Field Underwriting Guide

Field Underwriting Guide

The information contained in this guide is intended for the training and education of Colonial & Insurance Company employees and benefit representatives only. Colonial has not authorized any other use of this information. Do not give or show it to prospective insureds, employers of prospective insureds, or anyone else not employed by or contracted with Colonial & Insurance Company or other Unum Group business units.

Table of Contents Underwriting Glossary of Terms...1 Underwriting Memo...4 Track an App for Underwriting...5 Transfer and Stacking...6 Adding a rider to an existing policy...7 Service to Existing Policies...8... 8... 8...9... 9 Hospital Confinement...10 Intensive Care...10...11 Policy Change Matrix...12 Special State Compliant Questions...14 When to use Which Application?...15 Knockout Questions AccHlth and App 06 and 08 Applications...18 Enrollment Method...16 Height and Weight Charts...20 /Hospital Confinement...20...21 Term 1000, Universal 1000, Whole 1000...22 Juvenile...23 Underwriting and...24 Medical Conditions...25 and Health Application List...76 A&H Replacement Form List...78 Term 1000, UL1000 and WL1000 Chart...80 Insurance Replacement...84 HIPAA, HIV, LTC, Forms List...86

About This Pamphlet The Field Underwriting Guide was developed as an educational tool to assist Colonial s sales organization with the underwriting process. If you need to contact the Underwriting department, please dial 1.800.43.VOICE extension 6210 and choose from the following options:,, Individual, Option 1, Hospital Confinement, Intensive Care Term, Universal, Whole Option 2 Select, Group VSTD and Group VGTL Option 3 You may also email the Underwriting Department through the ProducerNet at colonialunderwriting3@unum.com. Our toll free fax line is 1.888.668.7967.

Glossary of Terms The following is a glossary of commonly used terms in the Underwriting process. The definitions are both industry-standard and Colonial specific. Actively Working - The applicant must be working on a full-time basis and paid regular earnings at the account in which coverage is being offered. The employee is not on any type of leave such as Family Medical Leave,, etc. Actively Working may be defined differently in certain states, and definitions may vary by product. Amendment - An amendment is done when the Underwriter determines that the premium, face amount or smoker status originally submitted for a life policy needs to be altered. Face amount and premium changes can occur as a result of the health risk of the applicant. Smoker status changes occur based on medical test results. The amendment, along with the policy, is mailed to the producer for delivery to the applicant. The applicant must sign a copy of the amendment and that signed copy must be forwarded to the Underwriting Department for the policy to be issued. Annual Income - Basic annual earnings. This does not include income from commissions, bonuses, overtime pay, any other extra compensation or include income from sources other than the current employer. Annual Income of commissioned employees - Income actually received from commissions and does not include renewal commissions, bonuses, overtime pay and any other extra compensation, or include income received from sources other than the current employer. Commission should be average over the 12 month period prior to the date of the application for coverage or based on the prior year s W-2 income. Attending Physicians Statement (APS) - Information from a physician who has treated, or is currently treating, the proposed insured for one or more conditions that may affect insurability. Benefit Period - The maximum length of time that benefits may be payable for a specific disability. Beneficiary - The person to whom the death benefit of an insurance policy is payable at the time of death of the insured. Birth Exclusion - Applies to and Hospital Income coverage. Excludes coverage for pregnancy if delivery occurs within 9 months from the coverage effective date of the policy. This 9 month pre-existing will not be waived under any circumstances. The definition of Pre-Existing Condition varies by state and product. Refer to the policy or outline for the product in your state for an accurate definition. Blood Profile - Report containing results from testing an applicant s blood and urine. This profile is used in the underwriting process to evaluate the health risk of the proposed insured. Comprehensive Health Coverage - Major Medical Coverage. Note that some states require a proposed insured have Comprehensive Health Coverage to be eligible for specific supplemental insurance plans. See page 10. 1

2 Declination - Denial of coverage on a proposed insured. Domestic Partner - Colonial recognizes domestic partners ONLY if the account we are writing allows domestic partners to be covered by their core benefits. A letter, on company letterhead, must be submitted by the account indicating they recognize domestic partner as described above. Duplicate Coverage - Duplication of benefits provided by more than one policy/ rider. Colonial does not allow duplication of benefits. Elimination Period - The period of time during which no benefits are payable. Endorsement - Statement by the underwriting department altering the application as originally completed by the applicant and/or producer. Note that some states do not allow endorsement and any changes to the application must be initialed by the applicant. Evidence of Insurability - Any statement or proof of a person s physical condition and/or other factual information affecting acceptability for insurance. Exclusion Rider - A rider attached to a policy to exclude from coverage any loss arising from a specific disease or physical impairment. (Not available in all states). Fully Underwritten - The process in which full medical history on the proposed insured is reviewed to determine eligibility for coverage. This may include Health questions, blood profiles, APS, medical exams, motor vehicle reports, inspection reports, etc. Guaranteed Issue (GI) - Act of issuing coverage to all eligible applicants regardless of health history. Guaranteed Issue is available for certain products when the Home Office determines participation requirements have been met. The appropriate application must always be completed and pre-existing still applies to the policy. Inspection Reports - A report made by a consumer reporting agency concerning the proposed insured s personal life, activities, occupation, and economic standing. An inspection report is considered an investigative consumer report as defined by the Fair Credit Reporting Act. Insurable Interest - Considered to be present if (a) the named beneficiary will suffer an economic loss upon the death of the proposed insured or (b) the parties to the insurance contract have a close relationship either by blood or marriage. Job Title - The designated title indicated by a group for a specific job. This title does not necessarily indicate the nature of work performed by a proposed insured. Knockout question - A question on the application, when answered yes, automatically results in declination of coverage. Medical Exam - A report regarding the proposed insured s health based on physical examination and questioning of the proposed insured. Medical Information Bureau - An organization established to provide information that alerts underwriters to the possibility that a proposed insured has an unrevealed impairment that has been admitted to or detected by other insurers. Motor Vehicle Report - A copy of the proposed insured s driving record that is obtained from the state motor vehicle department.

Occupation - The classification assigned to a profession based on the specific job responsibilities and duties that are specific to a particular industry or nature of employment. Owner - The person who owns an insurance policy and has the right to make changes and designate beneficiaries. Paramedical - Is a medical exam Payer - The person paying the premium for an insurance policy. It can be someone different from the applicant, proposed insured, or policyowner. Pre-Existing Condition - A sickness or physical condition, for which any covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the effective date of the policy. Pre-existing will not be waived under any circumstances. The definition of Pre-Existing Condition varies by state and product. Refer to the policy or ProducerNet by product in your state for an accurate definition. Prohibited Account - Accounts whose nature of business have been determined to be an unacceptable risk for the sale of Colonial products. Replacement - Any transaction involving the purchase of life insurance in which the agent knows that the existing insurance has been or will be lapsed, surrendered, or modified. Many states require signed replacement forms in order to complete the transaction. All internal and Health (A&H) product replacements require a signed replacement form. (see replacement sections for your states specific replacement form) Internal Replacement are not allowed. Simplified Issue - A level of underwriting that requires the proposed insured to answer minimal health questions. Transfer of Coverage - Proposed insured agrees to cancel existing coverage and/ or attached riders in order to apply for new coverage. Internal Transfers / Replacements are not permitted. Underwriting Authorization (HIPAA) Because of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Colonial had to revise the Underwriting Authorization on all the applications. HIPAA required the Authorization to be on a separate sheet of paper and not made a part of the application. This new Underwriting Authorization allows Colonial to obtain medical and non-medical information necessary for underwriting the application. Waiting Period (for benefits) - The period of time after the coverage effective date, during which no benefits will be payable. Waiting Period (for eligibility) - The period of time between an employee s date of hire and enrollment in the benefits program. Waiver of Monthly Deduction (Waiver of Premium) - A contract provision that exempts an individual from the requirement to pay premiums while he or she is disabled. Colonial requires that a specified period of total disability must have occurred in order to be eligible for this benefit. 3

Underwriting Memo Applications submitted to the Home Office are evaluated in the Underwriting Department. If the Underwriter determines additional information is needed to complete the processing of the application, the writing level representative is contacted for that additional or missing information. This correspondence is referred to as an Underwriting memo. The Underwriting memo, along with a copy of the application, can be located on Track an App in ProducerNet and viewed by the writing representative or their management hierarchy. Paper copies are not mailed. For Colonial sales representatives, Track an App can be accessed via the ProducerNet>Sales and Service. For Brokers, Track an App can be accessed via ColonialConnect for Brokers> Sales and Service. Once in Track an App, go to Business in Process to review outstanding Underwriting issues listed by account and sales summary. There is a column which indicates yes or no to Underwriting issues. This pertains to all policies associated with that sales summary. If the sales summary does contain Underwriting issues, the producer can access the information at the policy level by clicking on the yes. The next view will allow you to determine whether the file is in process based on Home Office review or Sales Organization review. In addition, it will give the producer a short description of the information under review. If no additional information is listed for that policy, the status is either issued or declined. The producer only needs to be concerned with applications that have a yellow LTR icon next to the application number. Two additional links are provided at the policy level. The link provided via the policy number will give the producer policy detail information including the status. The white envelope symbol is a link that allows the producer to email the Underwriting department with any questions regarding that particular file. The producer must respond to any Underwriting memos in writing directly on the application or supplemental health form based on the information being requested. Do not make any corrections on the memo as this does not become part of the issued policy. Individual policy information will remain in Track an App for 14 days after the final policy within that sales summary has been resolved. The writing level representative is given 16 days from the date of the Underwriting memo to return the additional or missing information to the Underwriting Department. If your application was written in a non-endorsement state, all changes made on the application must be initialed by the applicant in order for the Underwriting department to approve the application. Non-endorsement states are AL, KY, HI, LA, MD, MO, NH, OR, PA, SC and WV. If, after the 16 day timeframe, we have not received a response to our request for additional information, the file will be declined for no reply. In addition, the applicant will receive a letter informing them of the denial of coverage. The declination will result in a charge back to the advance and the never effect rate for all producer s compensated for that application. Reopens will not be permitted. A new application must be submitted. 4

Track an App for Underwriting All underwriting memos requesting additional information, as well as a copy of the application, are available on Track an App for review and response. Paper copies are not mailed. All responses should be faxed to the underwriting toll free fax at 1-888-668-7967 or mailed to the Home Office. Track an App is a ProducerNet tool designed to allow the sales organization to track applications as they are processed through the Home Office. This section pertains to the processing handled by the Underwriting Department. For Colonial sales representatives, Track an App can be accessed via the ProducerNet>Sales and Service. For Brokers, Track an App can be accessed via Brokernet>Work Essentials. Once in Track an App, go to Business in Process to review outstanding Underwriting issues listed by account and sales summary. There is a column which indicates yes or no to Underwriting issues. This pertains to all policies associated with that sales summary. If the sales summary does contain Underwriting issues, the producer can access the information at the policy level by clicking on the yes. The next view will allow you to determine whether the file is in process based on Home Office review or Sales Organization review. In addition, it will give the producer a short description of the information under review. If no additional information is listed for that policy, the status is either issued or declined. The producer only needs to be concerned with applications that have a yellow LTR icon next to the application number. Two additional links are provided at the policy level. The link provided via the policy number will give the producer policy detail information including the status. The white envelope symbol is a link that allows the producer to email the Underwriting department with any questions regarding that particular file. The producer must respond to any Underwriting memos in writing directly on the application or supplemental health form based on the information being requested. Individual policy information will remain in Track an App for 14 days after the final policy within that sales summary has been resolved. Please allow 7 to 10 days after submission for the application to be initially reviewed by an Underwriter prior to calling underwriting or sending an email through Track an App. Again, underwriting memos as well as a copy of the application are available through Track an App for you to review and handle. An email notification will be sent to the writing representative notifying them of correspondence from Underwriting. The email will provide the reason for correspondence and related policies or sales summaries; however, you should check Track an App at least twice a week for any issues on business submitted. In order to receive an email from us, you must have a valid email address on file with us. 5

6 Transfer and Stacking Transfer A transfer occurs when a Colonial insured agrees to cancel existing coverage and/or attached riders in order to apply for new coverage with similar benefits. The application being completed should indicate the coverage as being transferred and the transfer section on the application should indicate the policy number(s) of the coverage or rider being canceled. In addition, a separate applicant signature in the transfer section is required. Only the new AccHlth application does not require a separate transfer signature. Completing the application properly in a transfer situation is very important. By doing so, the producer will ensure that the prior coverage gets cancelled as of the effective date of the new coverage and avoids a gap in coverage for the insured. In addition, it ensures that the bill sent to the account shows the correct deductions for that insured. The other benefit of a transfer is that if the new coverage is declined for any reason, the prior coverage will, in most instances, be placed back in force. A transfer can occur when an insured is increasing or decreasing benefits within a product, moving from one generation of a product to a newer generation or when adding family members to a policy. In most instances of a transfer, additional underwriting is required and the appropriate health questions need to be answered. It is important to remember that sometimes the transaction involves transferring an existing rider such as the Care disability rider transferring to a 1000 plan. If you are using Sales Automation, a request for service form needs to be completed in order to cancel the rider. You cannot cancel a rider through Sales Automation without canceling the base plan as well. In a manual or Harmony enrollment situation, you can indicate rider only in the transfer section and sign the transfer request. Each product has specific guidelines for transfer situations you may encounter. You can find this information in the Underwriting Overview section for the product on ProducerNet or in the Product Reference Pamphlet for each product. All A&H product transfers require an internal A&H replacement form (see A&H replacement section for state specific form). Internal life transfers / replacements are not permitted. Stacking Stacking occurs when a Colonial customer has existing coverage and is trying to increase or add additional duplicate benefits without giving up the existing product. An example would be when an insured has a stand alone disability plan and is trying to add Care with a disability rider. The disability benefit is duplicated by the Care disability rider so it would not be allowed.

Colonial does not allow stacking within the same product, generation of product or alternate product with similar benefits in any instance. This often duplicates one or more benefits and can cause overinsurance to occur. The only exception to this rule is when the insured has aged into a new age band and wishes to increase their coverage. This can only be done if the plan design and product generation of the new coverage matches the plan design and product generation of the existing coverage. An example would be an application with a current DI 1000 with a plan 2, 14/14 day elimination period, 6 month benefit period, who has entered a new age band; can only stack a new DI 1000, plan 2, 14/14 day elimination period, 6 month benefit period. Each product has specific guidelines for when stacking is allowed. You can find this information in the Underwriting Overview section for the product on ProducerNet or in the Product Reference Pamphlet for each product. Adding a rider to an existing policy Several Colonial products have optional riders that can be purchased if the base plan is purchased. It is important that the application be completed and submitted properly when adding a rider to an existing base plan. This section is not intended for riders added at the initial purchase of the base plan. If the insured wishes to add an optional rider to an existing policy, the application should only indicate the plan code and premium of the rider or riders being added. The plan code and premium of the existing base policy should not be indicated on the application. In addition, you must answer all the appropriate questions on the application. More than likely the actively at work, replacement, medicare and certain health questions will apply in rider addition situations. The other key to handling rider additions correctly is that they must be manually submitted to the New Business department. Electronic transmission of rider additions will result in the coverage going to the warehouse and a delay in processing the business will occur. Each product has specific guidelines for the correct Underwriting for riders available with that product. You can find this information in the Underwriting Overview section for the product on ProducerNet or in the Product Reference Pamphlet for each product. NOTE: You may hear the addition of a rider to an existing base plan referred to as a dependent add or dependent addition. 7

Service to Existing Policies This section is designed to give you the information necessary to service existing Colonial policies. Please refer to the attached policy change matrix which reflects the necessary paperwork required to request / service existing policies. : coverage may be increased or decreased by changing the monthly benefit amount, elimination period or benefit period. Any changes to an existing disability policy require a new application reflecting the desired change, with the exception of a decrease to the monthly benefit amount. This type of transaction can be submitted on a Request for Service form reflecting the lower benefit amount. When submitting this new application for the desired change a transfer signature is required in all cases as this type transaction transfers the prior policy to the new policy. : The benefit level of cancer coverage may be increased or decreased, family status may be changed or the applicant may transfer to the newest generation of cancer coverage in the cancer portfolio. A new application is required when increasing or decreasing benefit level, changing from a current cancer plan to a newer version or changing from individual to one parent or one parent to two parent coverage. When submitting an application requesting any of these changes, the transfer signature is required. If the desired change is to go from a two parent to a one parent or one parent to individual coverage, a Request for Service form can be submitted. If adding a new spouse or dependent to an existing family cancer plan, a new application indicating that a spouse or dependent is being added must be submitted. Note on the app that this is an update to existing coverage and you should not submit a sales summary with the application. The cancer question must be answered and reflect the health for the spouse or child being added. This is the only individual that will be underwritten. Dependents are allowed to continue cancer coverage past age 25 without evidence of insurability by submitting an application in the dependent s name and providing the existing policy number that dependent is currently covered under. The new app must be submitted within six (6) months of the dependent turning 25. (Refer to the policy transfer matrix as to required paperwork for requested transaction.) 8

: The (CI) face amount may be increased or decreased. The applicant may also change from CI with cancer to CI without cancer or to CI without cancer to CI with. An insured cannot have with and a stand alone plan. The tobacco status may also be changed. The existing plan must be in force at least one (1) year before any changes can be made to the policy. A new application must be submitted and the transfer signed. An insured cannot have with and a stand alone plan. : Universal face amounts may be increased or decreased, the death benefit option may be changed, and the tobacco status may be changed. A new application is required when increasing the face amount, changing the death benefit option from A to B or changing the tobacco status A Request for Service form may be submitted when decreasing the face amount or changing the death benefit option from B to A. All Level Term change requests (face amount changes or tobacco/nontobacco changes) require a new application. Existing Whole 1000 policies can not be increased. In order to obtain additional whole life coverage, a new application for the additional face amount is required. The maximum total face amount allowed for The maximum total face amount allowed for a single Whole 1000 policy is $100,000. This can be reflected as multiple policies. Spouse or Dependent term riders can be added to existing UL, Level Term or Bridge by submitting an application for the spouse/dependent to be added and the policy number the rider is being added to. An al Death Benefit Long Term Care and/or Waiver of Monthly deduction (or Waiver of Premium) rider may be added to existing UL life plans only if an increase is being applied for. You cannot increase an existing rider. The al Death Benefit rider and the Waiver of Premium rider for Level Term and Whole life policies can only be purchased at the original issue of the base policy. They cannot be added to an existing policy. 9

Hospital Confinement: The benefit level of hospital confinement coverage may be increased or decreased, family status may be changed or the applicant may transfer to the newest generation of hospital confinement coverage in the hospital confinement portfolio. A new application is required when increasing or decreasing benefit level, changing from a current hospital confinement plan to a newer version or changing from individual to one parent or one parent to two parent coverage. When submitting an application requesting any of these changes, the transfer signature is required. If the desired change is to go from a two parent to a one parent or one parent to individual coverage, a Request for Service form can be submitted. If adding a new spouse to an existing family hospital confinement plan, a new application indicating that a spouse is being added must be submitted. Note on the app that this is an update to existing coverage and you should not submit a sales summary with the application. The cancer question must be answered and reflect the health for the spouse being added. This is the only individual that will be underwritten. Dependents can be added to an existing family plan by submitting a Request for Service form indicating the dependents name and date of birth. Dependents are also allowed to continue cancer coverage past age 25 without evidence of insurability by submitting an application in the dependent s name and providing the existing policy number that dependent is currently covered under. The new app must be submitted within six (6) months of the dependent turning 25. Intensive Care: A new application is required when increasing or decreasing benefit level, or changing from individual to one parent or one parent to two parent coverage. When submitting an application requesting any of these changes, the transfer signature is required. If the desired change is to go from a two parent to a one parent or one parent to individual coverage, a Request for Service form can be submitted. If adding a new spouse to an existing family hospital confinement plan, a new application indicating that a spouse is being added must be submitted. Note on the app that this is an update to existing coverage and you should not submit a sales summary with the application. The cancer question must be answered and reflect the health for the spouse being added. This is the only individual that will be underwritten. 10

Dependents can be added to an existing family plan by submitting a Request for Service form indicating the dependents name and date of birth. Dependents are also allowed to continue cancer coverage past age 25 without evidence of insurability by submitting an application in the dependent s name and providing the existing policy number that dependent is currently covered under. The new app must be submitted within six (6) months of the dependent turning 25. : There are multiple change that can be requested for an existing accident plan. These type request can be made by submitting a new application or may only require a Request for Service form, Please refer to the attached Policy Change Matrix for the required paperwork based on the change request desired. 11

Policy Change Matrix Product Requested Change Required Paperwork Increase Units New App Decrease Units Request for Service Change Elimination or Benefit Period New App Change Plan Design (on/off or off) New App Drop / Terminate Rider Request for Service Increase Face New App Decrease Face (Universal ) Request for Service Decrease Face Not Available (Whole and Term) Add Riders New App Change Plan Design (Tob or Non-Tob) New App Change Plan Design (Option A to B) New App Change Plan Design (Option B to A) Request for Service Drop / Terminate Rider(s) Request for Service Increase Face New App Decrease Face Request for Service Change Plan Design (CI w/c or New App CI w/o C) or (Tob or Non-Tob) Family to Individual Request for Service Individual to Family New App Adding a NEW spouse to a New App family plan when there has been a divorce or death of first spouse Spouse Continuation - Death of Request for Service Main Insured Add Dependent to Family Plan Request for Service Dependent Continuation age 25 Not Available Individual to Family New App Family to Individual Request for Service Add Rider(s) or Increase Units New App on Existing DI Rider Decrease Units on Existing DI Rider Request for Service Change Elimination Period or New App Benefit Period Spouse Continuation - Divorce Request for Service or Death of Main Insured Add Dependent or Spouse to New App Individual Plan Add Dependent or New Spouse Request for Service to Family Plan Dependent Continuation age 25 Request for Service Drop / Terminate Rider(s) Request for Service 12

Product Requested Change Required Paperwork Hosp Confinement Individual to Family New App Family to Individual Request for Service Increase or Decrease to Level New App Add Dependent to Family Plan Request for Service Add Dependent to Individual Plan New App Adding a NEW spouse to a family New App plan when there has been a divorce or death of first spouse Dependent Continuation age 25 Request for Service Spouse Continuation - Divorce Request for Service or Death of Main Insured Individual to Family New App Family to Individual Request for Service Add Riders or Change Level New App (Increase or Decrease) Add Dependent to Family Plan Request for Service Add Dependent to Individual Plan New App Adding a NEW spouse to a family New App plan when there has been a divorce or death of first spouse Spouse Continuation - Divorce Request for Service or Death of Main Insured Dependent Continuation age 25 Request for Service Drop / Terminate Rider(s) Request for Service Intensive Care Individual to Family New App Family to Individual Request for Service Increase or Decrease to Level New App Add Dependent to Family Plan Request for Service Add Dependent to Individual Plan New App Adding a NEW spouse to a family New App plan when there has been a divorce or death of first spouse Spouse Continuation - Divorce Request for Service or Death of Main Insured Dependent Continuation age 25 Request for Service 13

Special State Compliant Questions In addition to the health questions on the applications, some states require us to ask what we term as special state compliant questions. This section is designed to give you some additional information about those questions and which products require the questions to be answered. Question State Critical Illness Medicare Eligible Medicare Certification Form #49277 Guide for People with Medicare #45503 Important Notice to Persons on Medicare Form #48433 Comprehensive Health Coverage (if answered No, coverage should not be issued) Comprehensive Health Coverage (if answered No, coverage should not be issued) Comprehensive Health Coverage (if answered No, coverage should not be issued) Are you currently covered or do you have any application pending for any other specified disease coverage or for the same specified disease that this policy would cover? Will purchase of this policy result in your being covered 8 or more specified diseases? Do you wish to purchase Hospice and Home Health Care (if answered No, issue coverage. If answered Yes, write applicant to see if he wants 0714.) All All CA, VT, DC GA MA MA MA X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) CO X X Hospital Confinement X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) List all health insurance KY X X X X Do you wish to purchase optional Alcoholism coverage (if answered Yes, coverage should not be issued) Are you covered under a Qualified plan (If answered No, coverage should not be issued) Presently covered under any other health insurance policy (if yes, list on app) Do you have coverage providing benefits for hospital and medical services and supplies (If no, coverage should not be issued) Do you have specified disease or specified accident coverage (If yes, should not issue coverage) MN MN X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) NJ X X X X X NJ PA X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) Do you have other cancer coverage SC X X X Do you (age 65 or older only) have insurance, other than life, in force with us or any other insurer (If yes, Disclosure Form (53657) Do you have (a)major medical or (b)basic hospital/medical insurance (If no, should not issue coverage) SC X X X X X NY X (Grp & Ind) X (Grp & Ind) X Base plans only 14

Question State Critical Illness Are you currently covered or have an app pending for specified disease coverage (If yes should not issue coverage) Will purchase of this policy result in your being covered for 8 or more specified diseases? (If yes should not issue coverage) Are you currently covered or do you have any application pending for any other specified disease coverage or for the same specified disease coverage included in this coverage? Will purchase of this policy result in your being covered for 8 or more specified diseases? Will coverage applied for replace for be in addition to any existing specified disease coverage for any proposed insured? NY NY MA MA KS X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) X (Grp & Ind) Hospital Confinement For the and /Sickness riders, follow the instructions in the disability column. For the Sickness Hospital Confinement rider and Intensive Care coverage, follow the instructions in the Hospital Confinement column. X When to use Which Application? It seems like every time Colonial introduces a new product, we also introduce a new application. We recognize this is a burden on the sales organization and in an effort to assist in understanding when to use which application, we have added this section. We are in the process of correcting the multiple applications per product situation. We have developed an application, called the AccHlth App that can be used for all accident and health products. This application will eventually replace the existing applications for all accident and health products. In addition, we have reduced the number of life applications to two applications based on which life product is being offered. Both applications handle all underwriting levels from simplified issue to fully underwritten. Currently the two new applications are App 07 which supports Term 1000 and App 08 which supports Universal 1000 and Whole 1000. The eventual goal is to have one life application which will support all life products as well as all levels of underwriting. This section provides a list of the appropriate application based on the enrollment method used. A listing of these application form numbers and your state version can be found in this guide on pages 76-83. If you have questions about the correct application for the product being offered, please contact the Underwriting Department at 1.800.VOICE extension 6210. 15

Enrollment Method Product Harmony Simple App 1.0 AccHlth App AccHlth App Care AccHlth App AccHlth App CA Care AccHlth App AccHlth App PS Care AccHlth App AccHlth App 1000 AccHlth App AccHlth App CA DADD AccHlth App AccHlth App Educator DI 1.0 AccHlth App AccHlth App Medical Bridge 3000 AccHlth App AccHlth App 1000 AccHlth App AccHlth App 1.0 AccHlth App AccHlth App AccHlth App AccHlth App Intensive Care AccHlth App Not Scheduled Banner VSTD Group Enrollment Form / EOI Not Scheduled DI Select DI Select App Not Scheduled Banner VGTL Not Scheduled Not Scheduled Group Supplemental Health 1000 Group 1000 Group 1000 Group Enrollment Form / EOI Group Hybrid Enrollment Form / EOI Group Hybrid Enrollment Form / EOI GSH Enollment Form Group Hybrid Enrollment Form / EOI Group Hybrid Enrollment Form / EOI Universal 1000 App 08 Not Scheduled Whole 1000 App 08 App 08 Term 1000 App 06 App 06 # Medical Bridge Not Supported Not Supported # Medical Bridge 1000 Not Supported Not Supported # HI Secure Not Supported Not Supported **CP97 (service only) Not Supported Not Scheduled **Bridge (service only) Not Supported Not Scheduled * Check PRP or ProducerNet to verify availability for Non-payroll Sales in your state. ** No longer available for new sales. Can only service existing, in-force policies. # ONLY available for sale in MN, OR and VT until MB 3000 is approved. 16

Enrollment Method (continued) Paper AccHlth App / All App AccHlth App / All App AccHlth App / All App AccHlth App / All App AccHlth App / All App AccHlth App / All App AccHlth App AccHlth App / All App AccHlth App / All App AccHlth App AccHlth App / All App AccHlth App / All App Individual Sales* Non-payroll App Non-payroll App Non-payroll App NA NA NA N/A NA Non-payroll App N/A NA NA Group Enrollment Form / EOI DI Select App Group Enrollment Form / EOI Group Enrollment Form / EOI Group Hybrid Enrollment Form / EOI Group Hybrid Enrollment Form / EOI NA NA NA NA NA NA App 08 / All App App 08 / All App App 08 / All App Non-payroll App Non-payroll App Non-payroll App AccHlth App / All App AccHlth App / All App GAP App GAP App 97 / App 92 GAP App / App 92 NA NA NA NA NA 17

Knockout questions AccHlth and App 06 and 08 applications In designing the new AccHlth and App 06 and 08 applications, Colonial faced several challenges: Create a simple version with knock out questions at the lower levels of coverage; do not require height and weight. Make the application easy to read. Include instructions for all sections. Allow the producer to know at the point of sale whether coverage would be issued. Provide easy enrollment for products in the accident, disability and supplemental health portfolio. Knock-out Questions at Lower Levels To accomplish all of these goals, we needed to make the knock-out questions more restrictive at the lower levels (For example, Up to 66 ⅔ percent of income or $3,000 in monthly benefit for disability and up to level 3 for hospital confinement.) Manual Process for submitting applications with a Yes response For these yes response situations, we have developed a manual process to address them: 1. Write the coverage using a paper AccHlth application. 2. Answer the appropriate health questions for the level of coverage for which the applicant is applying 3. Regardless of the level of coverage for which the applicant is applying, have the applicant answer questions: D1 through D5 when applying for disability. H1 and H2 when applying for hospital confinement (Medical Bridge, Medical Bridge 1000 or Medical Bridge 3000) 18

4. Provide health details for any yes answer on the application in the Health Details section of the application 5. Submit the application to the Home Office Once the application is received in the Underwriting Department, it will be evaluated based on the five-year health history provided by the applicant. If the medical conditions and/or medications disclosed are deemed an acceptable risk, then we will issue the coverage. Otherwise, the file will be declined. It should benoted that yes answers to questions 4, 5, 7, D1 and D2 will in most instances result in a declination. This process is for accounts that do not qualify for guaranteed issue or those that do not meet the minimum participation guidelines to qualify for guarantee issue. Resources on Medical Conditions Remember, the Medical Conditions section of this guide will provide you with guidelines on whether a specific health condition is an acceptable risk. If the applicant has a borderline medical condition, the guide will provide you with the additional medical information the Underwriter will require in order to fully evaluate the particular condition. 19

Height and Weight Chart for and Hospital Confinement Height (Feet and Inches) Weight 4 0 110 4 1 117 4 2 124 4 3 131 4 4 138 4 5 145 4 6 152 4 7 159 4 8 166 4 9 173 4 10 180 4 11 185 5 0 195 5 1 202 5 2 209 5 3 216 5 4 223 5 5 230 5 6 237 5 7 243 5 8 250 5 9 257 5 10 264 5 11 271 6 0 278 6 1 285 6 2 292 6 3 300 6 4 308 6 5 316 6 6 324 6 7 332 6 8 340 6 9 348 20

Height and Weight Chart for Height (Feet and Inches) Weight 4 10 187 4 11 193 5 0 201 5 1 207 5 2 215 5 3 223 5 4 229 5 5 236 5 6 243 5 7 250 5 8 257 5 9 265 5 10 271 5 11 279 6 0 287 6 1 295 6 2 302 6 3 312 6 4 317 6 5 325 6 6 334 6 7 341 6 8 349 6 9 358 21

Height and Weight Chart for Term 1000 Universal 1000 (CP10) and Whole 1000 Height Weight Weight (Feet and Inches) Band 1 Face Amounts Band 2 Face Amounts Term 1000 (ONLY) 4 10 173 187 4 11 179 193 5 0 186 201 5 1 192 207 5 2 199 215 5 3 206 223 5 4 212 229 5 5 217 236 5 6 225 243 5 7 230 250 5 8 238 257 5 9 245 265 5 10 251 271 5 11 258 279 6 0 265 287 6 1 274 295 6 2 281 302 6 3 289 312 6 4 297 317 6 5 304 325 6 6 312 334 6 7 321 341 6 8 328 349 6 9 337 358 22

Juvenile Height and Weight Chart Ages 0-2 Ages 3-9 Ages 10-14 Ht Min Max Ht Min Max Ht Min Max 24 8 23 30 18 40 48 44 92 26 10 26 34 22 44 52 54 108 28 13 31 38 26 54 56 63 126 30 15 36 42 32 64 60 74 144 32 18 40 46 38 78 64 87 166 34 21 42 50 46 94 68 100 186 36 23 45 54 56 111 72 113 206 38 26 48 58 66 128 76 126 228 40 29 52 23

Underwriting and To determine insurability, the Underwriting Department underwrites all Universal 1000, Term 1000, Whole 1000 and applications using in-house information, as well as other underwriting sources as this information relates to the health questions on the application. That is, during the risk assessment process, underwriters may use claims history, previous application history, attending physician statements, pharmacology drug databases, etc. Please note that Colonial s applications are designed for simplicity. However, we must also manage risk appropriately and apply appropriate underwriting at the time an application is submitted a standard practice throughout the insurance industry. This practice is not new; in fact, it has always been Colonial s philosophy for the Universal 1000, Term 1000, Whole 1000 and products. What does this mean to the writing sales rep? It is important that you communicate the following to each and every customer applying for Universal 1000, Term 1000 Whole 1000and products: Even though you answer all questions as NO, your application must go through complete underwriting which includes review of previous claims and application history with Colonial. All Colonial Voluntary individual products are subject to underwriting, therefore you should disclose to the proposed insured that there is a possibility he or she may not qualify for coverage when there are health/ life style conditions present. The only exception is if the insured has guaranteed issue on the Universal 1000 or Term 1000 life products because the account has met the minimum participation guidelines. If a medical condition is disclosed when you are taking the application information, please refer to the Medical Conditions section of this guide to determine if this condition may affect insurability. If the condition is not listed, you may call the Underwriting Department s phone support team at 800.43.VOICE (438.6423), option 9, then extention 6210. 24

Medical Conditions Introduction This section was developed to provide information on some of the most common health conditions along with information needed for the underwriting process. This list is not intended to be all inclusive or to provide black and white answers. All Colonial Voluntary individual products are subject to underwriting, therefore, you should disclose to the proposed insured that there is a possibility they may not qualify for coverage when there are health conditions present. You should refer to this guide for additional information when a medical condition is disclosed. If the condition disclosed is not in this guide, at a minimum, you should provide the following information: Diagnosis Date of diagnosis Type of treatment Medications currently taken Degree of recovery Amount of time lost from work Name/address of health care provider (Dr., Hospital, etc.) You may contact the Underwriting department regarding conditions not in this guide. However, the underwriter cannot indicate whether a health condition would be insurable until the underwriting process has been completed. Part of the underwriting process may include telephone interviews with the applicant, requesting medical records, Paramedical exams, and MIB reports. Certain conditions may require that a signed exclusion rider be obtained in order to issue coverage. If this is necessary, an underwriting memo will be sent to the agent to obtain the signed rider. Medical conditions that may be acceptable by themselves may constitute an uninsurable risk when there are other medical conditions present. For example, hypertension controlled by one medication may be acceptable, however, in conjunction with non-insulin dependent diabetes, would be an unacceptable risk. 25

Medical Conditions Abscess Hospital Confinement - location of abscess - date diagnosed and date of last treatment - cause - degree of recovery - any residuals Hospital Confinement - cause of injury - date of accident and type of last treatment - when release from doctor - if hospitalized, how many days - any residuals or loss of conscious - any time missed from work; if yes, how long Aids / ARC Hospital Confinement 26

Alcoholism Decline, Do Not Submit ; submit an alcohol questionnaire Hospital Confinement - date treated and date of last treatment - date stopped drinking - any relapses - degree of recovery - any type of support system (i.e. AA) ** if less than 8 years treatment free do not submit application Allergies Hospital Confinement Alzheimer s Disease Hospital Confinement Okay to Issue Amputations Hospital Confinement - reason for amputation, if other than an accident, do not submit application - what part of the body affected - date of procedure - do you have a prosthesis 27

Anemia Hospital Confinement - type - any medication - underlying cause - any hospitalization - any blood transfusions - time missed from work - cause of condition; if anxiety refer to anxiety section - smoker or non-smoker Aneurysm Intensive Care Hospital Confinement - date diagnosed - treatment received - location of bulge - decline if diagnosed less than 5 years Angina Intensive Care Hospital Confinement - date diagnosed and date of last treatment - treatment received - name and date of medication prescribed - frequency of attacks and date of last attack 28

Angioplasty Intensive Care Hospital Confinement Anxiety Hospital Confinement - date diagnosed - frequency of attacks and severity - type treatment and date of last treatment - name of medication(s) - any inpatient treatment or outpatient; if yes, how long - time missed from work - cause Aortic Stenosis Intensive Care Hospital Confinement - surgically repaired, if yes, decline - date diagnosed - severity - mild, moderate or severe - smoker or non-smoker 29

Arteriosclerosis Intensive Care Hospital Confinement - date diagnosed - test performed and results - any surgery or angioplasty, do not submit - smoker or non-smoker - height and weight Arthritis Hospital Confinement - date diagnosed - type arthritis - how treated - severity (mild, moderate, severe) - any time missed from work - part of body affected - any assistance device required; if yes, what type ** if Rheumatoid Arthritis and/or treatment includes methotraxate, Imuran, Rituxam, Chemcia, Kimeret, humira, or gold shots; do not submit disability, hospital confinement, or life applications. Asthma ** Hospital Confinement - date diagnosed - frequency of attacks - date of last attack - are lungs clear between attacks - type of treatment and medication(s) - severity (mild, moderate, severe) - any time missed from work - smoker or non-smoker - any inpatient treatment or outpatient; if yes, date and type treatment 30 ** if issued, may issue with signed asthma exclusion rider

Attention Deficit Hyperactivity Disorder Intensive Care Hospital Confinement - age diagnosed - diagnostic severty (mild, moderate, severe) - any hospitalization - any history of drug or alcohol abuse - list of predominant symptoms - treatment, include any drugs prescribed - any other mental or nervous disorder - any time missed from work Atrial Fibrillation Hospital Confinement Intensive Care Decline, Do Not Submit - date diagnosed and date of last treatment - how treated, list any medications and any devices used to treat - number of episodes - any underlying impairments Autistic Disorder Intensive Care Hospital Confinement - age diagnosed - any other disorders - any history of seizures/epilepsy - level of intellectual funcion - ability to live and work independently 31

Back/Neck ** Hospital Confinement - date diagnosed and date of last treatment - type injury (sprain/strain/rupture/herniation) - type treatment, any surgery ** if issued, may issue with signed back/neck exclusion rider Bell s Palsy Hospital Confinement - date diagnosed and type treatment - full recovery - cause - residuals - any time missed from work Biopsy Hospital Confinement - date of biopsy - results of biopsy - location of biopsy - any time missed from work 32

Blood Clot (Thrombosis) Hospital Confinement - date treated - location of clot - type treatment and medication(s) - underlying cause - degree of recovery - any hospitalization Blood Pressure (Hypertension) Dependent upon reading Intensive Care Dependent upon reading Hospital Confinement - date diagnosed - type treatment, medication(s) - includes diuretics - last 2 blood pressure readings and date taken - height and weight - any inpatient treatment - any time missed from work - smoker or non-smoker - any other health conditions such as high cholesterol or diabetes **if 3 or more meds, and applying for disability, crtical illness or hospital confinement; do not submit. **if diabetic with hypertension; do not submit. Bone Disorder Hospital Confinement - any prior or planned surgery - diagnosis - part of body affected - type and date(s) of treatment - time missed from work - date of onset - name of meds used in treatment 33

Bone Spurs Hospital Confinement - any prior or planned surgery - location of bone spur - date diagnosed and date of last treatment - time missed from work **if planned surgery; do not submit. Broken Bone Hospital Confinement - date broken - location of break - how treated, any surgery - time missed from work - released by doctor **any surgery planned; if yes, do not submit Bronchitis Hospital Confinement - date diagnosed - number of episodes and date of last attack - are lungs clear between attacks - type treatment and medication(s) - any inpatient treatment - smoker or non-smoker - any time missed from work - severity (mild, moderate, severe) 34

Burns Hospital Confinement - date of burn(s) - cause and degree of burn - any prior or planned surgery - any residuals - location of burn Bursitis / Tendonitis Hospital Confinement - date diagnosed and date of last treatment - location - type treatment and medication(s) - prior episodes - time missed from work, Internal Decline unless treatment free for 10 years Hospital Confinement - date diagnosed - location of cancer - type treatment - date of last treatment - any recurrence **do not submit for DI or unless 5 years treatment free. **if currently under treatment; do not submit. 35

, Skin (not melanoma) Hospital Confinement - type skin cancer (basal cell or in-situ) - location of cancer - type treatment ** may issue with a skin cancer exclusion rider unless 5 years treatment free Cardiomyopathy Intensive Care Hospital Confinement Carpal Tunnel Syndrome ** Hospital Confinement - date diagnosed - prior or planned surgery 36 ** if issued, may require signed carpal tunnel exclusion rider Cataracts Hospital Confinement - any surgery planned - cause - type treatment and dates - degree of impairment and recovery ** if applicant is diabetic; do not submit for critical illness, disability or hospital confinement.

Cerebral Palsy Hospital Confinement Chest Pain Hospital Confinement - cause (cardiac or non-cardiac) - final diagnosis - current medication or treatment - frequency of attacks - degree of recovery - date of diagnosis - time missed from work - any hospitalization Cholesterol Hospital Confinement - date diagnosed - treatment/medications and dosage - height/weight - last cholesterol reading including total & LDL/.HDL readings and dates taken - any other conditions, i.e high blood pressure, diabetes - smoker or non-smoker 37

Chronic Fatigue Syndrome Hospital Confinement - date diagnosed and date of last treatment - time missed from work - type treatment and medication(s) - list underlying cause and conditions - any anxiety or depression **if hospitalized do not submit applications for disability or hospital confinement. Cirrhosis Intensive Care Hospital Confinement Colitis Hospital Confinement - type and cause - type treatment - number of attacks - prior or planned surgery - degree of recovery - time missed from work or hospitalized - date last treated - severity: mild, moderate, severe **if ulcerative colitis, do not submit disability or hospital confinement applications 38

Colon Disorders Hospital Confinement - date and type diagnosis - type treatment and date of last treatment - frequency of attacks - time missed from work or hospitalized - prior or planned surgery - any malignancy Colostomy/Colectomy if no malignancy Hospital Confinement - date of procedure - reason and findings from procedure - any further treatment - any underlying problems or malignancy Concussion Hospital Confinement - date of occurrence - any loss of consciousness, if so how long - any residuals Congestive Heart Failure Intensive Care Hospital Confinement 39

COPD (Chronic obstructive pulmonary disease) Intensive Care Hospital Confinement Coronary Artery Disease Intensive Care Hospital Confinement - test performed and findings - date of procedure - any surgery or angioplasty - smoker - last 2 blood pressure readings Coronary Bypass Surgery Intensive Care Hospital Confinement Coronary Thrombosis Intensive Care Hospital Confinement 40

Crohn s Disease Hospital Confinement - date diagnosed - type treatment - frequency of attacks - degree of recovery Cystic Fibrosis Hospital Confinement Cystic Kidney Hospital Confinement - any planned surgery - final, exact diagnosis - date diagnosed - one or both kidneys - size and number of cysts - any residuals Cysts Hospital Confinement - date diagnosed - location and type of cysts - type treatment 41

D&C Hospital Confinement - date and reason for procedure - any residuals Dementia Hospital Confinement Decline, Do Not Submit Decline, Do Not Submit Decline, Do Not Submit Depression Hospital Confinement - underlying cause - type treatment and name of medication(s) - any inpatient treatment or time missed from work - frequency of attacks - severity - any suicide attempts **if bi-polar or manic do not submit application for disability, hospital confinement or life Diabetes Mellitus - Insulin Intensive Care Hospital Confinement 42

Diabetes Mellitus - Oral Meds / Diet Intensive Care Hospital Confinement - age and date diagnosed - height and weight - fasting blood sugar reading and date - glycated hemoglobin (A1C) reading and date - last blood pressure reading - type treatment - any complications from the diabetes **if diagnosed prior to age 40, do not submit disability or hospital confinement applications **if diagnosed prior to age 30, do not submit critical illness or life applications **if applicant has high blood pressure, do not submit disability or hospital confinement applications Dislocation Hospital Confinement - date and location of dislocation - cause of dislocation - degree of recovery Diverticulitis / Diverticulosis Hospital Confinement - date diagnosed - was surgery performed - exact diagnosis - if no surgery, number of attacks - type treatment and medication(s) - severity (mild, moderate, severe) 43

Down Syndrome Hospital Confinement Decline, Do Not Submit Decline, Do Not Submit Decline, Do Not Submit Drug Dependency Hospital Confinement - date treated - type drug - any inpatient treatment - type of treatment - any relapse - degree of recovery **do not submit if less than 5 years treatment free Dysplasia Hospital Confinement - date diagnosed and CIN level - type treatment and date of last treatment - follow up treatment - results and date of last PAP smear ** if hysterectomy, okay after 5 years since last treatment for disability and hospital confinement Eating Disorders (Anorexia nervosa; Bulimia nervosa) Decline, Do Not Submit Decline, Do Not Submit Hospital Confinement Decline, Do Not Submit 44

Embolism Intensive Care Hospital Confinement Emphysema Intensive Care Hospital Confinement Encephalitis Hospital Confinement - date diagnosed - type treatment and medication(s) - degree of recovery / any residuals Endometriosis ** Hospital Confinement - date diagnosed and date of last treatment - type treatment and medication(s) - prior or planned surgery - was hysterectomy performed (partial or complete) **may issue with a signed genitourinary exclusion rider 45

Epilepsy Hospital Confinement - date of onset - date of last seizure - type treatment and medication(s) - type of epilepsy ** grand mal and petit mal seizures within last 2 years will be declined Female Disorder ** Hospital Confinement - date diagnosed - disorder diagnosed - type treatment - any malignancy - degree of recovery - partial or complete - any planned surgery ** may be issued with a genitourinary exclusion rider Fibroids, Uterine ** Hospital Confinement - date diagnosed - type treatment and date of last treatment - date and number of episodes - any prior or planned surgery - has applicant had a total or partial hysterectomy ** may be issued with a genitourinary exclusion rider 46

Fibromyalgia Hospital Confinement Fractured Skulls Hospital Confinement - date of fracture - any loss of consciousness, if so, how long - any surgery - type treatment - any residuals or complication Fractures Hospital Confinement - date of fracture - locations of fracture - any surgery - any residuals - time missed from work - degree of recovery - type treatment Gallbladder Disorder Hospital Confinement - date diagnosed - type treatment and medication(s) - any surgery - any malignancy 47

Gastric Ulcer Hospital Confinement - date diagnosed - frequency of attacks - date of last attack - type treatment - any bleeding - list all medications and dosage - any planned surgery **if bleeding ulcer do not submit disability or hospital confinement application Gastric Bypass / Banding Hospital Confinement - any complications - date of procedure - height and weight before and after - has weight stabilized ** if procedure within 5 years of application date, DO NOT submit application. Gastrointestinal Disorders Hospital Confinement - date and type of diagnosis - type treatment and date of last treatment - frequency of attacks - degree of recovery - time missed from work - any malignancy 48

Glaucoma Decline, Do not issue Hospital Confinement - date diagnosed and date of last treatment - underlying cause - type treatment and medication(s) Gout Hospital Confinement - part of body affected - date diagnosed - frequency of attacks - type treatment - severity (mild, moderate, severe) - underlying cause or condition - time missed from work ** do not submit disability, hospital confinement or life applications if moderate/severe attacks and loss from work Headaches Hospital Confinement - date diagnosed - type headaches - severity (mild, moderate, severe) - frequency of headaches - type treatment - time missed from work - underlying cause 49

Head Injuries Hospital Confinement - date of occurrence - any loss of consciousness, if so, how long - any residuals or complications Heart Attack Intensive Care Hospital Confinement Heart Catherization Intensive Care Hospital Confinement - date of catheritization - reason for procedure - results of catheritization Heart Murmur Hospital Confinement - date diagnosed - type of murmur - symptoms - type treatment and date of last treatment - any other associated heart problems 50

Heart Problems* Intensive Care Hospital Confinement - date diagnosed and date of last treatment - type problem diagnosed - symptoms - type treatment and medication(s) - need height and weight *Check for the specific conditions listed in this guided for information needed **if pacemaker or defibrillator; do not submit applications Heart Valve Replacement Intensive Care Hospital Confinement Hepatitis Intensive Care Hospital Confinement - date and type diagnosed - cause - type treatment and medication(s) - any residuals or liver problems - duration and date of last treatment ** do not submit application if diagnosed as B or C 51

Hernia Okay to Issue Okay to Issue Okay to Issue Hospital Confinement - type - location - if repaired surgically - treatment other than surgery - if fully recovered, any residuals Herniated Disc ** Hospital Confinement - date diagnosed - any surgery - how treated and date of last treatment **if treated within 5 years a sign back exclusion rider will be required Hip Disorder ** Hospital Confinement - date of surgery - degree of recovery - last date of physical therapy **if treated within 5 years a signed hip exclusion rider is required and will exclude both hips Hodgkin s Disease Hospital Confinement 52

Hypertension (Blood Pressure) Okay to Issue Okay to Issue Intensive Care Hospital Confinement - date diagnosed and any inpatient treatment - smoker or non-smoker - type treatment / medications to include diuretics - last 2 blood pressure reading and date taken - height and weight - any time missed from work - any other health conditions such as high cholesterol or diabetes ** if 3 or more medications, do not submit application if applying for disability, critical illness or hospital confinement **if diabetes with hypertension do not submit application Hyperthyroidism Hospital Confinement - date diagnosed - type treatment and date of last treatment - cause - degree of recovery - any radiation treatment, surgery or malignancy Hypothyroidism Hospital Confinement - date diagnosed - type treatment and date of last treatment - cause - degree of recovery - any radiation treatment, surgery, or malignancy 53

Hysterectomy Hospital Confinement - date of procedure - reason for procedure - any malignancy - degree of recovery - partial or complete hysterectomy Irregular Heart Beat Intensive Care Hospital Confinement - date and results of ECG / diagnosed - heart rate - any symptoms - any other disorders - type arrhythmia, irregularity - type treatment and medication(s) - date of last attack Irritable Bowl Syndrome Hospital Confinement - date diagnosed - treatment, medications - time missed from work - hospitalization - severity - number of episodes, how often 54

Joint Disorder Hospital Confinement - date diagnosed, date of last treatment and actual diagnosis - any prior or planned surgery - part of body effected - type treatment and medication(s) - any time missed from work - cause, injury or condition - is disorder debilitating **may issue with a signed exclusion rider Kidney Disorder (other than stones or infection) Intensive Care Hospital Confinement - date and type of diagnosed - any residuals - degree of recovery and date of last treatment - cause - type treatment and medication(s) **if transplant recipient - do not submit application Kidney Stones Hospital Confinement - number of attacks - type treatment and date of last treatment - degree of recovery 55

Knee / Knee Replacement ** Hospital Confinement - date and cause of injury - type treatment and date of last treatment - any time missed from work - degree of recovery **may issue with a signed knee exclusion rider Liver Abscess Intensive Care Hospital Confinement - date diagnosed and date of last treatment - single or multiple abscess, any malignancy - type treatment and medication(s), recovered - results of liver function teste Liver Disorder (other than hepatitis) Intensive Care Hospital Confinement - date diagnosed and date of last treatment - cause - type treatment and medication(s) - cause - degree of recovery - any complications - any malignancy 56

Lupus, Systemic (SLE) Hospital Confinement Lupus, Discoid Hospital Confinement - date diagnosed and date of last treatment, type treatment - any evidence of systemic lupus - any urinary abnormalities - degree of recovery - any medications - any treatment for depression Melanoma Hospital Confinement - date diagnosed - location - Clark s level and Breslow measurement **if Clark s level 3-5 and Breslow measurement greater than.75, consider as internal cancer **if Clark s level 1-2 and Breslow measurement less than.75, consider as skin cancer Meningitis Hospital Confinement - date diagnosed and date of last treatment - type treatment and medication(s) - any residuals or hospitalization - degree of recovery - type of meningitis (viral or bacterial) 57

Mental or Nervous Disorder Hospital Confinement - date diagnosed and date of last treatment - symptoms, diagnosis - underlying cause - type treatment and medication(s) - any inpatient treatment - any time missed from work - degree of recovery Mitral Valve Prolapse Intensive Care Hospital Confinement - date diagnosed and date of last treatment - type treatment and medication(s) - symptoms - any other associated heart problems Multiple Sclerosis Hospital Confinement Decline, Do not issue Decline, Do not issue Decline, Do not issue Murmur, Organic Decline, Do not issue Decline, Do not issue Intensive Care Hospital Confinement - date diagnosed and date of last treatment - type murmur - type treatment and medication(s) 58 - symptoms - any other associated heart problems

Murmur, Functional Hospital Confinement - date diagnosed and date of last treatment - type murmur - type treatment and medication(s) - symptoms - any other associated heart problems Muscular Dystrophy Hospital Confinement Myocardial Infarction (Heart Attack) Intensive Care Hospital Confinement Nephrectomy (removal of kidney) Hospital Confinement - date diagnosed, date of surgery - underlying cause, any residuals - is other kidney functioning properly - normal urinalysis - fully recovered 59

Nephritis (kidney infection) Hospital Confinement - date diagnosed and last attack - number of episodes - fully recovered and date of last treatment - normal renal function - degree of recovery Nephrosclerosis Hospital Confinement Organ Transplant Intensive Care Hospital Confinement **donors are acceptable if no residuals or complications Osteoporosis Hospital Confinement - date diagnosed and date of last treatment - underlying cause, severity, joint affected - type treatment and medication(s) - any impairments or fractures - any time missed from work - type treatment and medication (include injection) 60

Ovarian Cyst Okay to Issue Ok to issue, if no malignancy Okay to Issue, if no malignancy Hospital Confinement - planned or prior surgeries - date diagnosed - treatment - one or both ovaries - singular or multiple cyst - time missed from work - hospitalization - any other residuals - any malignancy **may issue with genitourinary exclusion rider Pacemaker (Defibrillator) Intensive Care Hospital Confinement Palpitations Hospital Confinement - date diagnosed and date of last treatment - type treatment and medication(s) - diagnosis and symptoms, pulse rate - any other associated heart problems - degree of recovery Palsy Hospital Confinement - date diagnosed and date of last treatment - type treatment and medication(s) - degree of recovery, underlying cause - any residuals, area affected - type palsy 61

Pancreatic Disease Hospital Confinement - date diagnosed and date of last treatment - type treatment and medication(s) - underlying cause and diagnosis - any malignancy - degree of recovery ** if age 50 or younger, decline, do not submit for disability or hospital confinement Paralysis Hospital Confinement - date onset - underlying cause - part of body affected - severity (mild, moderate, severe) - type treatment and medication(s) - date last seen by doctor - any wheelchair or prosthesis involved Parkinson s Disease Hospital Confinement 62

Peptic Ulcer Hospital Confinement - date diagnosed and date of last treatment - frequency of attacks - type treatment and medication(s) - date of last attack - any bleeding - degree of recovery Pericarditis Hospital Confinement - date diagnosis and date of last treatment - type treatment and medication(s) - number of episodes - any other associated heart problems Phlebitis Hospital Confinement - date diagnosed - underlying cause - type treatment and medication(s) - number of episodes - location - degree of recovery - any residuals 63

Pituitary Gland Disorders Hospital Confinement - date diagnosed and date of last treatment - exact diagnosis - type treatment and medication(s) - any prior or planned surgery - degree of recovery - any residuals Pleurisy Hospital Confinement - date diagnosed and date of last treatment - any underlying cause or associated disease - type treatment and medication(s) - any prior episodes - any residuals - time missed from work - duration - degree of recovery Pneumonia Hospital Confinement - date diagnosed and date of last treatment - any underlying cause or associated disease - any prior episodes - type treatment and medication(s) - duration - any residuals, any time missed from work - degree of recovery 64

Polycystic Kidney Intensive Care Hospital Confinement, if no malignancy Polycystic Ovarian Disease ** Hospital Confinement - date diagnosed and date of last treatment - any time missed from work **may issue with signed genitourinary exclusion rider Prostate Disorder, if no malignancy Hospital Confinement - date diagnosed and date of last treatment - symptoms and diagnosis - last PSA - biopsy - any malignancy - underlying cause and degree of recovery - type treatment and medication(s) Psychosis Hospital Confinement 65

Pulmonary Fibrosis Hospital Confinement Pulmonic Stenosis Hospital Confinement - date diagnosed and date of last treatment - any prior or planned surgery - any other associated heart problems - any medication(s) Renal Disease, if no malignancy Hospital Confinement - date diagnosed and actual diagnosis - date of last treatment - type treatment and medication(s) - number of episodes - degree of recovery Respiratory Disorder Hospital Confinement - date diagnosed and date of last treatment - exact diagnosis - severity (mild, moderate, severe), smoker or non-smoker - frequency of attacks - type treatment and medication(s) - how often medication taken - any inpatient treatment and when 66 - degree of recovery

Restless Leg Syndrome Okay to Issue Okay to Issue Okay to Issue Okay to Issue Hospital Confinement - date diagnosed - type treatment and medications - time missed from work - inpatient treatment Rheumatic Fever Hospital Confinement - date diagnosed - any residual or heart related problems - any treatment or medication(s) being prescribed - degree of recovery Rotator Cuff ** Hospital Confinement - date diagnosed and date of last treatment - prior episodes - underlying cause - type treatment and medication(s) - which shoulder - degree of recovery **may issue with a signed shoulder exclusion rider 67

Sarcoidosis Hospital Confinement - date diagnosed and date of last treatment - any prior episodes - type treatment and medication(s) - degree of recovery, smoker or non-smoker - organ affected, what stage - date and result of last chest x-ray Seizures Hospital Confinement - date of onset - date of last seizure - type treatment and medication(s) - prior episodes - underlying cause - type seizures **do not submit if seizure within 2 years for disability or hospital confinement Sexually Transmitted Diseases (STDs) Hospital Confinement - Type of STD - Date of Onset: - Date and Degree of recovery - treatment and any medications 68

Shoulder ** Hospital Confinement - date diagnosed - any prior episodes - underlying cause and which shoulder - type treatment and date of last treatment **may issue with a signed shoulder exclusion rider on disability only Sickle Cell Hospital Confinement Skin Hospital Confinement - date diagnosed and date of last treatment - type (melanoma, basal cell, squamous, epithelioma) - present at time of application - type treatment and medication(s) - confined to epidermis - was there metastasis **if within 5 years need a signed skin cancer exclusion rider for cancer only. *may need to obtain a pathology report for life 69

Skull Fracture Hospital Confinement - date diagnosed, any surgery - any loss of consciousness, if so how long - date of last treatment - degree of recovery - any residuals or complications Sleep Apnea Hospital Confinement - date diagnosed - is applicant using CPAP - any prior or planned surgery - any residuals - type treatment and medication(s) - any time missed from work, if so date returned - degree of recovery - current height and weight - mild, moderate or severe Spinal Cord Disorders Hospital Confinement 70

Stress Related / Anxiety Disorders Hospital Confinement - date diagnosed and date of last treatment - underlying cause - diagnosis - type treatment and medication(s) - frequency of attacks - any inpatient treatment - any time missed from work - date of last attack - degree of recovery Stroke Intensive Care Hospital Confinement Substance Abuse Hospital Confinement - date of last treatment - any inpatient treatment - type of treatment - any relapses - what substance **if treated within 8 years do not submit application 71

Tachycardia Intensive Care Hospital Confinement - date of ECG / diagnosed - results of ECG - heart rate - any symptoms - any other disorders - type arrhythmia, irregularity - type treatment and medication(s) - date of last attack and frequency of attacks Temporomandibular Joint Syndrome Hospital Confinement - date diagnosed - type treatment - any further treatment or surgery anticipated Tendonitis Hospital Confinement - date diagnosed and date of last treatment - location - type treatment - prior episodes - time missed from work - degree of recovery 72

Thrombosis (Blood Clot) Hospital Confinement - date treated - location - type treatment and medication(s) - underlying cause - degree of recovery - any hospitalization Thyroid Disorder Hospital Confinement - diagnosed disorder and date of last treatment - underlying cause / symptoms - type treatment and medication(s) - degree of recovery - any malignancy Transient Ischemic Attack Intensive Care Hospital Confinement - date of attack and date of last treatment - type treatment and medication(s) - number of episodes - any impairments or residuals - degree of recovery 73

Tuberculosis Decline, Do not issue Hospital Confinement - date last treated - type treatment, any medications - age at diagnosis, smoker or non-smoker - degree of recovery - date of last chest x-ray and results ** if treated within 2 years do not submit application for disability or hospital confinement Tumors Hospital Confinement - date diagnosed and date of last treatment - type treatment and medication(s) - location of tumor - any malignancy - type tumor - any underlying disorders / residuals - degree of recovery Ulcerative Colitis Hospital Confinement - date diagnosed and date of last treatment - type treatment and medication(s) - frequency of attack - degree of recovery - mild, moderate or severe 74

Ulcer Hospital Confinement - location of ulcer - type ulcer - frequency of attack - type treatment and medication(s) - date last attack - any bleeding - degree of recovery - date at onset Varicose Veins Hospital Confinement - any planned surgery - underlying cause - location - type treatment and date of last treatment - any time lost from work - any complications or residuals - any edema (swelling) X-ray Hospital Confinement - date and reason for x-ray - what part of the body - diagnosis / findings and type treatment 75

and Health Applications State Acchlth All App 08 Individual App 08 AK 62356 68550 68597 AL 62355 68543 68590 AR 62357 68573 68521 AZ 62353 68543 68590 All App 06 Individual App 07 CA* 62354 68558 68605 65356 65906 CO* 62358 68551 68598 65365 65920 CT 62359 68572 68522 DC 62353 69532 69575 DE 62353 68543 68590 FL* 62360 68571 68523 65366 65909 GA 62361 68559 68606 HI 62353 68561 68608 IA 62364 68543 68590 ID* 62575 68545 68592 65389 65937 IL* 62362 65983 65984 65360 65923 IN 62363 68544 68591 KS 62365 68560 68609 KY* 62366 68562 68614 65363 65917 LA 62353 69531 69576 MA* 62417 68549 68596 65380 65913 MD 62368 68548 68595 ME 62367 68564 68611 MI 62369 68563 68610 MN 62370 68552 68599 MO 62397 68570 68618 MS 62353 68543 68590 MT 62371 69530 68590 NC 62373 68546 68593 ND 62374 68569 68617 NE 62353 68543 68590 NH 62416 68568 68616 NJ 62372 68554 68603 NM 62405 68575 68519 76

and Health Applications (continued) State Acchlth All App 08 Individual App 08 NV 62353 69538 69539 NY 97516 97751 97752 OH 62353 68567 68612 OK 62375 68553 68607 OR 62376 65982 65985 PA 62377 68547 68594 RI 62379 65981 65986 SC 62380 68565 68613 SD 62353 68543 68590 TN 62403 68555 68600 TX 62381 68543 68602 All App 06 Individual App 07 UT* 62382 68576 68518 65387 65928 VA 62414 68556 68601 VT 62413 68557 68604 WA 63469 68566 68615 WI 62415 65980 65987 WV 62353 68543 68590 WY 62353 68543 68590 * As of the printing of this manual, All App 08 or Ind App 08 had not been approved in all states, until these apps are approved in your state, you will need to use All App 06 or Ind App 07. 77

A&H Replacement Forms State Internal Replacement Form External Replacement Form AK 69558 None AL 69558 None AR 11646 11646 AZ 69558 None CA 69558 None CO 10166 10166 CT 11646 11646 DC 69558 None DE 9178 9178 FL 69558 None GA 69558 None HI 69558 None IA 11646 11646 ID 9178 9178 IL 11646 11646 IN 69558 None KS 69558 None KY 10768 10768 LA 69558 None MA 51135 51135 MD 69558 None ME 69558 None MI 69558 None MN 69558 None MO 69558 None MS 69558 None MT 69558 None NC 69558 None ND 69558 None NE 69558 None NH 9178 9178 NJ 11646 11646 NM 69558 None NV 69558 None 78

A&H Replacement Forms (continued) State Internal Replacement Form External Replacement Form NY 97757 None OH 69558 None OK 11646 11646 OR 69558 None PA 11646 11646 PR 69558 None RI 69558 None SC 49331, 51376 49331, 51376 SD 69558 None TN 69558 None TX 9178 9178 UT 11646 11646 VA 11646 11646 VT 11646 11646 WA 9178 9178 WI 10166 10166 WV 5628 5628 WY 69558 None 79

Term 1000, UL1000 and WL1000 Chart State App 06 Term 1000 ACR Term 1000 All App 06 Ind App 07 App 08 UL1000 / WL1000 AK 64855 NA 68509 AL 64863 64821 68496 AR 64855 64821 68502 AZ 64855 NA 68496 CA* 64856 NA 65356 65906 68498 CO* 64869 NA 65365 65920 68509 CT 64864 64902 68504 DC 64855 64821 68506 DE 64855 NA 68496 FL* 64857 NA 65366 65909 68499 GA 64862 NA 68509 HI 65603 NA 68509 IA 64855 NA 68509 ID* 64855 NA 65389 65937 68509 IL 64876 64821 68500 IN 64870 64821 68509 KS 64865 64821 68509 KY* 64866 NA 65363 65917 68509 LA 64855 64821 68497 MA* 65429 64901 65380 65913 68509 MD 64871 NA 68509 ME 64872 NA 68509 MI 64867 64821 68509 MN 64877 64821 68509 MO 64855 NA 68496 MS 64855 64821 68496 MT 64855 NA 68496 NC 64868 64821 68509 ND 64878 NA 68505 NE 64879 NA 68509 NH 64855 NA 68509 NJ 64858 NA 68507 80

Term 1000, UL1000 and WL1000 Chart (continued) State App 06 Term 1000 ACR Term 1000 All App 06 Ind App 07 App 08 UL1000 / WL1000 NM 64855 NA 68503 NV 64855 NA 68512 NY 97579 97580 97763 OH 64855 64821 68509 OK 64855 64821 68509 OR 64855 NA 69533 PA 64859 64903 68509 RI 64880 NA 68509 SC 64875 NA 68501 SD 64855 NA 68496 TN 64855 NA 68509 TX 64860 NA 68509 UT* 64855 64821 65387 65928 68509 VA 64861 64904 68509 VT 64873 64821 68509 WA 64894 64893 68509 WI 64874 NA 68508 WV 64855 NA 68509 WY 64855 NA 68509 * As of the printing of this manual, All App 08 or Ind App 08 had not been approved in all states, until these apps are approved in your state, you will need to use All App 06 or Ind App 07. ** UL 1000 and WL 1000 are not approved to be written on All App 06 or Ind App 07, until your state approves All App 08 or Ind App 08, App 08 is the ONLY approved app for UL 1000 and WL 1000. 81

Term 1000, UL1000 and WL1000 Chart (continued) State ACR UL 1000 ACR WL 1000 All App 08 Ind App 08 AK 69534 69535 68550 68597 AL 68589 68581 68543 68590 AR 68589 68581 68573 68521 AZ NA NA 68543 68590 CA* NA NA 68558** 68605** CO* 69534 69535 68551** 68598** CT 68584 69565 68572 68522 DC 68589 68581 69532 69575 DE NA NA 68543 68590 FL* 68586 68578 68571** 68523** GA 69534 69535 68559 68606 HI 69534 69535 68561 68608 IA 69534 69535 68543 68590 ID* 69534 69535 68545** 68592** IL* 68589 68581 65983 65984 IN 69534 69535 68544 68591 KS 69534 69535 68560 68609 KY* 69534 69535 68562** 68614** LA 68589 68581 69531 69576 MA* 69534 69535 68549** 68596** MD 69534 69535 68548 68595 ME 69534 69535 68564 68611 MI 69534 69535 68563 68610 MN 69534 69535 68552 68599 MO 68583 69566 68570 68618 MS 68589 68581 68543 68590 MT 68589 68581 69530 68590 NC 69534 69535 68546 68593 ND 68589 68581 68569 68617 NE 69534 69535 68543 68590 NH 69534 69535 68568 68616 NJ 68589 69549 68554 68603 NM 68589 68581 68575 68519 NV 68589 68581 69538 69539 82

Term 1000, UL1000 and WL1000 Chart (continued) State ACR UL 1000 ACR WL 1000 All App 08 Ind App 08 NY 97772 97750 97751 97752 OH 69534 69535 68567 68612 OK 69534 69535 68553 68607 OR 68585 68580 65982 65985 PA 69534 69535 68547 68594 RI 69534 69535 65981 65986 SC 68582 68577 68565 68613 SD 68589 68581 68543 68590 TN 69534 69535 68555 68600 TX 69534 69535 68543 68602 UT* 69534 69535 68576** 68518** VA 69534 69535 68556 68601 VT 69534 69535 68557 68604 WA 69534 69535 68566 68615 WI 68589 68581 65980 65987 WV 69534 69535 68543 68590 WY 69534 69535 68543 68590 * As of the printing of this manual, All App 08 or Ind App 08 had not been approved in all states, until these apps are approved in your state, you will need to use All App 06 or Ind App 07. ** UL 1000 and WL 1000 are not approved to be written on All App 06 or Ind App 07, until your state approves All App 08 or Ind App 08, App 08 is the ONLY approved app for UL 1000 and WL 1000. 83

LIFE INSURANCE - REPLACEMENT FORMS STATE INTERNAL EXTERNAL Alabama 56384 56384 Alaska 56384 56384 Arizona 56384 56384 Arkansas 56384, 18857 56384, 18857 California C17432 C17432 Colorado 56384 56384 Connecticut NA NA Delaware NA C17463 D. C. NA NA Florida 16665 16665 Georgia 15133 15133 Hawaii 56384 56384 Idaho NA 16905 Illinois NA C17534, 17535 Indiana 16392 16392 Iowa 56384 56384 Kansas 56384 56384 Kentucky 56384 56384 Louisiana 56384 56384 Maine 56384 56384 Maryland 56384 56384 Massachusetts 56384 56384 Michigan NA C17480, C17481 Minnesota NA 49559 Mississippi 56384 56384 Missouri NA C17118 Montana 56384 56384 Nebraska 56384 56384 Nevada C17732 C17732 New Hampshire 56384 56384 New Jersey 56384 56384 New Mexico 56384 56384 North Carolina 56384 56384 84

LIFE INSURANCE - REPLACEMENT FORMS (continued) STATE INTERNAL EXTERNAL North Dakota NA NA Ohio 56384 56384 Oklahoma 16057, C17074 16057, C17074 Oregon 56384 56384 Pennsylvania NA C18731 Puerto Rico Na NA Rhode Island 56384 56384 South Carolina 56384 56384 South Dakota 40650 40650 Tennessee NA C17969 Texas 56384 56384 Utah 56384 56384 Vermont 56384 56384 Virginia 56384 56384 Washington NA 19234 West Virginia 56384 56384 Wisconsin 56384 56384 Wyoming NA C17677 85

HIPAA, HIV, LTC Forms List State HIPAA HIV Consent AK 57643, 57646, 59571 or 62891 AL 57643, 57646, 59571 or 62891 AR 57643, 57646, 59571 or 62891 AZ 57643, 57646, 59571 or 62891 Misc Forms LTC Supp TPN LTC none 68542 68587 none Arbitration Form 54930 68542 68587 40171 68541 69543 42564 69548 69546 CA* 59571 ONLY 66709, 66704 68542 68587 CO 57643, 57646, 59571 or 62891 CT 57643, 57646, 59571 or 62891 DC* 57643, 57646, 59571 or 62891 DE 57643, 57646, 59571 or 62891 FL* 57643, 57646, 59571 or 62891 GA 57643, 57646, 59571 or 62891 HI* 57643, 57646, 59571 or 62891 IA 57643, 57646, 59571 or 62891 ID 57643, 57646, 59571 or 62891 IL 57643, 57646, 59571 or 62891 IN 57643, 57646, 59571 or 62891 KS 57643, 57646, 59571 or 62891 KY 57643, 57646, 59571 or 62891 LA 57643, 57646, 59571 or 62891 66708, 66704 68540 68587 42623 68542 68587 66707, 66704 68539 68587 66706, 66704 68542 68587 66705 Requires TPN for all including LTC 68538 68587 40399 69545 68587 65598, 66704 68542 68587 40147 68542 68587 none 68542 68587 65598, 66704 68542 68587 66704 68542 68587 65597, 66704 68525 68587 42267 68537 68587 none 68536 68587 86

HIPAA, HIV, LTC Forms List (continued) State HIPAA HIV Consent MA 57643, 57646, 59571 or 62891 MD 57643, 57646, 59571 or 62891 66702 LTC is called Chronic Illness Accelerated Benefit Rider, must also have 69537 Misc Forms LTC Supp TPN LTC 69544 68587 66704 68542 68587 ME 64897 ONLY 66703, 66704 68535 68587 MI 57643, 57646, 59571 or 62891 MN 57643, 57646, 59571 or 62891 MO 57643, 57646, 59571 or 62891 MS 57643, 57646, 59571 or 62891 MT 57643, 57646, 59571 or 62891 66700, 66701 68542 68587 none 68542 68587 40400 68542 68587 none Arbitration Form 57684 68542 68587 66699 68542 68587 NC 62891 ONLY none 68534 68587 ND 57643, 57646, 59571 or 62891 NE 57643, 57646, 59571 or 62891 NH 57643, 57646, 59571 or 62891 NJ* 57643, 57646, 59571 or 62891 NM 57643, 57646, 59571 or 62891 NV 57643, 57646, 59571 or 62891 42526 68542 68587 66698, 66704 68542 68587 52179 68542 68587 66697, 66704 68533 68587 none 68532 68587 none 68542 68587 NY* 97330 or 97331 97773, 97790 97754 97756 OH 57643, 57646, 59571 or 62891 OK 57643, 57646, 59571 or 62891 OR 57643, 57646, 59571 or 62891 41220 68542 68587 none 68531 68587 65440 68530 68587 87

HIPAA, HIV, LTC Forms List (continued) State HIPAA HIV Consent PA* 57643, 57646, 59571 or 62891 RI 57643, 57646, 59571 or 62891 SC 57643, 57646, 59571 or 62891 SD 57643, 57646, 59571 or 62891 TN* 57643, 57646, 59571 or 62891 TX* 57643, 57646, 59571 or 62891 UT* 57643, 57646, 59571 or 62891 VA 57643, 57646, 59571 or 62891 65439, 66704 17555 required for WL and Term, 61735 required for UL Misc Forms LTC Supp TPN LTC 68529 68587 69833, 66704 68542 68587 none 68542 68587 66704 68542 68587 none 68528 68587 40901 68527 68587 41299 68542 68587 65437 68524 69550 VT* 64896 ONLY 65438 Requires TPN for all including LTC WA* 57643, 57646, 59571 or 62891 WI 57643, 57646, 59571 or 62891 WV 57643, 57646, 59571 or 62891 WY 57643, 57646, 59571 or 62891 68542 68587 65436, 66704 68542 68587 65435, 66704 68542 68587 43799 68526 68587 none 68542 68587 * As of the print date of this manual, your state have not been approved for LTC, you may refer to the product section in Producer Net to determine if your state has approved LTC. 88

NOTES 89

NOTES 90

NOTES 91

NOTES 92

Colonial 1200 Colonial Boulevard Columbia, South Carolina 29210 coloniallife.com 2010 Colonial & Insurance Company. Colonial products are underwritten by Colonial & Insurance Company, for which Colonial is the marketing brand. 2/10 59342-5