LIFE INSURANCE APPLICATION PACKET - … Life and Annuity Insurance Company P.O. Box 830619...

LIFE INSURANCE

APPLICATION PACKET

Includes:

� Application

� HIPAA Disclosure(must be given to every Applicant)

� Conditional Receipt

� Supplemental Life Application(must be completed if Riders are purchased)

� Description of Information Practices(must be given to every Applicant)

ILD-1038-NY 1/04 8/04

Application Instructions12 Complete each question in the Application for Life Insurance (ILD-1038).

Please use a pen with black ink. If additional benefits and/or riders are selected, follow the same procedures for the Supplemental Life Application.

3 Provide complete names, addresses, SSN/Tax IDs and birthdates for all applicants, owners, beneficiaries and doctors. Complete the signature area on the back of the application.

4 Each applicant must be given the Description of Information Practices and HIPAADisclosure Form.

5 If cash is submitted with the application, complete and sign the Conditional Receipt and give to the applicant.

Complete and sign any additional forms (i.e. 1035 exchange, state replacements,etc.).See Protective Life and Annuity Administrative Forms Packet.

7 Fax App - To expedite the underwriting process you can FAX the application to (205) 268-4516. The entire application must be faxed.

8 CONTACT YOUR HOME OFFICE to determine where to send the completed paperwork. There may be special processing procedures. Unless otherwise advised by your home office, make checks payable to Protective Life and Annuity Insurance Company.If you are sending the business directly to Protective, please use the following address:

Protective Life and Annuity Insurance CompanyInstitutional Distribution GroupP.O. Box 830735Birmingham, AL 352831-800-265-1545

9Advise the Proposed Insured that they will be contacted by a Company representative to collectmedical information and/or arrange a time for a paramedical exam.

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For Additional Information, ContactProtective Life and Annuity Insurance Company

at (800) 265-1545

ILD-1038-NY 1/04 8/04

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Protective Life and Annuity Insurance Co.Institutional Distribution GroupP.O. Box 830735, Birmingham, AL 35283

Life Insurance Application toProtective Life and Annuity Insurance Company

4. PRIMARY BENEFICIARY Name, Address, Social Security No., Birthdate, Relationship, Percentage

CONTINGENT BENEFICIARY (If any)

6. REGARDING ALL PERSONS PROPOSED FOR INSURANCE:Please answer all questions. If any Question (#7a-m) is answered “yes”, give detailsunder Question 8.

a. Within the past 5 years have you been treated for cancer, diabetes, cardiovascular disease, stroke,central nervous system disorders, muscular disorders or respiratory disorders, hypertensionor cholesterol? ..........................................................................................................................

b. During the past 5 years have you consulted a physician or visited a clinic or hospital as a patient? ....c. Will the policy applied for replace or change any life insurance or annuity in force? .........................d. Do you have an application pending in another company? (If yes, give company and amount in Section 9) ....e. Has any life or health insurance applied for ever been declined, postponed or offered other than

applied for?..........................................................................................................................................f. Have you piloted or been a crew member aboard an aircraft within the past 2 years or have any

intention of becoming a pilot? If yes, complete the aviation questionnaire.........................................g. Have you ever participated in a sport or avocation such as racing, hang gliding, scuba, sky or skin diving?

If yes, complete the hazardous sport or racing questionnaire. ...........................................................h. Have you smoked a cigarette or used tobacco in any form? If “yes”, include type of tobacco and

date last used in Section 8 below .......................................................................................................i. Have you ever had a DUI conviction, had your driver's license suspended or revoked, or been

convicted of more than two moving violations? If “yes”, indicate date of incident(s) and driver’slicense number in Section 8..................................................................................................................

j. Within the last 10 years, have you been convicted of a felony? .........................................................k. Are you a permanent resident of the United States, Puerto Rico or Canada?....................................l. Do you have any intention of traveling or residing outside the U.S. or Canada within the next two years? ...m. Had a parent or sibling who died of cancer, diabetes, heart disease or stroke prior to age 60?.........

5. PLAN INFORMATIONInitial Premium $_______ Initial Face Amount $_______Planned Periodic Premium $____________Plan Type ____________________________________

Level Death Benefit Increasing Death BenefitPremium Mode:

Annual Semi-Annual Quarterly PACCash With Application $_______________Issue best available Underwriting Class? X Yes

7. DETAILS OF ALL "YES" ANSWERS (Please attach an additional sheet of paper if necessary)Question Date of Details, Diagnosis, Names & Address of Doctors, HospitalsNumber Occurrence Treatment, Medication, Results Duration & Medical Facilities Consulted

ILD-1038-NY 1/04 1 8/04

1. Proposed Insured 1 ____________________________________________________________ ___________ _____________ ________ ________________________Name Birth Date State of Birth Sex Social Security No.______________________________________ ____________ ________________________________ ___________________ ________________________Occupation Marital Status Driver’s Lic. No. & State Home Phone No. Work Phone No._________________________________________________________________________________________________________________________________________ Home Address (Street Address - City, State, Zip)________________________________________________________ ______________________________________________________________ ______________Employer’s Name Employer’s Address Years Employed

2. Proposed Insured 2 – Relationship to Proposed Insured 1: _____________________________________________________________

____________________________________________________________ ___________ _____________ ________ ________________________Name Birth Date State of Birth Sex Social Security No.______________________________________ ____________ ________________________________ ___________________ ________________________Occupation Marital Status Driver’s Lic. No. & State Home Phone No. Work Phone No._________________________________________________________________________________________________________________________________________ Home Address (Street Address - City, State, Zip)________________________________________________________ ______________________________________________________________ ______________Employer’s Name Employer’s Address Years Employed

3. □ Owner if other than a Proposed Insured (Owner must sign Page 2)□ Payor (if other than Owner – furnish information in Remarks on Page 2)

_______________________________________________________ ______________________________________ _______________________________Name Relationship Soc. Sec. No. or Tax I.D. No.

____________________ ____________________________________________________________________________________________________________________Birthdate Address (Street Address - City, State, Zip)

_______________________________ _____________________________ All notices and reports will be sent to the Owner unless otherwise specified in RemarksHome Phone No. Work Phone No.

Prop. Ins. 1 Prop. Ins. 2Yes No Yes No

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11. REMARKS

12. HOME OFFICE ENDORSEMENTS

ILD-1038-NY 1/04 2 8/04

9. PROCESSING PROCEDURESDepending on the amount of insurance, Protective Lifeand Annuity will contact you to collect answers to perti-nent medical information or a paramedical organizationwill handle these requirements by a medical examand/or tests. Protective Life and Annuity may call youregarding an investigative consumer report. The most convenient place to call: Home BusinessBest Days: Mon. Tue. Wed. Thur. Fri.Best Time: Morning Afternoon Evening

10. In order to speed processing, please providename, address and phone number of ProposedInsured's personal physician:

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

DECLARATIONS: I represent that all statements and answers made in all parts of this application are full, completeand true to the best of my knowledge and belief. It is agreed that:

(a) All such statements and answers shall be the basis of any insurance issued and shall be attached to and made apart of the policy.

(b) No agent or medical examiner can make, alter or discharge any contract, accept risks, or waive the Company'srights or requirements.

(c) No insurance shall take effect unless: (1) a policy is delivered to the Owner; (2) the full first premium is paid whilethe Proposed Insured is alive; and (3) there has been no change in health and insurability from that described inthis application. However, if the premium is paid as set forth in the attached Agreement(s) and the Agreement(s)are delivered to the Owner, the terms of the Agreement(s) shall apply.

(d) Acceptance of a policy by the Owner shall constitute ratification of any changes made by the Company under"Home Office Endorsements." Changes as to plan, amount, age at issue, classification or benefits will be madeonly with the Owner's written consent.

AUTHORIZATION: The Proposed Insured acknowledges receipt of the Description of Information Practices. TheProposed Insured hereby authorizes any licensed physician, medical practitioner, hospital, clinic, or other medicallyrelated facility, insurance company, the MIB, consumer reporting agencies (CRA) or other organization, institution orperson, that has any records or knowledge of me or my health, to give to Protective Life and Annuity Insurance Co., itsCRA or its reinsurer any such information. A photographic copy of this authorization shall be as valid as the original.Protective Life and Annuity can give information to MIB, consumer reporting agencies, reinsurers and other insurers. Ialso hereby authorize Protective Life and Annuity Insurance Company to draw and test my blood and urine as may benecessary to underwrite my application for insurance coverage. These tests to be performed, may include, but are notlimited to, tests for cholesterol and related blood lipids, diabetes, liver or kidney disorders, immune disorders, the pres-ence of antibodies to the Human Immunodeficiency Virus (HIV) (if permitted by law). This is the virus that has beenassociated with Acquired Immune Deficiency Syndrome (AIDS). This authorization shall be valid 24 months from thedate shown below or in the event of a claim of benefits, the duration of such claim.Does this policy meet your insurance needs and financial objectives? Yes No

X _______________________________________________ X ______________________________________________Proposed Insured 1 (Signature) Proposed Insured 2 (Signature)

X _______________________________________________________________________________________________Owner, if other than Proposed Insured 1 or Proposed Insured 2.

Owner Signed At _________________________, ________________________ . Date ______________________City State Mo./Day/Yr.

X _______________________________________________________________________________________________Parent Guardian (Signature)

8. LIFE INSURANCE IN FORCE (Including Business Insurance): (If none, insert "none")Year Life Accidental To Be

Person Company Issued Amount Death Amount Replaced?

Agent: Will this policy replace or change any existing insurance policy(s) or annuity? Yes NoX_______________________________________________________________________________________________

Agent Signature Agent Name (print) Broker Number Broker Dealer or Financial Institution (Print) Phone Number

Supplemental Life ApplicationPlease print using black ink.

Protective Life and Annuity Insurance CompanyInstitutional Distribution Group

P.O. Box 830735Birmingham, AL 35283

1. ADDITIONAL BENEFITS

Accidental Death Benefit $____________

Waiver of Premium

Questions 7a. - 7m. on the application must be answered for all persons applying for insurance on this SupplementalLife Application.

ILD-1038-NY 1/04 8/04

2. CHILDREN'S RIDER _______ units

Dependent Children Date of Birth Birthplace Height Weight

3. LIFE INSURANCE IN FORCE (for insured - including business)Accidental

Person Company Year Issued Life Amount Death Benefit Replacement?

Protective Life and Annuity Insurance Company P.O. Box 830619 Birmingham, AL 35283-0619

This Authorization to Obtain and Disclose Information complies with the Health Insurance Portability and

Accountability Act of 1996 (“HIPAA”) as related to Life Insurance.

USE OF MEDICAL, NON-HEALTH AND NON-MEDICAL INFORMATION I (we) authorize Protective Life and Annuity Insurance Company (Protective Life and Annuity) and its reinsurers to obtain, directly or through designated third parties, and to use any information about or relating to me (us) that may affect my (our) insurability. Protective Life and Annuity and its reinsurers, Life Insurance Representative(s) or regional sales office representing me on my (our) application for insurance may:

a.

b.

c. d.

obtain and use health and medical information from all dates of service, including but not limited to information about chart notes, EKG’s, nicotine use, physical and mental diseases and illness, and psychiatric disorders (excluding psychotherapy notes); obtain and use non-health and non-medical information, including but not limited to financial information, credit reports, consumer reports, driving record, criminal record, character, general reputation, personal characteristics or behavioral and lifestyle factors and information about avocations and aviation activity; use all of this information to evaluate an application for insurance, a claim for insurance benefits, or both; use any information relating to communicable diseases and other risk factors relating to me or to my spouse or life partner to evaluate an application for insurance on either me or my spouse or life partner.

RELEASE AND DISCLOSE INFORMATION FROM THIRD PARTIES

I (we) authorize the following persons and organizations to release and disclose the information described in the USE OF MEDICAL, NON-HEALTH AND NON-MEDICAL INFORMATION section to Protective Life and Annuity, directly through the following designated third parties or its representative(s) acting on its behalf:

a. b.

c. d. e.

my (our) doctor(s); medical practitioners; pharmacists and Pharmacy Benefit Managers; medical and related facilities, including hospitals, clinics, facilities run by the Veteran’s Administration, Kaiser Permanente, The Cleveland Clinic Foundation including all satellite facilities and The Mayo Clinic; insurers; reinsurers; my (our) current and previous employers; MIB, Inc. (MIB); and commercial consumer reporting agencies (CRA).

All of these persons and organizations other than MIB may release the information described above to a CRA acting for Protective Life and Annuity. MIB may not release the information described in the USE OF MEDICAL, NON-HEALTH AND NON-MEDICAL INFORMATION section to a CRA. TESTING OF BLOOD, ORAL FLUIDS AND URINE

I (we) authorize Protective Life and Annuity to draw and test my (our) blood, and/or oral fluids, and urine as necessary to underwrite my (our) application for insurance. These tests may include, but are not limited to:

a. tests for cholesterol and related blood lipids, diabetes, liver or kidney disorders, immune disorders (other than HIV/AIDS). b. tests for the presence of drugs, nicotine, or their metabolites.

This authorization does not include genetic testing. Unless otherwise required by law or regulation, Protective Life and Annuity may, but is not obligated to, release any of these test results directly to me or to my spouse or life partner. RELEASE OF MEDICAL, NON-HEALTH, NON-MEDICAL AND TESTING INFORMATION

I (we) authorize Protective Life to release and disclose the information described in the USE OF MEDICAL, NON-HEALTH AND NON-MEDICAL INFORMATION section and the TESTING OF BLOOD, ORAL FLUIDS AND URINE section:

a. to its affiliates, its reinsurers, persons or organization providing services relating to insurance underwriting for Protective Life and Annuity, MIB and as otherwise required by law.

b. to release and disclose the information to other duly licensed life insurers if I (we) have applied or apply to the other insurers for insurance.

c. to its reinsurers, to make a brief report of my personal health information to MIB. d. to the Life Insurance Representative(s) representing me to duly licensed specific life insurers for the purpose of applying

for life insurance if my (our) application with Protective Life and Annuity is declined or if Protective Life and Annuity is unable to offer coverage at an acceptable rate.

e. to the Life Insurance Representative(s) and its staff, affiliated companies and/or entities, insurance companies and their re-insurers representing me on my (our) application for insurance if it is necessary to provide an explanation of the reasons for Protective Life and Annuity’s decision to impose special underwriting requirements, whenever my application cannot be approved as submitted, or in connection with a claim for benefits.

Home Office – ORIGINAL Applicant - COPY PL-HIPAA-NY Page 1 of 2 04/2016

AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

SPECIAL REQUIREMENT FOR HIV/AIDS TESTING

If Protective Life and Annuity intends to test for the presence of antibodies to the Human Immunodeficiency Virus (HIV), which is the virus that has been associated with Acquired Immune Deficiency Syndrome (AIDS), Protective Life and Annuity may require a separate authorization. I (we) hereby authorize Protective Life and Annuity:

a. to obtain and use the results of any HIV tests that I (we) separately authorize. b. (if permitted by law) to disclose the results of any tests to its reinsurers and MIB.

GENERAL INFORMATION

a. This authorization shall be valid for 24 months from the Date of Authorization shown below. b. During the evaluation of my (our) insurance application, I (we) understand that I (we) have the right to revoke the

authorizations in the previous sections (above) by writing to Protective Life and Annuity at P.O. Box 830619 • Birmingham, Alabama 35283-0619. If this authorization is revoked, this would result in the file being closed and no coverage provided.

c. I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment).

d. I (we) understand that any information about me (us) that is disclosed pursuant to this authorization may be subject to re-disclosure and no longer covered by certain federal rules governing privacy and confidentiality of health information. The information contained in these medical and financial records will be held in confidence and may be used only for the purpose of the procurement, or underwriting for the possible procurement or the evaluation of life, health, long term care, or other insurance products.

e. I (we) understand that my (our) personal information, including my (our) protected health information disclosed under this authorization will be incorporated into and made a part of any life and/or disability insurance policy(ies) issued by the Company and that the policy(ies) will be delivered to the policy owner.

f. 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. Any modifications to this authorization may preclude Protective Life and Annuity’s ability to process this application.

AUTHORIZATIONS AND INVESTIGATIVE CONSUMER REPORT

I (we) have been given a copy of this Authorization to Obtain and Disclose Information along with the Description of Information Practices.

I (we) authorize the preparation of an investigative consumer report and would like to be interviewed if an investigative consumer report will be made. (Please refer to the Description of Information Practices for additional information regarding the interview for an Investigative Consumer Report.)

THIS AUTHORIZATION MUST BE SIGNED WITHOUT MODIFICATION AND RETURNED WITH THE

APPLICATION BEFORE PROCESSING. SIGNATURES

Date of Authorization: X______________________

______________________________________________________________________________________________________ List Health Care Providers X___________________________________ ____________________________ _______________ _____________________ Proposed Insured 1 (Signature) Print Name of Proposed Insured 1 Birthdate Social Security Number X___________________________________ ____________________________ _______________ _____________________ Proposed Insured 2 (Signature) Print Name of Proposed Insured 2 Birthdate Social Security Number ___________________________________ X________________________________ ________________________________ If Minor, Print Name Parent or Legal Guardian (Signature) Print Name of Parent or Legal Guardian


Protective Life and Annuity Insurance Company P.O. Box 830619 Birmingham, AL 35283-0619

This Authorization to Obtain and Disclose Information complies with the Health Insurance Portability and

Accountability Act of 1996 (“HIPAA”) as related to Life Insurance.

USE OF MEDICAL, NON-HEALTH AND NON-MEDICAL INFORMATION I (we) authorize Protective Life and Annuity Insurance Company (Protective Life and Annuity) and its reinsurers to obtain, directly or through designated third parties, and to use any information about or relating to me (us) that may affect my (our) insurability. Protective Life and Annuity and its reinsurers, Life Insurance Representative(s) or regional sales office representing me on my (our) application for insurance may:

a.

b.

c. d.

obtain and use health and medical information from all dates of service, including but not limited to information about chart notes, EKG’s, nicotine use, physical and mental diseases and illness, and psychiatric disorders (excluding psychotherapy notes); obtain and use non-health and non-medical information, including but not limited to financial information, credit reports, consumer reports, driving record, criminal record, character, general reputation, personal characteristics or behavioral and lifestyle factors and information about avocations and aviation activity; use all of this information to evaluate an application for insurance, a claim for insurance benefits, or both; use any information relating to communicable diseases and other risk factors relating to me or to my spouse or life partner to evaluate an application for insurance on either me or my spouse or life partner.

RELEASE AND DISCLOSE INFORMATION FROM THIRD PARTIES

I (we) authorize the following persons and organizations to release and disclose the information described in the USE OF MEDICAL, NON-HEALTH AND NON-MEDICAL INFORMATION section to Protective Life and Annuity, directly through the following designated third parties or its representative(s) acting on its behalf:

a. b.

c. d. e.

my (our) doctor(s); medical practitioners; pharmacists and Pharmacy Benefit Managers; medical and related facilities, including hospitals, clinics, facilities run by the Veteran’s Administration, Kaiser Permanente, The Cleveland Clinic Foundation including all satellite facilities and The Mayo Clinic; insurers; reinsurers; my (our) current and previous employers; MIB, Inc. (MIB); and commercial consumer reporting agencies (CRA).

All of these persons and organizations other than MIB may release the information described above to a CRA acting for Protective Life and Annuity. MIB may not release the information described in the USE OF MEDICAL, NON-HEALTH AND NON-MEDICAL INFORMATION section to a CRA. TESTING OF BLOOD, ORAL FLUIDS AND URINE

I (we) authorize Protective Life and Annuity to draw and test my (our) blood, and/or oral fluids, and urine as necessary to underwrite my (our) application for insurance. These tests may include, but are not limited to:

a. tests for cholesterol and related blood lipids, diabetes, liver or kidney disorders, immune disorders (other than HIV/AIDS). b. tests for the presence of drugs, nicotine, or their metabolites.

This authorization does not include genetic testing. Unless otherwise required by law or regulation, Protective Life and Annuity may, but is not obligated to, release any of these test results directly to me or to my spouse or life partner. RELEASE OF MEDICAL, NON-HEALTH, NON-MEDICAL AND TESTING INFORMATION

I (we) authorize Protective Life to release and disclose the information described in the USE OF MEDICAL, NON-HEALTH AND NON-MEDICAL INFORMATION section and the TESTING OF BLOOD, ORAL FLUIDS AND URINE section:

a. to its affiliates, its reinsurers, persons or organization providing services relating to insurance underwriting for Protective Life and Annuity, MIB and as otherwise required by law.

b. to release and disclose the information to other duly licensed life insurers if I (we) have applied or apply to the other insurers for insurance.

c. to its reinsurers, to make a brief report of my personal health information to MIB. d. to the Life Insurance Representative(s) representing me to duly licensed specific life insurers for the purpose of applying

for life insurance if my (our) application with Protective Life and Annuity is declined or if Protective Life and Annuity is unable to offer coverage at an acceptable rate.

e. to the Life Insurance Representative(s) and its staff, affiliated companies and/or entities, insurance companies and their re-insurers representing me on my (our) application for insurance if it is necessary to provide an explanation of the reasons for Protective Life and Annuity’s decision to impose special underwriting requirements, whenever my application cannot be approved as submitted, or in connection with a claim for benefits.


AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

SPECIAL REQUIREMENT FOR HIV/AIDS TESTING

If Protective Life and Annuity intends to test for the presence of antibodies to the Human Immunodeficiency Virus (HIV), which is the virus that has been associated with Acquired Immune Deficiency Syndrome (AIDS), Protective Life and Annuity may require a separate authorization. I (we) hereby authorize Protective Life and Annuity:

a. to obtain and use the results of any HIV tests that I (we) separately authorize. b. (if permitted by law) to disclose the results of any tests to its reinsurers and MIB.

GENERAL INFORMATION

a. This authorization shall be valid for 24 months from the Date of Authorization shown below. b. During the evaluation of my (our) insurance application, I (we) understand that I (we) have the right to revoke the

authorizations in the previous sections (above) by writing to Protective Life and Annuity at P.O. Box 830619 • Birmingham, Alabama 35283-0619. If this authorization is revoked, this would result in the file being closed and no coverage provided.

c. I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment).

d. I (we) understand that any information about me (us) that is disclosed pursuant to this authorization may be subject to re-disclosure and no longer covered by certain federal rules governing privacy and confidentiality of health information. The information contained in these medical and financial records will be held in confidence and may be used only for the purpose of the procurement, or underwriting for the possible procurement or the evaluation of life, health, long term care, or other insurance products.

e. I (we) understand that my (our) personal information, including my (our) protected health information disclosed under this authorization will be incorporated into and made a part of any life and/or disability insurance policy(ies) issued by the Company and that the policy(ies) will be delivered to the policy owner.

f. 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. Any modifications to this authorization may preclude Protective Life and Annuity’s ability to process this application.

AUTHORIZATIONS AND INVESTIGATIVE CONSUMER REPORT

I (we) have been given a copy of this Authorization to Obtain and Disclose Information along with the Description of Information Practices.

I (we) authorize the preparation of an investigative consumer report and would like to be interviewed if an investigative consumer report will be made. (Please refer to the Description of Information Practices for additional information regarding the interview for an Investigative Consumer Report.)

THIS AUTHORIZATION MUST BE SIGNED WITHOUT MODIFICATION AND RETURNED WITH THE

APPLICATION BEFORE PROCESSING. SIGNATURES

Date of Authorization: X______________________

______________________________________________________________________________________________________ List Health Care Providers X___________________________________ ____________________________ _______________ _____________________ Proposed Insured 1 (Signature) Print Name of Proposed Insured 1 Birthdate Social Security Number X___________________________________ ____________________________ _______________ _____________________ Proposed Insured 2 (Signature) Print Name of Proposed Insured 2 Birthdate Social Security Number ___________________________________ X________________________________ ________________________________ If Minor, Print Name Parent or Legal Guardian (Signature) Print Name of Parent or Legal Guardian


Protective Life and Annuity Insurance Company P.O. Box 830619 Birmingham, AL 35283-0619 Term Life Insurance Universal Life Insurance

This agreement provides only a limited amount of insurance, for a limited period of time, and then only if all the terms and conditions of this agreement are met. No Agent of Protective Life and Annuity Insurance Company (the Company) can alter or waive any of the provisions of this Agreement. No life insurance is provided under the terms of this document in the event of the death of the proposed insured(s) by suicide. In the event of suicide, while sane or insane, the Company’s sole liability will be the return of any money received. Received: Check in the amount of $______________, Pre-Authorized Funds Withdrawal, Other __________________________

as conditional payment of the first premium for an insurance policy on the life of Proposed Insured(s)_______________ _______________________________________________________________________________________________________. An application for life insurance on each person proposed for insurance is being made today to the Company. This conditional payment is received under and is subject to the exact conditions set out below, all of which are a part of this Agreement. ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO PROTECTIVE LIFE AND ANNUITY INSURANCE COMPANY. DO NOT MAKE CHECKS PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK. CASH, MONEY ORDERS AND CASHIER’S CHECKS WILL NOT BE ACCEPTED. NOTE: Premium may not be collected (1) where the face amount applied for plus any in force life insurance and accidental death benefits (including those applied for) on Proposed Insured(s) with the Company and its affiliates exceeds $1,000,000; OR (2) on Proposed Insured(s) under 15 days of age or over age 80; OR (3) for cases in which the Proposed Insured(s) intends to leave the United States within the next 60 days. Any premium received under (1), (2) or (3) of this note will be refunded. CONDITIONS UNDER WHICH INSURANCE MAY BECOME EFFECTIVE PRIOR TO POLICY DELIVERY Unless each and every condition below has been fulfilled exactly, no insurance will become effective prior to policy delivery to the Owner: (A) on the Effective Date the Proposed Insured(s) is (are) insurable exactly as applied for under the Company’s published underwriting

rules for the plan, amount and premium rate class applied for; (B) the amount paid with the application and shown above is equal to the first full modal premium for the plan, amount and premium rate

class applied for; and (C) the Proposed Insured(s) has/have completed all examinations and/or tests requested by the Company. No more than two

examinations will be requested. EFFECTIVE DATE OF COVERAGE Insurance issued based on the application will take effect on the latest of: (A) the date of the application; (B) the date requested in the application; or (C) the date of the last of any medical examinations or tests required under the rules and practices of the Company. AMOUNT OF COVERAGE - $1,000,000 MAXIMUM (per Proposed Insured) The total amount of insurance on Proposed Insured(s) which may become effective prior to delivery of the policy to the Owner shall not exceed $1,000,000 with the Company and its affiliates. This amount includes other life insurance and accidental death benefits on such Proposed Insured(s) currently in force and applied for with the Company and its affiliates. TERMINATION AND REFUND OF PREMIUM There shall be no insurance coverage under this Agreement and this Agreement shall be void if: (A) premium payment is (1) by check, and it is not honored by the drawee bank upon presentation; (2) by Pre-Authorized Funds Withdrawal (PAW), and the deduction is not honored by the drawee bank; (3) by Payroll Deduction Authorization (PDA) and the Employer does not make payroll deductions as authorized by the Employee; or (B) if the application to which this Agreement was attached is not approved as applied for by the Company within ninety days from its

date, the Company’s only liability in such event(s) will be to return any money received. NOTICE TO APPLICANT: You should retain a copy of this Agreement. The Original will be retained by Protective Life and Annuity. __________________________________________ _____________ ________________________________________ ___________ Agent Signature Date Owner Signature Date

ALL MONIES WILL BE DRAFTED/DEPOSITED IMMEDIATELY UPON RECEIPT OF THIS FORM.

PL-CR-NY (08/11) Original – HOME OFFICE Copy - OWNER

CONDITIONAL RECEIPT AGREEMENT

Protective Life and Annuity Insurance Company P.O. Box 830619

Birmingham, AL 35283-0619

(Including MIB, Inc. Notice and Fair Credit Reporting Act Notice)

DISCLOSURE OF INFORMATION

In considering your application for insurance, information from various sources must be considered. These include the results of your physical examination, if required, and any reports Protective Life and Annuity may receive from doctors and hospitals who have attended you. Information regarding your insurability will be treated as confidential. Protective Life and Annuity, or its reinsurers, may, however, make a brief report of any personal health information thereon to the MIB, Inc., (MIB), formerly known as Medical Information Bureau, a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information about you in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at 866-692-6901. If you question the accuracy of the information in MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of MIB’s information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734. Protective Life and Annuity, or its reinsurers, may also release information from its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at www.mib.com. INVESTIGATIVE CONSUMER REPORT Furthermore, as part of our procedures for processing your insurance application, an investigative consumer report may be prepared by one or more of the commercial agencies offering this service whereby information is obtained through personal interviews with your neighbors, friends, or others with whom you are acquainted. This inquiry includes information as to your insurance risk score, character, general reputation, personal characteristics or behavioral and lifestyle factors, except as may be related directly or indirectly to your sexual orientation. You have the right to be personally interviewed if we order an investigative consumer report. You also have the right to receive a copy of the report by making a written request to Protective Life and Annuity, within a reasonable period of time, to receive additional detailed information about the nature and scope of this investigation. YOU CAN REVIEW AND CORRECT YOUR INFORMATION As a general practice, we will not disclose personal or privileged information about you to anyone else without your consent, unless a legitimate business need exists or disclosure is required or permitted by law. You are entitled, upon request, to receive a more detailed statement of our information practices. You also have the right to access the personal information about you that we have in our records. You may see a copy of the information, or we will send it to you, whichever you prefer. You also have the right to request correction of personal information we may have about you which you think is wrong. To exercise these rights, please write to us at the address appearing at the end of this notice. Ask our agent/producer for assistance or call or write us at Protective Life and Annuity Insurance Company, Attention: New Business, P.O. Box 830619, Birmingham, Alabama 35283-0619. Telephone: 800-366-9378

THIS NOTICE MUST BE GIVEN TO THE PROPOSED INSURED

PL-DIP-NY (1/11) R: 03/2016

DESCRIPTION OF INFORMATION PRACTICES

http://www.mib.com/

PL-406-NY 6/2012

Protective Life and Annuity Insurance Company P.O. Box 830619

Birmingham, AL 35283-0619

CONTINUATION OF INFORMATION

Proposed Insured 1: First Name Middle Name Last Name Policy Number

Proposed Insured 2: First Name Middle Name Last Name Policy Number

I have read or have had read to me the completed Supplemental Application before signing below. The above statements and answers are true and complete to the best of my knowledge and belief. I agree that such statements and answers shall be attached to and made part of the application and shall be considered the basis of any insurance issued.

Proposed Insured 1 (Sign Name in Full) Date Proposed Insured 2 (Sign Name in Full) Date Signature of Parent or Guardian Date Signature of Witness Date

The attac Print For (1)

(2)

(3) (4)

I (WSupthe i Sign ____Sign ____Sign ____Sign ____Sign ____Sign By sand Sign X __ Pro

SUP

SIGN

PRO

PL-

statements andched application

t Name of Propo

any policy to bWill anyone ofuture premiuIf Yes, compleWill any portiIf Yes, compleWill a trust, inIf Yes, compleIs the Propo$1,000,000 orIf Yes, comple

We) have read oplement are coinformation bei

ned in ________ _____________nature of Propose

_____________nature of Propose

_____________nature of Owner/

_____________nature of Owner/

_____________nature of Witness

signing below, I that the life insu

ned at: ________

______________oducer Signatur

PPLEMENT TO L

NATURES

ODUCER CERTI

701-NY

d answers to the; and shall beco

osed Insured(s):

e issued as a reother than the Inums or obtain aete the “Statemeon of the initial

ete the “Premiumncluding familyete the “Trust Ceosed Insured ar more? ete the “Stateme

or have had reorrectly recordeing provided in

______________ (State)

______________ed Insured 1

______________ed Insured 2

______________/Trustee & Title i

______________/Trustee & Title i

______________s

hereby certify thrance being app

_____________ (C

_____________re

LIFE INSURANC

IFICATION

e questions listeme a part of any

_____________

esult of this apnsured, his or h

any right, title ont of Owner Intel or future prem

m Financing Discy trust, own thisertification” (Applage 65 or olde

nt of Owner Inte

ad to me (us) ed and are full, this Suppleme

______________

______________

______________

______________f Corporation 1

______________f Corporation 2

______________

hat to the best oplied for conform

______________City and State)

______________

CE APPLICATIO

ed below shall by policy based o

_____________

plication: her family, or er interest in this

ent” (Application miums be borrowclosure” (Discloss policy? ication Supplemer AND total c

ent” (Application

the completedcomplete and

ent is being relie

__, this ____

___ ________Address,

___ ________Address,

___ ________Address,

___ ________Address,

___

of my knowledgems to the Compa

______________

_____________

ON

become a part on this application

______________

mployer/busines policy? Supplement – Pwed, loaned orure and Acknow

ment – Part III) coverage appl

Supplement – P

d Supplement btrue to the besed upon in con

_______ day of _ _____________Date of Birth, Te

_____________Date of Birth, Te



e and belief, the ny’s guidelines.

_______ ____Date

________ ____

Prod

of the attached an.

_____________

ess partner pay

Part II) r otherwise finawledgement)

lied for across

Part II)

before signing st of my (our) knsidering the ap

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information pro

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application; shal

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complete, accur

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ATION SUPPLEM

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Birmingham

the terms of the

Yes No

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____________. (Year) _____________

_____________

_____________

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rate, and correc

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MENT – PART I

urance CompanP.O. Box 83061

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er to determine eive the valuablou the following

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nonforfeitudividend ca

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have answeredto occur and yo

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whether you aree information nequestions and e

ase of a new lifeurrendered, parntract, or otherwor modified into

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the above quesoker is required ce policies or an

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therwise changinke a careful coms that you do not

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vidend accumula

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stions, a replaceto provide you w

nnuity contracts.

ved in this transa

my signature fo

______________ Broker or A

______________ Time

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Administrat

PPENDIX 11 SERVICES OF TN OF REPLACE

ng the status of parison if you art understand.

uity contract, hassigned to the in d as extended the use of non

the amount of thbenefit will continh values are releto be released owing or withdraw

ations or paid-up

ction in the amou

ment as definedwith a complete

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action.

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r legal and regu

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______________

Protive Office: 280

THE STATE OFEMENT

existing life insure contemplating

s existing coveransurer replacing term insurancenforfeiture bene

he existing life innue in force? eased, including

on one or more owal of any portiop additions is to

unt of premium p

d by New York ed Disclosure St

plicant: _______

plicant: _______

ent/Broker: ____

latory purposes

______________resentative

roker Number: _

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otective Life an01 Highway 280

P.O. Box 260P.O. Box 8

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F NEW YORK

urance policies og replacement, t

age been, or is itg the life insura e or under anofits, dividend ac

nsurance or annu

g all transactionof the existing poon of the loan vabe borrowed or

paid?

Insurance Regutatement and the

_____________

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for this applicati

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d Annuity Insu South, Birming6, Birmingham830735, Birming

Telephone:

EFINITION OF R

or annuity contrathe agent or bro

t likely to be: nce policy or

other form of ccumulations,

uity benefit or

ns wherein an olicies? alue, including withdrawn on

ulation No. 60 hae IMPORTANT

______________

______________

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ion.

______________

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_____________ne Number

05/2015

rance Companygham, AL 3522, AL 35202-260gham, AL 3528: 1-800-265-154

REPLACEMENT

acts, and in ordeker is required t

Yes N

Yes N

Yes N

Yes N

Yes N Yes N

as occurred or i notice regardin

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YOUR PROTECrding Replacemecoverage. This me you apply for

e of Applicant(s):

ess: __________

e of Agent or Bro

pany: _________

nformation on ex The following Approximati

__________

use when: • an existing l• an existing a• an existing l

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y not be in yoururchase of a new

ment is requireds important infor

Y REFUND PERurn it and receMPORTANT No

ompany, Agent o

CTION, the Depent or Change oDisclosure State

r your coverage o

____________

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oker: _________

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xisting coverage g replaced compions, if the follow_____________

life insurance poannuity contract life insurance po

EPARTMENT O

r best interest tow life insurance

d to be providedmation comparin

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otice form provi

or Broker if you h

partment of Finaof Life Insurance ement, which coor at a later date

______________

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on this form waspany(ies): _____wing replaced co______________

olicy is being use is being used to

olicy is being use

P

OF FINANCIAL SLICONY DISC

LICONY

o surrender, lapspolicy or annuity

to you no later ng your existing

0 days from the you are not saided to you whe

have any questio

ancial Services o Policies or Annontains informate, but no later tha

______________

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s obtained from:______________ompany(ies) faile_____________

ed to fund a life io fund a life insued to fund an an

Page 1 of 4

Administrat

SERVICES OF TCLOSURE STATY Appendix 10A

se, change or boy contract wheth

than upon deliv policy or contrac

e date of deliveratisfied with theen you applied

ons.

of the State of uity Contracts aion on all propoan at the time of

_____________

_____________

______________

dress: ________

: _____________ed to provide info______________

nsurance policyrance policy; or nuity contract.

Protive Office: 280

THE STATE OFTEMENT A1

orrow from exister issued by the

very of the new ct to the new po

ry of your new e new policy or for your new p

New York reqund the Definition

osed and existingf policy or contra

___ Telephone

______________

___ Telephone

______________

______________ormation in the p_____________

y;


P.O. Box 260 P.O. Box 8

F NEW YORK

ing life insurance same or a diffe

policy or contracolicy or contract.

life insurance pr contract. For policy or contra

ires that you ben of Replacemeng coverage affeact delivery.

e Number: _____

_____________

e Number: _____

_____________

_____________prescribed time: ______________

d Annuity Insu0 South, Birming06, Birmingham830735, Birming

Telephone:DISCLOSUR

ce policies or annerent insurance c

ct. Please revie

policy or annui further details

act.

e given the IMPnt forms at the ti

ected, may be pr

_____________

______________

_____________

______________

______________ __________________________

05/2015

rance Compangham, AL 3522, AL 35202-260gham, AL 3528: 1-800-265-154RE STATEMENT

nuity contracts icompany.

ew this documen

ty contract, yo on the terms o

PORTANT Noticime you apply forovided to you a

_____________

_____________

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y 3 6 3 5

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B-7376 (NY) Page 2 of 4 05/2015

DISCLOSURE STATEMENT CONTINUED: 1. DESCRIPTION OF TRANSACTION: Proposed Policy/Contract Existing Policies/Contracts Affected (1) (2) (3) As of _____________ As of ___________ As of ___________ _________________________ Company __________________ ________________ ________________ _________________________ Customer Service Phone # __________________ ________________ ________________

Contract Number

#_________________

#_______________

#_______________

Issue Date

__________________

________________

________________

_________________________ Type of Insurance __________________ ________________ ________________ $________________________ Base Policy Face Amount $_________________ $_______________ $_______________ _________________________ Rider __________________ __________________ ________________ ________________ _________________________ Rider __________________ __________________ ________________ ________________ _________________________ Rider __________________ __________________ ________________ ________________ _________________________ Rider __________________ __________________ ________________ ________________ _________________________ Rider __________________ __________________ ________________ ________________ $________________________ Total Annualized Premium $_________________ $_______________ $_______________ N/A Current Surrender Charge $_________________ $_______________ $_______________ ________________________% Guaranteed Interest Rate _________________% _______________% _______________% ________________________% Current Loan Interest Rate _________________% _______________% _______________% _________________________ Current Loan Balance __________________ ________________ ________________ _________________________ Contestable Expiry Date __________________ ________________ ________________ _________________________ Suicide Expiry Date __________________ ________________ ________________ Existing coverage to be changed by: (1) (2) (3) Lapse or Surrender [ ] [ ] [ ] Amendment or Reissue [ ] [ ] [ ] Loan or Withdrawal [ ] [ ] [ ] Death Benefit Reduction To $_________________ $_______________ $_______________ Reduced Paid-Up For $_________________ $_______________ $_______________ Extended Term To __________________ ________________ ________________

Other __________________

________________ ________________

Cash released by change $_________________ $_______________ $_______________ Use of cash released: ________________________________________________________________________________________________

B-7376 (NY) Page 3 of 4 05/2015

DISCLOSURE STATEMENT CONTINUED: 2. SUMMARY RESULT COMPARISON: Proposed With Existing Coverage Changed Existing Coverage Unchanged Guaranteed Non-Guaranteed Annual Premium Guaranteed Non-Guaranteed $________________ $________________ Current Year $________________ $________________ $________________ $________________ 5 Years Hence $________________ $________________ $________________ $________________ 10 Years Hence $________________ $________________

Guaranteed Non-Guaranteed Surrender Value Guaranteed Non-Guaranteed $________________ $________________ End of 1st Year $________________ $________________ $________________ $________________ 5 Years Hence $________________ $________________ $________________ $________________ 10 Years Hence $________________ $________________

Guaranteed Non-Guaranteed Death Benefit Guaranteed Non-Guaranteed $________________ $________________ End of 1st Year $________________ $________________ $________________ $________________ 5 Years Hence $________________ $________________ $________________ $________________ 10 Years Hence $________________ $________________

Guaranteed Non-Guaranteed Dividends Guaranteed Non-Guaranteed $________________ $________________ End of 1st Year $________________ $________________ $________________ $________________ 5 Years Hence $________________ $________________ $________________ $________________ 10 Years Hence $________________ $________________

B-7376 (NY) Page 4 of 4 05/2015

DISCLOSURE STATEMENT CONTINUED:

AGENT/BROKER’S STATEMENT: 1. The primary reason(s) for recommending the new life insurance policy or annuity contract is (are):

2. The existing life insurance policy or annuity contract cannot meet the applicant’s objectives because:

3. The advantages of continuing the existing life insurance policy or annuity contract without changes are:

REMARKS: The attached proposal, including sales material, was used in this sale.

No proposal or sales material was used in this sale.

If sales material and/or a proposal was used in this transaction, such material and/or proposal, or a list of such information used in the sale of the proposed life insurance policy or annuity contract, must accompany the submission of this form to the replacing insurer. Copies of the sales materials, and any proposals, must also be given to the applicant. If more than three existing life insurance policies or annuity contracts are to be affected by this transaction or if more than one new life insurance policy or annuity contract is proposed, Section 1 of this Disclosure Statement must be completed for such additional life insurance policies and annuity contracts. I have personally completed this form and certify that it is correct to the best of my knowledge and ability. Date: ___________________________________ Signature of Agent/Broker________________________________________ I hereby acknowledge that I received and read the above Disclosure Statement. Date: ___________________________________ Signature of Applicant: __________________________________________ Date: ___________________________________ Signature of Applicant: __________________________________________

B-870

DATE TO: FROM

In accenclo Pleas

This a Policy Addre

04 (NY) 10/02

E: ____________

Insuranc Address: Fax #: __

M: Name of Address: Fax #: __ Policyow Existing Please bauthorizeDisclosuthis infor

cordance with osed alternate N

e forward this i

authorization is

yowner’s Name

ess (Street, City

_____________

e Company to b

: ____________

______________

Agent: _______

: ____________

______________

wner: _________

Policy Number

be advised thaes the insurer pre statement at

rmation be furn

New York StatNew York State

information to t

s valid until revo

e (Printed)

y, State, Zip Co

______________

be replaced: __

______________

_____________

_____________

______________

_____________

_____________

(s): __________

t the policyowproposed to bettached. In accished within tw

AU

te Insurance De Disclosure Sta

the Agent name

PROTECT

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de)

____________

______________

_____________

______________

______________

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wner named is replaced to re

cordance with Nwenty (20) days

This notic

UTHORIZATION

epartment Regatement.

ed above and to

TIVE LIFE AND P.O

Birmingham1-8

dersigned in w

_____________

______________

______________

_____________

______________

______________

______________

______________

considering rlease the inform

New York State to:

1. The a2. PROT3. The a

ce has been:

TO DISCLOSE

ulation No. 60,

o:

ANNUITY INSUO. Box 830735 m, Alabama 3528800-265-1545

writing.

Policyo

ProAdmin. Office:

NOTICE T

______________

_____________

______________

___________ Te

_____________

______________

______________

_____________

replacing the pmation needed Insurance Dep

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URANCE COMP

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owner’s Signatu

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TO INSURER O

_____________

______________

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elephone: ____

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______________

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policy(ies) listed for completingpartment Regul

bove AND ANNUITY I of the existing

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d Annuity Insu0 South, Birming06, Birmingham830735, Birming

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OF PROPOSED

______________

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ed above. Tg the alternate ation No. 60, it

INSURANCE CO policy and/or c

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05/2015

rance Compangham, AL 3522, AL 35202-260gham, AL 3528: 1-800-265-154

REPLACEMENT

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______________

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he policyowne New York Stat is required tha

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REPLACEMEN

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nce policy or ant or broker is rw life insurance on and its advaou should:

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Page 1 of 2

Administrat

T OR CHANGE

PPENDIX 10C SERVICES OF THANGE OF LIF

BENEFIT AND

nuity contract inequired to give policy or annuitntages and disa

a summary resu

t your existing liable to effect thclosure Stateme

x implications a

existing coveragantageous are:

nsurance policy he same type of

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Protive Office: 280

E OF LIFE INSUR

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RANCE POLICI

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Y REGULATION

th the surrendere together with any life insurancyou. Your decis

until you are sur

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d Annuity Insu South, Birming6, Birmingham830735, Birming

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r, lapse or changa signed Disclo

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05/2015

rance Companygham, AL 3522, AL 35202-260gham, AL 3528: 1-800-265-154TY CONTRACTS

TRACTS

ge of existing lifosure Statemennuity contracts tgood one – or

nd fully the effec

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B-7378 (NY) Page 2 of 2 05/2015

You have the right, within 60 days from the date of delivery of a new life insurance policy or annuity contract, to return it to the insurer and receive an unconditional full refund of all premiums or considerations paid on it, or in the case of a variable or market value adjustment policy or contract, a payment of the cash surrender benefits provided under the policy or contract, plus the amount of all fees and other charges deducted from gross considerations or imposed under the life insurance policy or annuity contract, and may have the right to reinstate or restore any life insurance policies and annuity contracts that were surrendered, lapsed or changed in the transaction to their former status to the extent possible and in accordance with the insurer’s published reinstatement rules to the extent such rules are not inconsistent with the provisions of this part. IMPORTANT: This right should not be viewed as reinstating or restoring your life insurance policy or annuity contract to the same condition as if it had never been replaced. There may be consequences in reinstating or restoring your life insurance policy or annuity contract, including but not limited to:

• The right to reinstate or restore your life insurance policy or annuity contract applies only to companies subject to New York Insurance Laws;

• Your life insurance policy or annuity contract is subject to your specific company’s reinstatement rules, which may vary from company to

company. These rules may require payment of both premium and interest; however, you will not be subject to evidence of insurability, or a new contestable or suicide period;

• You may not receive the interest or investment performance during the period the life insurance policy or annuity contract was replaced;

and • There may be unfavorable federal income tax consequences as a result of the reinstatement of your life insurance policy or annuity

contract.

IMPORTANT: In the case of a variable or market value adjustment policy or contract, the value of the policy or contract may increase or decrease during the 60 day period depending on the performance of the underlying investments, which may effect the value of the refund you receive.

I hereby acknowledge that I read the above “IMPORTANT NOTICE” and have received a copy of same.

Date: ________________________________________ Signature of Applicant: ______________________________________________

Date: ________________________________________ Signature of Applicant: ______________________________________________

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P.O. Box 2606, Birmingham, AL 35202-2606Administrative Office: P.O. Box 830735, Birmingham, AL 35283

To you (or a person authorized by law who consented to the test for you);

To anyone whom you have specifically authorized to receive such information by signing a written release;

Home Office: 2801 Highway 280 South, Birmingham, AL 35223Protective Life and Annuity Insurance Company

Telephone: 1-800-265-1545HIV RELATED INFORMATION - NEW YORK

Who Can Receive HIV Related Information?

To a health care facility (such as a hospital, blood bank, or clinical laboratory) or a health care provider (such as a physician, nurse, ormental health counselor) providing care to you or your child, and anyone working for such a facility or provider who reasonably needs theinformation to supervise, monitor or administer a health service;

To a person who your doctor believes is at significant risk for HIV infection, if you do not notify that person after being counseled to do so;

To a committee or organization responsible for reviewing or monitoring a health facility;

To a federal, state, country, or local health officer when state or federal law requires disclosure;

Under New York State Public Health Law, HIV related information is confidential and may only be given:

To a government agency, when the agency needs the information to supervise, monitor or administer a health or social service;

To an authorized foster care or adoption agency;

B (NY) - Info

To insurance companies and other third party payors such as Medicaid, if necessary for the payment of services to you;

To any person to whom a court orders disclosure under limited circumstances set forth by law. Except in an emergency situation, advancenotice and an opportunity to oppose the release of such information would be given to you;

To the Division of Parole, the Division of Probation, the Commission of Correction, or a medical director of a local correctional facility, aspermitted by HIV confidentiality regulations of such organization;

By a physician to the person who consents for your health care (parent, guardian, etc.) if disclosure is necessary to provide timely care foryou, and you have been counseled regarding the need for disclosure. A physician may not disclose such information if it is against yourbest interest to do so.

You can ask your doctor if HIV related information about you has been released to anyone listed above.

1.

2.

3.

•

••••

4.Taking an HIV antibody test is voluntary. You do not have to take the test.If you do not wish anyone to know your test results or even that you have been tested, you can go to an anonymous test site. This is aplace where you can receive counseling and the HIV test without giving your name or address. You can find the nearest anonymous testsite by calling the AIDS Hotline at 1-800-541-2437.

B-7375 (NY) NY-ConsentPage 1

A positive test result means that you have been exposed to the virus and are infected. It does not mean that you have AIDS or that youwill become sick with AIDS in the future; but it is an indication that you may develop AIDS and may wish to consider further independenttesting.

A negative test result means that you are probably not infected with the virus. It takes the body time to produce HIV antibodies. If youhave been exposed to HIV recently, you need to be retested in several months to make sure you are not infected. Your doctor orcounselor will explain this to you.

What are the benefits of taking the test?If you test negative:

You can learn how to protect yourself from getting infected with the virus in the future. Ask your doctor or counselor how.

If you test positive:

ADDRESS: _________________________________________________________________________________________________________

To determine your insurability, the Insurer named above has requested that you provide a sample of your blood for testing and analysis. Alltests will be performed by a licensed laboratory.

Voluntary Testing

P.O. Box 2606, Birmingham, AL 35202-2606Administrative Office: P.O. Box 830735, Birmingham, AL 35283

What tests may be performed?Tests which may be performed include: determinations of blood cholesterol and related lipids (fats) and screening for liver or kidneydisorders, diabetes, immune disorders, and the presence of HIV antibodies/antigens.

What is the HIV Antibody Test?The HIV antibody test is a blood test. The test shows if you have antibodies to the virus that causes AIDS. A sample of your blood will betaken from your arm with a needle. If the first test shows that you have antibodies, a different test will then be done on the same bloodsample to make sure the first test was right. The HIV antigen test directly identifies AIDS viral particles.

Home Office: 2801 Highway 280 South, Birmingham, AL 35223Protective Life and Annuity Insurance Company

Telephone: 1-800-265-1545

Knowing that you are infected is important for your health. Your doctor can care for you better.If you are a woman or man who is thinking of having a child, you can learn about the risks of passing the virus to your baby.If you are a woman who is already pregnant, your doctor can provide information on the full range of options and services available toyou.

You can learn how to avoid giving the virus to others.

NOTICE AND CONSENT FOR BLOOD TESTING

NOTICE AND CONSENT FOR BLOOD TESTING WHICH MAY INCLUDE AIDS VIRUS (HIV) ANTIBODY/ANTIGEN TESTING AND AUTHORIZATION OF RELEASE OF HIV TEST INFORMATION

EXAMINER: _________________________________________________________________________________________________________

5.

6.

7.

If you test positive, you should be careful about telling others what your test showed. Some HIV positive people have been discriminatedagainst by employers, landlords and others. If you experience discrimination because of release of HIV related information, you maycontact the New York State Division of Human Rights at (212) 870-8624 or the New York City Commission of Human Rights at (212) 566-5493. These agencies are responsible for protecting your rights.

For More InformationIf you have further questions about informed consent for HIV antibody testing, you may contact the New York State Department of Healthat (518) 486-1595.

B-7375 (NY) Page 2 NY-Consent

Confidentiality of Test ResultsIf you take the HIV antibody test, your test results are confidential. Under New York State Law, confidential HIV related information canonly be given to people you allow to have it by signing this consent and release form, or to those persons included on the back of this form.

By signing this release form, you agree that the test results will be reported by the laboratory to the insurer. When necessary for businessreasons in connection with insurance you have or have applied for with the insurer, the insurer may disclose test results to others involvedsolely in the underwriting process such as its affiliates, reinsurers, employees or contractors. If the insurer is a member of the MIB, Inc.,and if the test results for HIV antibodies/antigens are other than normal, the insurer will report to the MIB, Inc., a generic code whichsignifies only a non-specific blood and/or urine test abnormality. If your HIV test is normal, no report will be made about it to the MIB, Inc.Other test results may be reported to the MIB, Inc., in a more specific manner. The organizations described in this paragraph maymaintain the test results in a file or data bank. There will be no other disclosure of test results or even that the tests have been doneexcept as may be required or permitted by law or as authorized by you.

If your HIV test results are normal, no routine notification will be sent to you. If the HIV test results are other than normal, the insurer willcontact you. The insurer may also contact you if there are other abnormal test results which, in the insurer's opinion, are significant. Theinsurer will ask you for the name of a physician, other health care provider, or other designee to whom you may authorize disclosure andwith whom you may wish to discuss the results. If you elect to receive the HIV test results directly, you may call the State HealthDepartment's toll-free number for further information about AIDS, the meaning of HIV test results and the availability and location of HIVcounseling services. You should consult your physician about the meaning of and need for counseling, where appropriate, as to the HIVtest results.

Risks Involved with Disclosure and Sources of Help

Name and address of facility/provider obtaining release:

Name and address of person signing this form (if other than above):

Name and address of person who will be given HIV related information:

Date Signature

Date

Signature of person who will be tested Signature of person authorized to consent for person to be tested

Name of person who will be tested (Please print) Name of person authorized to consent (Please print)

Name Title

Facility/Provider Name

Name: _____________________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________________

Name: _____________________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________________

Reason for release of HIV related information: ______________________________________________________________________________

Name of person whose HIV related information will be released: ________________________________________________________________

Relationship to person whose HIV information will be released: _________________________________________________________________

Name: _____________________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________________

____________________________________________________ _____________________________________________________

Time during which release is authorized: From: _____________________ To: ______________________

My questions about this form have been answered. I know that I do not have to allow release of HIV related information, and that I can changemy mind at any time.

_________________________________________________________________________________________________________

My questions about the HIV test have been answered. I agree to take the HIV antibody test.

____________________________________________________

____________________________________________________

B-7375 (NY) Page 3 NY-Consent

____________________________________________________ _____________________________________________________

____________________________________________________ _____________________________________________________

I have explained the means by which the HIV antibody test is done, the meaning of the results and the possible consequences of disclosure ofthe test results to the individual above, and have answered any questions she/he had about the test.

LIFE INSURANCE APPLICATION PACKET - … Life and Annuity Insurance Company P.O. Box 830619...

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Transcript of LIFE INSURANCE APPLICATION PACKET - … Life and Annuity Insurance Company P.O. Box 830619...