----------------------- Page 1----------------------- APPLICATION TO: RELIANCE STANDARD LIFE INSURANCE COMPANY ADMINISTRATIVE OFFICE: PHILADELPHIA, PENNSYLVANIA ______________________________________________________________________________________________ A Policyholder Policy Number R E N Location Full Time Employment Date Class Y O O I T L C Hours Per Week Occupation Salary Hrly. Mthly. P E M S Wkly. Yrly. HOW TO APPLY: E Employee’s Last Name First Name Middle Initial PLEASE PRINT OR ________________________________________________________________________________________ TYPE ALL Employee’s Birth Date Social Security Number Sex Male INFORMATION, E N month date year Female E WITH THE Y O Age State of Birth Height Weight O I EXCEPTION OF T L C SIGNATURES. P E M S Street Address City State Zip E 1. Complete Sections A and Amount of Coverage Applied For $________________ B. If you are a Is this: your first application (with RSL)? late enrollee or a change in amount of coverage (with RSL)? New Total Amount $___________ are applying for _______________________________________________________________________________ amounts over Beneficiary(ies) Full Name(s) Relationship % of Proceeds ______________________________________________________________________________ the Guaranteed Issue amount, ______________________________________________________________________________ also complete Section C. __________________________________________________________________ B Are you actively performing all the duties of your occupation or profession on a full-time basis? 2. Please sign and Yes No IF NO, EXPLAIN. date the back ______________________________________________________________________________ of this ______________________________________________________________________________ application. Is this insurance now applied for intended to replace, in whole or in part, any insurance on the life of the applicant? 3. Return the Yes No IF YES, PROVIDE NAME OF COMPANY AND AMOUNT OF INSURANCE application to _____________________________________________________________________________ your personnel _________________________________________________________________ office for processing. C Have… You had; been told you had/have; or been treated for any of the following within the past five years: 1 Consultation with any physician YES 2 To the best of your knowledge, any YES or received any medical care, NO physical impairment or disease? NO treatment or advice? 3 AIDS, AIDS related complex, or YES 4 A disease of the nervous, genito- YES disorder of the immune system? NO urinary or digestive systems, heart NO or lungs, high blood pressure, diabetes cancer or a tumor of any kind? If you answered YES to any of the questions in Section C, please give details in #5 below. 5 Question Illness or Nature Doctor’s Full Name # of Injury Date and Address _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ____________________________________ _____________________________________________________________________________ _____________________________________________________________________________________________________ __ FOR HOME OFFICE ADMINISTRATIVE USE ONLY: Billing Date: _______________________ SEE NEXT PAGE LRS-8774-0793 SmartChoice ----------------------- Page 2----------------------- I REPRESENT that to the best of my knowledge and belief each of the statements and answers is complete and true. I understand that the amount of insurance for which I am applying will become effective on the date the application is approved by the Insurance Company. I CERTIFY that I am an employee of the sponsoring organization and otherwise meet the eligibility requirements for applying for this insurance. I AUTHORIZE my employer to deduct premium contributions required to be made by me from my salary as consideration for insurance on me issued by RELIANCE STANDARD LIFE INSURANCE COMPANY. I understand coverage will be effective as stated above, provided premiums are paid and service waiting periods are satisfied, as applicable. I authorize you to adjust these deductions based on underwriting changes, or rate changes resulting from age changes. During the continuance of this agreement, my employer will forward the premium to the Insurance Company as it falls due. This authorization may be revoked by me by written notice to my employer. I ACKNOWLEDGE receipt of the “Notice Regarding Information Practices.” I AUTHORIZE any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, organization, institution, person or the Medical Information Bureau (MIB) to release any information or records(s) on me or my health to be used in determining the acceptability of my application for insurance. I authorize any such information or record(s) to be released to Reliance Standard Life Insurance Company, its reinsurers or authorized representatives. I also authorize Reliance Standard Life Insurance Company or its reinsurers to make a brief report to the MIB. This authorization, or a photographic copy, shall be binding as the original and valid for a period not exceeding twelve (12) months from this date. I understand that I may elect to be interviewed if an investigative consumer report is to be prepared in connection with this application and that I am entitled to a copy thereof. I further understand that I am entitled to receive a copy of this Authorization upon request. Please review the front of the application for completeness before signing. Incomplete sections may cause coverage to be delayed or declined. Signature X________________________________________ ___________________________ Applicant Date REQUEST TO WAIVE COVERAGES OFFERED I certify that I have been advised of the features and benefits of the program offered to me through my employer and have decided not to participate. _________________________________________ __________________________ EMPLOYEE SIGNATURE DATE RELIANCE STANDARD LIFE INSURANCE COMPANY LRS-8774-0793 SmartChoice ----------------------- Page 3----------------------- NOTICE REGARDING INFORMATION PRACTICES In considering this Application, Reliance Standard Life Insurance Company ("we", "us" or "our") collects certain information about all proposed insureds ("you" or "your"). The precise information varies according to the amount and type of coverage you apply for. Generally, we seek information about your: (1) age; (2) occupation; (3) physical condition; (4) medical history; (5) hobbies; and (6) other relevant activities. You are the most important source of information, but we may also verify or collect information on you or your family from: (1) physicians; (2) other health care providers; (3) employers; (4) other insurers to which you have applied; (5) consumer investigative organizations; and (6) the Medical Information Bureau ("MIB"). The MIB is a not-for-profit organization of life insurance companies which operates an information exchange for its members. This information may alert us to a need for further investigation, but under MIB rules such information cannot be used: (1) either wholly or in part to increase the premium for insurance; or (2) to deny issuance of insurance. We may collect information by: (1) phone; (2) correspondence; or (3) personal contact. Information will be treated as confidential. Reliance Standard Life Insurance Company or its reinsurers may, however, with your authorization make a brief report to the MIB. 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, the MIB, upon request, will supply such company with the information in its file. The information supplied to other member companies may alert them to a need for further investigation. In some circumstances, however, information may be released to third parties without your authorization (with the exception of the MIB). These include persons or organizations who are: (1) performing business functions for us; (2) conducting actuarial or scientific studies or audits; or (3) our reinsurers. We or our reinsurers may also release information to other life insurance companies to whom you apply for life or health insurance coverage, or to whom a claim for benefits is submitted. Please be assured that although such disclosures may occur, they are not always or even often made. When a disclosure is necessary, only as much information as is reasonably necessary to achieve the intended purpose will be disclosed. You have the right to acquire and, if necessary, correct any personal information we or the MIB collect. Upon written request to us, we will within 30 days of receipt: (1) inform you of the nature and substance of the recorded information; (2) permit personal viewing and copying of the information in our possession; (3) disclose the identities of those persons such information has been disclosed to within the last two years; and (4) provide you with procedures for correction, amendment or deletion of the recorded information. Medical information will be disclosed to a physician that you choose. You may write to us for a fuller explanation of our information practices. You may also contact the MIB via its website (www.mib.com) or by telephone to arrange for disclosure of any information it may have on you. The MIB's toll-free telephone number is 866-692-6901 (TTY 866-346-3642 for hearing impaired). If you question the accuracy of information in the MIB's file, you may contact the MIB in writing and seek correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts 02184-8734. KEEP THIS NOTICE FOR YOUR RECORDS. Home Office: Chicago, Illinois Administrative Office: Philadelphia, Pennsylvania