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To Apply: Send this completed form with your premium check payable to: ADMINISTRATOR SPJ GROUP INSURANCE PROGRAM P.O. Box 10374 Des Moines, IA 50306-8812 QUESTIONS? 1-800-503-9230 customerservice.service@mercer.com Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Society of Professional Journalists G-19430 FL Group Policy No. G-201,230 10/14 AG-10862 14332/27682/ 1018/51857 0000001-0000001-0000691

Please answer these brief questions. Member Spouse 1. Has the applicant/member or spouse, if applying, ever been diagnosed with, or been treated for: chest pain; disease or disorder of the heart, liver, kidneys, blood or lungs; high blood pressure; stroke or other neurological disorder; mental/nervous disorder; drug or alcohol abuse; diabetes; cancer or tumor by a licensed medical provider? G Yes G No G Yes G No 2. Has the applicant/member or spouse, if applying, been tested positive for exposure to the HIV infection or been diagnosed as having AIDS Related Complex (ARC) or Acquired Immune Deficiency Syndrome (AIDS) caused by HIV infection or other sickness or condition derived from such infection? G Yes G No G Yes G No 3. Has the applicant/member or spouse, if applying, during the past 5 years, consulted a licensed medical provider or been confined or treated in any hospital or similar institution, for any reason other than those stated above? G Yes G No G Yes G No 4. Has the applicant/member or spouse, if applying, used tobacco or nicotine in any form during the past 12 months? G Yes G No G Yes G No 5. Is the applicant/member or spouse, if applying, now taking prescription medication or receiving medical attention? G Yes G No G Yes G No 6. Has the applicant/member or spouse, if applying, ever had life or health insurance declined, modified, or rated? G Yes G No G Yes G No For "Yes" answers to questions 1-6 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" in the box at the right G Yes G No *00000001000* G-19430 FL Group Policy No. G-201,230 10/14 AG-10862 0000002-0000001-0000691

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., 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. *Wherever the term spouse appears will read as Domestic Partner throughout the application. **Dependent Child must be unmarried, up to 23 years of age if a full-time student (subject to state variations). All dependents must be dependent in accordance with IRS guidelines. Important Notice: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Date Date Member/Applicant's Signature Spouse/Domestic Partner's Signature G-19430 FL! Group Policy No. G-201,230 10/14 AG-10862 0000003-0000001-0000691

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Group Policy No. G-201,230 10/14 AG-10862 0000005-0000001-0000691

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FOR SPJ MEMBERS AND THEIR FAMILIES 0000011-0000001-0000691

Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 10374 Des Moines, IA 50306-8812 Administered by: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 10374 Des Moines, IA 50306-8812 Questions? 1-800-503-9230 http://www.personal-plans.com/spj AR Ins. Lic. #100102691 CA Ins. Lic. #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC TX Ins. Lic. #1850385 Underwritten MN #40291395 By: OK #100100336 The United States Life Insurance Company in Underwritten the City of By: New York 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 www.americangeneral.com/ratings. Policies are issued by The United States Life Insurance Company in the City of New York (all states). The United States Life Insurance Company in the City of New York is responsible for the financial obligations of insurance products it issues and is a member of American International Group, Inc. (AIG) If applicable, an additional $2 billing fee will be included on your billing notice payable to the administrator. To save the fee, select Electronic Funds Transfer (EFT) as a safe and secure payment option. *00050001000* This brochure is a brief summary of benefits only and is subject to terms, conditions, limitations and exclusions of Group Policy Number G-201,230, Form No. G-19000. Coverage may vary or may not be available in all states. Copyright 2015 Mercer LLC. All rights reserved. 0000012-0000001-0000691

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