CUSTOMER SERVICE

315-451-8180

9:00AM – 5:30PM EST www.nilife.com

Policy Service Request — Form L-7 NY Use this form to make a change in your name, address, or beneficiary designation. Make certain the insured’s name and all affected policy numbers appear at the top of the form and that all information is clearly printed in full detail. Do not send your policy with the completed change form. Any other changes or inquiries can be requested by sending us your written instructions or by emailing our office at: [email protected].

Bank Draft Authorization — Form AG-2032 NY If you change banks or wish to begin using the pre-authorized payment plan, you must sign the form in the area marked by an “x”. Return the completed authorization form and voided check from the account you want drafted.

Accident & Health Claims — Form C-5 NY Part A: All questions are to be completed by the claimant. Be sure to sign and date the bottom of the form. Part B: If a claim is presented in first two (2) years of policy activation, please complete all fields. Part C: To be completed by your employer if your policy provides benefits for loss of time from work. Note: If your policy includes hospital benefits, include the itemized hospital bill with the claim form.

Life Claims — Form C-30 NY The proof of death claim form consists of the Claimant’s Statement, which must be completed by the named beneficiary. A copy of the death certificate or other proof of death should be attached to and accompany the proof of death claim form. In certain, limited instances the Company may also request a certified death certificate or a physician’s statement from the physician who treated the insured during his or her last illness if coverage has been in effect two years or less.

315-451-8180 • www.nilife.com PO Box 5009 • Syracruse, NY 13220

What Comes Next

First, we would like to commend you for taking the first steps in making sure your family has the insurance it needs. Second, we would like to take a moment to go over the next few steps in the process. Tomorrow: Your premium of will be deducted from your account. This should post to your account in the next one to five days. If it has not posted within five business days, please call us so we can check the status of the premiums. Next 7 days: You will receive a call from the National Income Life Service Center to verify all the information on the application and to see if you have any questions. 6-8 weeks: Your insurance application will be underwritten. During this time you will still see the deductions from the account you chose, as you are covered by the conditional receipt in your folder. Also, please read over the sheet in your folder that explains the underwriting process more thoroughly. After you have been approved, you will receive your policy in the mail. If for any reason your policy is not issued as originally applied for, your agent will contact you to discuss any changes. Again, we congratulate you for taking steps to ensure your family has the insurance it needs. If we can be of any assistance, please never hesitate to call or email us. We are here to serve you and make sure we follow through with the expectations your organization and/or family has come to expect of us.

Customer Name (please print) Customer Signature Date

Agent Name Office Phone Office Email

AG-2612 NY (R2-22)

National Income Life Insurance Company P.O. Box 5009 Syracuse, New York 13220

Summary Applicant’s Name______________________________________________________________ Date_____________________ Insured’s Whole Life Insurance

Premium

Freedom of Choice/Final Expense Benefit

$ _____________________________ $ ________________

Cash Value per 1000: After 10 Years _____ After 20 Years _____ $ _____________________________ $ ________________

Insured’s Term Insurance- Lump Sum or  Beneficiary’s Readjustment Income (if elected at time of Insured’s death)

or $ _______________monthly for ______________ months

Spouse’s Whole Life Insurance Freedom of Choice/Final Expense Benefit

$ _____________________________ $ ________________

Cash Value per 1000: After 10 Years _____ After 20 Years _____ Spouse’s Term Insurance

$ _____________________________ $ ________________

Children’s Natural Death (natural, step, or legally adopted children are eligible) $ ______________ Per Covered Child $ ________________ Accidental Death

Auto Death

Common Carrier Death

Insured’s

$________________________

$________________________

$________________________

Spouse’s

$________________________

$________________________

$________________________

Children’s

$________________________

$________________________

$________________________

Hospital Benefits (from accident)

$ ___________________________ per day (up to 365 days)

Intensive Care (from accident)

$ ___________________________ per day (up to 14 days)

$ ________________

Emergency Accident Benefit Rider (for treatment received within 72 hours of accidental injury)

Up To $________________________

$________________

Additional Benefits 1. Lay-off and Strike Waiver of Premium* 2. __________________________________________________________________________________________________ 3. __________________________________________________________________________________________________ 4. __________________________________________________________________________________________________ Policy loan interest rate is 8% per year, fixed, payable in arrears. What I like best about the insurance program: ______________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Organization ______________________________________ Premium $ ___________________________ per ____________ From:

Checking or

Savings (Check One)

Your Representative _______________________________________ Phone (_____)_________________________________ Local Agency Office: Address ___________________________________________________________ Agent Code # _______ A complete policy summary with cost data will be delivered with your policy. If you decide not to keep the policy, you may return it within 10 days after you receive it. * Receipt of Lay-off and Strike Waiver of Premium benefits may be considered taxable income.

Read your policy(s) carefully when received and contact us if you have questions. Service is Our Commitment AG-2324 (R7-12) NY

IMPORTANT Information & Instructions

Family Information Guide i

This kit should be kept in a safe place at home. DO NOT KEEP IN A SAFE DEPOSIT BOX

Vital Statistics

FAMILY INFORMATION GUIDE

First Name ___________________________________________ Last Name ___________________________________________ Date of birth __________________________________________ Place of birth _________________________________________ Social Security

___ ___ ___ - ___ ___ - ___ ___ ___ ___

Birth Certificate Location_________________________________

CONTACT INFORMATION Email ______________________________________________

Phone ______________________________________________

City ________________________________________________

State __________________ Zip __________________________

Employed

Retired

Date Retired _________________________________________

Employer____________________________________________

Supervisor___________________________________________

Address ____________________________________________

Phone ______________________________________________

City _______________________________________________

State __________________ Zip _________________________

Additional Information ________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________

Spouse Vital Statistics MARITAL STATUS

Single

Divorced

Separated

Married

Widowed

Domestic Partner

First Name ___________________________________________ Last Name ___________________________________________ Date of birth __________________________________________ Place of birth _________________________________________ Social Security

___ ___ ___ - ___ ___ - ___ ___ ___ ___

Veterans Information Service Number ______________________________________

VA Claim Number _____________________________________

Branch of Service _____________________________________

Name of War _________________________________________

Enlistment Dates _____________ to _____________________

Place of Enlistment ____________________________________

Rank / Rate at discharge ________________________________ Place of Discharge ____________________________________ VGLI Policy Number ___________________________________

Discharge papers

Home

Other

Policy Amount ________________________________________

Location _____________________________________________

Persons To Be Notified

FAMILY INFORMATION GUIDE

In the event of an emergency, please notify the following people immediately FAMILY NOTIFICATION LIST

1

2

3

4

Main Contact ________________________________________

Relationship __________________________________________

Sig. Other ___________________________________________

Phone ______________________________________________

City ________________________________________________

State __________________ Zip __________________________

Name _______________________________________________ Relationship __________________________________________ Sig. Other ___________________________________________

Phone ______________________________________________

City ________________________________________________

State __________________ Zip __________________________

Name _______________________________________________ Relationship __________________________________________ Sig. Other ___________________________________________

Phone ______________________________________________

City ________________________________________________

State __________________ Zip __________________________

Name _______________________________________________ Relationship __________________________________________ Sig. Other ___________________________________________

Phone ______________________________________________

City ________________________________________________

State __________________ Zip __________________________

ADDITIONAL EMERGENCY CONTACTS - friends, neighbors, co-workers, etc

1

2

3

4

Name _______________________________________________ Relationship __________________________________________ Sig. Other ___________________________________________

Phone ______________________________________________

City ________________________________________________

State __________________ Zip __________________________

Name _______________________________________________ Relationship __________________________________________ Sig. Other ___________________________________________

Phone ______________________________________________

City ________________________________________________

State __________________ Zip __________________________

Name _______________________________________________ Relationship __________________________________________ Sig. Other ___________________________________________

Phone ______________________________________________

City ________________________________________________

State __________________ Zip __________________________

Name _______________________________________________ Relationship __________________________________________ Sig. Other ___________________________________________

Phone ______________________________________________

City ________________________________________________

State __________________ Zip __________________________

Living Trust

FAMILY INFORMATION GUIDE

Trust Location _______________________________________

Last Update __________________________________________

Trustee _____________________________________________

Relationship _________________________________________

Phone ______________________________________________

City, State ___________________________________________

Attorney ____________________________________________

Firm ________________________________________________

Phone ______________________________________________

City, State ___________________________________________

Last Will & Testament Will Location _________________________________________

Last Update __________________________________________

Executor ____________________________________________

Relationship _________________________________________

Phone ______________________________________________

City, State ___________________________________________

Attorney ____________________________________________

Firm ________________________________________________

Phone ______________________________________________

City, State ___________________________________________

LIFE INSURANCE

HEALTH / MEDICAL

Insurance Policies Company _________________________________________ Health

Disability

Accidental

Other

Company _________________________________________ Health

Disability

Accidental

Other

Company _________________________________________

Policy # ____________________________________________ Coverage Amount/Type ________________________________

Policy # ____________________________________________ Coverage Amount/Type ________________________________

Policy # _____________________________________________

Group

Accident

Coverage Amount _____________________________________

Whole

Term

Term Expiration Date ___________________________________

Company _________________________________________

Policy # _____________________________________________

Group

Accident

Coverage Amount _____________________________________

Whole

Term

Term Expiration Date ___________________________________

Company _________________________________________

Policy # _____________________________________________

Group

Accident

Coverage Amount _____________________________________

Whole

Term

Term Expiration Date ___________________________________

Digital Accounts

FAMILY INFORMATION GUIDE

Social Accounts Legacy Contact ______________________________________________________________________________ Recovery Email Address _______________________________

Password___________________________________________

FACEBOOK

Username ____________________________ Password __________________________________________

TWITTER

Username ____________________________

Password __________________________________________

LINKEDIN

Username_____________________________

Password __________________________________________

INSTAGRAM Username_____________________________ Password __________________________________________

CEMETERY

FUNERAL

PREFERENCES

Funeral Instructions Burial

Cremation

Mausouleum

Funeral Home _____________________________________

Church Denomination __________________________________

Chapel ___________________________________________

Minister _____________________________________________

Mass

Yes

Rosary

SERVICE

Church

No

Yes

Funeral Home

No

Private Home

Name / Location of Service___________________________________________________________________________________ Address ___________________________________________

Phone ____________________________________________

City ______________________________________________

State __________________ Zip ________________________

Name / Location of Cemetery_________________________________________________________________________________ Address ___________________________________________

Phone _____________________________________________

City ______________________________________________

State __________________ Zip ________________________

I have reserved facilities

VETERANS

I have not reserved facilities

National

State

Private

Location ______________________________________________________+++++______________________________________

In the event of death, handle final expenses and arrangements with my FREEDOM OF CHOICE certificate Call 315-451-8180 or email [email protected] with the following information Policy Number ________________________________________ Coverage Amount _____________________________________ FREEDOM OF CHOICE Certificate Location______________________________________________________________________

Signature ___________________________________________

Date ________________________________________________

FREEDOM OF CHOICE   Funeral Benefit Plan (life insurance)

offered by National Income Life Insurance Company

Choice of Funeral Home Attention: Funeral Director

Please fax the signed form to 254-741-5705. For questions, call 315-451-8180 or email [email protected].

Agent’s Signature

AG-2077 NY (R3-22)

ASSIGNMENT I hereby assign $

of life insurance policy # Policy Number

Amount

with National Income Life Insurance Company to Print Name

in connection with my contract with the assignee dated

Dated this

day of

Date



.

Month/Year



Witness Beneficiary Name

Beneficiary Address



PO Box 5009 Syracuse, NY 13220 NILife.com

NATIONAL INCOME LIFE INSURANCE COMPANY c/o National Income Life Service Center P. O. Box 2608, Waco, TX 76702

www.nilife.com

Dear Policyholder, Everyone likes to save time and money and we want to help you do just that. By authorizing us to automatically withdraw your premium from your checking account, you may be able to enjoy a slight reduction in your premium and save on postage. It is convenient, saves you time, and could possibly save checking fees at your bank. If you wish to have your premium deducted automatically, please complete the form below, sign in the area marked with an X, and send it to our office at the address above along with a voided check from your account. Please include the date you would like the premium to be drafted each month. If no date is noted on the form, we will withdraw your premium on the Policy's Due Date every month. Please include all Policy Numbers on the form for which you would like to have premiums drafted each month.

AUTHORIZATION FOR PREAUTHORIZED PAYMENTS National Income Life Insurance Company is authorized to initiate debit entries to the account indicated below, and the depository institution named below is authorized to debit the same to such account. This authority can be terminated by the undersigned at any time by written notification to the Company, provided only that the Company and the depository will have a reasonable opportunity to act on such notification. Depository Name Address Transit/ABA No. Type of Account:

Account No. Checking

Savings

Requested draw date, if any:

X

Signature of Payor Name of Insured Policy Number(s) of Existing Policies

Date ,

,

,

PLEASE ATTACH A VOIDED PERSONAL CHECK AG-2032 NY (R19)

numbers used in an illustration. Each index is useful in some ways, but they all have shortcomings. Ask your agent which will be most helpful to you. Regardless of which index you use, compare index numbers only for similar policies — those that offer basically the same benefits, with premiums payable for the same length of time. Remember that no one company offers the lowest cost at all ages for all kinds and amounts of insurance. You should also consider other factors: • How quickly does the cash value grow? Some policies have low cash values in the early years that build quickly later on. Other policies have a more level cash value build-up. A year-by-year display of values and benefits can be very helpful. (The agent or company will give you a policy summary or an illustration that will show benefits and premiums for selected years.) • A  re there special policy features that particularly suit your needs? • H  ow are nonguaranteed values calculated? For example, interest rates are important in determining policy returns. In some companies, increases reflect the average interest earnings on all of that company’s policies regardless of when issued. In others, the return for policies issued in a recent year, or a group of years, reflects the interest earnings on that group of policies; in this case, amounts paid are likely to change more rapidly when interest rates change.

LIFE INSURANCE BUYER’S GUIDE This guide can help you when you shop for life insurance. It discusses how to: •F  ind a Policy That Meets Your Needs and Fits Your Budget • Decide How Much Insurance You Need •M  ake Informed Decisions When You Buy A Policy Prepared by the National Association of Insurance Commissioners The National Association of Insurance Commissioners is an association of state insurance regulatory officials. This association helps the various Insurance departments to coordinate insurance laws for the benefit of all consumers. This Guide Does Not Endorse Any Company or Policy

Reprinted by National Income Life Insurance Co. P.O. Box 5009, Syracuse, NY 13220 www.nilife.com

BG-31 NY

Important Things To Consider

1. R  eview your own insurance needs and circumstances. Choose the kind of policy that has benefits that most closely fit your needs. Ask an agent or company to help you. 2. Be sure that you can handle premium payments. Can you afford the initial premium? If the premium increases later and you still need insurance, can you still afford it? 3. Don’t sign an insurance application until you review it carefully to be sure all the answers are complete and accurate. 4. Don’t buy life insurance unless you intend to stick with your plan. It may be very costly if you quit during the early years of the policy. 5. Don’t drop one policy and buy another without a thorough study of the new policy and the one you have now. Replacing your insurance may be costly. 6. Read your policy carefully. Ask your agent or company about anything that is not clear to you. 7. Review your life insurance program with your agent or company every few years to keep up with changes in your income and your needs.

Buying Life Insurance When you buy life insurance, you want coverage that fits your needs. First, decide how much you need — and for how long — and what you can afford to pay. Keep in mind the major reason you buy life insurance is to cover the financial effects of unexpected or untimely death. Life insurance can also be one of many ways you plan for the future. Next, learn what kinds of policies will meet your needs and pick the one that best suits you. Then, choose the combination of policy premium and benefits that emphasizes protection in case of early death, or benefits in case of long life, or a combination of both.

It makes good sense to ask a life insurance agent or company to help you. An agent can help you review your insurance needs and give you information about the available policies. If one kind of policy doesn’t seem to fit your needs, ask about others. This guide provides only basic information. You can get more facts from a life insurance agent or company or from your public library.

What About the Policy You Have Now?

If you are thinking about dropping a life insurance policy, here are some things you should consider: • If you decide to replace your policy, don’t cancel your old policy until you have received the new one. You then have a minimum period to review your new policy and decide if it is what you wanted. • It may be costly to replace a policy. Much of what you paid in the early years of the policy you have now, paid for the company’s cost of selling and issuing the policy. You may pay this type of cost again if you buy a new policy. • Ask your tax advisor if dropping your policy could affect your income taxes. • If you are older or your health has changed, premiums for the new policy will often be higher. You will not be able to buy a new policy if you are not insurable. • You may have valuable rights and benefits in the policy you now have that are not in the new one. • If the policy you have now no long meets your needs, you may not have to replace it. You might be able to change your policy or add to it to get the coverage or benefits you now want. • At least in the beginning, a policy may pay no benefits for some causes of death covered in the policy you have now. In all cases, if you are thinking of buying a new

numbers used in an illustration. Each index is useful in some ways, but they all have shortcomings. Ask your agent which will be most helpful to you. Regardless of which index you use, compare index numbers only for similar policies — those that offer basically the same benefits, with premiums payable for the same length of time. Remember that no one company offers the lowest cost at all ages for all kinds and amounts of insurance. You should also consider other factors: • How quickly does the cash value grow? Some policies have low cash values in the early years that build quickly later on. Other policies have a more level cash value build-up. A year-by-year display of values and benefits can be very helpful. (The agent or company will give you a policy summary or an illustration that will show benefits and premiums for selected years.) • A  re there special policy features that particularly suit your needs? • H  ow are nonguaranteed values calculated? For example, interest rates are important in determining policy returns. In some companies, increases reflect the average interest earnings on all of that company’s policies regardless of when issued. In others, the return for policies issued in a recent year, or a group of years, reflects the interest earnings on that group of policies; in this case, amounts paid are likely to change more rapidly when interest rates change.

LIFE INSURANCE BUYER’S GUIDE This guide can help you when you shop for life insurance. It discusses how to: •F  ind a Policy That Meets Your Needs and Fits Your Budget • Decide How Much Insurance You Need •M  ake Informed Decisions When You Buy A Policy Prepared by the National Association of Insurance Commissioners The National Association of Insurance Commissioners is an association of state insurance regulatory officials. This association helps the various Insurance departments to coordinate insurance laws for the benefit of all consumers. This Guide Does Not Endorse Any Company or Policy

Reprinted by National Income Life Insurance Co. P.O. Box 5009, Syracuse, NY 13220 www.nilife.com

BG-31 NY

Important Things To Consider

1. R  eview your own insurance needs and circumstances. Choose the kind of policy that has benefits that most closely fit your needs. Ask an agent or company to help you. 2. Be sure that you can handle premium payments. Can you afford the initial premium? If the premium increases later and you still need insurance, can you still afford it? 3. Don’t sign an insurance application until you review it carefully to be sure all the answers are complete and accurate. 4. Don’t buy life insurance unless you intend to stick with your plan. It may be very costly if you quit during the early years of the policy. 5. Don’t drop one policy and buy another without a thorough study of the new policy and the one you have now. Replacing your insurance may be costly. 6. Read your policy carefully. Ask your agent or company about anything that is not clear to you. 7. Review your life insurance program with your agent or company every few years to keep up with changes in your income and your needs.

Buying Life Insurance When you buy life insurance, you want coverage that fits your needs. First, decide how much you need — and for how long — and what you can afford to pay. Keep in mind the major reason you buy life insurance is to cover the financial effects of unexpected or untimely death. Life insurance can also be one of many ways you plan for the future. Next, learn what kinds of policies will meet your needs and pick the one that best suits you. Then, choose the combination of policy premium and benefits that emphasizes protection in case of early death, or benefits in case of long life, or a combination of both.

It makes good sense to ask a life insurance agent or company to help you. An agent can help you review your insurance needs and give you information about the available policies. If one kind of policy doesn’t seem to fit your needs, ask about others. This guide provides only basic information. You can get more facts from a life insurance agent or company or from your public library.

What About the Policy You Have Now?

If you are thinking about dropping a life insurance policy, here are some things you should consider: • If you decide to replace your policy, don’t cancel your old policy until you have received the new one. You then have a minimum period to review your new policy and decide if it is what you wanted. • It may be costly to replace a policy. Much of what you paid in the early years of the policy you have now, paid for the company’s cost of selling and issuing the policy. You may pay this type of cost again if you buy a new policy. • Ask your tax advisor if dropping your policy could affect your income taxes. • If you are older or your health has changed, premiums for the new policy will often be higher. You will not be able to buy a new policy if you are not insurable. • You may have valuable rights and benefits in the policy you now have that are not in the new one. • If the policy you have now no long meets your needs, you may not have to replace it. You might be able to change your policy or add to it to get the coverage or benefits you now want. • At least in the beginning, a policy may pay no benefits for some causes of death covered in the policy you have now. In all cases, if you are thinking of buying a new

policy, check with the agent or company that issued you the one you have now. When you bought your old policy, you may have seen an illustration of the benefits of your policy. Before replacing your policy, ask your agent or company for an updated illustration. Check to see how the policy has performed and what you might expect in the future, based on the amounts the company is paying now. How Much Do You Need? Here are some questions to ask yourself: • H  ow much of the family income do I provide? If I were to die early, how would my survivors, especially my children, get by? Does anyone else depend on me financially, such as a parent, grandparent, brother or sister? • Do I have children for whom I’d like to set aside money to finish their education in the event of my death? • How will my family pay final expenses and repay debts after my death? • Do I have family members or organizations to whom I would like to leave money? • Will there be estate taxes to pay after my death? • How will inflation affect future needs? As you figure out what you have to meet these needs, count the life insurance you have now, including any group insurance where you work or veteran’s insurance. Don’t forget Social Security and pension plan survivor’s benefits. Add other assets you have: savings, investments, real estate and personal property. Which assets would your family sell or cash in to pay expenses after your death? What Is the Right Kind of Life Insurance? All policies are not the same. Some give coverage for your lifetime and others cover you for a specific number of years. Some build up cash values and others do not. Some policies combine different kinds of insurance, and others let you change from one kind of insurance to another. Some policies may offer other benefits while you are still living. Your choice should be based on your needs and what you can afford. There are two basic types of life insurance: term insurance and cash value insurance. Term insurance generally has lower premiums in the

early years, but does not build up cash values that you can use in the future. You may combine cash value life insurance with term insurance for the period of your greatest need for life insurance to replace income. Term insurance covers you for a term of one or more years. It pays a death benefit only if you die in that term. Term insurance generally offers the largest insurance protection for your premium dollar. It generally does not build up cash value. You can renew most term insurance policies for one or more terms even if your health has changed. Each time you renew the policy for a new term, premiums may be higher. Ask what the premiums will be if you continue to renew the policy. Also ask if you will lose the right to renew the policy at some age. For a higher premium, some companies will give you the right to keep the policy in force for a guaranteed period at the same price each year. At the end of that time, you may need to pass a physical examination to continue coverage, and premiums may increase. You may be able to trade many term insurance policies for a cash value policy during a conversion period — even if you are not in good health. Premiums for the new policy will be higher than you have been paying for the term insurance. Cash Value Life Insurance is a type of insurance where the premiums charged are higher at the beginning than they would be for the same amount of term insurance. The part of the premium that is not used for the cost of insurance is invested by the company and builds up a cash value that maybe used in a variety of ways. You may borrow against a policy’s cash value by taking a policy loan. If you don’t pay back the loan and the interest on it, the amount you owe will be subtracted from the benefits when you die, or from the cash value if you stop paying premiums and take out the remaining cash value. You can also use your cash value to keep insurance protection for a limited time or to buy a reduced amount without having to pay more premiums. You also can use the cash value to increase your income in retirement or to help pay for needs such as a child’s tuition without canceling the policy. However, to build up this cash value, you must pay higher premiums in the earlier years of

the policy. Cash value life insurance may be one of several types; whole life, universal life and variable life are all types of cash value insurance. Whole Life Insurance covers you for as long as you live if your premiums are paid. You generally pay the same amount in premiums for as long as you live. When you first take out the policy, premiums can be several times higher than you would pay initially for the same amount of term insurance. But they are smaller than the premiums you would eventually pay if you were to keep renewing a term policy until your later years. Some whole life policies let you pay premiums for a shorter period, such as 20 years, or until age 65. Premiums for these policies are higher since the premium payments are made during a shorter period. Universal Life Insurance is a kind of flexible policy that lets you vary your premium payments. You can also adjust the face amount of your coverage. Increases may require proof that you qualify for the new death benefit. These premiums you pay (less expense charges) go into a policy account that earns interest. Charges are deducted from the account. If your yearly premium payment plus the interest your account earns is less than the charges, your account value will become lower. If it keeps dropping, eventually your coverage will end. To prevent that, you may need to start making premium payments, or increase your premium payments, or lower your death benefits. Even if there is enough in your account to pay the premiums, continuing to pay premiums yourself means that you build up more cash value. Variable Life Insurance is a kind of insurance where the death benefits and cash values depend on the investment performance of one or more separate accounts, which may be invested in mutual funds or other investments allowed under the policy. Be sure to get the prospectus from the company when buying this kind of policy and STUDY IT CAREFULLY. You will have higher death benefits and cash value if the underlying investments do well. Your benefits and cash value will be lower or may disappear if the investments you chose didn’t do as well as you expected. You may pay an extra premium for a guaranteed death benefit.

Life Insurance Illustrations You may be thinking of buying a policy where cash values, death benefits, dividends or premiums may vary based on events or situations the company does not guarantee (such as interest rates). If so, you may get an illustration from the agent or company that helps explain how the policy works. The illustration will show how the benefits that are not guaranteed will change as interest rates and other factors change. The illustration will show you what the company guarantees. It will also show you what could happen in the future. Remember that nobody knows what will happen in the future. You should be ready to adjust your financial plans if the cash value doesn’t increase as quickly as shown in the illustration. You will be asked to sign a statement that says you understand that some of the numbers in the illustration are not guaranteed. Finding a Good Value in Life Insurance After you have decided which kind of life insurance is best for you, compare similar policies from different companies to find which one is likely to give you the best value for your money. A simple comparison of the premiums is not enough. There are other things to consider. For example: • Do premiums or benefits vary from year to year? • H  ow much do the benefits build up in the policy? • W  hat part of the premiums or benefits is not guaranteed? • W  hat is the effect of interest on money paid and received at different times on the policy? Once you have decided which type of policy to buy, you can use a cost comparison index to help you compare similar policies. Life insurance agents or companies can give you information about several different kinds of indexes that each work a little differently. One type helps you compare the costs between two policies if you give up the policy and take out the cash value. Another helps you compare your costs if you don’t give up your policy before its coverage ends. Some help you decide what kind of question to ask the agent about the

policy, check with the agent or company that issued you the one you have now. When you bought your old policy, you may have seen an illustration of the benefits of your policy. Before replacing your policy, ask your agent or company for an updated illustration. Check to see how the policy has performed and what you might expect in the future, based on the amounts the company is paying now. How Much Do You Need? Here are some questions to ask yourself: • H  ow much of the family income do I provide? If I were to die early, how would my survivors, especially my children, get by? Does anyone else depend on me financially, such as a parent, grandparent, brother or sister? • Do I have children for whom I’d like to set aside money to finish their education in the event of my death? • How will my family pay final expenses and repay debts after my death? • Do I have family members or organizations to whom I would like to leave money? • Will there be estate taxes to pay after my death? • How will inflation affect future needs? As you figure out what you have to meet these needs, count the life insurance you have now, including any group insurance where you work or veteran’s insurance. Don’t forget Social Security and pension plan survivor’s benefits. Add other assets you have: savings, investments, real estate and personal property. Which assets would your family sell or cash in to pay expenses after your death? What Is the Right Kind of Life Insurance? All policies are not the same. Some give coverage for your lifetime and others cover you for a specific number of years. Some build up cash values and others do not. Some policies combine different kinds of insurance, and others let you change from one kind of insurance to another. Some policies may offer other benefits while you are still living. Your choice should be based on your needs and what you can afford. There are two basic types of life insurance: term insurance and cash value insurance. Term insurance generally has lower premiums in the

early years, but does not build up cash values that you can use in the future. You may combine cash value life insurance with term insurance for the period of your greatest need for life insurance to replace income. Term insurance covers you for a term of one or more years. It pays a death benefit only if you die in that term. Term insurance generally offers the largest insurance protection for your premium dollar. It generally does not build up cash value. You can renew most term insurance policies for one or more terms even if your health has changed. Each time you renew the policy for a new term, premiums may be higher. Ask what the premiums will be if you continue to renew the policy. Also ask if you will lose the right to renew the policy at some age. For a higher premium, some companies will give you the right to keep the policy in force for a guaranteed period at the same price each year. At the end of that time, you may need to pass a physical examination to continue coverage, and premiums may increase. You may be able to trade many term insurance policies for a cash value policy during a conversion period — even if you are not in good health. Premiums for the new policy will be higher than you have been paying for the term insurance. Cash Value Life Insurance is a type of insurance where the premiums charged are higher at the beginning than they would be for the same amount of term insurance. The part of the premium that is not used for the cost of insurance is invested by the company and builds up a cash value that maybe used in a variety of ways. You may borrow against a policy’s cash value by taking a policy loan. If you don’t pay back the loan and the interest on it, the amount you owe will be subtracted from the benefits when you die, or from the cash value if you stop paying premiums and take out the remaining cash value. You can also use your cash value to keep insurance protection for a limited time or to buy a reduced amount without having to pay more premiums. You also can use the cash value to increase your income in retirement or to help pay for needs such as a child’s tuition without canceling the policy. However, to build up this cash value, you must pay higher premiums in the earlier years of

the policy. Cash value life insurance may be one of several types; whole life, universal life and variable life are all types of cash value insurance. Whole Life Insurance covers you for as long as you live if your premiums are paid. You generally pay the same amount in premiums for as long as you live. When you first take out the policy, premiums can be several times higher than you would pay initially for the same amount of term insurance. But they are smaller than the premiums you would eventually pay if you were to keep renewing a term policy until your later years. Some whole life policies let you pay premiums for a shorter period, such as 20 years, or until age 65. Premiums for these policies are higher since the premium payments are made during a shorter period. Universal Life Insurance is a kind of flexible policy that lets you vary your premium payments. You can also adjust the face amount of your coverage. Increases may require proof that you qualify for the new death benefit. These premiums you pay (less expense charges) go into a policy account that earns interest. Charges are deducted from the account. If your yearly premium payment plus the interest your account earns is less than the charges, your account value will become lower. If it keeps dropping, eventually your coverage will end. To prevent that, you may need to start making premium payments, or increase your premium payments, or lower your death benefits. Even if there is enough in your account to pay the premiums, continuing to pay premiums yourself means that you build up more cash value. Variable Life Insurance is a kind of insurance where the death benefits and cash values depend on the investment performance of one or more separate accounts, which may be invested in mutual funds or other investments allowed under the policy. Be sure to get the prospectus from the company when buying this kind of policy and STUDY IT CAREFULLY. You will have higher death benefits and cash value if the underlying investments do well. Your benefits and cash value will be lower or may disappear if the investments you chose didn’t do as well as you expected. You may pay an extra premium for a guaranteed death benefit.

Life Insurance Illustrations You may be thinking of buying a policy where cash values, death benefits, dividends or premiums may vary based on events or situations the company does not guarantee (such as interest rates). If so, you may get an illustration from the agent or company that helps explain how the policy works. The illustration will show how the benefits that are not guaranteed will change as interest rates and other factors change. The illustration will show you what the company guarantees. It will also show you what could happen in the future. Remember that nobody knows what will happen in the future. You should be ready to adjust your financial plans if the cash value doesn’t increase as quickly as shown in the illustration. You will be asked to sign a statement that says you understand that some of the numbers in the illustration are not guaranteed. Finding a Good Value in Life Insurance After you have decided which kind of life insurance is best for you, compare similar policies from different companies to find which one is likely to give you the best value for your money. A simple comparison of the premiums is not enough. There are other things to consider. For example: • Do premiums or benefits vary from year to year? • H  ow much do the benefits build up in the policy? • W  hat part of the premiums or benefits is not guaranteed? • W  hat is the effect of interest on money paid and received at different times on the policy? Once you have decided which type of policy to buy, you can use a cost comparison index to help you compare similar policies. Life insurance agents or companies can give you information about several different kinds of indexes that each work a little differently. One type helps you compare the costs between two policies if you give up the policy and take out the cash value. Another helps you compare your costs if you don’t give up your policy before its coverage ends. Some help you decide what kind of question to ask the agent about the

National Income Life Insurance Company

P.O. Box 5009 Syracuse, New York 13220

315-451-8180 www.nilife.com

POLICY SERVICE REQUEST PLEASE PRINT CLEARLY

POLICIES TO BE CHANGED

Policy Number

Insured

Owner

Policy Number

Insured

Owner

Policy Number

Insured

Owner

ADDRESS CHANGE Old Address

New Address

Cell Phone

Telephone

Date Change Effective

NAME CHANGE Change name of Former Name

Insured

Owner

Premium Payor

Beneficiary

Court Order

Correction

New Name Reason for change:

Marriage

Divorce

Adoption

BENEFICIARY CHANGE

PRIMARY BENEFICIARY:

Unless otherwise specified, proceeds to be paid in equal shares to the survivor(s).

ADDRESS

RELATIONSHIP BIRTHDATE

CONTINGENT BENEFICIARY - To be paid if no surviving Primary Beneficiary at the time of death. Unless otherwise specified, proceeds to be paid in equal shares to the survivor(s).

ADDRESS

RELATIONSHIP BIRTHDATE

MISCELLANEOUS

Date

Signature of Owner

Printed Agent Name L-7 (R14) NY

Agent Signature

IT IS NOT NECESSARY TO SEND US YOUR POLICY.

Agent Number L7NY

NATIONAL INCOME LIFE INSURANCE COMPANY C/O NILICO Service Center PO BOX 2500 I Waco, TX 76702 Phone (800) 516-4466 I Fax (254) 741-5705 Web www.nilife.com I Email [email protected]

INSTRUCTIONS FOR SUBMITTING AN ACCIDENT, HEALTH OR DISABILITY WAIVER OF PREMIUM CLAIM Accident Claims - Complete Part A and Part E for all Claims, and Part B if policy is less than 2 years old.

I Include a copy of all itemized Hospital/Doctor bills and Proof of Treatment which include procedure and diagnosis codes. Cancer Claims - Complete Part A for all Claims, and complete Part B if policy is less than 2 years old. I A Pathology report must be included in the initial claim for the diagnosis of Cancer. Disability Waiver of Premium Claims - Complete Part A for all Claims, and Complete Part B if policy is less than 2 years old. I Have your Employer Complete Part C - 'Employers Statement'. I Have the doctor complete Part D - 'Attending Physician's Statement'. Submit the form yourself, Do not leave it for the doctor to submit.

Part A - To be Completed by the Insured for all Claims Policy Numbers Policyowner's Mailing Address

Policyowner's Name Policyowner's Employer Policyowner's Union and Local # (if Union member)

Policyowner's Occupation

Policyowner's Email Address

Policyowner's Phone #

Patient's Name

Patient's Date of Birth

Patient's Gender Male Female Patient's Relationship to Policyowner Does patient have any other insurance coverage which provided benefits for this claim? No Yes Self Spouse Child Other If yes, Name: 1. This Claim is in Connection with: (please check) Was patient confined to hospital due to Accident/Illness No Yes Accident Cancer Disability Waiver of Premium claim? 2 . Date of Accident/Illness 3 . Date First Treated 4 . Nature of Injury/Illness sustained & how it happened 5. Name & Address of Provider treating this condition

Release of Medical Information Authorization

I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, the Medical Information Bureau or other organization, that has any records of me or my health, to give to the National Income Life Insurance Company or its reinsurers any such information with respect to illness, injury, medical history, consultation, or treatments which include alcohol, drug or chemical dependency treatment. Information received is for the purpose of evaluating this claim and determining our liability under your existing coverage with National Income Life Insurance Company. This authorization shall remain valid for one year. You have the right to receive a copy of this authorization upon request. A photographic copy of this authorization shall be as valid as the original. Patient's Signature C-5 (R17) NY

Date Page 1 of 4

N22190

Part B - Health Information

ONLY COMPLETE IF POLICY IS LESS THAN 2 YEARS OLD List all sickness or injuries and physicians for which treatment was required in the past 5 years

Physician & Address

Date Symptoms Appeared

Condition

Part C - To be Completed by the Employer

Date of Initial Treatment

Date Diagnosed

DISABILITY WAIVER OF PREMIUM ONLY

Employee's Name

Occupation

When did sickness or accident occur?

When did he/she cease work?

If injured, how did it happen? When did employee resume any part of employee's work, supervisory or other? Company Name

Phone Number

Street Address

City

Signature of Employer

State

Zip

Date

Title C-5 (R17) NY

Page 2 of 4

Y22190

Part D - To be Completed by the Attending Physician

Patient's Name

Patient's Address

Patient's Date of Birth Diagnosis and current conditions:

(If diagnosis code other than international classification of diseases, give name)

Date of Services

Does condition arise out of patient's employment? Yes No If Condition due to pregnancy, date pregnancy commenced

REPORT OF SERVICES (or attach itemized bill) Procedural Code Description of Surgical or Medical (Give name if not Place of Services Services current terminology)

Charges

TOTAL CHARGES IF HOSPITALIZED, NAME AND ADDRESS OF HOSPITAL AND DATES OF CONFINEMENT Hospital Address Dates

Result of an Accident?

Date of Accident?

Yes No Date patient first consulted you for this condition Patient ever had similar condition? If yes, when:

Yes

No

Patient still under your care for this condition? Yes No Was patient referred to you? Yes No If yes, name and address of referring physician

Patient was continuously TOTALLY DISABLED (unable to Patient was PARTIALLY DISABLED work) From To From To If still disabled, date patient should be able to return to Does patient have any other health coverage? No Yes If yes, Name: work Please give name and address of any physicians or other practitioners you referred the patient to see Name Address Phone

Physician's Name (Please print) Physician's Address

Phone

Signature of Physician C-5 (R17) NY

Date Page 3 of 4

N26310

Part E - AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA Insured's Name

Date Of Birth

Social Security Number

Policy Number

Insured's Address I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, medical facility, other insurance company, consumer reporting agency, Medical Information Bureau (MIB), or other health care provider that has provided payment, treatment or services to me or on my behalf ("My Providers") to disclose my entire medical record and any other protected health information concerning me to the National Income Life Insurance Company (NILICO) and its agents, employees, and representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco; but excludes psychotherapy notes. By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct any physician, health care professional, hospital, clinic, medical facility, or other health care provider to release and disclose my entire medical record without restriction. This protected health information is to be disclosed under this authorization so that NILICO may: 1) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 2) administer coverage; and 3) conduct other legally permissible activities that relate to any coverage I have or have applied for with NILICO. This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to NILICO, Attention: Claims Department, at the above address. I understand that a revocation is not effective to the extent that any of My Providers has relied on this authorization or to the extent that NILICO has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to this authorization may be re-disclosed and no longer covered by federal rules governing privacy and confidentiality of health information. I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record, NILICO may not be able to process my claim or make any benefit payments. I have received a copy of this authorization. Name and address of person(s) or category of person to whom this information will be sent National Income Life Insurance Company C/O NILICO Service Center PO Box 2500, Waco, TX 76702 Authority to sign on behalf of Insured. Parent Legal Guardian Executor of Estate

Name of person signing form:

Child

Spouse

Next of Kin

Other (please specify relationship to Insured) -

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 be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Signature of Patient/Beneficiary/Guardian or Personal Representative

Date

Please make a copy of this authorization and retain for your record. C-5 (R17) NY

Page 4 of 4

Y26310

Proofs of Death Submitted to:

NATIONAL INCOME LIFE INSURANCE COMPANY C/O NILICO Service Center PO BOX 2500 I Waco, TX 76702 Phone (800) 516-4466 I Fax (254) 741-5705 Web www.nilife.com I Email [email protected]

INSTRUCTIONS FOR SUBMITTING A LIFE CLAIM 1) Complete as Follows: I I I I

Part A and C by the Beneficiary, Guardian or Personal Representative for all claims. Part B by the Beneficiary - To be completed only if policy is less than 2 years old. Part D by the Physician - To be completed only if policy is less than 2 years old. Part E by the Beneficiary - Complete Authorization for Release, sign and date.

2) To expedite Payment, all questions must be answered fully and accurately. 3) Send this completed form, along with a Death Certificate (Certified Death Certificate required if face amount exceeds $15,000), and Obituary (if available) to one of the above.

Part A - To be Completed by Beneficiary Policy Numbers Deceased's Name Deceased's Address Date of Death

Deceased's Date of Birth Deceased's Gender Deceased Union and Local # (if Union member) Male Female Did Death Result From: Suicide Homicide Accident If yes, please include all Accident/Police Reports and Newspaper Articles Place of Death (if Hospital, Give Name) Cause of Death

Beneficiary's Name

Beneficiary's Relationship to Insured

Beneficiary's Mailing Address

Beneficiary's Telephone Number Beneficiary's Social Security Number

Beneficiary's Email Address

Beneficiary's Date of Birth

Part B - To be Completed by Beneficiary COMPLETE ONLY IF POLICY IS LESS THAN 2 YEARS OLD Give the names and addresses of all physicians who treated the deceased during the 5 years prior to death: Name

Address

Disease or Condition

Dates

When did deceased first complain, or give other indication of illness? When did deceased first consult a physician for last illness?

C-30 (R17) NY

Page 1 of 4

N22210

Part C - AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA Insured's Name

Date Of Birth

Social Security Number

Policy Number

Insured's Address I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, medical facility, other insurance company, consumer reporting agency, Medical Information Bureau (MIB), or other health care provider that has provided payment, treatment or services to me or on my behalf ("My Providers") to disclose my entire medical record and any other protected health information concerning me to the National Income Life Insurance Company (NILICO) and its agents, employees, and representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco; but excludes psychotherapy notes. By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct any physician, health care professional, hospital, clinic, medical facility, or other health care provider to release and disclose my entire medical record without restriction. This protected health information is to be disclosed under this authorization so that NILICO may: 1) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 2) administer coverage; and 3) conduct other legally permissible activities that relate to any coverage I have or have applied for with NILICO. This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to NILICO, Attention: Claims Department, at the above address. I understand that a revocation is not effective to the extent that any of My Providers has relied on this authorization or to the extent that NILICO has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to this authorization may be re-disclosed and no longer covered by federal rules governing privacy and confidentiality of health information. I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record, NILICO may not be able to process my claim or make any benefit payments. I have received a copy of this authorization. Name and address of person(s) or category of Name of person signing form: person to whom this information will be sent National Income Life C/O NILICO Service Center PO Box 2500, Waco, TX 76702 Authority to sign on behalf of deceased. Parent Legal Guardian Child Spouse Next of Kin Other (please specify relationship to Insured) Executor of Estate 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 be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Signature of Patient/Beneficiary/Guardian or Personal Representative

Date

Please make a copy of this authorization and retain for your record.

C-30 (R17) NY

Page 2 of 4

Y22210

Part D - To be Completed by Physician

COMPLETE ONLY IF POLICY IS LESS THAN 2 YEARS OLD Manner of Death Date of Death

Deceased's name

How long have you treated this patient? Were you the patient's medical attendant or adviser before last illness or infirmity? If so, when and for what disease? When was the patient diagnosed with the disease or impairment that resulted in death? Was the patient ever treated for drug or alcohol abuse? If so, please list dates and locations of treatment. Was the patient ever disabled? If so, when and for what reason? From what other disease or impairment has the patient suffered, and when?

Disease or Impairment

Duration

Was the patient confined to a hospital during the past 3 years? If so, provide the name and address of the hospital. Give names & addresses of the referring physicians or other practitioners who, to your knowledge, attended the patient during the past 5 years Name Address Disease or Impairment Dates

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 be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Physician's Name (PRINT) Physician's Signature

Fax Number C-30 (R17) NY

Street Address City

State

Zip

Phone Number Page 3 of 4

N26320

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [ This form has been approved by the New York State Department of Health]

Patient Name

Date Of Birth

Social Security Number

Patient Address I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a). I specifically authorize release of such information to the person(s) indicated in Item 8. 2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL

CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9(b). 7.

Name and address of health provider or entity to release this information:

8.

Name and address of person(s) or category of person to whom this information will be sent:

9(a).

A.I. Records, P.O. Box 2608, Waco TX 76702

Specify information to be released: Medical Record from (insert date) to (insert date) Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. Other: Include: (Indicate by Initialing)

Alcohol/Drug Treatment Mental Health Information HIV-Related Information

Authorization to Discuss Health Information (b)

10. 12.

By initialing here

I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here:

(Attorney/Firm Name or Governmental Agency Name) Reason for release of information: 11. Date or event on which this authorization will expire:

INSURANCE

If not the patient, name of person signing form: 13. Authority to sign on behalf of patient:

All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Date: Signature of Patient or representative authorized by law.

* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts. C-30 (R17) NY

Page 4 of 4

Y26320

NATIONAL INCOME LIFE INSURANCE COMPANY ℅ National Income Life Service Center P.O. Box 2608 • Waco, TX 76702 • www.nilife.com LAY-OFF WAIVER OF PREMIUM CLAIM FORM If you have been regularly employed within the same industry for 12 consecutive months and are laid-off, you may qualify for lay-off waiver of premium. Lay-off Waiver of Premium provides for a waiver of premiums while the insured is on a qualified lay-off and is actively seeking work. Qualified lay-off is the termination of employment in an announced reduction of force due to economic reasons affecting at least 10 persons. If this application is returned within 60 days after date of lay-off, one month’s premium will be waived for each full month thereafter the insured is unemployed as a result of such lay-off. The maximum benefit period is three months. Waiver will only apply to policies which were in force 60 days prior to the start date of the lay-off. If the premium is being waived on a policy on which the laid-off employee is the insured, waiver will also apply to otherwise qualifying policies on which the laid-off employee’s family member is the insured. Receipt of lay-off Waiver of Premium benefits may be considered taxable income. Send this application to National Income. This must be signed by the employer or union officer. Insured (Laid-off person)

Policy Number(s)

Insured Family Members

Policy Number(s)

Address

Phone

Occupation Employer Name Union & Local No.

Phone

Date you quit work due to lay-off? Are you now employed?

Yes

r

No

r

Date you returned to work? X

Dated

The above person was laid-off on Dated

Signature of Insured

CERTIFICATION BY EMPLOYER OR UNION REPRESENTATIVE Date X

and is unemployed at this time.

Signature of Representative of the Employer or Union Local Officer

Title

AG-2147 NY (R12-09)

From

First Class Postage Required

Address

National Income Life Insurance Company ℅ National Income Life Service Center P.O. Box 2608 Waco, TX 76702

NATIONAL INCOME LIFE INSURANCE COMPANY ℅ National Income Life Service Center P.O. Box 2608 • Waco, TX 76702 • www.nilife.com STRIKE WAIVER OF PREMIUM CLAIM FORM Strike Waiver of Premium provides for waiver of premiums while the insured is on authorized strike and thereby prevented from engaging in his usual occupation. One month of premium is waived for each month of the strike. If the strike lasts less than a month, one month of premium will be waived. The maximum waiver is 12 months. Waiver will only apply to policies which were in force for 90 days prior to the strike. If the premium is being waived on a policy on which the striking union member is the insured, waiver will also apply to otherwise qualifying policies on which the union member’s family member is the insured. Receipt of Strike Waiver of Premium benefits may be considered taxable income. Complete the form below and send it to the Company at the above address. The form must be signed by an authorized union official. Insured (Striking Union Member) Insured Family Members Address Occupation Union & Local No. On what date did you quit work due to a strike? Month No r Are you currently working? Yes r If so, on what date did you return to work?

Month

Policy Number(s) Policy Number(s) Phone Employer Phone Day Day

Year Year

Dated Signature of Insured (Striking Union Member)

CERTIFICATION BY UNION OFFICIAL

This is to certify that the above Union member was prevented from working from to because of a duly authorized, official strike. Dated Signature of Union Local Officer

Title

AG-79 (R02-19) NY

From

First Class Postage Required

Address

National Income Life Insurance Company ℅ National Income Life Service Center P.O. Box 2608 Waco, TX 76702

Experience and Stability

Online Services

With agency offices throughout the state of New

In our effort to continually provide you with the best possible service, many of our policyowner services are available online.

York, National Income Life is a 100 percent union label company organized by the Office and Professional Employees International Union, Local 277. NILICO is a wholly owned subsidiary of American Income Life, a company serving policyowners for over 60 years with offices throughout North America. National Income Life is dedicated to serving the residents of New York with the same professional, personal service policyowners of our parent company have come to expect.

Secure access to your individual policy information: • Coverage Amounts • Beneficiary Designations • Policy Status Convenient access to a variety of forms: • Beneficiary Change Forms • Claim Forms • Strike Waiver and Layoff Waiver* Claim Forms Direct email access to customer service: • Ask Questions • Send Service Requests

To access these services online, visit NILife.com * Receipt of Layoff and Strike Waiver of Premium benefits may be considered taxable income.

OPPORTUNITY UNLIMITED. Visit www.nilife.com today!

CUSTOMER SERVICE

315-451-8180

9:00AM – 5:30PM EST www.nilife.com