Use this form to start the term insurance application process. Understand that completion of this form does not constitute an offer of insurance. Insurance will not take effect until the policy is delivered and the first premium is received by Empire Fidelity Investments Life Insurance Company. If you have any questions about how to fill out this form, please call the Customer Service Center at 888-343-8376, Monday through Friday, 8 a.m. to 5 p.m. Eastern time. Term Insurance Request Form 1 PROPOSED INSURED S INFORMATION Proposed Insured s Name (Please Print) Address City State ZIP Code 1) Phone Number: - - 2) Date of Birth: - - 3) Gender: Male Female (MM-DD-YYYY) 4) Term of Insurance Plan Elected: 10 yr 15 yr 5) Coverage Amount: $ 6) Premium Quoted: $ 20 yr (Minimum Face $250,000) 2 SET UP A PHONE MEETING (Indicate below a time for us to contact you to obtain additional information. Please set aside approximately 15 minutes of your time for this telephone call.) 1) I would like to be contacted at my: Phone Number Above Other - - 2) Please call me Monday Friday between: 8 a.m. Noon ET 1 p.m. 5 p.m. ET 6 p.m. 8 p.m. ET 3 EMPIRE FIDELITY INVESTMENTS REPRESENTATIVE INFORMATION (For Fidelity Use Only) I certify that, to the best of my knowledge and belief, the applicant does have one or more existing policies or contracts. does not have any existing policies or contracts. To the best of my knowledge and belief, this policy will replace any other insurance or annuity. will not replace any other insurance or annuity. SIGNATURE OF EMPIRE FIDELITY INVESTMENTS REPRESENTATIVE DATE Rep Code: A Branch Code: Please mail this form to Empire Fidelity Investments Life Insurance Company, P.O. Box 770001, Cincinnati, OH 45277-0051, or fax it to 800-847-0344. Fidelity insurance products are issued by Fidelity Investments Life Insurance Company (FILI), 100 Salem Street, Smithfield, RI 02917, and in New York, by Empire Fidelity Investments Life Insurance Company, New York, N.Y. FILI is licensed in all states except New York. A contract s financial guarantees are subject to the claims-paying ability of the issuing insurance company. Req Form-NY (1010) 565080.2.0 1.922843.101 Fidelity Brokerage Services LLC, Member NYSE, SIPC
Complete this form to provide consent to review medical information. If you have any questions about how to fill out this form, please call the Customer Service Center at 888-343-8376, Monday through Friday, 8 a.m. to 5 p.m. Eastern time. Term Insurance Authorization to Obtain and Disclose Information Form This authorization was designed to comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) rules. I (Proposed Insured) authorize or acknowledge: Those entities listed below to disclose medical and other relevant information about me for the purpose of determining eligibility for insurance to Empire Fidelity Investments Life Insurance Company (EFILI), New York, N.Y., and its underwriter, as well as their respective agents, contractors, employees, representatives, affiliates, assigns, and reinsurers, and to testify as to such information, all to the extent permitted by law: any physician, medical professional, hospital, clinic, or other medically related facility; any insurance or reinsurance company; any consumer reporting agency; other insurance support organizations; any employer; the Medical Information Bureau, Inc.; or any other person, organization, or institution that has any records or knowledge of me or of my health. That Empire Fidelity Investments Life Insurance Company may make a brief report to the Medical Information Bureau, Inc. That if any of my information is re-disclosed, it may no longer be protected by federal rules governing privacy and confidentiality of health information. That if I refuse to sign this Authorization, EFILI may not be able to process my application, or if coverage has been issued, may not be able to make benefit payments. That this Authorization will be valid for two years from the date shown below, and that a photocopy of it will be as valid as the original. That I may revoke this Authorization at any time by requesting such of EFILI in writing at its address stated below, unless action has already been taken in reliance upon it, or during a contestability period under applicable law. That I may receive a copy of this Authorization upon request. That I have received the Investigative Consumer Reports Notice, the Privacy Notice, and the Important Notice. Signed at this day of 20 Name of Proposed Insured Signature of Proposed Insured Please mail this form to Empire Fidelity Investments Life Insurance Company, P.O. Box 770001, Cincinnati, OH 45277-0051, or fax it to 800-847-0344. Fidelity insurance products are issued by Fidelity Investments Life Insurance Company (FILI), 100 Salem Street, Smithfield, RI 02917, and in New York, by Empire Fidelity Investments Life Insurance Company, New York, N.Y. FILI is licensed in all states except New York. A contract s financial guarantees are subject to the claims-paying ability of the issuing insurance company. AUTH FORM-NY (1010) 563003.2.0 1.920095.101 Fidelity Brokerage Services LLC, Member NYSE, SIPC 025250001
Insurance Department of the State of New York Definition of Replacement In order to determine whether you are replacing or otherwise changing the status of existing life insurance policies or annuity contracts, and in order to receive the valuable information necessary to make a careful comparison if you are contemplating replacement, the agent is required to ask you the following questions and explain any items that you do not understand. AS PART OF YOUR PURCHASE OF A NEW LIFE INSURANCE POLICY OR A NEW ANNUITY CONTRACT, HAS EISTING COVERAGE BEEN, OR IS IT LIKELY TO BE: 1 2 3 4 5 6 Lapsed, surrendered, partially surrendered, forfeited, assigned to the insurer replacing the life insurance policy or annuity contract, or otherwise terminated? Changed or modified into paid-up insurance; continued as extended term insurance or under another form of nonforfeiture benefit; or otherwise reduced in value by the use of nonforfeiture benefits, dividend accumulations, dividend cash values or other cash values? Changed or modified so as to effect a reduction either in the amount of the existing life insurance or annuity benefit or in the period of time the existing life insurance or annuity benefit will continue in force? Reissued with a reduction in amount such that any cash values are released, including all transactions wherein an amount of dividend accumulations or paid-up additions is to be released on one or more of the existing policies? Assigned as collateral for a loan or made subject to borrowing or withdrawal of any portion of the loan value, including all transactions wherein any amount of dividend accumulations or paid-up additions is to be borrowed or withdrawn on one or more existing policies? Continued with a stoppage of premium payments or reduction in the amount of premium paid? If you have answered yes to any of the above questions, a replacement as defined by New York Insurance Department Regulation No. 60 has occurred or is likely to occur and your agent is required to provide you with a completed disclosure statement and the important notice regarding replacement or change of life insurance policies or annuity contracts. SIGNATURE OF APPLICANT Date SIGNATURE OF APPLICANT Date To the best of my knowledge, a replacement is involved in this transaction: SIGNATURE OF AGENT Date N.NYREPLACE-0102 1.710749.101 3.NY-DEFINE-FORM 2710640
Authorization to Obtain Information Form 1 DECLARATION TO RELEASE INFORMATION please be advised, in accordance with New York State Existing Insurance Company Name Insurance Department Regulation 60, please find below an authorization from, Name of Owner and Joint Owner (when applicable) to release benefits and values associated with the following life insurance policies or annuity contracts: Contract Number Contract Type Annuity Life Annuity Life Annuity Life Estimated Transfer Amount $ $ $ Exchange Type Full Partial Full Partial Full Partial (Please include a copy of the client s statement) 2 AUTHORIZATION I/We hereby authorize Name of Owner and Joint Owner (when applicable) to obtain from Name of Representative Name of Existing Insurance Company information showing all benefits and values associated with the life insurance policies and/or annuity contracts listed above, and take all actions reasonably necessary to obtain such additional information as may be required under New York State Insurance Department Regulation 60. SIGNATURE OF POLICY / CONTRACT OWNER DATE Owner s Social Security Number Date of Birth SIGNATURE OF JOINT OWNER DATE Joint Owner s Social Security Number Date of Birth 3 FIDELITY AUTHORIZATION In accordance with the New York State Insurance Department Regulation 60, please complete the sections of the enclosed Disclosure Statement for the policies/contracts listed above. Name of Representative SIGNATURE OF REPRESENTATIVE DATE Please return the completed Disclosure Statement within 20 days of receipt to: Empire Fidelity Investments Life Insurance Company P.O. Box 770001, Cincinnati, OH 45277-0051 or Fax to: 1-800-835-6443 418468.4.0 1.814043.104 Fidelity Brokerage Services LLC, Member NYSE, SIPC 011050101
Number Empire Fidelity Investments Life Insurance Company P.O Box 770001 Cincinnati, OH 45277-0050 1-888-343-8376 NOTICE AND CONSENT FOR BLOOD TESTING WHICH MAY INCLUDE AIDS VIRUS (HIV) ANTIBODY/ANTIGEN TESTING To determine your insurability, the Insurer named above ("the insurer") has requested that you provide a sample of your blood for testing and analysis. All tests will be performed by a licensed laboratory. Tests may be performed to determine the presence of antibodies or antigens to the Human Immunodeficiency Virus (HIV), also known as the AIDS virus. The HIV antibody test is actually a series of tests done by a medically accepted procedure. The HIV antigen test directly identifies AIDS viral particles. These tests are extremely reliable. Other tests which may be performed include determinations of blood cholesterol and related lipids (fats) and screening for liver or kidney disorders, diabetes, and immune disorders. All test results will be treated confidentially. They will be reported by the laboratory to the insurer. When necessary for business reasons in connection with insurance you have or have applied for with the insurer, the insurer may disclose test results to others such as its affiliates, reinsurers, independent contractors, and its employees to whom disclosure is reasonably necessary in the ordinary course of business to carry out the purposes for which that disclosure is authorized or required. If the insurer is a member of the Medical Information Bureau ( MIB, Inc. ), and if the test results for HIV antibodies/antigens are other than normal, the insurer will report to the MIB, Inc., a generic code which signifies only a non-specific blood test abnormality. The test results may also be disclosed to any member company that receives an application for health or life insurance on your life. If your HIV test is normal, no report will be made about it to the MIB, Inc. Other test results may be reported to the MIB, Inc., in a more specific manner. The organizations described in this paragraph may maintain the test results in a file or data bank. There will be no other disclosure of test results or even that the tests have been done except as may be required or permitted by law or as authorized by you. If your HIV test results are normal, no routine notification will be sent to you. If the HIV test results are other than normal, the insurer will contact you. The insurer may also contact you if there are other abnormal test results which, in the insurer's opinion, are significant. The insurer may ask you for the name of a physician or other health care provider to whom you may authorize disclosure and with whom you may wish to discuss the results. Positive HIV antibody/antigen test results do not mean that you have AIDS, but that you are at significantly increased risk of developing AIDS or AIDS-related conditions. You may wish to consider further independent testing. Federal authorities say that persons who are HIV antibody/antigen positive should be considered infected with the AIDS virus and capable of infecting others. Positive HIV antibody or antigen test results or other significant blood abnormalities will adversely affect your application for insurance. This means that your application may be declined, that an increased premium may be charged, or that other policy changes may be necessary. HIV CONSENT -GENERIC 1 (10/06)
I have read and I understand this Notice of Consent for Blood Testing Which May Include HIV Antibody/Antigen Testing. I voluntarily consent to the withdrawal of blood from me by needle, the testing of that blood, and the disclosure of the test results as described above. I understand that this consent shall be valid for thirty (30) months following the date shown below. I understand that I have the right to request and receive a copy of this authorization. A photocopy or transmitted facsimile of this form will be as valid as the original. I also have the right, upon written request, to an insurance institution (insurers), agent, or insurance support organization, for access to recorded personal information and a copy of same within thirty (30) business days from the date such request is received. I have the right to request, in writing, that any recorded personal information be corrected, amended, or deleted within thirty (30) business days from the date of receipt of my written request by an insurance institution, agent or insurance support organization. If my request is not honored, I have the right to file a concise statement of the correct, relevant or fair information; and the reasons why I disagree with such refusal to correct, amend, or delete recorded personal information. Proposed Insured Date of Birth Signature of Proposed Insured or Date State of Residence Parent/Guardian Adverse Underwriting Decision New York Law states that you have the right to identify on this authorization form anyone you would like us to notified in the event of an adverse underwriting decision. (Such as an individual or physician.) Name of Designee Address (Street Address) City/State/Zip Code In the event of an adverse underwriting decision the state of New York requires that we provide you with the New York Statewide AIDS Hotline at 1-800-541-2437 or the New York Statewide Department of Health HIV Confidentiality Hotline at 1-800-962-5065 which may be called for further information on AIDS, the meaning of HIV related test results and the availability and location of HIV related counseling services. (Please note that these numbers are only available in the state of New York.) The National AIDS Hotline number is 1-800-342-2437. HIV CONSENT -GENERIC 2 (10/06)
Empire Fidelity Investments Life Insurance Company P.O Box 770001 Cincinnati, OH 45277-0050 1-888-343-8376 DEFINITION OF TERMS According to New York Law the following terms have the following meanings: Adverse underwriting decision: (A) a declination of insurance coverage as applied for; or (B) an offer to issue insurance coverage at a higher than standard rate. AIDS: acquired immune deficiency syndrome, as may be defined from time to time by the centers for disease control of the United States public health service. HIV infection: infection with the human immunodeficiency virus or any other related virus identified as a probable causative agent of AIDS. HIV related test: any laboratory test or series of tests for any virus, antibody, antigen or etiologic agent whatsoever thought to cause or to indicate the presence of AIDS. HIV CONSENT -GENERIC 3 (10/06)
NOTICE OF DISCLOSURE OF INFORMATION PRIVACY NOTICE Personal information may be collected from persons other than you. Such information, as well as other personal or privileged information subsequently collected by us or your agent, may in certain circumstances be disclosed to third parties without authorization. You have a right of access and correction with respect to all personal information collected. A detailed notice of information practices will be furnished to you upon request. INVESTIGATIVE CONSUMER REPORTS As part of our regular underwriting procedure, an investigative consumer report may be obtained which will provide applicable information concerning a natural person's character, general reputation, personal characteristics, credit worthiness, credit standing, credit capacity, and mode of living. In certain instances, information may be obtained through personal interviews with your friends, neighbors, and associates. You may (1) request to be personally interviewed and/or (2) request a copy of the investigative consumer report. Further information on the nature and scope of the report will be provided upon written request to the Underwriting Manager, Fidelity Investments Life Insurance Company, P.O. Box 1440, Cincinnati, OH 45277-0050. You may receive a copy of such report by mailing a written request to us, your agent, or the reporting agency after proper identification. IMPORTANT NOTICE The underwriting process (evaluation and classification of risks) is necessary to assure reasonable cost of insurance and provide a mechanism by which policyholders pay their fair share of the cost. In considering your application, information from various sources is considered, including your own statements, the results of your physical examination (if required), and any reports we obtain from doctors or medical facilities where you have received treatment or consultation. Information regarding your insurability and/or any past or future claims will be treated as confidential. We, or our reinsurers, may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of insurance companies, which operates as an information exchange on behalf of its Members. If you apply to another Bureau Member company for life or health insurance coverage or a claim for benefits is submitted to such a company, the Bureau, upon request, will supply such company with the information it may have in its file. Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau's file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau's information office is Post Office Box 105, Essex Station, Boston, MA 02112, telephone number (866) 692-6901 (TTY 866-346-3642). We, or our reinsurers, may also release information in our file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim may be submitted ADVERSE UNDERWRITING DECISIONS If, at any point during the application process, you receive an Adverse Underwriting Decision, you have the right to know the specific items of information that support the reasons given for this decision and the identity of the source of that information. You also have a right to see and obtain copies of documents relating to this decision (certain exceptions do apply). If you ask us to correct, amend, or delete any information about you in our files and if we refuse to do so, you have the right to give us a concise statement of what you believe is the correct information. We will put your statement in our file so that anyone reviewing your file will see it. If you would like additional information concerning any Adverse Underwriting Decision, state law requires that you submit a written request within ninety (90) business days of the date this notice was mailed to you or other communication of an Adverse Underwriting Decision was received. Please send your request to Underwriting Manager, Fidelity Investments Life Insurance Company, Cincinnati, OH 45277-0050. DISCLOSURE-NOTICE-05