The United States Life Insurance Company in the City of New York Please answer these brief questions. To the best of your knowledge and belief: 1. Hav

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Harriet Bradley
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1 The United States Life Insurance Company in the City of New York APPLICATION FOR BUSINESS OVERHEAD INSURANCE Home Office: 175 Water Street, New York, NY (Herein called the Company) Administrative Office: AAJ GROUP INSURANCE PROGRAM, P.O. BOX 10374, Des Moines, IA Name of Association 2. Member/Applicant's Name G Male G Female First Middle Last 3. Membership Number (if any) 4. address 5. Member/Applicant's Address Number Street City State Zip Code 6. Name and Address of Member/Applicant's Physician 7. Home Phone No. ( ) Work Phone No. ( ) 8. PERSONAL DATA Age Date of Birth (MM/DD/YR) Place of Birth Height Ft. In. Weight Lbs. ft. in. Lbs 9. Are you now, and have you been for the last 90 days, performing all of the duties of your regular occupation for at least 30 hours per week for your present employer? 10. Occupation 11. Annual Earned Income (after business expenses) $ 12. Date of Hire 13. Business Address INSURANCE REQUESTED Business Overhead Insurance 14. Monthly Benefit Requested: (not to exceed the monthly expense you actually incurred) Waiting Period: G 15 day (Class 1) G 30 day (Class 2) Benefit Period: G 12 months (after age 65) G 24 months (prior to age 65) My share of the eligible expenses is: Number of full-time employees: 15. I wish to pay: G Annually G Semi-Annually G Quarterly PLEASE COMPLETE AND SIGN THE APPLICATION G NY 1 Group Policy No. G-224,547 AG / /25454/ 1018/

2 The United States Life Insurance Company in the City of New York Please answer these brief questions. To the best of your knowledge and belief: 1. Have you ever had or been treated for (Circle specific disorders experienced): a. Disease or disorder of the heart or murmur, chest pain, rheumatic fever, elevated blood pressure, stroke? b. Injury, pain or disorder of the neck or back? Sciatica? Any disabling injury? c. Arthritis, chronic pain, chronic fatigue, fibromyalgia, bursitis or rheumatism, or any other neurological disorder? d. Dizziness, epilepsy, convulsions, recurrent headaches, glaucoma, cataract or other disorder of the eyes or ears? e. Disease or disorder of the rectum or anus? Varicose veins or other vascular disorder? f. Diabetes or elevated glucose? Sugar, albumin or pus in urine? Thyroid or other glandular disorder? g. Duodenal or stomach ulcer, or other disorder of stomach, liver (including hepatitis), gall bladder? Colitis, diverticulitis, or other disorder of small or large intestine? h. Prostate disorder? Kidney stone or colic, nephritis, nephrosis or other kidney disorder? Urinary infection? i. Menstrual, uterine or ovarian disorder? Disorder of the breast? j. Bronchitis, emphysema, pleurisy, difficult breathing, blood spitting or other disorder of the lung or nose? k. Cancer or other tumor? Deformity or loss of limb? Congenital defect? l. Mental or emotional problem requiring help of a physician or psychologist? m. A surgical operation? A surgical operation advised but not performed? n. Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or disorders of the immune system? o. Alcohol or drug abuse? 2. Have you during the past 5 years, consulted any physician or other practitioner or been confined or treated in any hospital or similar institution, for any reason other than those stated above? 3. Are you now taking prescription medication or receiving medical attention? For "Yes" answers to questions 1-3 above, please provide details in the space provided below. If more space is needed, use a separate sheet of paper, signed and dated. If additional information is attached, check "Yes" Question # Condition Date Occurred Duration Degree of Recovery Name and Address of Physicians, Hospitals or Clinics Consulted EXISTING AND PENDING INSURANCE SECTION 4. Do you have any disability insurance in force or pending? (including group Coverage)... (If "Yes", please indicate companies and amounts) 5. Will this coverage applied for replace any insurance now in force?... (If "Yes", please indicate which insurance and the amount being replaced) PLEASE COMPLETE AND SIGN THE APPLICATION G NY 2 Group Policy No. G-224,547 AG /17 * *

3 The United States Life Insurance Company in the City of New York AUTHORIZATION AND DECLARATION OF EACH PERSON GIVING A STATEMENT OF INSURABILITY I hereby authorize any licensed physician, medical practitioner, pharmacy, pharmacy benefit manager and other sources, hospital, clinic, or other medical or medically related facility, insurance company, the MIB, Inc., formerly known as the Medical Information Bureau, or other organization, institution or person that has any records or knowledge of me or my health, to give to the Company or its reinsurers any such information. Such information will pertain to my employment, or other insurance coverage and medical care, advice, treatment or supplies for any physical or mental condition. This includes information obtained in connection with the preparation or procurement of an investigative consumer report as defined under the Fair Credit Reporting Act(s). To facilitate the rapid submission of such information, I authorize all said sources, except the MIB, to give such records or knowledge to any agency employed by the Company to collect and transmit such information. I understand that this information will be used by the Company solely to determine eligibility for insurance. I understand that I may revoke this authorization at anytime by giving written notice to the Company. I agree that such revocation will not affect any action, that any source has taken in reliance upon this authorization. I understand this authorization will be valid for 24 months from the effective date of coverage, if not revoked earlier. I know that I should retain a copy of this authorization for my records. I agree that a photocopy of this authorization is as valid as the original. To the best of my knowledge and belief, all statements made above are true and complete. I understand that my application for group insurance will be accepted or declined on the basis of these statements. Insurance will take effect only if a certificate is issued based on this application and the first premium is paid in full (a) during the lifetime of all proposed insureds; and (b) while there is no change in the insurability or health of such person from that stated in the application. Important Notice: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. A copy of this application will be attached to and made a part of your certificate. Date Member/Applicant's Signature G NY 3 Group Policy No. G-224,547 AG /

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11 ADMINISTERED BY: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box Des Moines, IA Questions: AR Insurance License # CA Insurance License #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC MN Insurance License # OK Insurance License # TX Insurance License # UNDERWRITTEN BY: The United States Life Insurance Company in the City of New York The most prominent independent ratings agencies continue to recognize The United States Life Insurance Company in the City of New York in terms of insurer financial strength. For current insurer financial strength ratings, please consult the Web site at Policies issued by The United States Life Insurance Company in the City of New York (US Life). Issuing company US Life is responsible for financial obligations of insurance products and is a member of American International Group, Inc. (AIG). Products may not be available in all states and product features may vary by state. Policy # G-224,547, Form # G This brochure is a brief description of benefits only and is subject to the terms, conditions, exclusions and limitations of the group policy. Copyright 2017 Mercer LLC. All rights reserved. G-224,547 AG /17 OO385P-AAJ

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Please answer these brief questions. To the best of your knowledge and belief: 1. During the past 5 years, have you had or been treated for (Circle sp

Please answer these brief questions. To the best of your knowledge and belief: 1. During the past 5 years, have you had or been treated for (Circle sp APPLICATION FOR GROUP DISABILITY INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Administrative Office: P.O. Box 10374, Des Moines,