one full year from your effective date of the respond by date, these rates are Direct Notice Bank Account Credit Card payments ahead.

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1 Issue Age Medicare Supplement Insurance s Offered in Wisconsin Underwritten by Transamerica Life Insurance Company Monthly Rate For Non-Tobacco Under 65 $99.68 $ $ $ $ $ $ $99.68 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ & Over $ $ $ $ $ $ $ Rates shown are per person based on their individual age. Rate Effective Date: 10/1/2016 MSRSGI2010.WI Pg26 IMPORTANT RATE GUARANTEE: If you apply by the respond by date, these rates are GUARANTEED NOT TO INCREASE for one full year from your effective date of coverage. Your Choice of Payment Options Direct Notice Bank Account Credit Card Get up to 5% off the basic monthly rate with our Smart Rewards program. With Smart Rewards you save by planning your payments ahead. To calculate the discounted rate, multiply the monthly amount shown by for Annual Direct Notice billing or 5.85 for Semi-Annual Direct Notice. For monthly EasyPay billing (automatic checking or credit card) multiply the amount shown by For example: if the monthly premium shown is $150, then your Smart Rewards monthly premium is $150 x.95 = $ In this example you save $7.50 a month or $90 a year! 4Please See Reverse

2 Issue Age Monthly Rate For Tobacco WI Under 65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ & Over Rate Effective Date: 10/1/2016 $ $ $ $ $ $ $ Issue Age: Rates do not increase each year just because your age does. You will lock-in the rate for your age when your coverage is issued. That means even 10 years from now you ll receive the same rate as your issued age with adjustments only for medical inflation. This Medicare Supplement Insurance plan from Transamerica Life Insurance Company is not connected with or endorsed by the U.S. Government or Federal Medicare Program. This is an advertisement for insurance. Pg27

3 OUTLINE OF COVERAGE TRANSAMERICA LIFE INSURANCE COMPANY Administrative Office: 520 PARK AVENUE, BALTIMORE, MD OUTLINE OF MEDICARE SUPPLEMENT COVERAGE Group Policy Form MS8100GPT.WI GROUP MEDICARE SUPPLEMENT INSURANCE NONPARTICIPATING Notice to Buyer: The Wisconsin Insurance Commissioner has set standards for Medicare Supplement insurance. The Certificate meets these standards. It along with Medicare may not cover all of your medical costs. You should review carefully all certificate limitations. For an explanation of these standards and other important information, see "Wisconsin Guide to Health Insurance for People with Medicare", given to you when you applied for the certificate. Do not buy the certificate if you did not get this guide. PREMIUM INFORMATION: We, Transamerica Life Insurance Company can only raise your premium if we raise the premium for all policies like yours in the State. Premiums will not automatically increase as your age increases. DISCLOSURES: Use this outline to compare benefits and premiums among Policies. READ YOUR CERTIFICATE VERY CAREFULLY: This is only an outline describing your certificate s most important features. The certificate is your insurance contract. You must read the certificate itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN CERTIFICATE: If you find that you are not satisfied with your certificate, you may return it to Transamerica Life Insurance Company, 520 Park Avenue, Baltimore, Maryland If you send the certificate back to us within 30 days after you receive it, we will treat the certificate as if it had never been issued and return all of your payments directly to you CERTIFICATE REPLACEMENT: If you are replacing another health insurance certificate, do NOT cancel it until you have actually received your new certificate and are sure you want to keep it. NOTICE: The certificate may not fully cover all of your medical costs. Transamerica Life Insurance Company is not connected with Medicare. Following is a brief description of what the Insurance Company pays and what you pay as of the date of issue of your certificate: MS8100GOT.WI PN07

4 Transamerica Life Insurance Company Group Policy MS8100GPT. WI Benefit Chart of Medicare Supplement s Sold on or After June 1, 2010 This chart shows the benefits we recommend See outline for description of plan benefits. Base includes: Hospitalization: Medical Expenses: Blood: coinsurance plus coverage for 365 additional days after Medicare benefits end. coinsurance (generally 20% of Medicare approved expenses) or copayments for hospital outpatient services. First three pints of blood each year. Hospice: 1 coinsurance % Copayment Travel Travel Travel Travel Travel Travel Travel Care Care Care Care Care Care Excess Excess Excess Monthly Issue Age Rate $99.68 $ $ $ $ $ $ Monthly Issue Age Rate with 5% Smart Rewards Payment Discount $94.69 $ $ $ $ $ $ This Medicare Supplement Insurance plan from Transamerica Life Insurance Company is not connected with or endorsed by the U.S. Government or Federal Medicare Program. This is an advertisement for insurance. MS8101GOT.WI PN08

5 Non-Tobacco Issue Age 1 Travel Transamerica Life Insurance Company 2010 Wisconsin Annualized Premium Rates (Wisconsin offers a Base and seven Optional. We suggest the below combinations.) Group s 2, 3, Excess 4,, Excess 5,, Excess 6 50% 7, Copayment Under 65 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , PN/09 MS8101GOT.WI

6 Tobacco Issue Age 1 Travel Transamerica Life Insurance Company 2010 Wisconsin Annualized Premium Rates (Wisconsin offers a Base and seven Optional. We suggest the below combinations.) Group s 2, 3, Excess 4,, Excess 5,, Excess 6 50% 7, Copayment Under 65 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , PN/10 MS8101GOT.WI

7 Non-Tobacco Issue Age Under 65 MONTHLY BENEFIT RATE CHART Use this rate chart to calculate your monthly premium on the Medicare Supplement Premium information sheet. Base w/o Mandates Travel Excess Charges Home Health Care 50% Copayment & Up PN/11

8 Tobacco Issue Age Under 65 MONTHLY BENEFIT RATE CHART Use this rate chart to calculate your monthly premium on the Medicare Supplement Premium information sheet. Base w/o Mandates Travel Excess Charges Home Health Care 50% Copayment & Up PN/12

9 MEDICARE SUPPLEMENT PREMIUM INFORMATION Annual Premium ($ ) BASIC MEDICARE SUPPLEMENT COVERAGE OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT CERTIFICATE Each of these riders may be purchased separately. ($ ) % of the Medicare hospital deductible ($ ) % of the Medicare hospital deductible per benefit period with no out-of-pocket maximum ($ ) 3. home health care An aggregate of 365 visits per year including those covered by Medicare ($ ) % of the Medicare deductible ($ ) % of the Medicare part B medical deductible subject to copayment or coinsurance of no more than $20 per office visit and no more than $50 per emergency room visit in addition to the Medicare deductible and in addition to out-of-pocket maximums. The emergency room copayment or coinsurance fee shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare expense. ($ ) 6. Medicare excess charges Difference between what Medicare pays and the amount charged by the provider which shall be no greater than the actual charge or the limiting charge allowed by Medicare, whichever is less. ($ ) 7. travel emergency rider After a deductible of $250.00, covers 80% of expenses associated with emergency medical care received outside the U.S.A. during the first 60 days of a trip with a lifetime maximum of $50,000 ($ ) TOTAL FOR BASIC CERTIFICATE AND SELECTED OPTIONAL BENEFITS ($ ) TOTAL MONTHLY PREMIUM IN ADDITION TO THE OUTLINE OF COVERAGE, TRANSAMERICA LIFE INSURANCE COMPANY WILL SEND AN ANNUAL NOTICE TO YOU 30 DAYS PRIOR TO THE EFFECTIVE DATE OF MEDICARE CHANGES WHICH WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT COVERAGE. MS8100GOT.WI PN13

10 LIMITATIONS AND EXCLUSIONS Benefits will not be paid for any expenses which result from: (a) expenses which are not determined to be Medicare Eligible Expenses by the Federal Medicare Program or its administrators, except as otherwise specified; (b) intentionally self-inflicted injury, while sane or insane; (c) alcoholism or drug addiction, except to the extent covered by Medicare and the alcoholism and drug abuse mandated benefits; (d) nursing home care costs beyond what is covered by the Medicare approved and the non-medicare approved skilled nursing facility benefits; (e) home health care above the number of visits covered by Medicare and the home health care benefit, unless the optional Care Rider is purchased; (f) physician charges above Medicare's approved charge, (unless Excess charges rider is purchased); (g) foreign travel medical expenses except to the extent covered by Medicare, unless the optional Travel Emergency Rider is purchased; (h) dental care, dentures, checkups, routine immunizations, cosmetic surgery, routine foot care, examinations for and the cost of eyeglasses or hearing aids, unless eligible under Medicare; or (i) waiting periods for pre-existing conditions; (j) usual, customary, and reasonable limitations; (k) outpatient Rx drugs.; This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult "Medicare & You" for more details. APPEAL OF CLAIM DENIAL The Covered Person or his representative has the right to appeal the denial of any benefits for a claim under the certificate. To appeal a denial, the Covered Person or his representative must submit a written request for a review of the benefit denial. The request should be accompanied by any supporting material and mailed to Transamerica Life Insurance Company, Administrative Office: P. O. Box 3550 Cedar Rapids, IA Within 30 days after receiving the request, Transamerica Life Insurance Company will notify the Covered Person or his representative of the result of this review. USUAL AND CUSTOMARY CHARGES means the normal charge made by most Physicians or medical services providers for a similar service or supply in the locality where the service is rendered or supply purchased. Usual and Customary Charges only applies to the Wisconsin mandated benefits for chiropractic services, hospital and ambulatory surgery charges, anesthetics for dental care, breast reconstruction, non Medicare covered diabetic supplies and equipment, and home health care services. GUARANTEED RENEWABLE FOR LIFE\PREMIUM SUBJECT TO CHANGE The certificate is annually renewable at your option. We may not cancel or decline to renew insurance coverage on the grounds of deterioration of health. We may cancel the certificate for nonpayment of premium or material misrepresentation, subject to the Incontestability provision. To renew, you must pay the renewal premium. It must be paid on or before the end of the premium period for which the preceding premium was paid or during the Grace Period. The renewal date is shown in the Schedule. MS8100GOT.WI PN14

11 MEDICARE SUPPLEMENT PART A HOSPITAL SERVICES PER BENEFIT PERIOD A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Note: This includes the Medicare deductibles for and, but does not include the plan s separate riders deductible. SERVICES PER BENEFIT MEDICARE PAYS THIS POLICY PAYS YOU PAY PERIOD HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous hospital services and supplies. First 60 days 61 st to 90 th days 91 st day and after while using 60 lifetime reserve days Once lifetime reserve days are used: 365 days All but $1,316 All but $329 per day All but $658 per day or l Optional Rider* or l Optional 50% Rider* $329 per day $658 per day 100% of Medicare eligible expenses** $1,316 or or $658 SKILLED NURSING FACILITY CARE You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital. Beyond the additional 365 days First 20 days 21 st through 100 th day 101 st day and after All approved amounts All but $ per day Up to $ per day INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital 190 days per lifetime 175 additional days per lifetime BLOOD First 3 pints amounts 100% First 3 pints HOSPICE CARE As long as your doctor certifies you are terminally ill and you elect to receive these services. All but very limited coinsurance or copayment for outpatient drugs and inpatient respite care or 100% of coinsurance or copayments *These are optional riders. **NOTICE: When your Medicare hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided the policy s Core Benefits. MS8100GOT.WI PN15

12 MEDICARE PART B BENEFITS MEDICAL EXPENSES Eligible expenses for physician s services, inpatient and outpatient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: BLOOD MEDICARE SUPPLEMENT POLICIES PART B BENEFITS PER CALENDAR YEAR First $183 of Medicare-Approved Amounts* Remainder of Medicare-Approved Amounts First 3 pints MEDICARE PAYS Generally 80% THIS POLICY PAYS or l Optional Rider** Generally 20% l Optional Medicare Excess Charges Rider** l Optional Medicare Copayment Rider** All costs YOU PAY $183 or Next $183 of Medicare-Approved Amounts* $183 ( ) CLINICAL LABORATORY SERVICES Tests for Diagnostic Services HOME HEALTH CARE PREVENTIVE MEDICAL CARE BENEFIT- NOT COVERED BY MEDICARE Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services during the first 60 days of each trip outside the USA Remainder of Medicare-Approved Amounts First $120 each calendar year charges First $250 each calendar year Remainder of charges 80% 20% 100% 100% of charges for visits considered medically necessary by Medicare 40 visits or l Optional Care Rider** $120 l Optional Travel Emergency Rider** 80% to a lifetime maximum of $50,000 $250 20% and amounts over the $50,000 maximum *Once you have been billed $183 of Medicare approved amounts for covered services (which are noted with an asterisk), your Medicare deductible will have been met for the calendar year. **These are optional riders. MS8100GOT.WI PN16