living." It is important to review the wording in the certificate booklet that applies to your benefits. ABSOLUTE ASSIGNMENT BENEFICIARY DESIGNATIONS are a special type of beneficiary designation that can ONLY be changed if the new owner agrees to the change. They change the ownership of the group life benefit. They are often done for estate planning, taxation issues, and for viatical arrangements. Forms are available from the Life Claims Service Center. Refer to Section A - Contact Information for more information. F3. Accidental Death & Dismemberment (AD&D) Claims (a) Accidental Death Claims require the following: Beneficiary Claim Form Certified copy of death certificate Enrollment form Any change of beneficiary designation if applicable Newspaper clipping and/or police report Employer provides payroll records for last period worked AD&D includes the following benefits in addition to life insurance: Accidental Death - Benefit paid if death is by accidental means. Usually, the benefit equals the life benefit. Dismemberment - Benefit paid due to loss of limbs or vision in the event of an accident. Seatbelt - Additional benefit of 10% of face amount or $25,000 (whichever is less), if accidental death was caused while using an unaltered seat belt. Repatriation - Pays up to an additional $5,000 to return remains of member to a mortuary, if accidental death occurred more than 100 miles from primary residence. Education Benefit - Pays an additional benefit in four equal installments of $3,000 to a maximum of $12,000 for the education of the child of the deceased. Refer to the exclusions section of the Certificate booklet for more information on AD&D exclusions. 24

F4. Accelerated Death Benefit (ADB) Claims ADB may be included with the Basic Life. It is not available for AD&D or Dependent Life coverages. This benefit is also referred to as Living Life Benefit (LLB). This provision offers up to 50% of the life benefit when an active member becomes terminally ill* and life expectancy is 12 months or less. Employees can request for less than the maximum, but only one payment will be made during the member's lifetime. *Refer to contract wording for specific definition. (a) Typical steps for an ADB claim: 1. Claim forms completed by group, member and physician: a) "Claim for Personal Accelerated Death Benefit" b) "Accelerated Death Benefit Attending Physician's Statement" 2. Employer provides payroll records for last period worked 3. Submit claim forms to Life Claims Service Center 4. Life Claims Service Center reviews 5. If approved, Life Claims Service Center pays ADB benefit to member 6. Employer should reduce the life benefit by the ADB amount paid (reducing monthly cost to employer) 7. Member may file for waiver of premium benefit on remaining benefit, if not already completed. Refer to Section F5 - Waiver of Premium Claims for more information. 8. Upon death of member, group files death claim a) Employer provides payroll records for last period worked b) Life Claims Service Center pays remaining amount to beneficiary c) Employer terminates member from billing statement Refer to Section H - Claim Forms for a list of forms. 25

F5. Waiver of Premium Claims Waiver of Premium (also referred to as "W of P", "Total and Permanent Disability" or "TPD") (WAIVER) is a standard provision of group basic and supplemental life policies throughout the industry. It is not available for AD&D or for dependent life. A member may qualify for WAIVER if he/she becomes totally disabled* before age 60 (65 in certain contracts), and is continuously totally disabled for 6 months. If WAIVER is approved, life coverage remains in force, without premium payments, assuming continuous total disability. Approvals are usually for one year with re-certification required annually. *If a member was totally disabled and under age 60 when coverage terminated, and dies within the first 12 months of continuous total disability, a death benefit may be payable even if premium payments ended. Proof of total disability would be required with the death claim. (a) Waiver of Premium Claims require the following: "Disability Claim" form "Application for Group Life Insurance Disability Benefits" form "Attending Physician's Statement" form Employer provides payroll records for last period worked Refer to Section H - Claim Forms for a list of forms. (b) How to apply for waiver: To apply for WAIVER, the group and member must complete the "Disability Claim" form. The doctor must complete the "Application for Group Life Insurance Disability Benefits" and the "Attending Physician's Statement" form. These forms should be completed no earlier than three months before the end of the WAIVER waiting period. Assuming a nine-month waiting period, proof can be submitted when the member has been continuously totally disabled six months but must be submitted prior to 12 months from the date disability commenced. (c) When waiver is approved: The member and group are notified of approval by letter. The "Re-certification for Waiver of Premium" form is sent with the member's letter that indicates the time frame in which to submit the re-certification assuming continuous total disability. We may request a copy of the Notice of Award for Social Security Disability benefits. Under certain conditions, we may also require an examination by our physician, at our expense, at reasonable intervals. A member cannot be covered under WAIVER and a conversion policy simultaneously. If a member converted when group coverage terminated, the conversion policy must be returned when WAIVER is approved. Conversion premiums are then refunded. (d) When waiver ends: Waiver ceases when any of the following occur: The member is no longer totally disabled. Written proof of continuous disability is not provided when required. The member refuses an examination by our physician when required. The benefit schedule provides for a termination or reduction of benefits at a specific age or retirement. When WAIVER ceases, or coverage is reduced, the conversion privilege is applicable. 26

Section G. STD & LTD CLAIMS Short Term Disability claims are processed by a claims unit that specializes in disability benefits. For disability claim forms or questions related to disability claims, please contact the Disability Service Center by calling 1-800-232-0113, Monday through Friday, 8:00 a.m. to 5:00 p.m. EST. G1. Short-Term Disability (STD) Claim Claims for weekly disability benefits should be filed using the "Short Term Disability Claim Form". You, as the employer, complete Section II. The employee should complete Section I and the attending doctor completes Section III. Mail or fax the completed claim form to the address below. All disability checks will be mailed directly to your member employee. Please contact the Disability Service Center to report the employee s return to work date. STD Claims Contact Information Topic: Phone: Fax: (770) 801-9393 Claims - Customer Service (800) 232-0113 (800) 850-0017 Mailing Address: Greater Georgia Life Insurance Company, Disability Service Center P.O. Box 723058, Atlanta, GA 31139-0058 STD MEMBER CLAIM PROCESS OVERVIEW The administration of Short Term Disability (STD) claims involves a comprehensive review of eligibility, medical information, job requirements and any corresponding functional limitations to determine whether or not a claimant is totally disabled under the provisions of the disability policy. The claim process begins with the completion of a three-part STD Claim Form, including data from the employee, the employer and the attending physician. Eligibility for benefits is confirmed by the policyholder's Benefit Representative who completes the employer's portion of the form. The claim should be submitted as soon as it becomes evident that the employee will be out of work in excess of the plan's initial elimination period. The claim form may be either faxed or mailed to GGL. Upon receipt of all three parts of the completed claim form and any clinical information (if requested), the Disability Case Manager (DCM) is in a position to evaluate the claim. The DCM works closely with policyholder's Benefit Representatives to obtain physical job descriptions and evaluate any opportunities for modified or light duty work. A claim decision is made within three days of receipt of all required information. The Claim Form with clinical documentation and occupational requirements are taken into consideration when a claim is reviewed. Once a claim is approved, STD benefits are issued to the claimant on a weekly basis. Periodic clinical updates are requested as needed. 27

Section G: LONG TERM DISABILITY CLAIM (continued) G2. Long Term Disability (LTD) Claim Long Term Disability claims are processed by a claims unit that specializes in disability benefits. For disability claim forms or questions related to disability claims, please contact the Disability Service Center by calling 1-800-232-0113, Monday through Friday, 8:00 a.m. to 5:00 p.m. EST. Submit the following Long Term Disability forms approximately 30 days before the end of the benefit waiting period: 1. "Long Term Disability Employee's Disability Benefits Application" The claimant must complete the Long Term Disability Employee's Disability Benefits application and have his/her physician(s) complete the "Long Term Disability Attending Physicians Statement Form". Send completed forms and items listed below to the Disability Service Center: Copy of awards from other sources of benefits: Social Security, Worker's Compensation, retirement, state disability, no-fault auto insurance and any other disability income. Proof of claimant's age. (Certified copy of the claimant's birth certificate) Give claimant additional "Attending Physician's Statement" forms for completion if claimant has more than one treating physician. 2. "Long Term Disability Employee Authorization For Release of Information" The claimant must complete the Long Term Disability Employee Authorization Release of Information form. 3. "Long Term Disability Employer's Report of Claim" The Employer should complete the Employer's Report of Claim in full and include the following: Job description (detailed duties, including physical requirements) Documentation of earnings in accordance with your plan description Workers Compensation information (copy of first report of accident and the decision, if any has been determined at this time). 4. "Long Term Disability Attending Physician's Statement" The claimant must complete the Long Term Disability Employee's Disability Benefits application and have his/her physician(s) complete the "Long Term Disability Attending Physicians Statement Form". Send completed forms and items listed below to the Disability Service Center. All forms must be completed to avoid undue delays in processing the claimant's request for benefits. Any questions about LTD claim filing procedures should be referred to: LTD Claims Contact Information Topic: Phone: Fax: (770) 801-9393 Claims - Customer Service (800) 232-0113 (800) 850-0017 Mailing Address: Greater Georgia Life Insurance Company, Disability Service Center P.O. Box 723058, Atlanta, GA 31139-0058 28

Section G: LONG TERM DISABILITY CLAIM (continued) LTD MEMBER CLAIM PROCESS OVERVIEW The administration of Long Term Disability (LTD) claims involves a comprehensive review of eligibility, medical information, job requirements and any corresponding functional limitations to determine whether or not a claimant is Totally Disabled under the provisions of the disability Policy. The claim process begins with the completion of the employee s, employer's and attending physician s portion of the LTD claim forms. The claim forms should be completed as soon as it becomes evident that the employee s illness or injury may exceed the Elimination Period under the LTD Policy. Each LTD claim undergoes an extensive review process by several individuals. The Disability Case Manager (DCM) is the primary person responsible for the assessment of the claim and making the appropriate determination. All LTD claims go through an initial screening to determine if Vocational Rehabilitation may be a possibility or if Social Security Disability benefits should be immediately pursued. If this initial review does not indicate either option at that time, the claim is reviewed again periodically. Furthermore, certain diagnoses are required to be immediately referred for Social Security assistance and certain other diagnoses require a mandatory review by an R.N. Additionally, all behavioral health claims are reviewed by our staff Psychologist. Once a claim is approved, LTD benefits are issued to the claimant on a monthly basis. The DCM continues to monitor each claim closely, requesting periodic updates as needed. 29

Section H. FORMS H1. MEMBER ENROLLMENT FORMS (a) Group Insurance Application [82-M-A2] (b) Medical Questionnaire 0103 MQuest (1/03)] (c) Life/Disability Coverage Waiver Authorization Form (d) Request for Group Life Conversion Information H2. MEMBER CHANGE FORMS a) Request for Change Form [83-A-RC] b) Group Life & Disability Change of Beneficiary or Insured s Name UN17G(GGL) 11/02 NOTE: IF YOUR GROUP HAS MEDICAL COVERAGE WITH BLUE CROSS BLUE SHIELD OF GEORGIA, COMBINED MEDICAL AND LIFE FORMS MAY BE USED FOR ENROLLMENT. H3. CLAIM FORMS LIFE and AD&D (a) Death Claim Forms [17568 Ed. 7/01] 1. Beneficiary Claim Form & Group Policyholder's Statement (b) Accidental Dismemberment or Loss of Sight Forms [GA84 (7/03)] 1. Accidental Dismemberment or Loss of Sight Claim Form 2. Proof of Accidental Dismemberment Attending Physician's Statement (c) Accelerated Death Benefit Forms 1. Claim for Personal Accelerated Death Benefit [GA6224 (7/03)] 2. Accelerated Death Benefit Attending Physician's Statement [GA6223 (297)] (d) Continuation of Life Insurance Forms 1. Disability Claim Form [297-G (GGL)] 2. Application for Group Life Insurance Disability Benefits [UN766G (GGL) (7/03)] 3. Attending Physician's Statement 4. Attending Physician's Statement Group Waiver of Premium Or Continuation of Benefits (Renewal purposes). [767G(GGL) Rev. 7/03] SHORT TERM DISABILITY Short Term Disability Claim Form LONG TERM DISABILITY Long Term Disability Employee Authorization For Release of Information Long Term Disability Employee's Disability Benefits Application Long Term Disability Attending Physician's Statement Long Term Disability Employer's Report of Claim A sample of each of these forms is provided on the following pages. 30

Life/Disability Coverage Waiver Authorization Form Greater Georgia Life Insurance Company Three Ravinia Dr, Ste. 1770 Atlanta,GA 30346 Please type or print all information. I understand that my employer offers a group life and/or disability insurance program which is underwritten by Greater Georgia Life Insurance Company and that, as an employee, I have a right to obtain such coverage for myself and my dependents. I also understand that some or all portions of this program may be available at no cost to me. However, after carefully considering the benefits and my rights, I have decided not to enroll in the following: Check appropriate box(es): (a) Basic Life and AD&D Insurance (b) Dependent Life Insurance (c) Short-Term Disability Insurance I understand that if I wish to participate in this program at some future date, my coverage or my dependents coverage will not be effective until after I submit evidence of insurability to Greater Georgia Life Insurance Company or its designee and I/we are approved for coverage. I understand that if a physical examination or further medical information is required for evidence of insurability, I will be responsible for any expenses associated with obtaining the physical examination or the medical information. Employee Name (please print): Social Security Number: Employee Signature: Date Signed (mo/day/yr): Group/Policy Number: Policyholder (Employer) Name: To the Employer: When this form is completed and signed by the employee, please make two copies. 1) Mail the original to: Greater Georgia Life Insurance Company P.O.Box 4445 Atlanta, Georgia 30302 2) Maintain one copy in the employee s personnel file. 3) Give the second copy to the employee.

GROUP LIFE & DISABILITY EMPLOYEE Send this info to SECTION I Employer (or Policyholder) Name and Address POLICYHOLDER Complete section 1 before giving to employee. Required for Identification Group Number SECTION II CHANGE OF BENEFICIARY I,, hereby revoke all previous Name of Insured Person nominations of beneficiaries under the Insurance on my life, including insurance for accidental death if any provided under Group Policy(ies) #. I nominate the following beneficiary(ies) with respect to all insurance now or hereafter provided under said policy(ies), in still reserving to myself the privilege of other and further changes, subject to the provisions of the policy or policies. Full Name Address Relationship Age Social Security No. If more than one beneficiary is designated, settlement will be made in equal shares to such of the designated beneficiaries (or beneficiary) as survive me, unless otherwise provided herein. If no designated beneficiary survives me, settlement will be made as provided for in the policy(ies). This change of beneficiary shall take effect as provided for in the policy(ies), and when received as so provided, the change shall be operative as of the date of this instrument whether or not I am alive at the time of such receipt, but without prejudice to the Company on account of any payment made by it before such receipt. The Company shall be bound by any trust deed, and shall not be liable for the application of monies by a trustee beneficiary. SECTION III CHANGE OR CORRECTION OF INSURED S NAME OR BENEFICIARY S NAME It is hereby requested that the name of the INSURED appearing on the Insurance records It is hereby requested that the name of the appearing on the Insurance records It is hereby requested that the name of the BENEFICIARY appearing on the Insurance records # as be changed to because of I HEREBY AUTHORIZE the changes in Section II and/or III. Date Signature of Insured Person ACKNOWLEDGMENT The authorized change(s) set forth in the foregoing instrument are hereby acknowledged. Dated at On Form UN17G(GGL) 11/02 Authorized By Title

It is most important for you, that all information contained herein be CLEARLY stated. A copy will be acknowledged and returned to you. This form when completed should be submitted to your Employer so that your insurance records may be changed. SUGGESTED WORDING PERTAINING TO SECTION II CHANGE OF BENEFICIARY Type of Beneficiary 1. Insured s Estate 2. One beneficiary 3. Two beneficiaries 4. Two beneficiaries in unequal shares 5. Three or more beneficiaries in unequal shares 6. One Primary and one Secondary beneficiary 7. One Primary and two Secondary beneficiaries *8. One Primary and unnamed children as Secondary beneficiaries 9. Two Primary beneficiaries and one Secondary beneficiary *10. One Primary and one or more named and unnamed children as Secondary beneficiaries *11. One Primary beneficiary with Common Disaster Provision (specified period not to exceed 30 days) 12. Trustee Wording to be Used Insured s Estate Dorothy Q. Smith, wife Peter Smith, father, and Anna Smith, mother, equally, or the survivor. Peter Smith, father, as to three fourths (3/4) and Anna Smith, mother, as to one fourth (1/4), or the survivor. Peter Smith, father, as to two fourths (2/4), Dorothy Q. Smith, wife, as to one fourth (1/4) and Anna Smith, mother, as to one fourth (1/4), the share of any deceased beneficiary to be payable to the survivors, in such proportions as their original shares are distributed, or the survivor. Dorothy Q. Smith, wife, if living; otherwise Quincy Smith, son. Dorothy Q. Smith, wife, if living; otherwise Quincy Smith, son, and Mary Smith, daughter, equally, or the survivor. Dorothy Q. Smith, wife, if living; otherwise the children born of the marriage of the Insured and said wife, or the survivors, equally, or the survivor. Peter Smith, father, and Anna Smith, mother, equally, or the survivor, if either survives; otherwise Dorothy Q. Smith, wife. Dorothy Q. Smith, wife, if living; otherwise Quincy Smith, son, Mary Smith, daughter, and any other children born of the marriage of the Insured and said wife, or the survivors, equally, or the survivor. Dorothy Q. Smith, wife, if she survives the Insured for a period of ten (10) days; otherwise the children born of the marriage of the Insured and said wife, or the survivors, equally, or the survivor. Dorothy Q. Smith, trustee under trust agreement dated 13. Trustee under the Last Will and Testament of Insured 14. Per stirpes provision for named children and their children The Trustees under the last Will and Testament of the Insured, provided said last Will and Testament has been allowed within six months after the death of the Insured by the Court having jurisdiction thereof; otherwise the Estate of the Insured. Dorothy Q. Smith, wife, if living; otherwise such of Richard Smith, William Smith and Mary Smith, children, who may be living and the surviving children of any of said children who may be deceased, per stirpes *If it is the intent to include adopted children or stepchildren, add to the phrase children of the marriage of the Insured and said wife either (a) and adopted children of either of both or (b) and the stepchildren of either or (c) the names of the children intended. We will furnish you with the exact language necessary to your intent. INSTRUCTIONS PERTAINING TO SECTION III CHANGE OF NAME This portion of the form is to be used in changing or correcting your name or beneficiary s name. Names should always be shown using given names: Example: Dorothy Q. Smith, and not as Mrs. John Smith. The same procedure should be followed when designating a beneficiary in Section II. INSTRUCTIONS PERTAINING TO SECTION INSURED S AUTHORIZATION This portion must be completed in every case as it authorizes the Company to comply with your request as set forth in Section II and/or III. Note: Owing to legal, administrative and other technical difficulties, it is inadvisable to name beneficiaries residing outside of the territorial limits of the United States and Canada. Your Employer may not be named as beneficiary.

Life Claims Service Center P.O. Box 724767 Atlanta, GA 31139-1767 Please accept our condolences on your recent loss. We realize there is not much we can say that will comfort you during this difficult time. However, we will do our best to assure that all your dealings with us are handled in a professional, caring and timely manner. To better meet your needs and speed the processing of your claim, lump sum proceeds of $5,000 and more are paid though our Control Plus Account SM program. Control Plus Account is a checkbook program paying competitive money market interest rates on the balances in your account and it is fully guaranteed by Greater Georgia Life (GGL). This improved method of payment is provided without cost to you as an additional benefit under a Group policy. As soon as your claim is approved, we will send your Control Plus Account kit containing your checkbook. Your funds will be immediately available to you simply by writing a check. You will have the opportunity to withdraw money as you need it, leaving the balance earning money market interest rates, or you may withdraw the total amount it s all based upon your needs. If you have questions, we encourage you to call our Beneficiary Service Center at our toll-free number, 1-800-551-7564, Monday to Friday, 8:30 a.m. to 4:30 p.m. eastern time. We are pleased to be able to serve you and hope we have relieved you of one worry during this difficult time. Respectfully yours, Greater Georgia Life Registered Mark of Greater Georgia Life

How to Complete Your Beneficiary Claim Form Please read this page before you fill out the Beneficiary Claim Form. Greater Georgia Life begins gathering information for your claim as soon as it learns of the death.* To complete processing of your claim, we must have: 1. A fully completed Beneficiary Claim Form from each beneficiary. (You may use a photo copy of the attached form if there is more than one beneficiary.) 2. A certified copy of the death certificate. 3. A copy of the enrollment form or beneficiary designation form on which the insured named beneficiaries. Section 1: Claimant/Beneficiary Information This information enables us to speed payment to you. Your telephone number(s) help us contact you quickly if any required information has been omitted. Social Security Number In nearly all cases, life insurance benefits are NOT subject to income tax. However, because you will be earning taxable interest under the Control Plus Account program, the Federal government requires us, and all other financial institutions that pay interest, to ask for and obtain your Social Security Number or other Taxpayer Identification Number. If you fail to supply is with your Social Security Number or other Taxpayer Identification Number, the Federal government requires us to withhold a portion of any interest we would otherwise pay you as a deposit against the taxes that may be due. If you are applying for a tax number, please write applied for in the appropriate space. Some persons have been notified by the Internal Revenue Service that they are subject to backup withholding because in the past they did not report all their interest or dividends. If you have been so notified, and the Internal Revenue Service has not written to you stating that you are no longer subject to backup withholding, you must cross out the statement right below your Social Security Number or Taxpayer Identification Number. We may need to contact you for more information if you are not a citizen of the United States and/or you reside in a foreign country. Claims by an Estate or Assignee If this claim is being filed by an Executor or Administrator, he or she must sign the Beneficiary Claim Form and submit certified copies of the appointment papers. Be sure to use the Estate s taxpayer number. Assignment of Benefits If you have assigned all or any portion of the claim to a funeral home for final expenses, please include a copy of that assignment and the itemized bill. If the policy proceeds have been assigned to a bank or other financial institution, the Beneficiary Claim Form must be signed by an authorized representative of that institution. Section 2: Information about the Insured (the Deceased) This information is necessary for purposes of identification. If the insurance coverage was issued within two years of the insured s death, or the death was due to an accident and the Group Policy provided for accidental death benefits, we may ask you for additional information. Section 3: Signature and Certification Please sign the Beneficiary Claim Form in the same manner as you would sign checks. Your signature may be used to verify Control Plus Account checks you write or instructions you give us in the future. You will also be certifying, under penalties of perjury, that your Social Security Number or other Taxpayer Identification Number and backup withholding status are true. *This Claim Form may have been sent before GGL has determined whether any insurance was in force at the time of death, whether any proceeds are payable and to whom any proceeds are payable. GGL retains its rights to make these determinations.

Group Number FOR GROUP POLICYHOLDER USE ONLY Employer Beneficiary Claim Form PLEASE RETURN THIS BENEFICIARY CLAIM FORM TOGETHER WITH AN OFFICIAL CERTIFIED COPY OF THE DEATH CERTIFICATE TO THE INSURED S GROUP EMPLOYER. Section 1: Claimant/Beneficiary Information Please type or print legibly. Name and address as stated will appear on checks. Name First Middle Initial Last Sex: Male Female Detach Here and return to the Insured s Group Employer Address Street City State Zip Beneficiary s Social Security Number or Taxpayer Identification Apartment No. Home Phone Daytime Phone Date of Birth ( ) ( ) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of failure to report all interest or dividends, or I am exempt. Cross out this statement if you have been so notified. In what capacity are you making this claim? Beneficiary Executor Trustee Other: Claimant s Relationship to the Insured: Spouse Child Parent Other: Section 2: Name Section 3: Information about the Insured (the Deceased) First Middle Initial Last Signature and Certification Month Day Year I certify, under penalty of perjury, that the Social Security Number or other Taxpayer Identification Number and Claimants Backup Withholding status information in Section 1 is correct. I understand that my signature may be used for signature verification for my Control Plus Account and other purposes. Signature Date (Sign as you would a check. Signature may be used for check verification.) It is a crime to knowingly, with intent to defraud, file a statement of claim containing any materially false or misleading information, or to conceal any material fact. Untrue or misleading statements may subject persons to criminal prosecution and civil penalties. For Use By GGL Only Return to: Examiner Claim # Date Approved/ Denied Benefit Total (Benefit and Interest) Life Claims Service Center PO Box 724767 Atlanta, GA 31139-1767

FOR USE BY THE GROUP POLICYHOLDER. NOT FOR USE BY BENEFICIARIES. Group Policyholder s Statement Please print all items. Any omissions may cause a delay in claim processing. Policy and Employer Data Group Number PCC Claim Br. Optional, additional, or supplemental (If different than basic) TO WHOM DO YOU WISH US TO DIRECT ALL CORRESPONDENCE ON THIS CLAIM? Employee Data Company Telephone No. PCC Claim Br. Case Group Suffix To the attention of Address (No. & Street) (City) (State) (Zip Code) Full Name of Insured Employee Social Security Number Date of Birth Date Employed or Title Type of Insurance Basic Life Opt./Add l/ Supp. Life AD & D Last Change in Amount of Insurance Amount of Insurance Increase Decrease Date $ $ $ $ $ $ $ $ $ Rate of Pay $ per Job Title (per life insurance schedule) Date Last Worked Original date of individual s insurance with GGL Date of Death Supp. AD & D TOTAL $ $ $ $ $ $ Had insurance been Yes If yes, indicate date terminated prior to death? No Was deceased insured for Group Survivor Income Benefits? Yes No If yes, complete form 10G SIB. Was claim for Waiver of Premium or Permanent & Total Disability Benefits submitted prior to death? Yes No If yes, claim #: Reason for Ceasing Work Was insured considered member / employee Illness (including disability leave of absence) Leave of Absence (other than disability) at the time of death? Quit Dismissed Vacation Temporary Layoff Retired Yes No Dependent Data Full name of Dependent Complete this section if this claim is for an insured dependent Social Security Number Male Female Date of Birth Address (No. & Street) City State Zip Code Relationship to insured employee Wife Husband Child If spouse, was he/she divorced or legally separated? Yes No If child, was he/she: Married? Yes No Employed? Yes No Full time student? Yes No If yes, was employment Full-time Part-time Date Employed: Date Dependent insured under GGL Insurance Accidental Death Claim Information Date of Accident or Incident Beneficiary Data Was Insurance terminated? Yes No If yes, indicate date: Amount of Dependent s Insurance claimed $ Date of Dependent s death If the Group Program provided an Accidental Death benefit and the death was due to an accident, please complete this section and attach copies of descriptive news articles and a police or coroner s report, if available. Was the death due to injury arising out of and during the course of employment? Yes No Social Security No. or Relationship to Name of each Beneficiary Tax I.D. No. if Estate or Trusts Employee Age Address (No. + Street, City, State, Zip Code) If a Beneficiary who is entitled to a benefit is deceased, give Name, Date of Death, and furnish a copy of his or her Death Certificate. THE INFORMATION GIVEN ABOVE IS CORRECT & COMPLETE ACCORDING TO OUR RECORDS. Employer (If other than policyholder) By (Signature & Title of Employer s Authorized Representative) Date Affiliate, Subsidiary, Branch, Employer number Policyholder By (Signature & Title of Employer s Authorized Representative) Date 17568 Ed. 7/01

Accidental Dismemberment or Loss of Sight Claim INSTRUCTIONS As soon as you learn that an insured person has suffered any of the losses covered under the policy, this form (completed by the policyholder, claimant and the attending physician) should be sent to Life Claims Service Center, PO Box 724767, Atlanta, GA 31139-1767. Include the following material: (a) Enrollment card (b) All available newspaper clippings pertaining to the injury and loss, and a police or accident report, if available. SECTION A GROUP NUMBER PCC CLAIM BR. Optional, additional, PCC CLAIM BR. or supplemental (if different than basic) NAME OF EMPLOYEE Life Claims Service Center PO Box 724767 Atlanta, GA 31139-1767 STATEMENT OF EMPLOYER or CASE NUMBER GROUP NUMBER SUFFIX NO. ADDRESS OF EMPLOYEE (NO., STREET, CITY, STATE, ZIP CODE) DATE ENTERED FULL-TIME EMPLOYMENT DATE LAST FULL-TIME EMPLOYMENT OCCUPATION / CLASSIFICATION DATE LAST WORKED AMOUNT OF BENEFIT WAS COVERAGE CONTINUED TO DATE OF ACCIDENT ON A PREMIUM PAYING BASIS? YES NO IF "NO" WHAT WAS THE DATE OF LAST PREMIUM PAYMENT EARNINGS AT DT LAST WORKED ORIG. EFF DATE OF EE INS. $ DATE OF ACCIDENT TIME OF ACCIDENT PLACE OF ACCIDENT DID ACCIDENT OCCUR IN COURSE OF EMPLOYMENT? YES NO It is hereby certified that the statements contained above are true to the best of my knowledge and belief. NAME OF EMPLOYER EMPLOYER S PHONE NO. ADDRESS OF EMPLOYER NAME OF PERSON AUTHORIZED (Please Print) AUTHORIZED SIGNATURE / TITLE DATE GROUP INSURANCE APPLICATION AND RECORD CARD SHOULD ACCOMPANY THIS FORM SECTION B STATEMENT OF EMPLOYEE NAME SOCIAL SECURITY NO. DATE OF BIRTH LEGAL ADDRESS EMPLOYEE S TELEPHONE NO. DATE OF INJURY DATE OF LOSS DATE FIRST TREATED BY PHYSICIAN NAME AND ADDRESS OF ATTENDING PHYSICIAN EXTENT OF LOSS DESCRIBE IN DETAIL HOW ACCIDENT OCCURRED I certify that the above statements by me are complete, true, and correctly recorded. I hereby authorize any hospital, physician or any other institutions or person who has attended or examined me to disclose to Life Claims Service Center all information acquired by reason of, and records pertaining to, such hospitalization, examination and attendance. I am willing that a photostat of this authorization be accepted with the same authority as the original. EMPLOYEE SIGNATURE DATE THE FURNISHING OF FORMS DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY ON THE PART OF THE COMPANY (over) FOR HEADQUARTERS USE CLAIM NO. EXAMINER BRANCH TOTAL BENEFIT DATE APPROVED / DENIED GA84 (7/03)

INSTRUCTIONS TO PHYSICIAN PROOF OF ACCIDENTAL DISMEMBERMENT ATTENDING PHYSICIAN S STATEMENT PATIENT S NAME AND ADDRESS DATE OF BIRTH 1. (A) WHEN DID THE ACCIDENT HAPPEN? DATE (B) WHEN DID PATIENT FIRST CONSULT YOU FOR THIS CONDITION? DATE (C) HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION? YES NO IF "YES" STATE WHEN AND DESCRIBE 2. WAS THE LOSS SOLELY THE RESULT OF AN ACCIDENTAL INJURY? YES NO IF "NO", WHAT DISEASE OR CONDITION WAS A CONTRIBUTORY CAUSE? 3. IS THE PATIENT COMPETENT TO ENDORSE CHECKS AND DIRECT THE USE OF THE PROCEEDS THEREOF? YES NO TO BE COMPLETED FOR LOSS OF SIGHT TO BE COMPLETED FOR LOSS OF LIMB(S) (4-S) DID THE ACCIDENTAL INJURY RESULT IN THE TOTAL AND IRRECOVERABLE LOSS OF SIGHT OF -- RIGHT EYE YES NO DATE OF LOSS WAS THE EYE ENUCLEATED? YES NO DATE LEFT EYE YES NO DATE OF LOSS WAS THE EYE ENUCLEATED? YES NO DATE (5-S) STATE THE DATE YOU FIRST DETERMINED THAT CENTRAL VISUAL ACUITY WAS IRRECOVERABLY REDUCED TO 20/200 OR LESS WITH CORRECTION: (4-L) DID ACCIDENTAL INJURY RESULT IN LOSS OF LIMBS YES NO (5-L) WHAT LIMBS HAVE BEEN SEVERED: DATE OF SEVERENCE O.D. MONTH DAY YEAR O.S. MONTH DAY YEAR RIGHT HAND LEFT HAND MO. MO. DAY DAY YR. YR. SNELLEN NOTATIONS ON THAT DATE: O.D.V. O.S.V. UNCORRECTED CORRECTED RIGHT FOOT LEFT FOOT MO. MO. DAY DAY YR. YR. IF CORRECTED CENTRAL VISUAL ACUITY IS GREATER THAN 20/200, INDICATE VISUAL FIELDS BELOW: DATE OF TEST: (6-L) PLEASE INDICATE EXACT POINT OF SEVERANCE MO. DAY YR. (6-S) CAN USEFUL VISION LIKELY BE RESTORED BY MEDICATION OR SURGERY? IF "YES", WHAT ARE THE PROSPECTS? YES NO I certify that the above answers and statements are true and complete according to the best of my knowledge and belief. Date Signature (Attending Physician) Degree Telephone Print Name of Physician Street Address City or Town State or Province Zip Code PATIENT IS RESPONSIBLE FOR ANY EXPENSE INVOLVED IN THE COMPLETION OF THIS FORM

LIFE CLAIMS SERVICE CENTER PO BOX 724767 ATLANTA, GA 31139-1767 Claim for Personal Accelerated Death Benefit The furnishing of forms does not constitute an admission of liability on the part of the Company. Employee Instructions 1. 2. 3. 4. Answer all of Section 2, Statement of Claimant. Print all answers clearly in ballpoint pen. If you change your answer, place your initials next to the correction. Have your doctor complete GA6223 Statement of Attending Physician. You can get this form from the employer. Also, include lab results and x-rays, if applicable. The x-rays will be returned to the physician. If applicable, provide the following documentation: If you are divorced, a copy of the court approved divorce settlement agreement. If you have assigned your rights under the group policy to an assignee or an irrevocable beneficiary, written consent from that assignee or irrevocable beneficiary, for payment of a personal accelerated death benefit. Be sure to keep a copy of this claim form and all additional documentation for your records. Give the employer this claim form and all additional documentation. Employer Instructions 1. 2. 3. 4. 5. Check that the employee has completed, dated and signed this claim form. Verify that all required documentation has been provided. Be sure that the employee has retained a copy of this claim form and all required documentation for their records. Complete all of Section 1, Statement of Employer. Include a copy of the employee s signed application card. Send this claim form and all required documentation to: GREATER GEORGIA LIFE INSURANCE COMPANY LIFE CLAIMS SERVICE CENTER PO BOX 724767 ATLANTA, GA 31139-1767 Section 1 Statement of Employer GROUP POLICY NUMBER SUFFIX # COMPANY ADDRESS/CITY, STATE/ZIP CODE NAME OF EMPLOYEE SOCIAL SECURITY NUMBER SEX Male Female DATE OF BIRTH MARTIAL STATUS Married Widowed Single Divorced ADDRESS OF EMPLOYEE (Number & Street, City, State, Zip Code) EARNINGS (wkly) AMOUNT OF INSURANCE $ DATE ENTERED FULL-TIME EMPLOYMENT EMPLOYED IN CAPACITY OF: DATE LAST PHYSICALLY AT WORK FULL-TIME REASON FOR LEAVING WORK: IS COVERAGE CONTINUING ON A PREMIUM PAYING BASIS? IF NO, WHAT WAS DATE OF LAST PREMIUM PAYMENT? Yes No NAME OF BENEFICIARY RELATIONSHIP AGE ADDRESS OF BENEFICIARY (Number & Street, City, State, Zip Code) SIGNATURE OF EMPLOYER EMPLOYER S PHONE NUMBER TITLE DATE GA6224 (7/03)

Section 2 Statement of Claimant All questions should be fully answered by the insured or his legally appointed guardian or committee. NAME (First, Middle, Last) BIRTHDATE (Mo, Day, Yr) LEGAL ADDRESS (Number & Street, City, State, Zip) STATE NATURE OF QUALIFYING MEDICAL CONDITION: INDICATE DATE THAT YOU LAST PHYSICALLY WORKED (MO, DAY, YR): INDICATE AMOUNT OF BENEFIT NOW BEING CLAIMED: $ Are you in the process or have you converted your Group Life Coverage to an Individual Policy? Yes No Names and Addresses of Physicians Who Have Treated You for Qualifying Condition Dates of Treatment Greater Georgia Life reserves the right to request an Independent Medical Examination at the Company s expense. Have divorce proceedings ever been instituted by or against you? Yes No If so, when and where? (If you answer yes to this question, please see #3 of Employee Instructions on the reverse side of this form). Have you assigned your rights under the group policy to an assignee or irrevocable beneficiary? Yes No Enter the taxpayer identification number in the appropriate space. For most individual taxpayers, this is the Social Security Number. Social Security No. - - or Employer ID No. - - Certification - Under penalties of perjury, I certify that: 1. The number shown on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest and dividends, or the IRS has notified me that I am no longer subject to backup withholding. Certification Instructions - You must cross out item (2) above if you have been notified by IRS that you are subject to backup withholding because of underreporting interest or dividends on your tax return. However, if after being notified by IRS that you were subject to backup withholding you received another notification from IRS that you are no longer subject to backup withholding, do not cross out item (2). SIGNATURE OF CLAIMANT DATE RELATIONSHIP TO INSURED MAILING ADDRESS OF CLAIMANT (Number & Street, City, State, Zip) I certify that the above statements by me are complete, true, and correctly recorded. I hereby authorize any hospital, physician or any other institution or person who was attended or examined me to disclose to the Greater Georgia Life Insurance Company all information acquired by reason of, and records pertaining to, such hospitalization, examination and attendance. I am willing that a photocopy of this authorization be accepted with the same authority as the original. WITNESS DATE SIGNATURE OF EMPLOYEE Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false or misleading information may be subject to criminal penalties. For Use By GGL Only EXAMINER CLAIM # DATE APPROVED / DENIED BRANCH TOTAL-BENEFIT AND INTEREST

P.O. Box 724767 Atlanta, GA 31139-1767 PATIENT S NAME (please print) Accelerated Death Benefit Attending Physician s Statement DATE OF BIRTH PRESENT ADDRESS (Number & Street) SOCIAL SECURITY NUMBER (CITY, STATE, ZIP) NAME OF PATIENT S EMPLOYER GROUP POLICY NUMBER Attending Physician s Statement of Disability The patient is responsible for completion of this form without expense to the Company. Space is available on the reverse side if you wish to amplify your answers. If #5 is not completed in full, claim processing will be delayed. 1 HISTORY When did symptoms first appear? PRESENT CONDITION Mo. Day Yr. 2 3 (a) (b) Subjective symptoms Objective findings Include results of current x-rays, EKGs or any other special tests relevant to your judgement of prognosis. (c) Is patient Ambulatory? Bed confined? House confined? Hospital confined? DIAGNOSIS 4 5 6 REMARKS TREATMENT (a) Date of first visit for above condition (b) Date of most recent visit PROGNOSIS In my best medical judgement, the above patient s life expectancy is than months MENTAL CONDITION Mo. Day Yr. months or less, or not more Is the patient competent to endorse checks and direct the proceeds thereof? Yes No ATTENDING PHYSICIAN S NAME (please print) DEGREE ADDRESS (Number & Street) (City, State, Zip) TELEPHONE ATTENDING PHYSICIAN S SIGNATURE DATE Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information may be subject to criminal penalties. To the Attending Physician: Please mail this report directly to the address shown below. GREATER GEORGIA LIFE INSURANCE COMPANY LIFE CLAIMS SERVICE CENTER P.O. BOX 724767 ATLANTA, GA 31139-1767 GA6223 (297)

DISABILITY CLAIM Life Claims Service Center P.O. Box 724767 Atlanta, GA 31139-1767 800-552-2137 I N S T R U C T I O N S When an insured person becomes disabled, complete and mail this statement, enrollment form, and any beneficiary changes to GGL at the address above. Enter in first item below, your Group Number. If applicable your PCC, Claim Branch and Premium Branch Code. Give form 766G, Application for Group Life Insurance Disability Benefits, to the insured person with instructions to be mailed to the Group Life & Disability Division, at the above address. STATEMENT OF POLICYHOLDER Please complete ALL items. Any omissions will cause delay in claim processing. GROUP NUMBER POLICYHOLDER DATA (EMPLOYER) Basic PCC Claim Br. Premium Br. Optional (if different than basic) GROUP NUMBER PCC Claim Br. Premium Br. Company Name To the attention of Title Telephone No. Address (No. & Street) (City) (State) (Zip Code) EMPLOYEE DATA Full Name of Social Security Number Date of Birth Date Employed Insured Employee Amount Life of Increase Decrease Date Insurance Insurance Last Change in Amount of Insurance Rate of pay Original effective date of Individual s life Insurance $ per Job Title (per life insurance schedule) Basic $ $ $ Date Last Worked Date of Disability Optional $ $ $ Total $ $ $ Was he/she insured for Group Survivor Income Benefits? Yes No If yes, complete Form 10G-S1B REASON FOR CEASING WORK Has Insurance been Yes If yes, indicate Date terminated? No ILLNESS (Including disability LEAVE OF ABSENCE (Other than disability) QUIT DISMISSED leave of absence) TEMPORARY LAYOFF RETIRED VACATION DOES YOUR COMPANY HAVE A FORMAL PENSION PLAN: YES NO WILL EMPLOYEE BE ELIGIBLE TO RETIRE UNDER THIS PLAN: YES NO PLEASE PROVIDE NORMAL RETIREMENT DATE: BENEFICIARY DATA Was Insured considered a member/employee at date of disability? Name of Beneficiary Relationship Age Address Social Security Number Yes No MODE OF SETTLEMENT OF CLAIM (Do NOT complete if the policy provides for waiver of premium only.) If policy provides for election of installments, indicate settlement desired after referring to the paragraph entitled Modes of Settlement in the policy: Installment of $ over months, or If method of payment is not known, please check and when determined, please notify us. THE INFORMATION GIVEN ABOVE IS CORRECT & COMPLETE ACCORDING TO OUR RECORDS. Employer (if other than Policyholder) By (Sign. & Title of Employer s Auth. Representative Date Policyholder By (Sign. & Title of Policyholder Auth. Representative Date Form 297G Ed. 7/00 297-G (GGL) Printed in U.S.A.

APPLICATION FOR GROUP LIFE INSURANCE DISABILITY BENEFITS POLICYHOLDER NAME: GROUP NUMBER BASIC PCC Claim Br. If Applicable POLICYHOLDER/EMPLOYER:(1) Insert Name and Group Number as requested above. The form should then be given to the insured person for completion by them and their Attending Physician. (To be completed by employee) EMPLOYEE: (1) Please fill out and sign this portion of your application for Group Life Insurance Disability Benefits. (IMPORTANT failure to fully answer all questions will cause delay in the claim processing.) Should you need assistance in completing this form, contact your Employer. (2) When completed and signed by you, forward to your Attending Physician. 1. ENTER YOUR FULL NAME (Please Print) 2. DATE OF BIRTH 3. MAILING ADDRESS CHECK ONE ENTER YOUR SOCIAL SECURITY NUMBER MALE FEMALE ARE YOU MARRIED? YES NO NUMBER OF CHILDREN DEPENDENT UPON YOU FOR SUPPORT TELEPHONE NUMBER (No., Street, Apt. No., P.O. Box or Rural Route) (City) (State) (Zip Code) 4. DESCRIBE THE DUTIES OF YOUR USUAL JOB IN YOUR OWN WORDS: JOB TITLE YOUR EMPLOYER 5. DID YOUR USUAL JOB INVOLVE: a. THE USE OF MACHINES, TOOLS, OR EQUIPMENT? b. TECHNICAL KNOWLEDGE OR SPECIAL SKILLS? c. ANY SUPERVISORY RESPONSIBILITIES? d. TRAVEL? YES NO PLEASE EXPLAIN ALL YES ANSWERS: 6. PLEASE DESCRIBE THE KIND AND AMOUNT OF PHYSICAL ACTIVITY INVOLVED IN YOUR JOB DURING A TYPICAL WORK DAY (CIRCLE NUMBER OF HOURS IN A DAY). WALKING STANDING SITTING 0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8 LIFTING AND CARRYING (DESCRIBE WHAT WAS LIFTED, HOW HEAVY IT WAS, HOW OFTEN IT WAS LIFTED AND HOW FAR IT WAS CARRIED). 7. HOW DOES YOUR ILLNESS OR INJURY NOW PREVENT YOU FROM PERFORMING YOUR USUAL DUTIES AS DESCRIBED IN ITEMS 4, 5 & 6? 8a. LIST ANY SKILLS YOU MAY HAVE AS A RESULT OF PRIOR EMPLOYMENT, TRAINING OR EDUCATION, OR MILITARY SERVICE: 8b. LIST LAST YEAR OF SCHOOL COMPLETED: (i.e. 6th Grade, 12th Grade, College Degree, etc.) UN766G (GGL) (7/03)

9. BEFORE YOU STOPPED WORKING, DID YOUR ILLNESS OR INJURY CAUSE YOU TO CHANGE: a. YOUR JOB OR DUTIES? YES NO b. YOUR HOURS OF WORK? YES NO c. YOUR ATTENDANCE? YES NO (EXPLAIN HOW YOUR CONDITION CAUSED THESE CHANGES AND SHOW THE DATES THE CHANGES WERE MADE.) 10. BRIEFLY DESCRIBE YOUR INJURY OR ILLNESS THAT PREVENTS, OR HAS PREVENTED YOU FROM WORKING: 11. IF CONDITION DUE TO INJURY, PLEASE INDICATE DATE OF INJURY WHERE DID IT OCCUR? 12. DESCRIBE HOW ACCIDENT OCCURRED 13. WHEN DID YOU BECOME UNABLE TO WORK BECAUSE OF YOUR DISABILITY? 14. IF YOU ARE NO LONGER DISABLED, ENTER DATE YOU WERE AGAIN ABLE TO WORK (MONTH, DAY, YEAR) ARE YOU STILL DISABLED? YES NO DATE OF FIRST TREATMENT FOR THIS ILLNESS OR INJURY 15. LIST THE NAME, ADDRESS AND TELEPHONE NUMBER OF THE DOCTOR WHO HAS YOUR LATEST MEDICAL RECORDS. IF YOU HAVE NO DOCTOR, CHECK HERE NAME AREA CODE & TEL. NO. ADDRESS 16. HOW OFTEN DO YOU SEE HIM? DATE YOU FIRST SAW HIM DATE YOU LAST SAW HIM 17. REASONS FOR VISITS TYPE OF TREATMENT RECEIVED 18. HAVE YOU SEEN ANY DOCTOR SINCE YOUR ILLNESS OR INJURY BEGAN? YES NO IF YES SHOW THE FOLLOWING: NAME AREA CODE & TEL. NO. ADDRESS 19. HOW OFTEN DO/DID YOU SEE HIM? DATE YOU FIRST SAW HIM DATE YOU LAST SAW HIM 20. REASONS FOR VISITS TYPE OF TREATMENT RECEIVED 21. HAS YOUR DOCTOR TOLD YOU TO RESTRICT YOUR ACTIVITIES IN ANY WAY? YES NO IF YES, GIVE NAME OF DOCTOR AND STATE WHAT HE TOLD YOU ABOUT RESTRICTING YOUR ACTIVITIES

22. CHECK ANY OF THE FOLLOWING WHICH APPLY TO YOU: CONFINED IN A HOSPITAL OR OTHER MEDICAL INSTITUTION. CONFINED TO A BED OR WHEEL CHAIR AT HOME. NONE OF THE ABOVE BUT UNABLE TO GO OUTSIDE. ABLE TO GO OUTSIDE ONLY WITH HELP OF ANOTHER PERSON OR DEVICE. ABLE TO GO OUTSIDE WITHOUT HELP. 23. ARE YOUR HOME DUTIES, SOCIAL ACTIVITIES OR ABILITY TO CARE FOR YOUR PERSONAL NEEDS LIMITED IN ANY WAY? YES NO IF YES DESCRIBE HOW AND WHY THEY ARE LIMITED. 24. DO YOU EXPECT TO RETURN TO WORK? DATE EXPECTED TO RETURN DATE RETURNED 25. HAVE YOU BEEN SEEN BY OTHER AGENCIES FOR YOUR INJURY OR ILLNESS (VA, VOCATIONAL REHABILITATION, WELFARE, ETC.)? YES NO IF YES SHOW THE FOLLOWING: NAME OF AGENCY ADDRESS OF AGENCY YOUR CLAIM NUMBER DATES OF VISITS TYPE OF TREATMENT OR EXAMINATION RECEIVED 26. HAVE YOU EVER FILED (OR DO YOU INTEND TO FILE) CLAIMS FOR DISABILITY BENEFITS UNDER ANY: WORKMEN S COMPENSATION LAW OR PLAN YES NO SOCIAL SECURITY YES NO 27. HAS THERE EVER BEEN ANY DECISION OR ANY PAYMENT (TEMPORARY, PERMANENT, OR WORKMEN S COMPENSATION CLAIM NUMBER (S) LUMP SUM) MADE ON THE CLAIM(S) FILED? IF YES LIST DETAILS BELOW. YES NO 28. ARE YOU ENTITLED TO DISABILITY BENEFITS FROM ANY OF THESE SOURCES BECAUSE OF THIS DISABILITY: Sources Workmen s Compensation Social Security Administration Health or Welfare Plan Retirement or Pension Plan State, Provincial or Federal Agency Other Identify Insurance or Agency Benefit Amount How Payable (Lump, Mthly, Wkly, etc.) From Thru 29. ARE YOU IN THE PROCESS OR HAVE YOU CONVERTED YOUR GROUP LIFE COVERAGE TO AN INDIVIDUAL POLICY? YES NO AUTHORIZATION The above answers are true and complete according to the best of my knowledge and belief. I authorize any employer, insurance company, medical prepayment plan, service organization, physician, practitioner or other person; any hospital, including the Veterans Administration or other institution, to release to or obtain from GGL Insurance Company any medical or benefit payment information that may be required to establish the validity of this claim, and further authorize said company, person or organization, to disclose any personal claim information required for medical case study or review. A photostat of this authorization shall be as valid as the original. EMPLOYEE S SIGNATURE DATE YOU MUST NOTIFY GREATER GEORGIA LIFE PROMPTLY IF: a. Your medical condition improves so that you would be able to work, even though you have not yet returned to work. b. You go to work whether as an employee or as a self-employed person.

ATTENDING PHYSICIAN S STATEMENT REPLY TO: Life Claims Service Center P.O. Box 724767 Atlanta, GA 31139-1767 POLICYHOLDER NAME: PATIENT S NAME DATE OF BIRTH GROUP NUMBER BASIC PCC Claim Br. If Applicable The purpose of this report is to assist us in making a disability determination. In filling out this report please include sufficient details of history, physical and diagnostic findings, clinical course, therapy and response to enable us to make this determination. After signing this form, return it to GGL at the above address. 1. HISTORY (a) Patient s Age (b) When did symptoms first appear or accident happen? (c) Date patient ceased work because of disability (d) Has patient ever had same or similar condition? If Yes state when and describe Mo. Day 20 Mo. Day 20 Yes No 2. DIAGNOSIS (including any complications) (a) Subjective symptoms (b) Objective findings (Including Current Signs, Laboratory Data & X-Ray Results) 3. DATES OF TREATMENT (a) Date of first visit (b) Date of last visit (c) Frequency Mo. Day 20 Mo. Day 20 Weekly Monthly Other (Specify) 4. NATURE OF TREATMENT (Including Surgery, if any) 5. PROGRESS (a) Check one (b) Is patient (c) If hospital confined Recovered Improved Unchanged Retrogressed Ambulatory? Bed confined? House confined? Hospital confined? Name of hospital Confined from through 6. PHYSICAL IMPAIRMENT (AS IT RELATES TO EMPLOYMENT) Class 1 - No limitation of functional capacity; capable of heavy physical activity. No restrictions. (0-10%) Class 2 - Slight limitation of functional capacity; capable of light manual activity. (15-30%) Class 3 - Moderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity. (35-55%) Class 4 - Marked limitations. (60-70%) Class 5 - Severe limitation of functional capacity; incapable of minimal (sedentary) activity. (75-100%) Remarks:

7. CARDIAC (IF APPLICABLE) (a) Functional capacity....... (American Heart Ass n.) { Class 1 (No limitation) Class 3 (Marked limitation) Class 2 (Slight limitation) Class 4 (Complete limitation) (b) Blood Pressure........... SYSTOLIC DIASTOLIC 8. MENTAL/ NERVOUS IMPAIRMENT (IF APPLICABLE) Class 1 - able to function under stress and engage in interpersonal relations (no limitations) Class 2 - able to function in most stress situations and engage in most interpersonal relations (slight limitations) Class 3 - able to engage in only limited stress situations and engage in only limited interpersonal relations (moderate limitations) Class 4 - unable to engage in stress situations or engage in interpersonal relations (marked limitations) Class 5 - significant loss of psychological, physiological, personal and social adjustment (severe limitations) Remarks: 9. COMPETENCY Is the patient competent to endorse checks and direct the use of the proceeds thereof? Yes No 10. PROGNOSIS (a) Do you expect a fundamental or marked change in the future? No Yes - Improvement Yes - Deterioration (b) If improved, will patient recover sufficiently to perform duties of HIS JOB No Yes 3-6 mos. 6-12 mos. Over 1 yr. OTHER WORK No Yes 3-6 mos. 6-12 mos. Over 1 yr. (c) If no improvement expected, please explain 11. REHABILITATION HIS JOB (a) Is patient a suitable candidate for trial employment or job training? Yes No (b) If yes, when could he commence trial employment? Mo. Day Yr. Full-time Part-time OTHER WORK Yes No Mo. Day Yr. Full-time Part-time (c) If no, please explain 12. REMARKS Date Name (Attending Physician) Print Degree Telephone Street Address City or Town State or Province Zip Code Signature

FIRST CLASS MAIL PLACE STAMP HERE LIFE CLAIMS SERVICE CENTER PO BOX 724767 ATLANTA, GA 31139-1767

6. PHYSICAL IMPAIRMENT (EMPLOYMENT RESTRICTIONS) Class 1 No restrictions. Class 2 Slight restrictions, please explain below. Class 3 Severe restrictions, please explain below. 7. MENTAL/NERVOUS IMPAIRMENT (if applicable, please explain determination below.) Class 1 No limitations. Class 2 Slight limitations. Class 3 Moderate limitations. Class 4 Severe limitations. 8. PROGNOSIS (a) Do you expect a fundamental or Yes Improvement complete (b) & (c) if applicable No marked change in the future? Yes Deterioration (b) If improved, will patient recover USUAL JOB OTHER WORK sufficiently to perform duties of Yes If so, when? Yes If so, when? (c) Comments No No 9. REHABILITATION (a) Is patient a suitable candidate for a Rehab. Program? Yes No (b) If yes, please give full details 10. CARDIAC (If Applicable) (a) Functional capacity... Class 1 (No limitation) Class 2 (Slight limitation) (American Heart Ass n.) Class 3 (Marked limitation) Class 4 (Complete limitation) (b) Blood Pressure... / SYSTOLIC / DIASTOLIC 11. TO BE COMPLETED FOR LOSS OF SIGHT SNELLEN NOTATIONS O.D.V. O.S.V. UNCORRECTED CORRECTED 12. IS THE PATIENT MENTALLY COMPETENT?... Yes No 13. CLARIFICATION / COMMENTS (i.e., additional studies, consultations, vocational training, etc.) Date Name (Attending Physician) Print Degree Telephone Street Address City or Town State or Province Zip Code Signature THE PATIENT IS RESPONSIBLE FOR ANY EXPENSE INVOLVED IN THE COMPLETION OF THIS STATEMENT.

Important Notice to Employee Please Read Carefully Atlanta Disability Service Center P.O. Box 723058 Atlanta, GA 31139-0058 SHORT TERM DISABILITY CLAIM FORM Phone: (800) 232-0113 Fax: (800) 850-0017 or (770) 801-9393 E-Mail: disability@wellpoint.com You or someone acting on your behalf, must complete Section I and then have your Employer complete Section II. Your physician must then complete Section III on the reverse. After all three sections are completed, please submit the form to us quickly as possible in order for us to make a timely claim decision. Any person who knowingly, and with intent to defraud any insurance company, files a statement of claim containing any false, incomplete or misleading information may be subject to criminal penalties. Section I To Be Completed By Employee Name of Employee ٱ Married ٱ Widowed Sex Date of Birth: ٱ Single ٱ Divorced ٱ Male ٱ Female Address of Employee (No. & Street, City, State, Zip) Phone No. Other No. Fax No. E-Mail Address: Social Security No. On what date were you first unable to work because of your disability? (Mo., Day, Yr.) For what injury or sickness are you being treated? If due to accident, when, where and how did it happen? ٱ Auto ٱ Worker s Comp ٱ Home ٱ Other Date you returned to work?(mo., Day, Yr.) Name of Employer: If not yet returned, when do you expect to? (Mo., Day, Yr.) I authorize the release to or by Greater Georgia Life Insurance Company any medical or insurance information required to process my claim. A photocopy of this authorization may be honored. EMPLOYEE S SIGNATURE: Date: Section II To Be Completed By Employer Name of Employee: Date Employed: Weekly or Hourly Wage at the time disability occurred: Employee Class: Group Policy No.: Effective Date of Insurance: Occupation/Job Title: Amount of Weekly Benefits: Date Employee Last Worked & Number of hours? ٱ AM ٱ PM Date Employee ٱ AM ٱ PM Returned to Work? Did injury or sickness arise out of or in the course of occupational employment for wages or profit? ٱ Yes ٱ No Comments: Insured Group Name: Branch or Division Address: Signature and Title: Phone No.: Date: Benefits are underwritten by Greater Georgia Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Section III To Be Completed By Physician Note to Physician: Completion of this form will assist your patient in presenting claim for group and/or individual disability benefits. Patient's Name: Date of Birth: Current Diagnosis: ICD-9 code/dsm IV: Subjective Findings: Objective Findings: Has patient ever had same or similar condition? If so, specify dates of treatment: No ٱ Yes ٱ Is condition due to injury or sickness arising out of patient s employment? (if Yes, please explain) Unknown ٱ No ٱ Yes ٱ Is Disability Due to Pregnancy? ٱ Yes ٱ No If Yes, LMP: / / EDC: / / (Mo., Day, Yr.) (Mo., Day, Yr.) Nature of surgical or obstetrical procedure, if any. (Describe fully) Outpatient ٱ Inpatient ٱ Was the patient hospitalized? If so, give date(s) of confinement and name of hospital/facility: Treatment Date patient first became unable to perform job duties: Date of first visit: Date of last visit: Patient's present condition: Treatment plan: Regressed ٱ Unchanged ٱ Improved ٱ Recoveredٱ Date Performed: / / (Mo., Day, Yr.) Functional impairments: Current medications & dosages: Extent of Disability Patient may return to work? ٱ Yes ٱ No If yes, Full Time, No Restrictions ٱ Light Duty (Please specify restrictions, limitations, hours, graduated return to work ٱ schedule, etc.) Is patient a suitable candidate for rehabilitation program? ٱ Yes ٱ No Psychiatric Condition Is the patient competent to endorse checks and direct the proceeds thereof? ٱ Yes ٱ No If no, please attach supporting documentation. Date Return to Full Duty: / / Date Return to Light Duty: / / Physician s Name and Specialty (Please Print): Physician's Signature: Physician's Address (No. & Street, City, State, Zip): Date: Telephone No.: E-Mail Address: Fax No.:

LONG TERM DISABILITY EMPLOYEE AUTHORIZATION FOR RELEASE OF INFORMATION Authorization to be completed by the claimant To Whom It May Concern: I, authorize any hospital, physician, medical practitioner, clinic, other medical or medically related facility, pharmacy, insurance company, Government Agency including but not limited to the Social Security Administration, to disclose or furnish to Greater Georgia Life Insurance Company (GGL), or its authorized representative, any and all information with respect to: any illness or injury including mental illness, drug/alcohol abuse, medical history, consultations, prescriptions, treatments or benefits and copies of all records that may be requested. In addition, I authorize any employer, statutory employer, business or individual that paid me for services rendered, including but not limited to, business associate(s), insurance company, Government Agency including but not limited to the Social Security Administration, educational institute, consumer reporting agency, accountant, and/or other individuals to disclose to GGL, or its authorized representative any and all information with respect to: work history, occupational requirements, educational history, wages, commissions, financial and corporate agreements, benefits insurance claims and coverage. The information provided to GGL, or its authorized representative is to be used for the evaluation and administration of my claim(s) with GGL or any of its affiliates. A photocopy of this authorization is to be considered a valid as the original and both are effective for one year from the date this authorization was signed. CLAIMANT S SIGNATURE CLAIMANT S SOCIAL SECURITY NUMBER DATE AUTHORIZED PERSONS SIGNATURE RELATIONSHIP OF AUTHORIZEPERSON Benefits are underwritten by Greater Georgia Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Long Term Disability Employee s Disability Benefits Application Atlanta Disability Service Center P.O. Box 723058 Atlanta, GA 31139-0058 Phone: (800) 232-0013 Fax: (800) 850-0017 E-Mail: disability@wellpoint.com Claimant Full Name (Last, First, Middle Initial ) Social Security No. Date of Birth Address City State Zip Code Phone No.: Fax No. Other No. E-Mail Address ( ) Height Weight Sex Marital Status ٱ Male ٱ Single ٱ Married ٱ Female ٱ Widowed ٱ Divorced Spouse s Name Spouse s Date of Birth Is Spouse Employed? ٱ Yes List names and dates of birth of unmarried children and/or dependents under age 19 ٱ No Employer s Name Group Policy No. Level of Education (Please check proper box) High School/Grade College Graduate Degree received 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 1 2 3 4 Employment Occupation (List the titles and duties of your occupation at the time of disability) Date of accident or date first noticed symptoms of illness (Mo, Day, Yr) I have been unable to work because of my current disability since (Mo, Day, Yr) I returned to work on a part-time basis on: Is your accident or illness related to your occupation? ٱ Yes ٱ No If Yes, explain. Have you or do you intend to file a Workers Compensation claim? ٱ Yes ٱ No Benefits are underwritten by Greater Georgia Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Claim History Describe how and where accident occurred or describe the onset and nature of your illness. Work ٱ Auto ٱ Other ٱ Home ٱ Date you were first treated for this illness or injury (Mo, Day, Yr). Have you ever had the same or similar condition in the past? (If yes, complete right side of form). Noٱ Yesٱ Hospital Name: Street Address: City: State Zip Code Doctor s Name: Specialty Street Address: City: State Zip Code Phone Number: Fax Number Hospital Name: Street Address: City: State Zip Code Doctor s Name: Specialty Street Address: City: State Zip Code Phone Number: Fax Number Income Describe other income you are receiving. Date Date Yes No Type Amount Began Ended ٱ retirement) Social Security (disability or ٱ $ ٱ disability State ٱ $ ٱ disability) Retirement (normal, early or ٱ $ ٱ Compensation Workers ٱ $ ٱ benefits Group disability ٱ $ ٱ $ (describe) Other ٱ Benefits Have you, or do you plan to apply for any benefit(s) described above? ٱ Yes ٱ No Type Date application filed Type Date application filed If your request for benefits is approved, do you want us to withhold a specific amount from each monthly benefit check for FEDERAL INCOME TAX purposes? ٱ Yes ٱ No If Yes, Amount $ (Indicate amount per week, $20.00 min.) If your request for benefits is approved, do you want us to withhold a specific amount from each monthly benefit check for STATE TAX purposes? ٱ Yes ٱ No If Yes, Amount $ (Indicate amount per week, $20.00 min.) Any person who knowingly and with intent to defraud or deceive any insurance company files a statement of claim containing any false or misleading information may be subject to criminal penalties. The above statements are true and complete to the best of my knowledge and belief. SIGNATURE OF EMPLOYEE DATE

Long Term Disability Attending Physician s Statement History NAME OF PATIENT SOCIAL SECURITY NUMBER DATE OF BIRTH WHEN DID SYMPTOMS FIRST APPEAR OR ACCIDENT HAPPEN? IS CONDITION DUE TO INJURY OR SICKNESS ARISING OUT OF PATIENT'S EMPLOYMENT? DATE PATIENT CEASED WORK DUE TO DISABILITY NAMES AND ADDRESSES OF OTHER TREATING PHYSICIANS: HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION? Yes ٱ No ٱ If yes, state when and describe Unknown ٱ No ٱ Yes ٱ DIAGNOSIS (If disabling condition is due to a mental disorder, the attached Behavioral Health Disability Report MUST also be completed) DIAGNOSIS (ICD-9/DSM-IV) IF PREGNANCY, EST. DATE OF DELIVERY SUBJECTIVE SYMPTOMS OBJECTIVE FINDINGS (INCLUDING CURRENT X-RAYS, EKG'S, LABORATORY DATA AND ANY CLINICAL FINDINGS) TREATMENT DATE OF FIRST VISIT DATE OF LAST VISIT FREQUENCY Weekly ٱ (specify) Other ٱ Monthly ٱ NATURE OF TREATMENT (INCLUDING SURGERY, MEDICATIONS PRESCRIBED,PHYSICAL THERAPY, SPEECH THERAPY, CARDIOPULMONARY PROGRAM, ETC.) PROGRESS PATIENT HAS Remained the same ٱ Recovered ٱ PATIENT IS House confined ٱ Ambulatory ٱ Regressed ڤ Improved ٱ Hospital confined ٱ Bed confined ٱ IS PATIENT MENTALLY COMPETENT TO ENDORSE CHECKS & DIRECT PROCEEDS THEREOF? ٱ Yes ٱ No HAS PATIENT BEEN HOSPITAL CONFINED (IF YES, PLEASE SPECIFY) Yes ٱ Admission date: Discharge Date: No ٱ Name of Hospital: Diagnosis: Benefits are underwritten by Greater Georgia Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

CARDIAC FUNCTIONAL CAPACITY (American Heart Association) ٱ Class 1 (no limitations) ٱ Class 2 (slight limitation) ٱ Class 3 (marked limitations) ٱ Class 4 (complete limitation) BLOOD PRESSURE ٱ Date of Reading: ٱ Systolic/Diastolic: IMPAIRMENTS (PHYSICAL) PHYSICAL IMPAIRMENTS (AS DEFINED IN FEDERAL DIRECTORY OF OCCUPATIONAL TITLES) ٱ Class 1- No limitation of functional capacity; capable of heavy work* No restrictions,(0-10%) ٱ Class 2- Medium manual activity* (15-30%) ٱ Class 3- Slight limitation of functional capacity; capable of light work* (35-55%) ٱ Class 4- Moderate limitation of functional capacity; capable of clerical/administrative (sedentary*) activity. (60-70%) ٱ Class 5- Severe limitation of functional capacity; incapable of minimum (sedentary*) activity. (75-100%) Remarks Please use reverse side of this form. Extent of Disability PATIENT MAY RETURN TO WORK? ٱ Yes ٱ No Date Return to Full Duty: / / ٱ Full Time, No Restrictions ٱ Light Duty (Please specify restrictions, limitations, hours, graduated return to work schedule, etc.) Date Return to Light Duty: / / IS PATIENT A SUITABLE CANDIDATE FOR REHABILITATION PROGRAM? ٱ Yes ٱ No PLEASE INCLUDE OFFICE NOTES FROM / / TO / / SIGNATURE PHYSICIAN'S NAME, SPECIALTY, & ADDRESS (PLEASE PRINT) DATE: PHYSICIAN'S SIGNATURE: TELEPHONE NUMBER: E-MAIL ADDRESS: FAX NUMBER:

Long Term Disability Employer s Report of Claim Claimant EMPLOYEE S NAME SOCIAL SECURITY NUMBER DATE OF BIRTH ADDRESS CITY STATE ZIP CODE PHONE NUMBER POLICY NO. EMPLOYEE DATE OF HIRE EFFECTIVE DATE OF LTD DATE EMPLOYEE LAST WORKED FULL TIME Employment OCCUPATION AT THE TIME LAST WORKED (Attach Job Description) WORK SCHEDULE AT TIME LAST WORKED REASON FOR LEAVING WORK Sickness Granted LOA Laid Off Retired Dismissed Other Resigned Vacation Income HOW IS EMPLOYEE PAID? Straight Salary Salary & Commissions Commissions Only Hourly Salary & Bonus EMPLOYEES PERCENT OF LTD PREMIUM CONTRIBUTION No. of days per week No. of hours per day HAS EMPLOYEE RETURNED TO WORK? Yes Part-time Full-time No Date Date EMPLOYEE S BASIC MONTHLY EARNINGS $ LTD Benefit If salary is based on less than 12 mos. No. of mos. Employee Pays % Pre-Tax Post-Tax Employer Pays % Other Benefits HAS INSURED RECEIVED OTHER DISABILITY PAYMENTS SINCE TIME LAST WORKED? Salary Continuance: Short Term: Other Type: Yes (Weekly Amount) Yes (Weekly Amount) Yes (Weekly Amount) Date Benefits Cease Date Benefits Cease Date Benefits Cease No No No DID CLAIM RESULT FROM JOB ACTIVITY? Yes No HAS WORKER S COMPENSATION CLAIM BEEN FILED? Yes Pending Denied (Enclose Copy) (include copy of 1 st report of accident) WORKER S COMPENSATION WEEKLY AMOUNT $ Retirement DATE BENEFIT BEGAN \ \ MONTH DAY YEAR IS EMPLOYEE COVERED BY EMPLOYER SPONSORED RETIREMENT PLAN? Yes No DOES RETIREMENT PLAN CONTAIN A DISABILITY PROVISION? Yes No IS EMPLOYEE, OR WILL THIS EMPLOYEE BE, ELIGIBLE FOR A DISABILITY OR RETIREMENT PENSION? Yes If Yes,type Monthly Amount $ Disability Retirement Other No Date Benefits Commence (Enclose copy of summary plan description) Note: If any portion of this pension benefits is attributable to the employee s contribution, please provide details including the percentage of his/her contribution to the total contriburion Benefits are underwritten by Greater Georgia Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

Certification 24. EMPLOYER S NAME 25. EMPLOYER S TELEPHONE NUMBER 26. EMPLOYER S FAX NUMBER 27. EMPLOYER S EMAIL ADDRESS 28. ADDRESS 29. EMPLOYER (Taxpayer) I.D. NUMBER (EIN) - 30. PUBLIC EMPLOYER SOCIAL SECURITY NO. 69-32. SIGNATURE OF AUTHORIZED INSURANCE REPRESENTATIVE 31. NAME OF PERSON COMPLETING THIS FORM (Please type or print) TITLE DATE Separate and send this form (with other enclosures) to the address shown on the front page. Give the remaining forms to the claimant.