EX-99.E APPLICATIONS 4 application_ex-e.htm

Exhibit e

Form of Application

Application for Individual Life Insurance Notice of Insurance Information Practices

Ameritas Life Insurance Corp. ("Company") [P.O. Box 81889, Lincoln, NE 68501/800-745-1112, Fax 402-467-7335]

To issue an insurance policy we need to obtain information about you and any other persons proposed for insurance. Some of that information will come from you and some will come from other sources. We may obtain information relating to any proposed insured's mental and physical health, general character and reputation, habits, finances, occupation, other insurance coverage, or participation in hazardous activities.

This information may be obtained from physicians, medical professionals, hospitals, clinics or other medical care institutions, or from MIB, Inc. ("MIB"), public records, consumer reporting agencies, financial sources, other insurance companies, agents, friends, neighbors and associates. We may obtain information through exchanges or correspondence, by telephone or by personal contact.

Information regarding your insurability or claims will be treated as confidential. The Company or its reinsurers may, however, make a brief report thereon to MIB, a not-for-profit- membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIG, upon request, will supply such company with the information in its file. Upon receipt of a request from you, the MIB will arrange disclosure of any information it may have in your file. If you question the accuracy of information in MIB's file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the MIB's information office is [50 Braintree Hill, Suite 400, Braintree, Massachusetts 02184-8734, telephone number (866) 692-601 (TTY 866-346-3642); website address www.mib.com.] The Company or its reinsurers may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.

Furthermore, as part of our procedure for processing your insurance application, an investigative consumer report may be prepared whereby information is obtained through personal interviews with your neighbors, friends, associates, or others with whom you are acquainted.

This inquiry and any subsequent investigative consumer report update which may also be requested includes information as to your character, general reputation, persona characteristics, and mode of living.

You have the right to be personally interviewed if we order an investigative consumer report. Please notify your agent if this is your wish. You are also entitled to receive a copy of the investigative consumer report whether or not an interview is conducted. You also have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigation.

To reduce costs and offer insurance coverage at the lowest possible premium, the Company may also use a Personal History Interview. A specially trained interviewer may call to discuss information contained in your application or to ask questions related to the underwriting of your insurance. We will attempt to conduct this telephone interview at your convenience and at a number you designate.

In the event of an adverse underwriting decision, upon written request, we will provide you with the specific reason in writing for that adverse underwriting decision.

As a general practice, we will not disclose personal information about you to anyone else without your consent, unless a legitimate business need exists or disclosure is required or permitted by law. A description of the circumstances under which information about you might be disclosed without your authorization will be sent to you upon request.

You have the right of access to personal information we maintain in our files and to request correction, amendment, or deletion of any information you believe to be incorrect. You may request a description of established procedures which will allow access to and correction of such personal information.

If you wish to have a more detailed explanation of our information practices, including your rights of access to and correction of personal information, please contact the Underwriting Department at the above address.

DETACH AND DELIVER TO PROPOSED INSURED BEFORE COMPLETION OF THE APPLICATION

UN 2551 9-19

09-13-19

Application for Individual Life Insurance	1010
Ameritas Life Insurance Corp. ("Company") [P.O. Box 81889, Lincoln, NE 68501/800-745-1112, Fax 402-467-7335]

Personal Information

1.Proposed Insured (One)

Name: ____________________________________________________Date of Birth: ______________ Sex: [ ] Male [ ] Female

Place of Birth: _______________________________________________________ Social Security/Tax ID No.: _________________

Driver’s License or other Government issued picture ID: ________________________________ State: _________________________

Home Address: ______________________________________________________________________Years at this Address: ______

City: ________________________________________________________ State: __________________________ ZIP: __________

Telephone (Preferred): __________________________________ (Alternate): ________________________ Best time to call: ______

If you are not available when we call, may we speak with your spouse? [ ] Yes [ ] No

Fax: __________________________________ E-mail: ____________________________________________________________

Residency Status: [ ] U.S. Resident [ ] Other: ______________________________________________________________________

Are you a U.S. Citizen? [ ] Yes [ ] No (If “No,” provide a copy of valid Passport and Visa)

Citizenship: ____________________ Visa Type:______________ Visa #: ________________ Number of years residing in U.S.: ____

Employer Name: ____________________________________________________________________________________________

Address: _______________________________ City: _________________________ State: _________ ZIP:____________________

Occupation: ____________________________________________________________________________ Years: ______________

Duties: ____________________________________________________________________________________________________

____________________________________________________________________________________________

2.Proposed Insured (Child)

Name: ___________________________________________________________________Relationship:_______________________

Date of Birth: _______________________________ Sex: [ ] Male [ ] Female Place of Birth: _______________________________

Social Security No.: _______________________________ Insurance in Force/Company: _________________________________

Driver’s License No.: ________________________________________________________________________________________

Name: ___________________________________________________________________Relationship:_______________________

Date of Birth: _______________________________ Sex: [ ] Male [ ] Female Place of Birth: _______________________________

Social Security No.: _______________________________ Insurance in Force/Company: _________________________________

Driver’s License No.: __________________________________________________________________________________ _____

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Owner Information (One) (complete only if Owner is other than Proposed Insured)

[ ] Individual [ ] Trust (provide copy) [ ] Partnership [ ] Corporation – State or County of Incorporation: _________________________

(For Trust, Partnership, or Corporation, complete IRS Form W-9; For Employer-Owned Life Insurance, complete Form UN 1166)

Full Name: ________________________________________ Relationship to Proposed Insured(s): __________________________

Trustee(s) Name: ___________________________________________________________________________________________

Date of Birth or Date of Trust: ______________________________ Social Security/Tax ID No.: _____________________________

Driver’s License or other Government issued picture ID: ______________________________________ State: __________________

Address: ______________________________________ City: __________________ State: ______________ ZIP: _____________

Telephone: _____________________________ Fax: ______________________ E-mail: _________________________________

Residency Status: [ ] U.S. Resident [ ] Other: ______________________________________________________________________

Are you a U.S. Citizen? [ ] Yes [ ] No (If “No,” provide a copy of valid Passport and Visa; and complete applicable IRS Form W-8)

Citizenship: ______________________ Visa Type: _____________Visa #: ___________ Number of years residing in U.S.: ________

Multiple Ownership (indicate type): [ ] Joint with Survivorship [ ] Tenants in Common

Successor Owner: Name: _____________________________________ Social Security/Tax ID No.: _________________________

____________________________________________________________________________________________

Owner Information (Two) (complete only if Owner is other than Proposed Insured)

[ ] Individual Trust (provide copy) [ ] Partnership [ ] Corporation – State or County of Incorporation:_____________________________

(For Trust, Partnership, or Corporation, complete IRS Form W-9; For Employer-Owned Life Insurance, complete Form UN 1166)

Full Name: ___________________________________________________ Relationship to Proposed Insured(s):_________________

Trustee(s) Name:____________________________________________________________________________________________

Date of Birth or Date of Trust: _____________________________________ Social Security/Tax ID No.:_______________________

Driver’s License or other Government issued picture ID: ______________________________________________ State:___________

Address: ______________________________________________ City: _____________________ State: _________ ZIP:________

Telephone:______________________________ Fax:_______________ E-mail: ________________________________________

Residency Status: [ ] U.S. Resident [ ] Other:______________________________________________________________________

Are you a U.S. Citizen? [ ] Yes [ ] No (If “No,” provide a copy of valid Passport and Visa; and complete applicable IRS Form W-8)

Citizenship: ___________________ Visa Type:_____________ Visa #: ______________ Number of years residing in U.S.: ________

Successor Owner: Name: ___________________________________________ Social Security/Tax ID No.: ____________________

____________________________________________________________________________________________

Beneficiary Information (subject to change by Owner)

Primary

Primary Beneficiary: ______________________________________________ Relationship to Proposed Insured:________________

Address: _____________________________________________ City: ________ State: _______ ZIP:____________________

Social Security/Tax ID: ____________________________________ Date of Birth or Date of Trust:_______________________

Primary Beneficiary: ______________________________________________ Relationship to Proposed Insured:________________

Address: _____________________________________________ City:________________ State:_________ ZIP: ___________

Social Security/Tax ID: ____________________________________ Date of Birth or Date of Trust: ______________________

Contingent

Contingent Beneficiary: ______________________________________________ Relationship to Proposed Insured:______________

Address: _____________________________________________ City: ________ State: _______ ZIP:____________________

Social Security/Tax ID: ____________________________________ Date of Birth or Date of Trust:_______________________

Contingent Beneficiary: ______________________________________________ Relationship to Proposed Insured:______________

Address: _____________________________________________ City:________________ State:_________ ZIP: ___________

Social Security/Tax ID: ____________________________________ Date of Birth or Date of Trust: ______________________

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Policy Details

[Ameritas Performance II VUL]

Specified Amount (base only) $______________________________

Death Benefit Option: [ ] Option A (Specified Amount) [ ] Option B (Specified Amount plus Account Value) [ ] Option C (Return of Premium)

Life Insurance Qualification Test: [ ] GPT- Guideline Premium Test (Default if no option is selected) [ ] CVAT- Cash Value Accumulation Test

Supplementary Benefits:

[	Accidental Death Benefit Rider	$	Scheduled Increase Rider	$
	Children's Insurance Rider	$	Total Disability Rider	$
	Guaranteed Insurability Rider	$	Waiver of Monthly Deduction Rider		]

Monthly Deduction Allocation:

If you have chosen the Individual Investment Option, do you want to select

A portfolio or portfolios from which to deduct your monthly expenses?

If "Yes," list portfolios(s) and/or Fixed Account and percentage allocated. If "No," then the expenses will be prorated form all funds. [ ] Yes [ ] No

Default is "No" if no option is selected.)

____________________________________________________________________________________________

Payor Payor Information:

Insured

Owner

Other: (provide details)

Name:________________________________________________ Address:________________________________________

Relationship: _____________________ Purpose:_______________________________________________________________

Send Premium Notices to:

Residence

Business

Premium Frequency:

Annual

Semi-Annual

Quarterly

Electronic Fund Transfer (complete EFT form and provide

voided check)

Salary Allotment

Single Premium

Other:

Planned Periodic Premium (modal): $_____________________

Additional First-Year Premium (lump sum amounts):	$

	1035 Exchange	$	(complete Absolute Assignment Form)

If this is a request for a one-time initial draft of the direct modal premium, check here [ ] and complete EFT form and provide voided check.

____________________________________________________________________________________________

Insurance Suitability Questions

a.	DO YOU UNDERSTAND THAT THE DEATH BENEFIT AND CASH VALUE MAY INCREASE OR DECREASE DEPENDING ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT AND THAT THE DOLLAR AMOUNTS ARE NOT GUARANTEED?	Yes	No
a.		Yes	No
b.	Do you believe that this policy will meet your insurance needs and financial objectives?	Yes	No
c.	Have you received a current copy of the Prospectus?	Yes	No

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Telephone Transfer Authorization If no election is made, the default will be "No."

I hereby authorize and direct the Company to make allowable transfers of funds or reallocation of premiums among available subaccounts based upon instructions received by telephone from: a) myself, as Owner; b) my Agent/Registered Representative; and c) the person(s) named below. The Company will not be liable for following instructions communicated by telephone that it reasonably believes to be genuine. The Company will employ reasonable procedures, including requiring the policy number to be stated, recording all instructions received by telephone, and mailing written confirmations. If the Company does not employ reasonable procedures to confirm that instructions communicated are genuine, the Company may be liable for any losses due to unauthorized or fraudulent instructions.

If no election is made, the default will be “No.”

a. Do you elect to have telephone transfer authorization? [ ] Yes [ ] No

b. Do you allow your Registered Representative to have telephone transfer authorization? [ ] Yes [ ] No

c. Provide the following information for additional person(s) you wish to have telephone transfer authorization:

Name ______________________________________________________________ SSN _____________________________

Address ______________________________________________________________________________________________

I understand: a) all telephone transactions will be recorded; and b) this authorization will remain in force until the authorization is revoked by either the Company or me. The revocation is effective when received in writing or by telephone by the other party.

____________________________________________________________________________________________

10.

Electronic Delivery Authorization If no election is made, the default will be "No."

Do you consent to electronic delivery of documents? [ ] Yes [ ] No

You have the right to revoke your consent at any time by calling us at the phone number provided on this application. Your consent will be effective until you revoke it.

Electronic delivery will include: policy and fund prospectuses; semi-annual and annual fund reports; quarterly policy reports; and additional documents as they become available in the future.

My e-mail address is: _______________________________________________________________________________________________

I (We) will notify the Company of any new e-mail address. I (We) understand that if consent for electronic delivery is given, but a legible e-mail address is not provided in this section, electronic delivery will not be initiated.

When documents are ready to be viewed electronically, you will receive an e-mail notification with a link to view the materials on our website.

Enrollment in this electronic delivery service requires that you have a personal computer with appropriate browser software, e-mail software, as well as communications access to the internet. While the Company provides such internet delivery free of charge, the size of the documents may be large. It is possible you could be charged by an Internet Service Provider or other party to receive or download such a document via the internet. Some documents are available as Portable Document Format (PDF) files requiring the use of Adobe Acrobat Reader software which is available on our website at no charge.

____________________________________________________________________________________________

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Allocation of Premiums

11.

Allocation Among Investment Options

Individual Investment Options Use whole percentages only. Must total 100%

If Dollar cost Averaging, a portion must be invested in the Money Market Fund or Fixed Account (see prospectus for restrictions) and the Dollar Cost Averaging section of the [Optional Investment Strategies] form must be completed.

[The Alger Portfolios:			Franklin Templeton Variable Insurance Products Trust:
	%	Alger Balanced Portfolio, Class I-2		%	Franklin Income VIP Fund, Class 2
	%	Alger Capital Appreciation Portfolio, Class I-2		%	Templeton Global Bond VIP Fund, Class 2

ALPS Variable Investment Trust (Morningstar)			Invesco Variable Insurance Funds:
	%	Morningstar Balanced ETF Asset Allocation Portfolio, Class II		%	Invesco Oppenheimer V.I. Global Fund, Series I
	%	Morningstar Growth ETF Asset Allocation Portfolio, Class II		%	Invesco V.I. Global Real Estate Fund, Series I
	%	Morningstar Income and Growth ETF Asset Allocation		%	Invesco V.I. International Growth Fund, Series I
	%	Portfolio, Class II		%	Invesco V.I. Small Cap Equity Fund, Series I

American Century Investments:			Ivy Variable Insurance Portfolios:
	%	American Century VP Income & Growth Fund, Class I		%	Ivy VIP Balanced, Class Il
	%	American Century VP Mid Cap Value Fund, Class I		%	Ivy VIP Science and Technology, Class Il

Calvert Variable Products, Inc.:			MFS® Variable Insurance Trust:
	%	Calvert VP EAFE International Index Portfolio, Class I		%	MFS® Total Return Series, Initial Class
	%	Calvert VP Investment Grade Bond Index Portfolio, Class I		%	MFS® Utilities Series, Initial Class
	%	Calvert VP Nasdaq 100 Index Portfolio, Class I		%	MFS® Value Series, Initial Class
	%	Calvert VP Russell 2000 Small Cap Index Portfolio, Class I
	%	Calvert VP S&P 500 Index Portfolio	MFS® Variable Insurance Trust II:
	%	Calvert VP S&P MidCap 400 Index Portfolio, Class I		%	MFS® Research International Portfolio, Initial Class
	%	Calvert VP Volatility Managed Growth Portfolio, Class F
	%	Calvert VP Volatility Managed Moderate Growth Portfolio, Class F	Morgan Stanley Variable Insurance Funds, Inc.:
	%	Calvert VP Volatility Managed Moderate Portfolio, Class F		%	Morgan Stanley VIF Core Plus Fixed Income Portfolio, Class I
				%	Morgan Stanley VIF Emerging Markets Equity Portfolio, Class I
Calvert Variable Series, Inc.:				%	Morgan Stanley VIF U.S. Real Estate Portfolio, Class I
	%	Calvert VP SRI Balanced Portfolio, Class I
			Neuberger Berman Advisers Management Trust:
DWS Variable Series I:				%	Neuberger Berman AMT Mid Cap Intrinsic Value Portfolio, Class I
	%	DWS Capital Growth VIP Portfolio, Class A		%	Neuberger Berman AMT Sustainable Equity Portfolio, Class I

DWS Variable Series II:			PIMCO Variable Insurance Trust:
	%	DWS International Growth VIP Portfolio, Class A		%	PIMCO Low Duration Portfolio, Administrative Class
	%	DWS Small Mid Cap Value VIP Portfolio, Class A		%	PIMCO Real Return Portfolio, Advisor Class
				%	PIMCO Total Return Portfolio, Administrative Class
Fidelity® Variable Insurance Products:
	%	Fidelity® VIP Contrafund® Portfolio, Initial Class	T. Rowe Price Equity Series, Inc.:
	%	Fidelity® VIP Equity-Income Portfolio, Initial Class		%	T. Rowe Price Blue Chip Growth Portfolio-II
	%	Fidelity® VIP Government Money Market Portfolio, Initial Class		%	T. Rowe Price Equity Income Portfolio-II
	%	Fidelity® VIP High Income Portfolio, Initial Class
	%	Fidelity® VIP Investment Grade Bond Portfolio, Initial Class	Third Avenue Variable Series Trust:
	%	Fidelity® VIP Mid Cap Portfolio, Initial Class		%	Third Avenue Value Portfolio ]
	%	Fidelity® VIP Overseas Portfolio, Initial Class
	%	Fidelity® VIP Strategic Income Portfolio, Initial Class	Ameritas Life Insurance Corp.:
					Fixed Account
			100	%	Total

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Financial Information

12.

Existing and Pending Insurance – Proposed Insured(s)

		Proposed Insured One	Proposed Insured Child
a.	Total insurance in force on the Proposed Insured(s)…………………………………………………………	$	$
b.	Total insurance currently pending with all companies, including this application. ………………………..	$	$
c.	Of the above pending amount, how much do you intend to accept? ………………………………………	$	$
d.	Provide information for each policy in force on the Proposed Insured(s), (attach additional page if necessary)

Proposed Insured: [ ] One [ ] Child

Company: _________________________________________________________ Group, Personal or Business: ________________

Issue Date: ____________________________ To Remain in Force? [ ] Yes [ ] No Face Amount: $____________________

Proposed Insured: [ ] One [ ] Child

Company: _________________________________________________________ Group, Personal or Business: ________________

Issue Date: ____________________________ To Remain in Force? [ ] Yes [ ] No Face Amount: $____________________

____________________________________________________________________________________________

13.

Financial Questions

Purpose of Insurance: ____________________________________________________________________________________

In the last 5 years, has either of the Proposed Insured(s) or the business had any major financial problems (bankruptcy, etc.)?

[ ] Yes [ ] No

(if "Yes," give details) ________________________________________________________________________

		Proposed Insured One	Proposed Insured Child
c.	Gross annual earned income (salary, commissions, bonuses, etc.)……………………………….	$	$
d.	Gross annual unearned income (dividend, interest, net real estate income, etc.) ………………..	$	$
e.	Household net worth: $_______________)
f.	If Owner, other than the proposed insured, is an individual:
	Net Worth: $ ________________________ Net Annual Income: $ ______________ Total Family Income: $ ________________
g.	If proposed insured is under 18 years of age: Estimate parent's Net Worth: $______________________
	Estimate parents' Income $________________________ Amount of insurance in force on life of parents: $___________________

____________________________________________________________________________________________

14.

Source of Premiums (check one or more)

[ ] Current Income [ ] Securities [ ] 1035 Exchange [ ] Insurance/Annuities (Loans/Withdrawals)

[ ] Insurance or annuity maturity value or death benefit [ ] Rollover/Transfer of 401(k), Pension Funds or Qualified Funds [ ] Cash Savings

[ ] Relative [ ] sale of personal property or real estate [ ] Employer [ ] Premium Finance [ ] Other: ____________________

____________________________________________________________________________________________

15.

Statement of Intent

Have you ever sold, assigned, or pledged as collateral a life insurance policy, or an interest in a life insurance policy? [ ] Yes [ ] No

(if "Yes," give details) ________________________________________________________________________________

b. Is there, or will there be, any agreement or understanding that provides for a party, other than the Owner,

to obtain any interest in any policy issued on the life of the proposed insured as a result of this application? [ ] Yes [ ] No

c. Will the premiums be financed through a loan? [ ] Yes [ ] No (if "Yes," list: lender, duration of loan, and collateral required)

_____________________________________________________________________________________________________

d. Will any entity other than a life insurance company be medically evaluating

the proposed insured either to obtain financing or to determine life expectancy? [ ] Yes [ ] No (if "Yes," give details")

_____________________________________________________________________________________________________

e. Will the policy, if issued, be placed in a trust? [ ] Yes [ ] No (if "Yes," give details and provide copy of trust)

_____________________________________________________________________________________________________

f. Will a captive insurance company own, control or benefit from this policy in any way? [ ] Yes [ ] No

g. Will the source of any portion of the premium payments be assets of, or from contributions to, a captive insurance company? [ ] Yes [ ] No

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Financial Information (continued)

16.

Business Insurance (complete for ALL Business Owned Insurance)

		Current Year	Previous Year
a.	Assets……………………………………………………………..	$	$
b.	Liabilities…………………………………………………………..	$	$
c.	Gross Sales……………………………………………………….	$	$
d.	Net income after taxes…………………………………………..	$	$
e.	Fair market Value of the business………………………………	$	$
f.	What percentage of the business is owned by Proposed Insured(s) _________________%
g.	Are other partners/owners/executives being insured? [ ] Yes [ ] No (if "Yes," give details)

____________________________________________________________________________________________

17.

Existing Insurance (Replacement)

Do you have any existing life insurance policies or annuity contracts? [ ] Yes [ ] No

(if "Yes," complete a Replacement Notice if required by State Law)

Will any life insurance policy or annuity contract presently in force with this or any other

company be discontinued, reduced, changed, or replaced if insurance now applied for is issued? [ ] Yes [ ] No (if "Yes," give details)

Company: _____________________________________________________________ Policy No.: ______________________

Amount: $________________________ Date: ______________________ Type of Policy: ____________________________

Company: _____________________________________________________________ Policy No.: ______________________

Amount: $________________________ Date: ______________________ Type of Policy: ____________________________

____________________________________________________________________________________________

18.

Insurance Producer's Replacement Statement

To the best of your knowledge, does the applicant have any existing life insurance policies or annuity contracts? [ ] Yes [ ] No

To the best of your knowledge, does the policy applied for involve replacement in whole or in

part, of any existing life insurance, annuity contract, or any other accident and sickness insurance? [ ] Yes [ ] No (if "Yes," give details)

Company: _____________________________________________________________ Policy No.: ______________________

Amount: $________________________ Date: ______________________ Type of Policy: ____________________________

Will a policy loan on one or more policies be utilized to pay any portion of the initial premium or deposit on the

policy applied for? [ ] Yes [ ] No

(if "Yes," give policy number(s) involved) _____________________________________________________________________

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Lifestyle Questionnaire

19.

Lifestyle Questions (please provide details for "Yes" answers)

Has any person proposed coverage:

Proposed Insured

One

Child

a..	Used tobacco or nicotine products in any form within the last five years?.........................................	Yes	No	Yes	No
	(in Details, provide dates and type: cigarettes, e-cigarettes, cigars, cigarillos,
	a pipe, chewing tobacco, nicotine patches, gum, etc.)

b.	Ever applied for insurance or reinstatement which has been: declined, postponed,
	Rated, modified; or had any such insurance canceled or a renewal premium refused?.............	Yes	No	Yes	No
	(in Details, provide date, reason, and company name)

c.	Received or claimed: indemnity, benefits, or a payment for any injury, sickness or
	Impaired condition within the last five years?.............................................................................	Yes	No	Yes	No

d.	Ever made any flights, or intend to within the next two years, as: a pilot, student pilot,
	Or crew member of any aircraft?................................................................................................	Yes	No	Yes	No
	(if "Yes," complete Aviation Questionnaire

e.	Been convicted of a moving traffic violation, had any traffic accidents in which you were
	Found to be at fault, or had a driver's license revoked or suspended within the past five years?	Yes	No	Yes	No

f.	Plead guilty to, convicted of, or currently have a charge pending for the violation of any criminal law?	Yes	No	Yes	No

g.	In the next year, any intention of traveling outside of the U.S. or Canada, or residing outside of the U.S.?	Yes	No	Yes	No

h.	Belong to or have entered a written agreement to become a member of:
	any active or reserve military, naval, aeronautic organization?.....................................................	Yes	No	Yes	No
	(if "Yes," complete Military Service Questionnaire)

i.	Engaged in or plan to engage in, within the next two years, any form of the following: …………	Yes	No	Yes	No
	(if "Yes," check all boxes below that apply and complete appropriate forms(s))
	[ ] Martial Arts [ ] Motorized racing [ ] Mountain climbing [ ] Parachuting/Skydiving [ ] Scuba diving
	[ ] Other ______________________________________________________________________________________________

Proposed Insured One – Details for any "Yes" answers to Lifestyle Questions: (indicate question letter and timeframe)

Proposed Insured Child(ren) – Details for any "Yes" answers to Lifestyle Questions: (indicate question letter and timeframe)

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Health Questionnaire

20.

Health Questions (please provide details for "Yes" answers)

Proposed Insured One:

Height:

ft.

In.

Weight

lbs

Proposed Insured Child:

Proposed Insured

Height:

ft.

In.

Weight

lbs

One

Child

Has your weighted changed by more than 10 bs. In the last 12 months?............................................

Yes

(If "Yes," list amount gained or lost and provide details.

Have your ever been told by a member of the medical profession that you have,

or been diagnosed with or treated for:

High blood pressure or high cholesterol levels?.............................................................................

Yes

Disorder of the eyes, ears, nor or throat?.......................................................................................

Yes

Dizziness, vertigo, fainting, seizures, recurrent headache; speech defect, tremor, neuropathy,

paralysis, multiple sclerosis, stroke, transient ischemic attach (TIA), memory loss, dementia or any

other disorder of the brain or nervous system?......................................................................

Yes

Shortness of breath, chronic cough, bronchitis, asthma, emphysema,

chronic obstructive pulmonary disease (COPD), sleep apnea, or chronic respiratory disorder?.....

Yes

Chest pain, irregular heartbeat, heart murmur, heart valve disease, heart attack,

coronary artery disease, heart failure, aneurysm or other disorder of the heart or blood vessels?

Yes

Intestinal bleeding, inflammatory bowel disease (including Crohn's disease or ulcerative colitis),

hepatitis, diverticulitis, recurrent indigestion or other disorder of the esophagus, stomach,

Intestines, pancreas, liver or gallbladder?.....................................................................................

Yes

Sugar, protein, or blood in urine, sexually transmitted disease (excluding HIV);

chronic kidney disease, kidney stone or other disorder of the kidneys or bladder?...................

Yes

Diabetes, elevated blood sugar, thyroid, pituitary, adrenal or other endocrine (glandular) disorders?

Yes

Disorder of the breasts, reproductive organs, or prostate?...........................................................

Yes

10.

C-section, miscarriage, or complication of pregnancy?..................................................................

Yes

11.

Arthritis, gout, lupus or disorder of or injury to the bones, muscles, wrists, hips, knees or other joints?

Yes

12.

Spinal, neck or back disorder or injury, including sprains, strains, or disc disorder?......................

Yes

13.

Mass, polyp, cyst, tumor or cancer?...............................................................................................

Yes

14.

Allergies, disorder of the skin, anemia, bleeding, clotting or other disorder of the blood?...............

Yes

15.

Anxiety, depression, stress, attention deficit hyperactivity disorder (ADHD),

eating disorder or other psychiatric or mental health disorder?......................................................

Yes

16.

Chronic fatigue, chronic pain, fibromyalgia, or fever of unknown cause?........................................

Yes

Are you currently pregnant? (If "Yes," list expected due date.) ………………………………………

Yes

Other than noted above, have you within the past five years:

Consulted or received treatment from a chiropractor?.......................................................................

Yes

Had a checkup, consultation, illness, injury, or surgery, been a patient in a hospital, rehabilitation

center or other medical facility, had an X-ray, EKG, heart scan, MRI or CT scan, biopsy or other

diagnostic test (excluding HIV)?........................................................................................................

Yes

Been advised by a member of the medical profession to have any diagnostic test (excluding HIV),

hospitalization, or surgery which has not been completed? ……………………………………………

Yes

Within the past ten years, have you ever:

Used marijuana, cocaine, heroin, barbiturates, tranquilizers, hallucinogens,

amphetamines, narcotics or any other drug, except as legally prescribed by a physician?............

Yes

Sought, received or been advised to see medical treatment,

counseling or participation in a support group for the use of alcohol or drugs?...............................

Yes

Consumed alcoholic beverages? If yes, specify extent. ………………………………………………..

Yes

Have you been diagnosed by a member of the medical profession as having Acquired Immune

Deficiency Syndrome (AIDS) or ever tested positive for Human Immunodeficiency Virus (HIV)?..............

Yes

Have any of your immediate family members (parents, brothers and sisters) died or been diagnosed

as having coronary artery disease, stroke, diabetes, cancer, polycystic kidney disease or

Huntington's disease prior to age 60?..................................................................................................

Yes

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Health Questionnaire (continued)

i.	Family History:		Age if Living	Age at Death	Cause of Death
		Father
		Mother
		Brothers
		Sisters

j.	1.	Name and address of personal or attending physician:



	2.	Telephone:	3.	Date last consulted:

	4.	Reason for last consultation and any medication/treatment given:



	5.	List any medications (prescription or nonprescription) you currently are taking:

Proposed Insured One

For each "Yes" answer, give details. (identify: question letter/number, diagnosis, dates, duration, treatment, names and addresses of all attending physicians and medical facilities and attach additional sheet, if needed)

Proposed Insured Child(ren)

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21.

Fraud Notice

Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

22.	Agreement
	The undersigned represent that their statements in this application and Part II, if such Part II is required by the Company are true and complete to the best of their knowledge and belief. It is agreed that:
		a.	the only statements to be considered as the basis of the policy are those contained in the application or in any amendment to the application;
		b.	any prepayment made with this application will be subject to the provisions of the TEMPORARY INSURANCE AGREEMENT;
		c.	If there is no prepayment made with this application, the policy will not take effect until:
			1.	The first premium is paid during the lifetime of the proposed insured(s) and while his/her health and the facts and other conditions affecting their insurability remain as described in this application and Part II, if required; and
			2.	the policy is delivered to the Owner;
		d.	no one except the President, a Vice President, the Secretary, or an Assistant Secretary can make, alter or discharge contracts or waive the Company's rights or requirements; and
		e.	this application was signed and dated in the state indicated.

	If applying for an indeterminate premium plan:
		a.	the premium for such plan is guaranteed for the initial guaranteed period, and after such period, the current annual premium is not guaranteed and may change; and;
		b.	the premium will never exceed the specified maximum.

Dated at:
	City	State	Month	Day	Year


Print or Type Proposed Insured Name	Print or Type Insurance Producer Name

	Producer No.	Sit. Code	% Split
X
Signature of Proposed Insured
(or Personal Representative if proposed insured is a minor)	X
	Signature of Insurance Producer	Producer State Lic. No.

Print or Type Owner if Not Proposed Insured
	Agency Name	Agency No.


Signature of Owner if Not Proposed Insured	Print or Type Insurance Producer Name


	Producer No.	Sit. Code	% Split
Print or Type Owner if Not Proposed Insured

	X
	Signature of Insurance Producer	Producer State Lic. No.
Signature of Owner if Not Proposed Insured

	Agency Name	Agency No.


	Print or Type Insurance Producer Name


	Producer No.	Sit. Code	% Split


	X
	Signature of Insurance Producer	Producer State Lic. No.



	Agency Name	Agency No.

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23.

Authorization to Obtain and Disclose Information

I authorize any health care providers, pharmacy benefit manager, hospitals, insurers, consumer reporting agency, government agency, financial institution, and/or account ting, educational institution, or employer; having data or acts about the proposed insured's or claimant's physical or mental condition, medical care, advice, treatment, the use of drugs, alcohol, or tobacco, HIV, AIDS and sexually transmitted diseases, prescription drug records, financial status, education records, or employment status or other relevant data or facts about the proposed insured or claimant; including wage and earnings, or data or facts with respect to other insurance coverage; to give all data or fats to the Company, its reinsurers, or any other agent or agency acting on the Company's behalf.

I authorize MIB, Inc., and any MIB member insurer, to provide any medical or personal information that it has about me to the Company, its reinsurers or any MIB-authorized third-party administrator performing underwriting services on the Company's behalf. I also authorize the Company, its reinsurers or authorized third-party administrator, to make a brief report of my protected health information to MIB, Inc.

Data or facts obtained will be released only: (1) to reinsurers; (2) to persons performing business duties as directed or contracted for by the Company related to the proposed insured's application or claim or other insurance-related functions; (3) as permitted or required by law; (4) to government officials when necessary to prevent or prosecute fraud or other illegal acts; and (5) to any person or entity having an authorization expressly permitting the disclosure. I acknowledge and agree that the personal data or facts used or disclosed under this authorization may be subject to redisclosure and no longer protected by federal privacy regulations.

I acknowledge and agree that the above data and facts will be used to: (1) underwrite an application for coverage; (2) obtain reinsurance; (3) resolve or contest any issues of incomplete, incorrect, or misrepresented information on the application identified above which may arise during the processing or review of the application, or any other application for insurance; (4) administer coverage and claims; and (5) complete a consumer report, investigative consumer report or telephone interview about the proposed insured or claimant.

I agree that this authorization is valid for such time limit, if any, permitted by applicable law in the state where the policy is delivered or issued for delivery. I also agree that a copy is as valid as the original. I, or my authorized representative, am entitled to a copy. For purposes of collecting data or facts relating to a claim for benefits, this authorization is valid for the duration of the claim. I understand that: (1) I can revoke this authorization at any time by giving written request to the Company; (2) revoking this authorization will not affect any prior action taken by the Company in reliance upon this authorization; and (3) failing to sign, or revoking this authorization may impair the Company's ability to process my application or evaluate my claim and may be a basis for denying this application or a claim for benefits.

I acknowledge receipt of Notice of Insurance Information Practices.

Dated at:
	City	State	Month	Day	Year


Print or type Proposed Insured Name		Print or Type Name of Personal Representative of Proposed Insured

X
Signature of Proposed Insured		Signature of Personal Representative of Proposed Insured


		Description of Authority of Personal Representative (Parent, Legal Guardian, Attorney-in-Fact) (attach documentation in support of your authority)

This Authorization complies with the HIPAA Privacy Rules.

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Portfolio

Percentage

Portfolio

Percentage