5Star Life application guide.

Spouse enrollment, when elected

Original page 3

Application fields

• first name
• last name
• DOB
• gender
• coverage amount
• one primary beneficiary name/relationship at100%

Policy and agent information

Original page 3

Application fields

• effective date
• signature date
• group number
• group situs state
• agent numbers and split percentages, maximum4 agents

Employee information

Original page 4

Application fields

• date of hire
• last name
• first name
• DOB
• SSN
• gender
• phone (printed optional)
• address
• city/state/ZIP

Employee coverage, when elected

Original page 4

Application fields

• coverage amount
• occupation class
• up to4 primary beneficiaries: name/percentage/relationship, total100%
• one contingent beneficiary: name/relationship at100%

Statement of Insurability

Original page 5

Application fields

• employer/group name
• employee/owner name
• SSN
• separate employee/spouse yes/no answers

Question topics

• I: five-year AIDS/related complex/immune-system disorder diagnosis, treatment or medication
• II: six-month inability to work, personal/medical walking/bathing/dressing assistance or confinement/hospitalization; retain exclusions and hospitalization definition
• III: twelve-month recommended diagnostic testing, surgery or hospitalization incomplete, or results not received
• IV A: five-year listed heart, stroke, cancer, lung/chronic respiratory, insulin-diabetes, liver or kidney conditions; retain oxygen/asthma qualifications
• IV B: two or more DUI convictions
• IV C: alcohol/drug dependency treatment/counseling or advice to reduce/discontinue alcohol
• V: life insurance applied for and rejected within ten years

Conditions, authorization and signatures

Original page 6

Application fields

• personal employee/certificate-owner signature
• employee date/city/state
• separate spouse signature if spouse coverage elected
• spouse date/city/state