APPLICATION FOR ORDINARY LIFE INSURANCE • GLOBE LIFE AND ACCIDENT ...

(Please Print) APPLICATION FOR ORDINARY LIFE INSURANCE ? GLOBE LIFE AND ACCIDENT INSURANCE COMPANY ? OKLAHOMA CITY, OK

1. Name of Employee as shown on Allotment______________________________________________________________________________________________________________________

2. Residence Address___________________________________________________________________________________________________________________________________________

Street

City

State

ZIP

3. Social Security No. ___________________ 4. Home Tel. ___________________ Work Tel. ___________________ E-mail: ___________________

5. Payroll Center_________________________________ City,State, (Dept. Code)_____________________________________ (_______________)

6. Does any Proposed Insured have any existing or any pending applications for Life insurance or Annuity contracts?.................................................................................YES NO

If yes, will the insurance being applied for replace or change any existing Life insurance or Annuity contract?..........................................................................................YES NO

7. Full Name of all Persons Proposed for coverage

Beneficiary

Sex

Birthdates MM DD YY

Age

Amount of Insurance

Weekly Premium

Plan

ADB (Yes / No)

a. Empl.

b. Spse.

a. Empl.

c.

a. Empl.

CHILDREN

d.

a. Empl.

e.

a. Empl.

f.

a. Empl.

g.

a. Empl.

8. EMPLOYEE'S BENEFICIARY: Spouse OR :

IF CHILD RIDER IS ISSUED IT WILL BE ATTACHED TO EMPLOYEE'S POLICY

IF THE ANSWERS TO QUESTIONS 9., 10.(a), OR 10.(b) ARE "YES"THE PROPOSED INSURED TO WHOM THE "YES" ANSWER APPLIES WILL BE ISSUED SUB-STANDARD COVERAGE IF

INDIVIDUAL COVERAGE APPLIED FOR. IF THE ANSWER TO QUESTION 10.(c) IS "YES", THE PROPOSED INSURED TO WHOM THE "YES" ANSWER APPLIES IS NOT ELIGIBLE FOR ANY

COVERAGE. IF ANY PROPOSED INSURED CHILD ANSWERS "YES"TO ANY OF THE QUESTIONS, THEY ARE NOT ELIGIBLE FOR COVERAGE UNDER THE CHILD RIDER. YES NO

9. Is any Proposed Insured disabled, confined to a hospital or nursing facility, or does any Proposed Insured require the use of a wheelchair?

10. In the past five years has any Proposed Insured ever been medically diagnosed or treated by a physician for:

(a) cancer, high blood pressure, coronary artery disease, chronic obstructive lung disease, chronic kidney disease or kidney failure, or any disease or disorder

of the heart, brain or liver?

(b) muscular disease, mental or nervous disorder, chronic glandular disease or disorder, diabetes, systemic lupus, cystic fibrosis, Down's syndrome, drug or

alcohol abuse, had any amputation caused by disease, or been hospitalized for any blood disease or disorder?

(c) Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or immune deficiency related disorders, or tested positive for antibodies to

the HIV virus or been diagnosed with a terminal illness?

11. CHECK APPLICABLE BOX FOR ANY PROPOSED INSURED TO WHOM A "YES" APPLIES: a. b. c. d. e. f. g.

Special Requests

Home Office Use Only

FOR ANY PROPOSED INSURED WHO APPLIES FOR A FACE AMOUNT WHICH EXCEEDS THE GUARANTEED ISSUE LIMIT OR APPLIES FOR A FACE AMOUNT WHICH, TOGETHER

WITH THE FACE AMOUNT IN FORCE WITH THE COMPANY, EXCEEDS THE GUARANTEED ISSUE LIMIT, GIVE DETAILS BELOW OF ANY "YES" ANSWER ABOVE AND COMPLETE THE

FOLLOWING QUESTIONS.

(If yes, check applicable box to which person YES answer applies and complete the questionnaire.)

14.

P.I. Line No.

Question No.

Name of Illness or Condition

Date of Date of Onset Recovery

Name and Addresses of Attending Physicians, Hospitals or Clinics

AGREEMENT: I hereby apply to Globe Life And Accident Insurance Company, for a policy to be issued solely and entirely in reliance upon the written answers to the foregoing questions, and I expressly agree on behalf of myself and any person who shall claim any interest in any policy issued on this

application as follows: (1) All statements and answers contained herein are full, complete and true to the best of my knowledge and belief. (2) The insurance hereby applied for shall not be considered in force until a policy is issued and delivered to me and the full first premium paid thereon while

the Proposed Insured's health and other conditions remain as described in this application. (3) I fully understand that if the Company should issue a graded death benefit, the death benefit payable during the first three years shall be a percentage of the initial face amount of insurance as follows: 25%

first policy year, 50% second policy year, 75% third policy year and 100% the fourth policy year and thereafter. If death is a result of an accident, then

the percentage reduction listed shall not apply.

Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Dated at

State of

this

day of

To the best of your knowledge as writing agent, does the Proposed Insured have any existing (or pending applications for) Life insurance or Annuity contracts? YES NO

To the best of your knowledge as writing agent, is the insurance applied for intended to

replace any existing Life insurance or Annuity?

YES NO

I certify that the above medical questions were asked and recorded as given by the Proposed Insured(s).

Signature of Employee / Proposed Insured Signature of Spouse

Signature of agent who completed application

No.

Signatures(s) of Any Insured Child 18 Years or Older

IGAPR(34)

Manager

No.

Signatures(s) of Any Insured Child 18 Years or Older

ESD3971 0418

Agent's Report

Globe Life And Accident Insurance Company

Complete the following questions on all proposed insureds.

1. Did you personally see proposed insured(s)? Yes No If No, why not?

2. Has a possible medical exam, inspection phone interview, or other medical requirement(s) been explained to proposed insured(s)? Yes No

3. For applicable proposed insureds, indicate the phone number and time of day to be reached:

NamePhone Number Time of Day

NamePhone Number Time of Day

NamePhone Number Time of Day

4. Did you attach the following completed forms, where required, to the application and leave a copy of these behind with the applicant?

? Description of Information Practices Notice (G-1342N) Yes No ? Authorization for Release of Health-Related Information (F3988) Yes No ? Authorization to Obtain and Disclose Information (ESD3971) Yes No

5. Agent's additional comments:

Signature of AgentAgent NumberDate

?2020 Globe Life Employee Services Division

ESD841567 1120

Globe Life And Accident Insurance Company

Globe Life Center Oklahoma City, Oklahoma 73184

Authorization for Release of Health-Related Information

This authorization is intended to comply with the HIPAA Privacy Rule

Name of proposed insured/patient (please print)

Date of birth

I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, medical facility, other insurance company, consumer reporting agency, MIB, Inc., 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 Globe Life And Accident Insurance Company (Globe) and its agents, employees, and representatives. This medical or health information may include information on the diagnosis and treatment of mental illness, alcohol, and drug use. This also may include information on the diagnosis, treatment, and testing results related to HIV, AIDS, and sexually transmitted diseases, unless otherwise restricted by state law.

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 Globe may: 1) underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; 2) obtain reinsurance; 3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer coverage; and/or 5) conduct other legally permissible activities that relate to any coverage I have or have applied for with Globe.

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 Globe to the attention of the Underwriting 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, and that, to the extent that Globe has a legal right to contest a claim under an insurance policy or to contest the policy itself, such revocation may prevent Globe from completing their review of policy claims. Such revocation shall not apply to any use or disclosure of my protected health information specifically allowed without authorization by HIPAA and no action relating to this authorization shall be construed as creating any restriction on the uses that HIPAA allows without my authorization. I understand that any information that is disclosed pursuant to this authorization may be redisclosed 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, Globe may not be able to process my application, or if coverage has been issued, may not be able to process policy claims. I acknowledge that I have received a copy of this authorization.

Signature of Proposed Insured/Patient or Personal Representative

Date

Description of Personal Representative's Authority or Relationship to Patient

INVESTIGATIVE CONSUMER REPORTS NOTIFICATION

As part of our routine underwriting procedure, an investigative consumer report may be obtained which will provide applicable information concerning character, general reputation, personal characteristics, and mode of living. This information will be obtained through personal interviews with your friends, neighbors, and associates. You may request to be interviewed in connection with the preparation of the report and upon request may receive a copy of the report.

NOTICE REGARDING MIB, INC.

Information regarding insurability will be treated as confidential. Globe Life And Accident Insurance Company or its reinsurers may, however, make a brief report thereon to MIB, Inc., a not-for-profit membership organization of life 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 it may have in its file.

Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 8666926901. If you question the accuracy of 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.

Globe Life And Accident Insurance Company or its reinsurers may also release information in 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 .

NOTICE OF INFORMATION PRACTICES

Personal information may be collected from other parties. Such information, and other personal or privileged information later collected, may be disclosed to third parties without authorization. You have the right of access and correction with respect to all personal information collected, and a full notice of your rights will be furnished upon request.

SEND ORIGINAL WITH APPLICATION ? GIVE COPY TO PROPOSED INSURED

F3988

GLB2200 0421

Authorization to Obtain and Disclose Information

Underwritten by Globe Life And Accident Insurance Company, a Globe Life company

1. Globe Life And Accident Insurance Company (referred to as Globe Life), its reinsurers, insurance support organizations, and their authorized representatives, may obtain medical and other information in order to evaluate my (our) application for Life or Health Insurance.

2. Any physician, practitioner, hospital, clinic, other medical or medically related facility, the Veterans Administration, the Medical Information Bureau, Inc., my employer, pharmacy or pharmacy benefit manager, and consumer reporting agency or insurance company who possess information of care, treatment or advice of me or my children may furnish such information to Globe Life or its representative upon presenting this authorization or a photocopy. To facilitate rapid submission of such information, I authorize all said sources, except MIB, to give such records or knowledge to any agency employed by the insurance company to collect and transmit such information.

3. This authorization includes information about drugs, alcoholism or mental illness. This authorization may include information on the diagnosis, treatment, and testing results related to HIV, AIDS, and sexually transmitted diseases, unless otherwise restricted by state law.

4. Globe Life or its reinsurers may make a brief report regarding me or my children to other companies to whom I have applied or may apply.

5. This authorization will be valid from the date signed for a period of two years and may be revoked by sending written notice to Globe Life And Accident Insurance Company. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information.

6. I authorize Globe Life to obtain an investigative consumer report on me.

7. I have read this authorization and I know that I may request a copy. I acknowledge receipt of required notice, form G-1342N.

8. I elect to be interviewed if an investigative consumer report is prepared in connection with this application.

9. I elect not to have personal information disclosed to non-affiliates of Globe Life for marketing purposes and to affiliates of Globe Life for purposes other than the marketing of insurance products and service.

Dated at State of

this

day of

AgentAgent Number

Signature of Employee / Proposed Insured Signature of Spouse

Signature(s) of Any Insured Child 18 Years or Older Signature(s) of Any Insured Child 18 Years or Older

ESD3971 1120

Compliance Department PO Box 8080

McKinney, TX 75070

Description of Information Practices

This description of the Information Practices of Globe Life And Accident Insurance Company ("Globe Life") and its independent agents is being provided in accordance with the requirements of the Insurance Information and Privacy Protection Law in effect in your state of residence.

Collection of Information

We collect and retain the following categories of personal information necessary for us to provide the insurance products and services that you requested: (1) unique personal identifiers, such as, your full name, address, email address, Social Security number, or similar identifiers; (2) health/medical information; (3) employmentrelated information; and (4) payment information such as checking account information. In addition, your Globe Life agent may collect information intended to aid in providing a wider selection of insurance products and services to you.

We may also collect or verify information by contacting medical professionals and institutions which have provided care to you or members of your family proposed for coverage, employers, or other insurance companies to which you have applied. We may collect information by exchanges of correspondence, by phone or personal contact.

In some cases, we may ask an insurance support organization to collect information and submit an investigative consumer report to us. That organization may retain a copy of the report and may disclose its contents to others for whom it performs such services. In the event of an adverse underwriting decision, you have a right to make a written request to receive detailed information of the specific reasons for the decision in writing.

Disclosures by Globe Life And Accident Insurance Company

Globe Life or its independent agents may make disclosures of personal information, without your authorization, to third parties for business purposes, as permitted by law to:

? Persons or organizations to underwrite your policy, process your premium, maintain your policy, administer a claim, respond to court orders and legal investigations, or report to consumer reporting agencies;

? Persons or organizations who may wish to market products or services, including affiliates of Globe Life;

? Other financial companies with joint marketing agreements to allow us to provide a wider selection of insurance products and services to you.

Please be assured that the above describes some of the disclosures which may be made, not disclosures which are always or even often made. In any event, the information disclosed without your authorization will be only as much as is reasonably necessary to accomplish the intended purpose.

Obtaining Additional Information or to Request Correction, Amendment, or Deletion

Upon request, you can access personal information about you in our files. You also have the right to request that we correct, amend, or delete any personal information that you believe is inaccurate. We will investigate and make changes as needed. To exercise your rights or if you have further questions, please write to us at the address below and provide us with your full name, complete address, date of birth, and all policy numbers under which you are insured. We at Globe Life hope that you find this description of our information practices helpful. We take our responsibilities and your rights, very seriously.

Globe Life

ATTENTION: Privacy Office Compliance Department PO Box 8080 McKinney, TX 75070

G-1342N 0820 GLB1008A

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