cover sheet: final expense application

Agent Name: (Please print) Agent #:

●□ Select - Tier 1 □ Standard - Tier 2 □ Modified - Tier 3

●□ yes □ no

● Where would you like the policy mailed?

□ To the Applicant (Not applicable in Pennsylvania) □ To the Agent

NOTES/ COMMENTS:

□ Cover Sheet DO:□ Disclosure of Accelerated Death Benefit - Complete the Entire Application□ Covid-19 Addendum - Have applicant initial all changes□ Application - Obtain all required signatures and information□ Physician Information & Medications List□ HIPAA Form (Agreement Authorization)□

● Submit with copy of voided check DO NOT:(For Monthly Bank Draft Modal Premium Only) - Use pencil or white-out

□ Replacement Form - Submit an agent check as initial premium

□ Optional: Medical Release Form -

For use in the following states: Arizona, Arkansas, Colorado, Connecticut, Illinois, Indiana, Iowa, Michigan,

Mississippi, Ohio, Tennessee, Wisconsin, Washington D.C.

To avoid delays in processing, please be sure that all items below are completed with the final application

Please select which tier the client is applying for

Submit deposit slip for electronic bank draft withdrawals

TIPS

Cover Sheet

Would you like the policy mailed contingent issue prior to the initial payment?

**If nothing is marked, the certificate will be mailed to the agent.**

CHECKLIST

Preauthorized Bank Draft Withdrawal Form

Name of Insured:

WAYS TO SUBMIT APPLICATIONS:A. FILE UPLOAD option on Agent Portal at KSKJLife.netB. SCAN & EMAIL the application, please send to [email protected]

PLEASE DO NOT MAIL ORIGINAL COPY IF YOU UPLOAD, FAX OR EMAIL THE APPLICATION.

Cover Sheet:Final Expense Application

Use for: Final ExpenseApplication Version: ICC20-FE120

KSKJLife.net | Phone: 855‐332‐8809 | Fax: 815‐483‐2271FE.CS 05.2021

mailto:[email protected]

LBR DISC 1-05

KSKJ LIFE, AMERICAN SLOVENIAN CATHOLIC UNION

The Option to Provide for Acceleration of Death Benefit Rider provides you with the right to receive a portion of the Accelerated Benefit Value of the policy in a lump sum if the insured is diagnosed with a life expectancy of 12 months or less. The Accelerated Benefit Value is the Death Proceeds on the date we receive your written request to exercise this option, multiplied by the Discount Factor and less any indebtedness. The money you receive from the benefit can be used for any purpose.

There is no additional premium charge for the Option to Provide for Acceleration of Death Benefit; however, your policy premiums are still payable after taking an accelerated benefit unless premiums are being provided under any Waiver of Premium Rider.

After payment of an accelerated death benefit, there will be a pro rata reduction in policy values based on the percentage of death benefits accelerated. Values included are the death benefit, cash value, indebtedness and any premium. Any dividend balances and rider amounts remain unchanged.

It is intended that benefits payable under the Option to Provide Acceleration of Death Benefit qualify as life insurance proceeds payable by reason of the death of an insured per Section 101 of the Internal Revenue Code. However, KSKJ Life, American Slovenian Catholic Union does not represent or guarantee that the proceeds shall receive such treatment; therefore, you are strongly encouraged to consult with your personal tax advisor. You should also consider that receiving or having the contractual right to receive such benefits may effect your entitlement to government or other benefits.

Applicant’s Signature Date

Agent’s Signature Date

MINNESOTA RESIDENTS:

This is a life insurance policy that pays Accelerated Death Benefits at your option under conditions specified in the policy. This policy is not a long-term care policy meeting the requirements of sections 62A.46 to 62A.56 or Chapter 62S.

DISCLOSURE OF OPTION TO PROVIDE FOR ACCELERATION OF DEATH BENEFIT

Addendum to Application

for COVID-19

Proposed Insured’s Name (Please Print):_____________________________________________________

1. Within the past 12 months, have you been advised by a medical professional to be quarantined, for any

period of time for the novel coronavirus (COVID-19)?................................................................. YES

2. Within the past 12 months, have you been treated for, examined for, diagnosed with, or tested positive for the

novel coronavirus (COVID-19) by a medical professional?.........................................................

3. Within the past 30 days, have you been advised by a medical professional to get specified medical care (suchas any diagnostic testing or hospitalization) which was not completed; as result of fever, cough, shortness of

breath, fatigue (excluding HIV/AIDS)? .....................................................................................

This Addendum to Application amends and is made a part of my individual life insurance application. To the best of my knowledge and belief, all answers and statements contained in this application are true, complete, and correctly recorded. I will notify KSKJ Life of any changes in the statements or answers given in this application between the time ofapplication and delivery of the policy.

Fraud Notice: Any person who knowingly presents a false statement in application for insurance may be guilty of a criminal offense and subject to penalties under state law.

Signed at___________________________________ Application Date________________________________________ (City and State)

Signature of Proposed Insured________________________________________________________________________

Signature of Owner (If other than Proposed Insured)_______________________________________________________

ICC20-COVID 05.2020

YES

YES

NO

NO

NO

* Annual, Semi-Annual, or Quarterly - A Check or Money Order MUST be submitted with the application for the initial premium

** If Monthly Pre-Authorized Bank Draft, Please submit "Pre-Authorized Bank Draft Withdrawal Form"

Please make Check or Money Order Payable to KSKJ Life

ICC20 - FE0120 Page 1 Final Expense

*Tier elgibility determined by health question reponses in parts B1, B2 & B3.

Face Amount: $______________________

Part 2: Payment Method

Modal Premium Amount: $__________________________________

Lodge Number

Social Security Number - -

Phone Number( ) -

Gender at Birth: Male Female

Annual Income$

Permanent Resident Address City State Zip

Date of Birth (mm/dd/yyyy)

Part 4: Owner (If other than the Proposed Insured)Full Name: First Middle Last

Part 1: Plan Tier & Face Amount

Plan Tier* Applying for: Select (Tier 1) Standard (Tier 2) Modified (Tier 3)

Part 3: Proposed InsuredFull Name: First Middle Last Maiden Name

Payment Method: Annual* Semi-Annual* Quarterly*

Source of Funds: Personal Check Money Order


Date of Birth (mm/dd/yyyy)

If Payor and/or Mailing or Billing Address are different from above, please complete information below

Full Name: First Middle Last Maiden Name

Address City State Zip

Date of Birth (mm/dd/yyyy) Phone Number( ) -


Phone Number( ) -


Email Address Relationship to Proposed Insured

PRIMARY: Full Name (First MI Last) Relationship

Address City State Zip

Part 5: Beneficiaries (with rights of revocation)

Relationship to Proposed InsuredEmail Address

Share % Address Phone Number

Share % AddressCONTINGENT: Full Name (First MI Last) Relationship Phone Number

Are you a U.S. Citizen? Yes No

Place of Birth Are you a current member of a KSKJ Life: Yes No

Email Address


Application for Individual Life Insurance KSKJ Life, American Slovenian Catholic Union

A Fraternal Benefit Society2439 Glenwood Avenue, Joliet, Illinois 60435

800-843-5755 www.kskjlife.com

For Home Office Use Only:

Certificate Number _______________

Effective Date___________________

BOLDED REQUIRED FOR APPLICATION TO BE PROCESSED




BOLDED REQUIRED (if applicable)



Check Here if Premium is Included with Application

Monthly Pre-Authorized Bank Draft**

1. Yes No

2. Yes No

Yes No

Yes No

Yes No

Yes No

3. Height

4. Weight

_________Feet _________Inches

_________________lbs 5. __________lbs Gain Loss No Change

1.

Yes No2.

Yes No

Yes No

Yes No

Yes No3.

Yes No

Yes No

Yes No

Yes No

4. Yes No

Page 2 Final Expense

Part AWithin the last 12 months, has the Proposed Insured smoked cigarettes, e-cigarettes, used nicotine-containing products, or used tobacco in any form?

a. If cigars only, please specify how many in the last 12 months: __________________

Name of Company Type of Coverage Face Amount Year Issued To Be Replaced?

Does the applicant have any existing life insurance or annuity contracts with KSKJ Life or any other company? If yes, provide complete:

Has the Proposed Insured Been treated or diagnosed by a licensed member of the medical profession :a) Or taken medication for Alzheimer’s disease, dementia, mental retardation, amyotrophiclateral sclerosis (also known as ALS or Lou Gehrig’s disease), Huntington disease, Down'ssyndrome, spina bifida that has not been surgically corrected, cystic fibrosis, or any terminalmedical condition (i.e., death expecting to result within 1 year)?

b) With congestive heart failure, chronic kidney failure, been on kidney dialysis, or receivedor been advised to have an organ transplant?

c) Has the proposed insured ever been in a diabetic coma, insulin shock, taken insulinshots prior to age 20 other than for pregnancy, and/or been advised to have an amputationdue to disease or disorder?d) Has the Proposed Insured ever tested positive for the antibodies to the AIDS (HIV) virus orby a licensed member of the medical profession, been medically diagnosed with orreceived treatment for HIV, acquired immune deficiency syndrome (AIDS) or AIDS -relatedcomplex (ARC)?

Within the past 2 years has the Proposed Insured:

If the proposed insured intends to replace or change any existing life insurance or annuity contract currently in force with KSKJ Life or any other company, please submit the state required forms.

Change of weight in past year

Part B1If ALL responses in Part B1 are answered "NO", proceed to Part B2

If ANY response in Part B1 is answered "YES", the Proposed Insured is not eligible for coverage.

Is the Proposed Insured hospitalized, bedridden, residing in a nursing home or long-term care facility, confined to a correctional facility, receiving hospice or home health care, confined to a wheelchair, or does the proposed insured require assistance with Activities of Daily Living such as taking medications, bathing, dressing, eating, or toileting?

a) By a licensed member of the medical profession, been diagnosed with, been treated for, oradvised to receive a treatment for any cancer (excluding basal cell), or advised that you stillhave cancer?b) By a licensed member of the medical profession, been advised to have surgery,hospitalization or a diagnostic test which has not yet been started, completed, or for whichresults are not known?c) By a licensed member of the medical profession, been diagnosed with, been treatedfor, or advised to receive treatment for cardiomyopathy, cirrhosis, liver failure, musculardystrophy, psychotic disorder or schizophrenia, or used or been advised to use oxygen toassist in breathing due to disease (other than for sleep apnea)?

d) Had your driver's license suspended?

In the past five years has the Proposed Insured been convicted of a felony or are you currently serving a term of parole or probation assigned by the court?

BOLDED QUESTIONS ARE REQUIRED FOR APPLICATION TO BE PROCESSED

BOLDED QUESTIONS ARE REQUIRED FOR APPLICATION TO BE PROCESSED

ICC20 - FE0120

5.

Yes No6.

Yes No

Yes No

Yes No

7.

Yes No

Yes No

Yes No8.

Yes No

Page 3 Final Expense

If ALL responses in Part B2 are answered "NO", proceed to Part B3.If ONE response in Part B2 is answered "YES", the Proposed Insured may be eligible for Modified Final Expense.If TWO OR MORE responses in Part B2 are answered "YES", the Proposed Insured is not eligible for coverage.For each "YES" answered, circle the condition that applies.

In Part B2, all diagnoses, treatments or advice must have been given by a licensed member of the medical profession.

Within the past 4 years has the Proposed Insured been diagnosed with cancer (excluding basal cell or squamous cell skin cancer), or received or advised to receive chemotherapy or radiation treatment for cancer?

Part B2

Within the past 3 years has the Proposed Insured:a) Been treated by a licensed member of the medical profession, for heart attack, angina (chestpain), stroke (CVA), transient ischemic attack (TIA), aneurysm, circulatory or blood disorder,peripheral vascular disease, had or been advised to have heart surgery of any kind, includingvalve replacement, bypass, angioplasty, stent implant, or pacemaker implant or atrialfibrillation?

Within the past 18 months has the Proposed Insured:a) Used illegal drugs or been diagnosed with, been treated for, or advised to receive treatmentfor alcohol abuse, drug abuse, organic brain disease, sickle cell anemia, or hemophilia?b) Experienced more than 12 seizures or been diagnosed with, been treated for, or advised toreceive treatment for hepatitis B or C or other liver disease?

c) By a licensed member of the medical profession, been diagnosed with, been treated for, oradvised to receive treatment for heart attack, stroke (CVA), transient ischemic attack (TIA),aneurysm, angina, peripheral vascular disease, had or been advised to have heart surgery ofany kind, including valve replacement, bypass surgery, angioplasty, stent implant orpacemaker implant?

Part B3If ALL responses in Part B3 are answered "NO", the Proposed Insured may be eligible for Select Final Expense.If ONE response in Part B3 is answered "YES", the Proposed Insured may be eligible for Standard Final Expense. If TWO OR MORE responses in Part B3 are answered "YES", the Proposed Insured is eligible for Modified Final Expense.

For each "YES" answered, circle the condition that applies.

In Part B3, all diagnoses, treatments or advice must have been given by a licensed member of the medical profession.

b) Taken insulin shots or by a licensed member of the medical profession,been diagnosedwith, treated for, or advised to receive treatment for chronic pancreatitis, hepatitis B or C orother liver disease, or experienced more than 12 seizures?

c) Used illegal drugs or by a licensed member of the medical profession, been diagnosed with,been treated for, or been advised to receive treatment for alcohol or drug abuse?

Within the past 5 years has the Proposed Insured, by a licensed member of the medical profession, been diagnosed with, been treated for, or been advised to receive treatment for kidney disease (not including kidney stones), Parkinson’s disease, systemic lupus, multiple sclerosis, scleroderma, chronic obstructive pulmonary disease (COPD), including emphysema, chronic asthma (requiring daily inhaler or oral medication use) or other chronic respiratory disease?

*** Once all questions have been answered in Parts B1, B2, and B3, please select plan tier on Page 1, Part 1 ***Please Proceed to Part C: Physician Information

Space Left Blank Intentionally

ICC20 - FE0120


Part C: Physician InformationPlease complete your Physician's information below:

Name:

Address:

Phone:

Date & Reason for Last Visit:Part D: Current MedicationsPlease include any medications within the last 4 years.

Medication - Dosages Last Used Date Reason for Taking

Address

City


AGREEMENT‐AUTHORIZATION

Name of Proposed Insured (please print) Social Security Number Date of Birth

AGREEMENT ‐ The application includes the Application and all approved supplemental forms or amendments KSKJ Life, American Slovenian Catholic Union, specifically designates as parts of the application by attaching copies of them to the policy delivered to the Owner.

I (WE): REPRESENT that, to the best of my (our) knowledge and belief, all statements included herein are true and complete; the insurance being applied for is suitable for the Owner’s insurance needs; AGREE this application will be the basis for and a part of any contract of life insurance issued; and, UNDERSTAND that no agent or person other than our executive officers may, in writing: change, modify or waive any of the printed statements herein; or, waive any of our rights or requirements.

I (WE) AGREE that:1. I (we) will notify KSKJ Life if any statement or answer given in the application changes prior to policy delivery, and2. Except as provided in the Conditional Receipt insurance, will not begin unless all persons proposed for insurance are livingand insurable as set forth in the application at the time a policy is delivered to the Owner, and3. The first modal premium is paid, and4. No information will be considered as having been given to KSKJ Life unless it is written in this Application.

Except as may be provided in a Conditional Receipt bearing the same date as this application and for the same amount as shown on page 3 of this application, I (We) AGREE that no life insurance will take effect until: this application is approved at the KSKJ Life Home Office; a contract of life insurance is issued; and, the full first premium for the contract is paid. All such conditions must be met while the health and other factors affecting the insurability of the Proposed Insured(s) remain as described in this application.

AUTHORIZATION ‐ This authorization complies with the HIPAA Privacy Rules

State Zip Phone Number

I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, or other health care provider that has provided payment, treatment or services to me or on my behalf within the past 5 years (“My Providers”) to disclose my entire medical record and any other protected health information concerning me to KSKJ Life, American Slovenian Catholic Union and its agents, employees, and representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes for specific purposes listed below. I also authorize any Pharmacy or Pharmacy Benefit Manager; Consumer Reporting Agency; Employer; Institution; Organization; or Person; and the MIB, Inc. whom may have any records or information regarding me and, if so indicated below, my minor children, to provide such records or information to : KSKJ Life; its reinsurer; or its legal representative. KSKJ Life may, at its discretion, obtain an investigative consumer report.

The undersigned understands that any records or information obtained will: be used to determine eligibility for insurance or benefits; and, be treated as confidential. However, KSKJ Life or its reinsurer may release any such records or information to: the MIB; other insurers to whom you may apply for insurance or submit a claim; or, as may be lawfully required.

Specific description of health information to be used or disclosed:____________________________________________(e.g. if not specifically limited or restricted, the types of information to be used or disclosed may include medical, psychiatric, or psychological records, records of evaluation and treatment for alcohol or drug abuse, records and results of HTLV‐ III, HIV , or AIDS testing, etc.)

Approximate dates of treatment:__________________________________________________________________________Purpose of the use or disclosure:_________________________________________________________________________ Purpose or organizations using or disclosing the information: KSKJ Life, American Slovenian Catholic UnionPersons or organizations receiving the information:__________________________________________________________

Yes No

City, State (REQUIRED) Date

Signature of Owner (if other than Proposed Insured - Required if applicable )

Agent Name (Please Print) Agent No.

Signature of Agent (REQUIRED)


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 used to administer 1) enrollment determinations; 2) obtain reinsurance; 3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer coverage; and 5) conduct other legally permissible activities that relate to any coverage I have or have applied for with KSKJ Life. The time limit of this authorization complies with the time limit, if any, permitted by applicable law in the state where the policy is delivered or issued for delivery. This authorization shall remain in force for at most 30 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 KSKJ Life at 2439 Glenwood Ave., Joliet, IL 60435‐5490, Attention: Underwriting Dept. I understand that a revocation is not effective to the extent that any of My Providers has relied on this Authorization or to the extent that KSKJ Life has a legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that any information that is disclosed pursuant to this authorization may be re‐disclosed and no longer covered by federal rules governing privacy and confidentiality of health information.

I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record, KSKJ Life may not be able to process my application, or if coverage has been issued, may not be able to make any benefit payments.

This Authorization includes the minor children of the Proposed Insured:

Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

KSKJ LIFE IS LICENSED TO DO BUSINESS IN THE STATE OF ILLINOIS AS A FRATERNAL BENEFIT SOCIETY. AS SUCH, IT IS NOT INCLUDED IN THE ILLINOIS LIFE AND HEALTH GUARANTY ASSOCIATION (OTHERWISE KNOWN AS THE GUARANTY ASSOCIATION). THIS MEANS THAT FRATERNAL BENEFIT SOCIETIES CANNOT BE ASSESSED FOR THE INSOLVENCY OF OTHER LIFE INSURERS OR OTHER FRATERNAL BENEFIT SOCIETIES. BY LAW, A FRATERNAL BENEFIT SOCIETY IS RESPONSIBLE FOR ITS OWN SOLVENCY. IF THERE IS AN IMPAIRMENT OF RESERVES, A CERTIFICATE HOLDER MAY BE ASSESSED A PROPORTIONATE SHARE OF THE IMPAIRMENT. THIS PROCESS IS DESCRIBED IN THE CERTIFICATE ISSUED BY THE SOCIETY.

Signed at:

Signature of Proposed Insured (REQUIRED)

This Space Left Blank Intentionally


Yes No

If not already a member, is the Proposed Insured a baptized Christian or a spouse of a KSKJ Life member in good standing?

Yes No

Licensed Agent Signature Agent # Split % (if applicable)

Licensed Agent Signature Agent # Split %


AGENT CERTIFICATION

I certify that I have asked the Proposed Insured all of the questions on this application and have accurately recorded them. I also certify that replacement of existing insurance….. Is or Is not ….. Involved.

Photogaphic evidence used for verification of the identitiy of the Proposed Insured: Driver's License Passport

Does this application need to be backdated to save age?

Other__________ ID

Date

Date


The insurance applied for will be effective on the issue date of the certificate

Provided, the following conditions are met, exactly:

3. The Payment is good and collectible.

1. Any accidental death benefits applied for; and2. Any other pending application for the Proposed Insured.

A. One or more of the receipts conditions have not been met exactlyB. The Proposed Insured dies by suicide


2. The amount paid is sufficient to pay the first mode premium for the amount and plan applied forincluding any riders; and

The maximum amount of insurance which may become effective under this Conditional Receipt may not exceed $25,000. Such maximum amount shall include:

There will be no conditional insurance coverage and KSKJ Life's liability will be limited to returning any premium submitted to KSKJ Life with this Receipt if any of the following occurs:

Please contact us if you do not, within 60 days from the date of this receipt, receive: the life insurance contract applied for; or, a return of the amount paid. Please include: the name of the agent; and, the date and amount paid.

Do not pay in cash. All remittances must be payable to KSKJ Life. Do not make payable to the agent or leave the payee blank.


2439 Glenwood Avenue, Joliet, IL 60435

THIS RECEIPT DOES NOT PROVIDE INSURANCE UNTIL ITS CONDITIONS ARE MET

Received from: in connection with an application for life insurance.

On the life of: the sum of: $

Date:____________________ Agent:________________________________________

1.The persons proposed for insurance are found to be standard risks for the amount and plan appliedfor in accordance with our underwriting rules then in effect;

CONDITIONAL RECEIPT

KSKJ Life, AMERICAN SLOVENIAN CATHOLIC UNION


NOTICE OF INFORMATION PRACTICES

KSKJ Life, AMERICAN SLOVENIAN CATHOLIC UNION

CONSUMER REPORT

This notice is to inform you that KSKJ Life, American Slovenian Catholic Union may obtain an investigative consumer report, as you have authorized. If obtained, the report will include information obtained through personal interviews with third parties, such as: financial sources, business associates, family members, friends, neighbors, or others with whom you are acquainted. The report may include information as to your: character, general reputation, personal characteristics, and mode of living. Within a reasonable period of time, you may, in writing, request additional, detailed, information regarding the nature and scope of any such report.

MIB, Inc.

Information regarding your insurability will be treated as confidential. I authorize KSKJ Life or its reinsurer to make a brief report of my personal health information to MIB, 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 for life or health insurance coverage, or if a claim for benefits is submitted to such member, the MIB will, upon request, supply such member with the information it may have in its file. Upon receipt of a request from you, the MIB will arrange disclosure of any information it may have in your file. If you question the accuracy of the MIB file information, you may contact the MIB and seek a correction in accordance with procedures set forth in the Federal Fair Credit Reporting Act. The address of the MIB’s information office is: MIB Inc., 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734; Telephone: (866) 692-6901. KSKJ Life or its reinsurer may also release file information to other insurers to whom you may apply for life or health insurance; or, a claim may be submitted.

PREAUTHORIZED BANK DRAFT WITHDRAWAL

I authorize KSKJ Life to draft specified premiums from the account listed below. I understand the draft will occur on the

date I select in Section A. If I select no date, the debit will occur upon approval.

Section A—Draft Date and Banking Information

If monthly, please indicate your preferred draft date (1st—28th):

Month____________ Date*________

New applications only: Would you like the initial premium to be drafted upon approval? □ Yes □ No

1. KSKJ Life debits your account monthly on the date you specify above. You will not receive a premium notice.2. KSKJ Life may immediately terminate the Preauthorized Bank Draft Withdrawal agreement if any check is not paid upon presentation.3. The Preauthorized Bank Draft Withdrawal’s use shall in no way alter or amend policy provisions with respect to termination.4. Should your preferred draft date fall on a holiday or weekend, the funds will be withdrawn on the next business day.

Payor Name_____________________________________

Bank Name______________________________________

Bank Address____________________________________

Routing # ___ ___ ___ ___ ___ ___ ___ ___ ___

Account # __________________________________

□ Checking □ Savings

_____________________________________________Authorized Account Holder’s Signature (Payor) Date

Section C—Signatures By signing below, the account holder(s) acknowledge they have received, read, and agreed to the Preauthorized Bank Draft Withdrawal agreement’s terms and conditions. Signatures should appear the same as on bank records. _______________________________________________ _______________________________________________ Print Authorized Account Holder’s Name (Payor) Print Additional Authorized Account Holder Name(s)

_______________________________________________

Additional Authorized Account Holder Signature(s) Date

HOME OFFICE USE ONLY Certificate # ___________________________________ Premium Amount $___________________________________

□ Initial Premium □ New Bank Draft □ Change:______Date ________Bank

Notes:_____________________________________________________________________________________________________

Please attach a copy of a voided check with this form and send with application —REQUIRED

2439 Glenwood Ave., Joliet, IL 60435 ǀ 800-843-5755 ǀ KSKJlife.com BankDraft 01.2021

Insured Name________________________________________________

Insured Address________________________________________________City_____________________ State __________________

Please do not send in a bank deposit slip in place of a voided check for setting up bank drafts. Some banks use different routing numbers onthe deposit slip and checks. If the wrong routing number is used, this can result in NSF drafts.

Section B—Preauthorized Bank Draft Withdrawal Terms and Conditions It is agreed that:

* Please indicate a date between the 1st and 28th only.(29th - 30th - 31st not available)

Payor Phone # ____________________________________(Best number to be reached at Mon-Fri 9 a.m. - 4 p.m.)

□ 2nd Wed. □ 3rd Wed. □ 4th Wed. Requested effective month _____________OR choose one of the following:

I authorize KSKJ Life, or authorized third-party service provider, to disclose personal and medical

information about me to my insurance agent and/or agency as stated in my life insurance application.

Information that KSKJ Life or an authorized third-party service provider may disclose includes medical

information and other personal information as it relates to actions KSKJ Life may have taken based on

this information, such as charging me a higher premium for my insurance, changing benefits to something

other than I applied for or declining my application for insurance.

The information will be used to help me with the insurance application process or to find other insurance

coverage options.

I understand that if the person or entity that receives the above information is not covered by federal

privacy regulations, the information described above may be re-disclosed by such person or entity and

will likely no longer be protected by the federal privacy regulations.

I understand that I may refuse to sign this authorization. If I refuse to sign, it will not affect the issuance

of the insurance for which I am applying.

Unless revoked earlier, this authorization will remain in effect for 24 months from the date I sign it. I

understand that I may revoke this authorization at any time, by written notice to:

KSKJ Life, Attn: Life Dept., 2439 Glenwood Ave., Joliet, IL 60435

I realize that my right to revoke this authorization is limited to the extent that KSKJ Life has taken action

in reliance on the authorization.

Please check the appropriate box below:

I request a signed copy of this authorization form.

I do not wish to have a signed copy of this authorization form.

____________________________________ _____/_____/_____

Signature of Applicant A (proposed insured) Date

____________________________________ _____/_____/_____

Signature of Applicant B (proposed insured) Date

AFR 01.2020

Authorization for Release of Information

WHITE COPY – HOME OFFICE YELLOW COPY – APPLICANT PINK COPY - AGENT

A Fraternal Benefit Society 2439 Glenwood Ave., Joliet, IL 60435

IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES

This document must be signed by the applicant and the agent, if there is one, and a copy left with the applicant.

You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements.

A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase.

A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement.

You should carefully consider whether a replacement is in your best interests. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured.

We want you to understand the effect of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form.

1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, orotherwise terminating your existing policy or contract? ____YES ____NO

2. Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy orcontract? ____YES ____NO

If you answered “yes” to either of the above questions, list each existing policy or contract you are contemplatingreplacing (include the name of the insurer, the insured or annuitant, and the policy or contract number if available)and whether each policy or contract will be replaced or used as a source of financing:

INSURER CONTRACT OR INSURED OR REPLACED (R) OR NAME POLICY # ANNUITANT FINANCING (F)

1. _____________________________________________________________________________________________2. _____________________________________________________________________________________________3. _____________________________________________________________________________________________

Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision.

The existing policy or contract is being replaced because .

I certify that the responses herein are, to the best of my knowledge, accurate:

Applicant’s Signature and Printed Name Date

Agent’s Signature and Printed Name Date

I do not want this notice read aloud to me. ____ (Applicants must initial only if they do not want the notice read aloud.)

Form RN-04 -1-

WHITE COPY – HOME OFFICE YELLOW COPY – APPLICANT PINK COPY - AGENT

A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense:

PREMIUMS: Are they affordable? Could they change? You’re older – are premiums higher for the proposed new policy? How long will you have to pay premiums on the new policy? On the old policy?

POLICY VALUES: New policies usually take longer to build cash values and to pay dividends. Acquisition costs for the old policy may have been paid, you will incur costs for the new one. What surrender charges do the policies have? What expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage?

INSURABILITY: If you health has changed since you bought your old policy, the new one could cost you more, or you could be turned down. You may need a medical exam for a new policy. Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage.

IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY:

How are premiums for both policies being paid? How will the premiums on your existing policy be affected? Will a loan be deducted from death benefits? What values from the old policy are being used to pay premiums?

IF YOU ARE SURRENDING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT:

Will you pay surrender charges on your old contract? What are the interest rate guarantees for the new contract? Have you compared the contract charges or other policy expenses?

OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS:

What are the tax consequences of buying the new policy? Is this a tax free exchange? (See your tax advisor.) Is there a benefit from favorable “grandfathered” treatment of the old policy under the federal tax code? Will the existing insurer be willing to modify the old policy? How does the quality and financial stability of the new company compare with your existing company?

Form RN-04 -2-

cover sheet: final expense application

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