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American Heritage Cancer & Dreaded Disease

The University of Mississippi offers a cancer/dreaded disease and intensive care policy with American

Heritage Life Insurance Company. The plan offers a Basic Option or an Enhanced Option for cancer

and dreaded disease benefits. The type of option chosen determines the amount of benefit paid.

Optional Intensive Care Riders are also available through this plan. To enroll in an Intensive Care

Rider (ICU) you must also be participating in an American Heritage cancer/dreaded plan.

Benefits and premiums are outlined in the Plan Brochure which can be accessed at

https://hr.olemiss.edu/canceranddreadeddiseases/.

All elections for new enrollment or changes are subject to underwriting through Allstate.

Coverage Options

Cancer and Dreaded Disease Benefits include but are not limited to: Hospital Confinement

Inpatient Drugs and Medicine

Ambulance

Family Member Lodging and Transportation

Hospice Care

Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy, and Immunotherapy

Blood, Plasma, and Platelets

Surgery

Skin Cancer

New or Experimental Treatment

Optional Intensive Care Rider (ICU) – When admitted to the intensive care unit, this rider

offers $400/day or $600/day for each day of confinement in a hospital intensive care unit, with

coverage at $200/day or $300/day for step-down units. This coverage begins with the first day of

admission and pays up to 45 days. This optional rider is not disease specific and pays a benefit for

covered confinement in a hospital intensive care unit for any covered illness or accident from the very

first day of confinement. Please note: To enroll in an Intensive Care Rider (ICU) you must also be

participating in an American Heritage cancer/dreaded plan.

Underwriting: Complete highlighted sections of the attached Application for Life and Health

Insurance (AHL). Failure to submit the form to Human Resources within 30-days of request will

result in closure of your application.

Upon completing Open Enrollment, save changes, and review the Benefits Summary for accuracy.

American Heritage is subject to underwriting. You must complete the attached Consolidated

Enrollment Form and Application for Life and Health Insurance (AHL) and submit to Human

Resources via fax (662-915-5836) or campus mail/drop off at Human Resources, Jackson Avenue

Center – Central. It is your responsibility to ensure forms are received by Human Resources.

All coverage changes become effective January 1, 2020.

https://hr.olemiss.edu/canceranddreadeddiseases/

Coverage that is active on 12/31/2019 will continue at the same level for plan year 2020 in the absence

of an open enrollment election/change.

IMPORTANT: PLEASE READ AS ACTION MAY BE REQUIRED.

In order to be in compliance with Form 1095-C and Affordable Care Act requirements,

please verify that all names, social security numbers and dates of birth are correct for any

family members who are currently enrolled or will be enrolled in an insurance plan. This

information can be accessed under the ‘Employee’ tab and then by clicking the

MyHRtools drop down box and selecting Open Enrollment Step 1: Update Beneficiaries /

Dependents. If any information is incorrect, please update.

When enrolling eligible dependents on an insurance plan, a copy of the dependent’s Social

Security Card MUST be provided to the Human Resources office. Furthermore, all listed

names on insurance applications must be listed as a legal name, nicknames are not

permitted.

In order to ensure the accuracy of W-2 processing for 2019, please verify all contact

information (address, phone number etc.) within myOleMiss. This can be accessed under

the ‘Employee’ tab and then by clicking the MyHRTools drop down box and selecting

Address & Communication Preferences. If any information is incorrect, please update

accordingly. Please note that updating your contact information within myOleMiss will

only update your address with the University, and does not update your contact

information with insurance vendors. Please also complete a Benefits Information

Change form to update your information with each respective vendor and submit the form

to Jackson Avenue Center – Central or fax to 662-915-5836. When changing your contact

information within myOleMiss, a link to this form will populate on the right side of the

screen. You may also access the form via the following link. http://hr.olemiss.edu/benefits/forms/.

http://hr.olemiss.edu/benefits/forms/

The University of Mississippi: Benefit Enrollment/Change Form

Spouse/Dependent Information – List all dependents you wish to cover or drop from the insurance plans you have selected. Check all benefits that apply.

Name (Last, First, MI)

Social Security Number M/F Birth Date Relationship D

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_________________________________________________________________________________________________________________________________________________________

Dental - Delta Dental (Group #1126) Premiums are withheld 12-Month / 9-Month Section 125 Cafeteria Plan

Employee Only Family

12-month / 9-month 12-month / 9-month

Low Plan (division: 00002) $28.81 / $38.42 $60.12 / $80.16

High Plan (division: 00001) $41.57 / $55.42 $86.49/ $115.32

Are you or your family member(s) currently covered under another dental plan: Yes No

If yes, provide the name of the participant(s) with other coverage. ___________________________________________________________________________

Waive/Cancel Coverage

________________________________________________________________________________________________________________________________________

Vision – Davis Vision (Group: UMM) Premiums are withheld 12-Month / 9-Month Section 125 Cafeteria Plan

12-month / 9-month 12-month / 9-month 12-month / 9-month

Employee Only $7.80 / $10.40 Employee + 1 $14.08 / $18.77 Family $21.89 / $29.19


Employee Name: Date of Hire:

Address: Status: 9-Month 12-Month

City/State/Zip: Home Phone:

SSN: University ID Number: Work Phone:

Date of Birth: Gender: Male Female Undeclared Is your spouse employed by the University of

Mississippi: Yes No

If yes, provide name: Email Address: Marital Status:

Check One: New Hire Legal Marriage/Divorce Birth/Adoption/Foster Care Ineligible Dependent Open Enrollment

Other Status Change ___________________________ Date of Qualifying Event _________________

University employees are paid twice a month. Premium deductions for 12-month employees occur over 24 pay periods and for a

9-month faculty member over 18 pay periods. Pay Mode: Semi-Monthly

FOR HUMAN RESOURCES ONLY

Effective Date: ________________



The University of Mississippi: Benefit Enrollment/Change Form ____________________________________________________________________________________________________________________________

Flexible Spending Accounts (FSA) Contributions are withheld 12-Month / 9-Month Section 125 Cafeteria Plan

Annual Election

Dependent Care Spending Account $ ___________

(annual election per family: $5,000)

Unreimbursed Medical Spending Account $ ___________

(annual election per individual: $2,700)

Prescription FlexCard Yes No

Waive Participation (To cancel participation in an existing plan, write ‘0’ in the blank next to the respective plan type.)

________________________________________________________________ ____________________________________________

Accidental Death and Dismemberment – National Union Fire Insurance Company of

Pittsburgh #PAI9032465 Section 125 Cafeteria Plan

Amount of coverage available is a minimum of $10,000 and a maximum of $250,000 (in $10,000 increments), with amounts above

$150,000 not to exceed 10x base salary. If you insure your spouse and/or dependent children under this plan, the amount of insurance

applicable to the members of your family is based on the composition of your family at the time of loss and is expressed as a percentage of

the employee’s coverage.

Employee Only Family Coverage Amount: $______________


Beneficiary Designation: Accidental Death & Dismemberment is a life insurance policy. Please make sure you designate a

beneficiary(ies) by completing the AD&D Beneficiary Designation Form that can be accessed at

http://hr.olemiss.edu/benefits/forms/. The designation form should be submitted to Human Resources via fax (662-915-5836) or

campus mail/drop off at Human Resources, Jackson Avenue Center – Central. It is your responsibility to ensure forms are received

by Human Resources. The employee is beneficiary for dependent coverage unless otherwise indicated.

__________________________________________________________________________________________________________ _____________

Long-Term Disability (LTD) – Standard Insurance Company You may elect disability coverage of 60% of your base salary up to $5,000 per month, until age 65. Benefits are payable after a 90 or 180

day elimination period subject to review by The Standard Insurance Company. *Pre-Existing Limitation may apply. **Guarantee Issue

only applies to new hires and employees newly eligible for benefits. If you waive coverage when first eligible and wish to enroll later,

Evidence of Insurability will be required and The Standard Insurance Company has the right at that time to refuse the request for coverage.

Premiums are withheld 12-Month / 9-Month

Plan 1 (90-day option) Plan 2 (180-day option)



12-Month Cost / 9-Month Cost $_________

Effective Date: _________________


$ pay period election (D/C)

$ pay period election (M/R)

Effective Date: _________________


Base Annual Earnings $______________

Position Title: ______________________________________________

Hours Worked Per Week: _______________

Effective Date: _________________

http://hr.olemiss.edu/benefits/forms/


Supplemental Term Life with AD&D – UNUM Premiums are withheld 12-Month / 9-Month

** Guarantee Issue only applies to new hires and employees newly eligible for benefits. If you waive coverage when first eligible and wish

to enroll later, Evidence of Insurability must be provided and UNUM has the right at that time to refuse the request for coverage.

Employee Coverage ** Amounts above $200,000 or 3 times salary, whichever is less, require Evidence of Insurability.

Employee Coverage

1X Salary 2X Salary 3X Salary

4X Salary 5X Salary 6X Salary

Maximum coverage available is 6X your annual base salary rounded to the

Next higher multiple of $1,000 to a maximum of $600,000

Waive Employee Coverage

Spouse Coverage ** Amounts above $25,000 require Evidence of Insurability. Spouse coverage cannot exceed 50% of the

employee’s approved coverage rounded own to the nearest $25,000.

.

$25,000 $50,000 $75,000 $100,000

Waive Spouse Coverage

Dependent Child(ren) Coverage - All children are covered from birth to 6 months for $5,000 and at $10,000 from 6 months to

age 19, or 25 if full-time student.

Elect Coverage

Waive Dependent Child(ren) Coverage

Beneficiary Designations UNUM is the administrator for beneficiary designation information. New plan participants will receive a letter and Beneficiary

Designation Form from UNUM within one month of enrollment. By completing the form, you are designating the person(s) who will

receive the payment if a UNUM life insurance claim is filed. Upon completion, the form must be returned directly to UNUM via email or

fax. Instructions will be provided in the letter and on the form. Current participants may contact Client Service Associates at 1-866-220-

8460 to verify beneficiary information on file with UNUM or make changes to their designation.

*If you do not designate a beneficiary, the payment of benefits will default to provisions of the contract.

Delayed Effective Date Employee: Insurance will be delayed for Employees not actively at work until the first of the month following

the date they return to work. Regularly scheduled vacation time is considered active employment. Dependent: Coverage for totally

disabled dependents will be delayed until the first of the month following the date the individual is no longer totally disabled.

Policy Limitations and Exclusions I understand all the policy exclusions and limitations listed in the certificate of coverage. If

electing to participate in any of the benefit plans mentioned above, I authorize the required payroll deductions. I understand that my

payroll deduction amount will change if my coverage or costs change. I understand that if I cancel/decline participation, I may join the

Plan at a specified later date; however, I will be required to provide evidence of insurability at my own expense, and the insurance

company may refuse my request. In the event of any variations between this form and the Plan document, the terms of the Plan document

will prevail.


Annual Salary $ _____________________

Coverage Amount 12-Month / 9-Month Cost

$___________________ $____________

Effective Date: _______________


Coverage Amount 12-Month / 9-Month Cost

$___________________ $____________



12-Month / 9-Month Cost $___________



Cancer/Dreaded Disease & Intensive Care - American Heritage (Underwritten by AllState) Premiums are withheld 12-Month / 9-Month Section 125 Cafeteria Plan

This plan is subject to underwriting. Those electing coverage will be contacted by a representative of the William Morris Group or AllState

to complete a medical health statement. Failure to complete the medical health statement in a timely manner or declination from underwriting

will result in non-issuance of the policy. Premium is based upon age at time of election.

Select only one plan type. (CP12 plan)

Employee Only Family

Plan 1 and 2 (Low Option) 12-month / 9-month 12-month / 9-month

Base – No Intensive Care

Age 18 - 64 $11.29 / $15.06 $22.71 / $30.28

Age 65 - 69 $25.92 / $34.56 $54.07 / $72.10

Age 70 - 74 $29.91 / $39.88 $62.56 / $83.42

Age 75 - 80 $32.82 / $43.76 $68.71 / $91.62

Plan 1+ (Low Option)

$400 per day Intensive Care

Age 18 - 64 $12.81 / $17.08 $26.56 / $ 35.42

Age 65 - 69 $28.13 / $37.52 $59.28 / $ 79.04

Age 70 - 74 $32.23 / $42.98 $67.97 / $ 90.64

Age 75 - 80 $35.54 / $47.40 $75.04 / $100.06

Plan 2+ (Low Option)


Age 18 - 64 $13.57 / $18.10 $28.49 / $ 38.00

Age 65 - 69 $29.24 / $39.00 $61.89 / $ 82.52

Age 70 - 74 $33.39 / $44.52 $70.68 / $ 94.24

Age 75 - 80 $36.90 / $49.20 $78.21 / $104.28

Plan 3 and 4 (High Option)

Base – No Intensive Care

Age 18 - 64 $21.21 / $28.28 $ 42.71 / $ 56.96

Age 65 - 69 $48.90 / $65.20 $102.35 / $136.48

Age 70 - 74 $56.39 / $75.20 $118.38 / $157.84

Age 75 - 80 $61.82 / $82.44 $129.89 / $173.20

Plan 3+ (High Option)


Age 18 - 64 $22.73 / $30.32 $ 46.56 / $ 62.08

Age 65 - 69 $51.11 / $68.16 $107.56 / $143.42

Age 70 - 74 $58.71 / $78.28 $123.79 / $165.06

Age 75 - 80 $64.54 / $86.06 $136.22 / $181.62

Plan 4+ (High Option)


Age 18 - 64 $23.49 / $31.32 $ 48.49 / $ 64.66

Age 65 - 69 $52.22 / $69.64 $110.17 / $146.90

Age 70 - 74 $59.87 / $79.84 $126.50 / $168.68

Age 75 - 80 $65.90 / $87.88 $139.39 / $185.86





Cancer/Dreaded Disease & Intensive Care – Life of Alabama Premiums are withheld 12-Month / 9-Month Section 125 Cafeteria Plan

This plan is subject to underwriting. Those electing coverage will be contacted by a representative of Life of Alabama to complete a

medical health statement. Failure to complete the medical health statement in a timely manner or declination from underwriting will

result in non-issuance of the policy. Premiums are withheld 12-Month / 9-Month Section 125 Cafeteria Plan

Cancer and Dreaded Disease Options: Select only one cancer plan type.

Employee Only 1 Parent Family Employee & Spouse 2 parent Family 12-month / 9-month 12-month / 9-month 12-month / 9-month 12-month / 9-month

Low Option $21.45 / $28.60 $24.91 / $33.22 $41.47 / $55.30 $43.31 / $57.74

High Option $39.32 / $52.42 $45.82 / $61.10 $76.12 / $101.50 $79.62 / $106.16

Waive/Cancel Cancer/Dreaded Disease Coverage

Intensive Care Options: Select only one intensive care plan type.

Employee Only 1 Parent Family Employee & Spouse 2 parent Family 12-month / 9-month 12-month / 9-month 12-month / 9-month 12-month / 9-month

$300 per day ICU $3.68 / $ 4.91 $3.96 / $ 5.28 $ 5.66 / $ 7.55 $ 6.74 / $ 8.99

$600 per day ICU $7.36 / $ 9.82 $7.92 / $10.56 $11.32 / $15.10 $13.48 / $17.98

$750 per day ICU $9.20 / $12.27 $9.90 / $13.20 $14.15 / $18.87 $16.85 / $22.47

Waive/Cancel Intensive Care Coverage

____________________________________________________________________________________________________________________________

I acknowledge that I voluntarily and without coercion made elections/waivers as documented on this form. I understand my salary will be reduced by the

amount(s) shown on this enrollment form for the eligible benefit options I have elected and since premiums are collected one month in advance, the

University will collect premiums in arrears as an additional payroll deduction. If my salary reduction for the elected insurance benefit(s) are increased or

decreased while this agreement remains in effect, my salary will automatically be adjusted to reflect the change.

Cafeteria Plan elections will be irrevocable for the Plan Year except for modifications due to a qualifying event (divorce, marriage, death of

spouse/dependent child, birth/adoption of a child, change of employment status of me or my spouse, cost of coverage/change, HIPAA special enrollment

rights, or other event specified by the IRS provided I complete enrollment paperwork with the Department of Human Resources to request the election

change within 60 days after the date of the qualifying event. Prior to each Plan Year, I will be given the opportunity to change my benefit election. If I

fail to complete and submit to the Department of Human Resources a new election form within the allotted enrollment period, I understand my election

will remain the same.

I understand my social security benefits may be reduced due to my participation in the Cafeteria Plan. My employer may reduce or cancel the amount of

my salary reduction or otherwise modify this agreement in order to satisfy certain provisions of the Internal Revenue Code.

I understand my elected benefits will cease upon my termination of employment but will be afforded an opportunity to continue coverage via COBRA for

qualifying plans.

If I participate in dependent care, reimbursements cannot exceed the amount incurred during the Plan Year. If I participate in an unreimbursed medical

expense plan, I may be reimbursed for qualifying out-of-pocket medical expenses. Claims must be filed with Southern Administrators and Benefit

Consultants (SABC) no later than 60 day into the subsequent Plan Year. Any account balance in excess of the $500 rollover processed after the 60-day

grace period will be forfeited.

I understand that privacy statements are available via the University website at http://hr.olemiss.edu/benefits/. If I do not have access to the internet, I can

request a paper copy from the Department of Human Resources. As an employee, I acknowledge that I am the subscriber of coverage, and that the

Privacy Policy is also applicable to my spouse and/or my dependents. I also understand I will be reissued the Privacy Statement, as a material

modification is made, and every three years, via the University’s email system.

This election and salary reduction agreement is subject to the terms of my employer’s cafeteria plan document.

EMPLOYEE SIGNATURE __________________________________________________ DATE SIGNED ____________________



Monthly Salary

$

Monthly Benefit$

Section 125

nn Yes nn No

Benefit Period

Months

Page 1 of 4 PAABJ1900MS3

Accident Rider Units

nn Yes nn No nn Individual nn Family

Elimination Period

Days Acc. Days Sick.

On The Job Rider

nn Yes nn No

nn GI nn CGI nn SI

Disability (DI)

Occupation Class nn Preferred nn Standard

Mode Premium

$

Abbreviations: GI - Guaranteed Issue CGI - Contingent Guaranteed Issue SI - Simplified Issue INSURANCE PLANS

(2015)

(Plan Type)Critical Illness

Riders

Section 125

nn Yes nn No

Mode Premium

$nn GI nn SI

Basic Benefit Amount

$

nn Individual nn Single Parent Family

nn Family

Units/Amt

Employee

Spouse

Dependent

Dependent

Dependent

Has any adult (19 and older) person to be insured used tobacco

in the last 12 months?

Relationshipto Employee

**nn Yes nn No

**nn Yes nn No

^nn Yes nn No

^nn Yes nn No

^nn Yes nn No

N/A

N/A

nn Yes nn No

nn Yes nn No

nn Yes nn No

nn Yes nn No

nn Yes nn No

^nn Yes nn No

^nn Yes nn No

^nn Yes nn No

Employee

Spouse

Employee/Payor Name (if other than Proposed Insured)

COMPLETE THIS SECTION FOR PERSONS TO BE INSURED

EMPLOYEE INFORMATION

PROPOSED INSURED INFORMATIONnn Mnn F

*Is the employee and the employee's spouse if applying for life and/or accident with sickness disability rider actively at work now, for wage or profit, and has he/she worked at least 20hours each week performing all duties of his/her regular occupation at his/her regular place of employment for at least the last 3 months except for minor illness or injury of 1 week or less,or normal pregnancy? ^For dependents ages 19 and older, if applying for Life policy. **If applying for Life or Critical Illness.

APPLICATION FOR LIFE AND HEALTH INSURANCE TO: American Heritage Life Insurance Company (AHL)1776 American Heritage Life Drive, Jacksonville, Florida 32224

Relationship

Relationship

Phone Number

Phone Number

Date of Birth

Date of Birth Social Security Number

Social Security Number

Last Name First Name Date of Birth

Sex Relationship Actively at Work*

Full Time Student^

Owner Phone Number

nn New Policy nn Change/Increase Policy #

Employee I.D. Number Date HiredEmployee/Payor Social Security NumberEmployee Date of Birth

Proposed Insured Name (Last, First, M.I.) Social Security Number

Phone Number

Employer

Owner Name and Address (if different than Proposed Insured)

Occupation

Residence Address ZipStateCity

Owner Date of Birth (if different than Proposed Insured)

Primary Beneficiary Name (Last, First, M.I.) and Address

Owner Social Security Number or Tax I.D. Number (if different than Proposed Insured)

Contingent Beneficiary Name (Last, First, M.I.) and Address

City

City

State

State

Zip

Zip

ZipStateCity

Owner Email Address

Rider RiderRiderRiderRiderRiderRiderRider

nn Producer Assisted x

nn Employee nn Spousenn Child nn Other

nn CILP1

CICR1 WBR

(Plan Type and Units)Accident

Riders

Section 125

nn Yes nn No

Mode Premium

$nn GI nn CGI nn SI

Monthly Salary

$

nn Individual nn Individual & Children

nn Individual & Spouse nn Family

Units/Amt

Rider RiderRiderRiderRiderRiderRiderRider APDIR APEXT APHCR BER OPTR AP6DF AP6AUC AP6ERS Rider AP6ADD

nn AP2 nn AP6nn AP3

(Plan Type)Cancer

Riders

Section 125

nn Yes nn No

Mode Premium

$

Units/Amt

RiderRiderRiderRiderRiderRider

Policy Options

Units/Amt

Hospital Radiation/Chemotherapy Surgery Related Misc.

nn CP10A nn CP12nn CP10B

CABR ICR CLR CPR CP12WBR-Variable

nn Individual nn Family

WBR-Fixed

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IF REQUESTING GUARANTEED ISSUE, PLEASE PROCEED TO QUESTION 15. FOR ALL OTHER ENROLLMENTS, IF ANYUNDERWRITING QUESTIONS BELOW ARE ANSWERED “YES”, PLEASE LIST THE REQUIRED HEALTH HISTORY IN QUESTION 14.

3b. If the answer to 3a. is yes, has that person(s) been diagnosed with or treated by amember of the medical profession for Leukemia, Hodgkin’s Disease, Lymphoma, orCancer with any lymph node involvement or more than one metastasis?

3a. Has any person to be insured ever been diagnosed with or treated by a member of themedical profession for any type of cancer, other than basal cell carcinoma?

Page 2 of 4 ABJ1900MS3 (2015)

Total Mode Premium:

Account (Case) NameRemarks

Billing Mode:

nn Monthly (12) nn Semi-Monthly (24)

nn Bi-weekly (26) nn Weekly (52)

nn Other

Coverage Effective Date

Date of First Deduction

Name on Bank/Credit Union Account

Bank/Credit Union Account Number

Routing Number

Draft Date $

1. Has any person to be insured, in the last 5 years, been diagnosed with or treated by amember of the medical profession for Acquired Immune Deficiency Syndrome (AIDS)or AIDS Related Complex (ARC), or tested positive for antigens or antibodies to anAIDS virus?

CGI & SI Accident w/ SicknessDI Rider, Cancer, SI CriticalIllness, CGI & SI Disability, CGI &SI Heart/Stroke, CGI & SI HospitalIndemnity & CGI & SI Life

• Anemia (other than iron deficiency)• Anxiety, depression or other mental or nervous

illness (that would include hospitalizations,disability from work, or suicide attempts)

• Asthma (other than taking non-steroidalmedication as needed with no hospitalizations),or any other lung disorder

• Cancer, except basal cell carcinoma• Diabetes• Epilepsy with a seizure • Heart attack, cardiomyopathy, congestive heart

failure, heart murmur (and taking medication(s)),angioplasty, coronary artery bypass surgery,coronary artery disease, stent, pacemaker, heartvalve replacement or any other heart disorder

• Hemophilia

• Hepatitis• Kidney Disease involving dialysis

or chronic renal failure• Liver Disease• Lou Gehrig's Disease (ALS)• Lupus• Multiple Sclerosis• Muscular Dystrophy• Parkinson's Disease, scleroderma,

polymyositis, or fibromyalgia• Stroke including aneurysm,

transient ischemic attack (TIA), orarteriovenous malformation

• Transplant of any organ• Counseling for, or excessive use

of, alcohol or any type of drugs

UNDERWRITING QUESTIONS

Billing Method: nn Payroll Deductionnn Bank/Credit Union Draft (Authorization Required)* *Complete form ABJ062

Abbreviations: EE - Employee SP - Spouse CH - Child(ren) Y - Yes N - No

SI Life 5. Has any person to be insured, in the last 2 years, been diagnosed or treated by amember of the medical profession for any of the following?

Cancer w/ Intensive Care, SI Heart/Stroke & SI HospitalIndemnity

4. Has any person to be insured, in the last 5 years, been diagnosed with or treated by amember of the medical profession for a stroke or transient ischemic attack (TIA), a heartattack, a heart condition, heart trouble, any abnormality of the heart, or any artery disease?

3c. If the answer to 3a. is yes, has that person(s), in the last 5 years, been diagnosed withor treated by a member of the medical profession for any other type of cancer (otherthan those listed in 3b. and/or basal cell carcinoma)?

Cancer, SI Critical IllnessCancer Rider, SI Heart/StrokeCancer Rider & SI HospitalIndemnity

All CGI 2. Has any person to be insured, in the last 6 months, been disabled or hospitalized foranything other than normal pregnancy, lacerations or broken bones due to an accident?

c Y c N c Y c N c Y c N







Account (Case) Number

EE SP CH

(Plan Type)Heart/Stroke

Riders

Section 125

nn Yes nn No

Mode Premium

$nn GI nn CGI nn SI

Units/Amt

nn Individual nn Family


nn HSP2

CIDR1 ICR WBR

*Must have minimum essential health coverage to elect Hospital Indemnity.

(Plan Type)Hospital Indemnity (SHOP)*

Riders

Section 125

nn Yes nn No

Mode Premium

$

IHR1 SAR1 IPBR1 OPBR1 OEAR1

nn Individual nn Individual & Children

nn Individual & Spouse nn Family

AHNR TR1 ADIR1

Units/Amt

Units


nn CHCnn CGI nn SI

Rider SDIR1

Life

Riders

Mode Premium$

ADB PW STR CTR LBR

Face Amount$

FPOR LTC OIRRider RiderRiderRiderRiderRiderRiderRider

Units/Amt

Death Benefit Option (Universal Life ONLY)nn 1 nn 2

nn Universal (UL20) nn Term (20YT)nn Universal (UL21)

nn GI nn SInn CGI

TIRRider

Units

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13. Provide the names and addresses of all physicians (or other members of the medical profession) for each person tobe insured; the required health history section may be used if additional space is needed.

12. Provide Height and Weight

Employee (SI Accident w/ Sickness DI Rider, Cancer w/ Intensive Care Option, SI Critical Illness,SI Disability, SI Heart/Stroke, SI Hospital Indemnity, and SI Life): Height: ft. in. Weight: lbs.

Spouse (SI Critical Illness and SI Life (when Policy Proposed Insured)): Height: ft. in. Weight: lbs.

15. Is this insurance to replace or change any existing life (if applied for) or health (if appliedfor) coverage? If yes, indicate product being replaced or changed and completereplacement form provided if required by your state.

11. Has any person to be insured, in the last 2 years, had or been diagnosed with or treatedby a member of the medical profession for any of the following?

14. Provide health history for any “Yes” answers to the Underwriting questions. Include physician’s (or other members ofthe medical profession) name, address and telephone number:

16. If you are applying for the type of coverage in the following list, is there any otherinsurance of that type (not listed in your answer to the Replacement Question) in forceor applied for other than this application on any person to be insured (Coverage Types:life, cancer, heart/stroke, disability, hospital, critical illness or accident)? If yes, listcompany name, policy number, year issued, type of coverage and amount of benefit.

17. Illustration Certification. Owner. The owner certifies that no illustration conforming tothe coverage applied for was provided, but that an illustration conforming to thecoverage issued will be provided upon delivery of the policy. If no, complete theapplicable illustration certification form provided, if required in your state.

All Life (Answer for ProposedInsured)

All-Existing Insurance(Answer for Proposed Insured)

All-Replacement(Answer for Proposed Insured)

Required Health History

SI Critical Illness (over $50,000)& SI Life (over $150,000)

SI Accident w/ Sickness DIRider & SI Disability

• Counseling for alcohol or drug abuse • Pancreas Disease

18. Do you currently have other health coverage that is minimum essential coverage, perfederal law? If you have answered “No,” you may not apply for Hospital Indemnitycoverage.

Hospital Indemnity

c Y c N N/A N/A



Height and Weight

Page 3 of 4 ABJ1900MS3 (2015)

IF REQUESTING GUARANTEED ISSUE, PLEASE PROCEED TO QUESTION 15. FOR ALL OTHER ENROLLMENTS, IF ANYUNDERWRITING QUESTIONS BELOW ARE ANSWERED “YES”, PLEASE LIST THE REQUIRED HEALTH HISTORY IN QUESTION 14.

• Cancer, except basal cell carcinoma • Central Nervous System Disease or disorder (to

include Multiple Sclerosis or Muscular Dystrophy)• Chronic Fatigue Syndrome • Diabetes • Emphysema• Fibromyalgia• Heart Disease

• Kidney Disease/Disorder• Liver Disease• Lung Disease• Lupus• Optic Neuritis• Parkinson’s Disease• Paralysis• Rheumatoid Arthritis

SI Life

• Any disorder of the back or neck • Asthma

Abbreviations: EE - Employee SP - Spouse CH - Child(ren) Y - Yes N - No

SI Accident w/ Sickness DIRider, SI Critical Illness &SI Disability

SI Accident w/ Sickness DIRider & SI Disability

SI Accident w/ Sickness DIRider, Cancer w/ IntensiveCare, SI Critical Illness, SI Disability, SI Heart/Stroke, SI Hospital Indemnity & SI Life

SI Accident w/ Sickness DIRider, SI Critical Illness, SI Disability, SI HospitalIndemnity & SI Life

7. Has any person to be insured, in the last 3 years: had his/her driver’s licensesuspended or revoked; been convicted of reckless or drunken driving; or been involvedin 3 or more motor vehicle accidents?

6. Has any person to be insured, in the last 5 years, had any medical or surgicalprocedures (including organ transplant) advised or recommended by a member of themedical profession, but not done at this time?

8. Has any person to be insured, in the last year, been diagnosed by a member of themedical profession with a systolic blood pressure reading higher than 150 more thanonce or a diastolic blood pres-sure reading higher than 100 more than once?

9. Has any person to be insured, in the last 2 years, had any disease, impairment of, ortreatment by a member of the medical profession (other than minor illness) for thefollowing? If yes, complete exclusion endorsement if applying for sickness disability rider.

10. Has any person to be insured, in the last 2 years, had or been diagnosed with or treatedby a member of the medical profession for any of the following?





UNDERWRITING QUESTIONS EE SP CH


c Y c N c Y c N N/A

c Y c N c Y c N N/A

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Percentage Credit

Page 4 of 4 ABJ1900MS3 (2015)

Signed at: City/State Date Signed

Signature of Proposed Insured

Signature of Owner, if other than Insured

Signature of Employee/Payor, if not Insured or Owner

REPRESENTATION. I have read or had read to me the completed application and understand that any misstatement ormisrepresentation in the application may result in loss of coverage. I represent that statements and answers given on thisapplication are true, complete, and correctly recorded. UNDERSTANDING. I understand that: if premiums for the coverage(s) is(are) to be paid by payroll deductions, these deductions may start before the "effective date" of coverage(s) and that this does notchange the effective date of coverage; and the “effective date” for health insurance coverages will be the date recorded on thepolicy/certificate/benefit statement, not the date the application is signed. If the coverage(s) is (are) not issued, American HeritageLife will refund any deductions it receives. I also understand that no producer (agent) has authority to waive any answer orotherwise modify this application, or to bind AHL in any way by making any promise or representation that is not set out in writingin this application. PREMIUM DEDUCTION AUTHORIZATION. I AUTHORIZE my employer to deduct from my salary or wages, ifapplicable, the necessary premium for the coverages requested. AUTHORIZATION TO OBTAIN AND DISCLOSE CERTAIN DATA(FOR SI LIFE AND CRITICAL ILLNESS). I authorize any physician, medical practitioner, hospital, clinic or other medical facility,Pharmacy Benefit Managers, insurance company, MIB, Inc. or other organization, institution or person, that has records orknowledge of me or my health including my prescription medication history to give to AHL, its subsidiaries or its reinsurers anyinformation. I also authorize AHL, or its reinsurers, to make a brief report of my health information to MIB, Inc. I understand thatthere is a possibility of redisclosure of any information disclosed pursuant to this authorization and that information, once disclosed,may no longer be protected by federal rules governing privacy and confidentiality. I acknowledge receipt of the Important NoticeAbout Privacy and MIB Notice form. A copy of this authorization is as valid as the original. This authorization applies to anydependent on whom insurance is requested. This authorization is valid for 24 months from the date signed. I understand that I mayrevoke this authorization at any time by notifying AHL in writing of my desire to do so.

Hospital Indemnity: I ACKNOWLEDGE THAT THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND ISNOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OROTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN ADDITIONAL PAYMENT WITH MY TAXES.

To be completed by home office or producer, prior to issue:

%%%%

Signature of Soliciting Producer Print Soliciting Producer Name

Producer’s Statement. I certify that to the best of my knowledge and belief the information on this form is complete, accurate andcorrectly recorded.

c Yes c No

SOLICITING PRODUCER MUST COMPLETE AND SIGN WHEN APPLICATION IS PRODUCER ASSISTED

All-Replacement 1. To your knowledge, is change or replacement involved?

2. To your knowledge, does any person to be insured have existing coverage in force?

3. The producer certifies that no illustration conforming to the coverage applied for was provided, butthat an illustration conforming to the coverage issued will be provided upon delivery of the policy.If no, complete the applicable illustration certification form provided, if required in your state.

c Yes c No

c Yes c No

Producer Name National Producer Number (NPN)Producer NumberServicing Producer:

Soliciting Producer:

All-Existing Insurance

GI, CGI & SI Life

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Important Notice About Privacy:

In processing your application, an investigative report may be made. Information is obtained through interviews with third

parties, such as family members, business associates, financial sources, friends, neighbors, or others with whom you are

acquainted. You may request to be interviewed in connection with the report and may also receive a copy of the report upon

request. This inquiry includes information as to your character, general information and personal characteristics. In certain

limited circumstances, we are allowed by law to disclose necessary items of personal information to third parties without your

specific authorization. You have the right to make a written request within a reasonable period of time for a complete and

accurate disclosure of additional information concerning the nature and scope of the investigation.

IN/MIB-3 (2012)

MIB Notice: Information regarding your insurability is treated as confidential. We or our reinsurers may, however, make a brief report to MIB, Inc. (MIB), a not-for profitmembership organization of life insurance companies, which operates an information exchange for its members. If you apply to another MIB membercompany for life or health insurance coverage or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company withthe information in its file. Upon receipt of a request from you, MIB arranges disclosure of any information it may have in your file. If you question theaccuracy of information in the MIB file, contact MIB and seek a correction in accordance with the procedure set forth in the Federal Fair Credit ReportingAct. The address of MIB’s information office is 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734, PH. #866-692-6901. American Heritage Lifeor its reinsurers may release information in its file to other insurance companies that you apply to for life or health insurance, or submit a claim to forbenefits. IN/MIB-3 (2012)

AMERICAN HERITAGE LIFE INSURANCE COMPANY HOME OFFICE: 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224-6688 (904) 992-1776 A Stock Company

IMPORTANT NOTICE TO PERSONS ON MEDICARE THIS INSURANCE DUPLICATES SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance. This insurance duplicates Medicare benefits when it pays: Hospital or medical expenses up to the maximum stated in the policy Medicare generally pays for most or all of these expenses. Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include: Hospitalization Physician services Outpatient prescription drugs if you are enrolled in Medicare Part D Other approved items and services

Before You Buy This Insurance

Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement insurance,

review the Guide to Health Insurance for People with Medicare, available from the insurance company.

For help in understanding your health insurance, contact your state insurance department or state health insurance assistance program (SHIIP).

AWD5262-1 (AWDPKG1)




This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when it pays:

hospital or medical expenses up to the maximum stated in the policy

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

outpatient prescription drugs if you are enrolled in Medicare Part D

other approved items and services





AWD3431-1




This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when:

any expenses or services covered by the policy are also covered by Medicare

Medicare generally pays for most or all of these expenses.

Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:

hospitalization

physician services

hospice

outpatient prescription drugs if you are enrolled in Medicare Part D

other approved items and services





AWD6301-1

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