Applicant's SSN - - Height Weight

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1 Application to AMERICAN FAMILY LIFE ASSURANCE COMPANY OF NEW YORK (Aflac New York) 22 Corporate Woods Boulevard, Ste. 2, Albany, New York For information, call toll-free Aflac New York s Protector Series Application for Payroll Life Insurance (Form NYR63000 Series) Please Print in Black Ink To Be Completed by Applicant Applicant's Name DOB Sex Last First MI Month/Day/Year New Policy Number Applicant's SSN - - Height Weight Applicant s Driver s License Number State of Issue State of Birth (Write spouse's name below if applying for spousal rider; if no spouse or spouse will not be covered, put N/A or none. ) Spouse s Name DOB Sex Last First MI Month/Day/Year Applicant s Address Street or Post Office Box Apt. No. City State ZIP Code Home Telephone ( ) Business Telephone ( ) Best Time to Call Name of Applicant s Employer Department No. Employee ID No. Occupation Do you have any other life coverage, not to include group guaranteed-issue life, with Aflac New York? If yes, give current policy number: Will the purchase of this life insurance policy give you more than $250,000 total face value ($100,000 if over age 50) of life insurance coverage with Aflac New York? Is the purchase of this policy intended to replace any life insurance or annuity now in force? If yes, please read and sign the Replacement Notice provided by your agent, if applicable. NOTE: Total life coverage with Aflac New York selected for the applicant cannot exceed $250,000 ($100,000 if over age 50).Total life coverage with Aflac New York for the proposed spouse cannot exceed $50,000. CHECK COVERAGE DESIRED: Endowment to Age 100 Policy (Series NYRR63100) Automatic Premium Loan 10-Year Term Policy (Series NYR63200) 20-Year Term Policy (Series NYR63300) Spouse 20-Year Term Life Insurance Rider (Series NYR63056) 30-Year Term Policy (Series NYR63500) Spouse 30-Year Term Life Insurance Rider (Series NYR63057) Issue Ages Total Number of Units Face Amount of Insurance *Insurance coverage is based on the number of units you select. Total number of units are limited as follows: 2 to 50 units at $5,000 per unit if age 50 or under 2 to 20 units at $5,000 per unit if age 51 or older The optional spouse rider coverage equals $2,500 per unit. The term and number of units of the optional spouse rider coverage must match the Proposed Insured s coverage, not to exceed 20 units. Exception: If the spouse does not qualify by age for the matching term, he or she may apply for a 10-year term rider, if eligible. Form NYR63001R Page 1 of 7 NYR63001R.3

2 Optional Rider for the Applicant Only Accidental-Death Benefit Rider (Form NYR63052) Optional Rider (available with whole life or term policies) Issue Ages Total Number of Units Child Term Life Insurance Rider (Form NYR63051) - $1,250 per unit (Total number of units must match the applicant, not to exceed 12 units.) 14 days to 17 years Amount of life insurance presently in force on applicant $ Amount of life insurance presently in force on each child under fourteen years and six months of age $ PLEASE NOTE: Your Beneficiary will be your estate unless otherwise indicated. We do not recommend that you name a minor child as your beneficiary. If you name a minor child as your beneficiary, any benefits due your minor beneficiary will not be payable until a guardian for the financial estate of the minor is appointed by the court or such beneficiary reaches the age of majority as defined by your state. We suggest you obtain legal advice before naming a minor child as your beneficiary. PRIMARY BENEFICIARY FULL NAME RELATIONSHIP DATE OF BIRTH % OF PROCEEDS CONTINGENT BENEFICIARY FULL NAME RELATIONSHIP DATE OF BIRTH % OF PROCEEDS Have you used tobacco products or products containing nicotine of any type in the last 12 months? Has your spouse, if applying for coverage, used tobacco products or products containing nicotine of any type in the last 12 months? Billing Method: Mode: Payroll Deduction 01 Weekly 01 Semimonthly 06 Semiannual Day Biweekly 01 Monthly 12 Annual Day Biweekly 03 Quarterly Billable Premium $ Premium Collected $ COMPLETE QUESTIONS 1 13 N/A 1. Are you, the applicant, actively employed with the employer listed on this application? 2. Have you, the applicant, been actively employed and working on a full-time basis with any employer for the last three consecutive months? If you answered "no" to s 1 and/or 2, a policy will not be issued; therefore, do not submit this application. 3. To the best of your knowledge and belief, in the last year, have you or anyone to be covered been declined or postponed for medical reasons on any life insurance application? Form NYR63001R Page 2 of 7 NYR63001R.3

3 4. To the best of your knowledge and belief, have you or anyone to be covered ever been treated with dialysis; been diagnosed with end-stage renal (kidney) disease, chronic renal failure (CRF), renal or pulmonary hypertension, congestive heart failure (CHF), cardiomyopathy, chronic or relapsing pancreatitis, or cirrhosis of the liver; been diagnosed or treated for AIDS by a member of the medical profession; or been diagnosed as having a terminal condition? 5. To the best of your knowledge and belief, have you or anyone to be covered ever been diagnosed with or received treatment by a member of the medical profession for Type I diabetes; Type II diabetes under age 30; Type II diabetes with complications to include retinopathy, neuropathy, or nephropathy; or Type II diabetes requiring insulin within the last five years? 6. To the best of your knowledge and belief, have you or anyone to be covered ever been diagnosed with or received treatment by a member of the medical profession for a heart attack prior to age 40; coronary artery disease involving more than two vessels; been advised to have heart valve replacement; or been diagnosed with or treated for heart-related chest pains within the last 12 months? 7. To the best of your knowledge and belief, have you or anyone to be covered ever had or been advised to have an organ transplant, or consulted with or been evaluated by a member of the medical profession about the need to have an organ transplant? 8. To the best of your knowledge and belief, in the last five years, have you or anyone to be covered been diagnosed with or treated for internal cancer, leukemia, melanoma (Clark s Level III or higher), stroke, alcohol or drug abuse, liver disease other than hepatitis A, multiple sclerosis, or systemic lupus? 9. To the best of your knowledge and belief, in the last five years, have you or anyone to be covered been diagnosed with major depression, bipolar disorder, or schizophrenia, or been hospitalized within the last 12 months for any mental or nervous disorder? 10. To the best of your knowledge and belief, in the last three years, have you or anyone to be covered been diagnosed with or treated for a transient ischemic attack (TIA), pulmonary fibrosis, emphysema, or chronic lung disease (excluding asthma)? 11. To the best of your knowledge and belief, in the last five years, have you or anyone to be covered been convicted of a felony or been convicted two or more times of operating a vehicle while under the influence of alcohol or drugs? 12. To the best of your knowledge and belief, within the last 12 months, have you or anyone to be covered been convicted of operating a vehicle while under the influence of alcohol or drugs, or do you or anyone to be covered currently have a suspended or revoked driver s license? If you answered "yes" to any of s 3 12, was it the: Applicant Spouse Child? If child, please list the name(s) of the child(ren) If the person named is the applicant, then a policy will not be issued; therefore, do not submit this application. If the person(s) so named is the spouse or a child, then that person is not eligible to be covered under the policy or any Rider(s). 13. To the best of your knowledge and belief, in the last two years, have you or anyone to be covered been hospitalized two or more times or had surgery recommended that has not yet been performed? PLEASE COMPLETE QUESTIONS IF YOU ANSWERED YES TO QUESTION 13 OR IF THE PURCHASE OF THIS COVERAGE WILL RESULT IN YOU OR YOUR SPOUSE (IF APPLICABLE) HAVING $50,000 OR MORE OF TOTAL LIFE COVERAGE WITH AFLAC NEW YORK. 14. To the best of your knowledge and belief, have you or anyone to be covered ever been diagnosed with or treated for a heart disease or disorder (including congenital), high blood pressure (hypertension), lupus, Crohn s disease, ulcerative colitis, diabetes, kidney disease, respiratory or neurological disorder or disease, depression, or a tumor? Form NYR63001R Page 3 of 7 NYR63001R.3

4 15. To the best of your knowledge and belief, in the last five years, have you or anyone to be covered missed five consecutive days of work due to sickness (not including days missed due to childbirth)? 16. To the best of your knowledge and belief, in the last five years, have you or anyone to be covered been treated or had surgery at a medical facility as an inpatient or outpatient (not including treatment or surgery due to childbirth)? 17. Details to s (attach an additional sheet of paper, if necessary) Name of Individual(s) Medical Condition(s) Onset (mo/yr) Surgery Performed or Recommended? (If yes, provide the type of procedure and date.) 13 For Hypertension and Diabetes, List the Average Reading (for the last three months) To the best of your knowledge and belief, within the last six weeks, have you or anyone to be covered been prescribed or taken any medication recommended by a Physician (not including prescription contraceptives)? If yes, please provide complete information below: (attach an additional sheet of paper, if necessary) Name of Individual(s) Name of Medication Frequency of Intake Date First Prescribed Medical Condition Taken For 19. Your Physician's Name Phone Number (if no regular Physician, Physician last seen) Address Date Last Seen by Physician Reason for Last Visit Based on Your Answers Above, Additional Underwriting May Be Required. Form NYR63001R Page 4 of 7 NYR63001R.3

5 APPLICANT'S STATEMENTS AND AGREEMENTS I understand that the Effective Date of the policy will be the date recorded in the Policy Schedule by Aflac New York s Home Office. I acknowledge receipt of, if applicable: Replacement Notice Life Buyer s Guide I understand that: (1) the policy of insurance I am now applying for will be issued based upon the written answers to the questions and information asked for in this application and any other pertinent information Aflac New York may require for proper underwriting; (2) Aflac New York is not bound by any statement made by me or any agent of Aflac New York, unless written herein; (3) the agent cannot change the provisions of the policy or waive any of its provisions either orally or in writing; (4) the policy, together with this application, any attached Riders, and any attached amendments, if any, constitutes the entire contract of insurance; and (5) no change to the policy will be valid until approved by Aflac New York s secretary and president and noted in or attached to the policy. NOTICE TO PERSONS APPLYING FOR INSURANCE REGARDING INVESTIGATIVE CONSUMER REPORT In connection with this application, an investigative consumer report may be prepared about you. Such reports are part of the process of evaluating risks for life and health insurance. Typically, this report will contain information about your character, general reputation, personal characteristics and mode of living. The information in the report may be obtained by talking with you or members of your family, business associates, financial sources, neighbors, and others you know. You may ask to be interviewed in connection with the preparation of any such report. Also, we may have the report updated if you apply for more coverage. Upon your written request, we will let you know whether a report was prepared and we will give you the name, address, and telephone number of the agency preparing the report. By contacting that agency and providing proper identification, you may obtain a copy of the report. Form NY0312 Third Party Notification (OPTIONAL) I request that a notice of cancellation for nonpayment of premium be provided to the person designated below. I elect NOT to designate any person to receive this notice. Last Name First Name MI Street/P.O. Box City State Zip Code I understand that I have the right to designate at least one (1) person other than myself to receive notice of lapse or termination of this life insurance policy for nonpayment of premium. I understand that notice will not be given until thirty (30) days after a premium is due and unpaid. Proposed Insured's Signature: X Date AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION I authorize the following to give information (as defined below) to American Family Life Assurance Company of New York (Aflac New York) or any person or entity acting on its part: any medical professional, medical care institution, insurer (including Aflac New York, with respect to other Aflac New York coverages), reinsurer, government agency (including departments of public safety and motor vehicle departments), MIB, Inc., formerly known as the Medical Information Bureau, consumer reporting agency, or employer. Information means facts or opinions relating to my past, present, or future physical or mental health or condition (excluding psychotherapy notes, drug and alcohol abuse records), employment, other insurance coverage, driving record, or any other medical or nonmedical facts that Aflac New York deems appropriate to determine eligibility for insurance or to evaluate a claim for benefits during the time this authorization is valid. I also authorize Aflac New York to give information to MIB, Inc. Form NYR63001R Page 5 of 7 NYR63001R.3

6 I understand that any disclosure of health information to Aflac New York for the purpose of determining eligibility for coverage other than health plan coverage means the information may no longer be protected by federal privacy regulations. I further understand, however, that such information may be redisclosed only in accordance with other applicable laws or regulations. I understand that this information will be used by Aflac New York for enrollment or to determine eligibility for insurance or for underwriting or risk rating (where applicable) purposes and, should coverage be issued, the information, if indicative of any material misstatement, may be used to contest a claim for benefits or the issuance of the policy itself during the contestability period provided in the policy. If any of the information indicates that you have made a material misstatement in your application, then we may use that information to contest your policy during the contestability period set forth in the policy. I understand that Aflac New York is conditioning the issuance of coverage on the provision of this authorization, and that, while I may refuse to sign this authorization, my refusal to do so could result in coverage not being issued. I understand that I may revoke this authorization at any time, except to the extent that Aflac New York has taken action in reliance on this authorization. My revocation must be submitted in writing to Aflac New York, Attn: Policy Service, 22 Corporate Woods Boulevard, Suite 2, Albany, New York Unless otherwise revoked, I agree that this authorization will expire on the earlier of the date Aflac New York notifies me of its declination of my application for coverage or, if a policy is issued, two years from the policy effective date. I agree that a copy of this authorization is as valid as the original. INFORMATION REGARDING THE MEDICAL INFORMATION BUREAU (MIB) PRENOTICE Information regarding your insurability will be treated as confidential. Aflac New York may, however, make a brief report thereon to MIB, Inc., formerly known as the Medical Information Bureau, 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, MIB, upon request, will supply such company with the information in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact MIB toll-free at (TTY ). 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 MIB s information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts Aflac New York may also release information in its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its web site at Form NY0308 NOTICE REGARDING ACCELERATED PAYMENT OF DEATH BENEFIT The policy for which you are applying contains an accelerated death benefit provision. There is no additional premium for this accelerated death payment provision. An administrative charge of $150 will be applied against any accelerated death benefit paid. RECEIPT OF ACCELERATED DEATH BENEFITS MAY AFFECT YOUR ELIGIBILITY FOR PUBLIC ASSISTANCE PROGRAMS AND MAY BE TAXABLE. I have read, or had read to me, the completed application, which will be attached to and made a part of the policy. I realize that policy issuance is based upon statements and answers provided herein, and they are complete and true to the best of my knowledge and belief. All statements made in this application are deemed representations and not warranties. I realize that any material misrepresentation therein may result in loss of coverage under the policy. I understand that the premium amount listed on this application represents the premium amount that my employer will remit to Aflac New York on my behalf, and I further understand that this amount, because of my employer's billing/payroll practices, may differ from the amount being deducted from my paycheck or the premium amount quoted to me by my agent. Signed and Dated at City and State on Date Applicant's Signature (X) Form NYR63001R Page 6 of 7 NYR63001R.3

7 I certify that I personally saw the applicant when the application was completed, and each question was asked of the applicant and answered as recorded. All answers are correct to the best of my knowledge and belief. To the best of my knowledge and belief, this policy will will not replace or change any existing life insurance or annuity policy(ies). Agent s Signature Date Agent's Writing Number Sit. Code MAKE CHECKS PAYABLE TO AFLAC NEW YORK. FOR INFORMATION, CALL TOLL-FREE VISIT OUR WEB SITE AT Form NYR63001R Page 7 of 7 NYR63001R.3