Branch/Order # 439-042440 Order Date: 9/17/2013 Print Date: 9/26/2013 Exam Appointment Information

Consumer Information Name: Adolfo Rodriguez DOB: 8/19/1995 Nearest Age: 18

Exam Appointment Date/Time: Thursday 09/26/2013 at 06:00 PM

Gender: M

Home Address: 21619 Mt McKinley Way , Katy, TX, 77449 Home: Work: Extn: Cell: (832)370-1006 Other: (713)459-9196

FMS Name: Linda L Kozak Exam Location: Home 21619 Mt McKinley Way Katy TX 77449

Customer Information Carrier: Western Reserve Life

Policy Amount: $150000 Policy Type: Life Policy Number: 014605603 Smoker: No

Address: Account: WESTERN RESERVE-FL-AGT CDE 5AN Address: 570 Carillon Pkwy Saint Petersburg FL 33716

Ordering Customer: Nguyen, Hiep Agent Name: Nguyen, Hiep Agent Code: 4879M Agency Name: WFG Agency Code: OC Associations:

Service to Perform

Lab Information Lab: Heritage Lab Code: 112600 Lab Slip: , Courier: FedEx Fasting: Preferred (6 Hours)

003 - EXAM & BLOOD-VENIPUNCTURE 072 - STATE REQ. CONSENT FORM-SPECIAL HANDLING 108 - BLOOD-VENIPUNCTURE KIT

Service Code Instructions

Interpretation Instructions

Scheduling Instructions

Packet Instructions

FMS Instructions Fasting 6 Hours Preferred (No fasting required if applicant is diabetic or pregnant.), Number of BP Recordings: 2,,, Applicant want to be seen Tuesday or Thursday @5:30-6pm

Form Information Document - FAST CoverSheet, HIV Consent Form - ACF0707TX.tif - ACF0707TX., Basic exam form - U324 0110 TX FINAL.tif - U324 0110,

Delivery Comments

State Instructions

Send packet per Agency instructions.

FAST: Yes (Account)

Phone# (866) 611-5885

Delivery Instructions

Original Exam Paperwork ExamForm Goes To: BRANCH - 11311 Stroud Dr Houston TX 77072 ECG Goes To: BRANCH - 11311 Stroud Dr Houston TX 77072

Application Packet Packet Goes To: LAB - 07920

Copy of Exam Mailing Address: Fax:

Medical Supplement Part II of WRL Express Application (For Term, Universal or Variable Life Insurance)

Western Reserve Life Assurance Co. of Ohio Home Office: Columbus, Ohio Mailing Address: 4333 Edgewood Road NE, Cedar Rapids, IA 52499 Administrative Office: PO Box 5068, Clearwater, FL 33758-5068

19

PROPOSED INSURED INFORMATION

Last Name:

First Name:

Date of Birth (Month/Day/Year)

Marital Status:

Social Security No.

Height (Ft., In.):

M.I. Weight (Lbs):

Name, address and telephone number of your primary care physician? (If none check box)  None Date and reason last consulted? What treatment was given or medication prescribed?

20

MEDICAL INFORMATION ABOUT THE PROPOSED INSURED

A) For the last 180 days have you been actively at work, on a full time basis, at your usual place of business  Yes or employment? B) To the best of your knowledge, have you within the last 10 years, had or been told by a member of the medical profession that you have, or been diagnosed with or treated for: 1) High blood pressure, heart attack, murmur, chest pain, palpitation, anemia, or any disease of the  Yes heart, blood vessels or blood? 2) Asthma, chronic bronchitis, pneumonia, emphysema, tuberculosis, or any disease or abnormality of the lungs or respiratory system?  Yes  Yes 3) Cancer, tumor, polyp or cyst? 4) Sugar, protein, or blood in the urine, sexually transmitted disease, or any disease or abnormality of the kidney, bladder, prostate, breasts, ovaries  Yes or reproductive system? 5) Stroke, seizure, epilepsy, fainting, loss of consciousness, tremor, paralysis, multiple sclerosis, or any disease of  Yes the brain or nervous system? 6) Anxiety, depression, suicide attempt, or any psychiatric, mental or nervous or emotional  Yes condition or disorder? 7) Diabetes, or any disease or abnormality of the thyroid,  Yes adrenal, pancreas, pituitary or other glands? 8) Ulcer, colitis, hepatitis, cirrhosis, or any disease or abnormality of the esophagus, stomach,  Yes intestines, rectum, gallbladder or liver? 9) Arthritis, gout, connective tissue disease, back trouble or any disease or abnormality of the joints, muscles or bones or any physical deformity  Yes or amputation?

21

DETAILS

 No

 No  No  No  No  No  No  No  No

10) Any disease or abnormality of the eyes, ears, nose,  Yes throat or skin? C) To the best of your knowledge, have you within the last 10 years: 1) Used amphetamines, heroin, cocaine, marijuana, or any other illegal or controlled substance except  Yes as prescribed by a physician? 2) Sought or been advised to seek treatment, limit or discontinue use of alcohol, drugs or other substance or joined an organization for alcohol  Yes or drug dependence or abuse? 3) Been on or are now on prescribed medication or  Yes prescribed diet? 4) Had or been advised to have any hospitalization, surgery, or any diagnostic test including, but not limited to, electrocardiograms, blood studies,  Yes scans, MRI’s or other test? 5) Had an examination, treatment or consultation with a doctor or health care provider other  Yes than above? D) Have you ever been diagnosed as having or told by a medical doctor that you have AIDS, HIV, or  Yes ARC disorders? E) Have you had a parent, brother, or sister, who has/had coronary artery or cardiovascular disease, internal  Yes cancer, or melanoma, prior to age 60? F) Has your weight changed by more than 15 pounds  Yes in the past year?

 No  No  No  No  No  No  No  No

 No

Give details for “No” answer to question 20A and all “Yes” answers to 20B, C, D, E and F

Question No. Diagnosis, disease, symptom, injury, etc. Dates Duration Treatments/Results?

22

 No

Name and Address of Attending Physicians and Hospitals

CERTIFICATION

I represent that I have read and understand all the statements and answers herein, based on the information provided to the Company during a telephone interview on a recorded line or to this examiner; and in Part 1 of my application; that they are complete and true to the best of my knowledge and belief, and are correctly recorded. I fully understand and agree that if any material information has been omitted from the application, it could provide the basis for the Company to rescind coverage and to refund all my premium as though my coverage had never been in force. I agree that this application and any policy or policies issued based on this application shall constitute the entire contract of insurance. Acceptance of the policy by me is acknowledgment and ratification of any corrections made in the application. I further acknowledge that the information contained in Parts 1 and 2 of this form is being obtained on behalf of Western Reserve Life Assurance Co. of Ohio and that such information will be released to the Company, its agents, employees, representatives and reinsurers. Date Signature of Examiner U324 0110 TX

Signature of proposed Insured Print Examiner’s Name

MEDICAL EXAMINATION REPORT - PART II PLEASE GIVE FULL DETAILS OF ADVERSE FINDINGS IN “DETAILS’ SPACE BELOW

Western Reserve Life Assurance Co. of Ohio EXAMINATION OF: (Print full name)

23. Height Ft.

In.

24. Weight 25. Girth-Chest Present 1 Yr. Ago Inap. Exp.

26. Girth Abdomen

34. Urinalysis See note below

Specific Gravity Albumin Sugar

YES IF PULSE IS IRREGULAR, complete exercise test, question 33f, below a. Are you satisfied specimen is authentic?................................. 29. Blood Pressure Systolic Diastolic b. Are you forwarding Specimen? IF BLOOD PRESSURE IS (Phase V) ABNORMAL, record additional c. Have you completed with this reading after 5 minutes. exam: 1st Reading An EKG?.................................. Additional Blood Profile?........................... On inquiry and examination is there evidence of: YES NO TVC?........................................ 30. Present or past disease or abnormalities of: . ............................................... 35. Have you any pertinent information a. Brain, nervous system? (test reflexes; coordination)................................. b. Eye, ears, nose, throat, teeth, gums?........................................................ affecting proposed Insured not c. Thyroid or lymph glands?.......................................................................... brought out above?....................... d. Lungs or respiratory system?.................................................................... e. Stomach or abdominal organs?................................................................ DETAILS f. Genito-urinary systems?........................................................................... g. Skin, skeletal structure or extremities?...................................................... 31. Varicose veins or ulcers?............................................................................... 32. Arteriosclerosis; other peripheral vascular disease?...................................... 33. Presence of past diseases or abnormalities of heart or blood vessels? (if “Yes”, complete questions 33a through g.)..................................................... 27. Temperature

28. Pulse Rate

NO

a. Is there a history of rheumatic fever, scarlet fever, endocarditis, recurrent tonsillitis?................................................................................... b. Is there hypertrophy? (If “Yes”, state degree)............................................ c. Is there a murmur?.................................................................................... Type: Quality: Intensity: Location: Systolic Soft Faint Apex Diastolic Rough Moderate Aortic Presystolic Blowing Loud Pulmonic d. Is murmur constant?.................................................................................. e. Is murmur transmitted?............................................................................. If “Yes”, where? f. EXERCISE TEST - 50 vigorous hops

Before exercise



Immediately after



3 minutes after

Pulse

Irregularities

Rate

No. per minute

Murmur Present

Absent

g. PLEASE RECORD FINDINGS USING FOLLOWING SYMBOLS: Position of apex beat......................... (_____ Ins. or _____ cms. from midsternum in _____ interspace) Murmur: Area of distribution............................ Point of greats intensity..................... Direction of transmission................... 

MEDICAL EXAMINER: YES

NO

YES

NO

Are you in any way related to the proposed Insured or Insurance Producer? If yes, give details. Was the examination conducted in a language other than English? If yes, indicate language used and if applicable, name & relationship of person acting as interpreter.

Name of Insurance Producer requesting examination: INSTRUCTIONS Complete all questions above. You must ask the proposed Insured each question and record the answer. No examiner has any authority to issue a certificate of health or to declare the proposed Insured acceptable for Insurance. Under our rules, only the Company’s underwriting department has authority to determine the insurability of the applicants for insurance. Mail the specimen for laboratory analysis to the laboratory listed on the collection kit or as instructed by your paramedical company.

EXAMINATION WAS MADE AT:

SIGNATURE OF EXAMINER



My Office

Print Examiner name:



Residence of proposed Insured

Company Branch #:



Place of Business of proposed Insured

Tax Identification Number:



Other:

Address: 11311 STROUD DR

At

AM/PM on

Others present (indicate None or list name/relationship):

If mailing, send to:

City: HOUSTON

PORTAMEDIC #439

State: TX Zip Code: 77072

Phone No.: 832-668-9466

Western Reserve Life Assurance Co. of Ohio 4333 Edgewood Road NE Cedar Rapids, IA 52499 AWD Fax #: 1-800-814-2205

Continuation of Exam Insurance Co.: Applicant:

Account number:

Last

First

Agent: Question #

Middle

Diagnosis:

Date:

Question #

Diagnosis:

Doctor:

Name:

Name:

Address:

Address:

Phone:

Phone:

Treatment/Meds:

Treatment/Meds:

Duration:

Duration:

Disposition:

Disposition:

Diagnosis:

Date:

Date of Birth:

Policy Number:

Doctor:

Question #

Overflow Page

Question #

Date:

Diagnosis:

Doctor:

Doctor:

Name:

Name:

Address:

Address:

Phone:

Phone:

Treatment/Meds:

Treatment/Meds:

Duration:

Duration:

Disposition:

Disposition:

Date:

Signature of Applicant:



Date:

Signature of Examiner:



Date:

Branch Address:

PORTAMEDIC 439

11311 STROUD DR



832-668-9466

HOUSOTN TX 77072

6914-4 1/09

PORTAMEDIC • HERITAGE LABS • HEALTH & WELLNESS • UNDERWRITING SOLUTIONS

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Branch # 439

Branch Name HORIZON PARAMEDS

Order #

Applicant

Appointment No Show Date/Time Applicant Missed Appointment Reason Description of appointment address:

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YES

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Date Branch Mgr Signature

Fill out this form and fax wth the original FAST cover page and Order Ticket to HHQA at 1-877-220-9277 as notification an imaged copy is unavailable.

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PORTAMEDIC • HERITAGE LABS • CLAIMS SERVICES • HEALTH & WELLNESS • UNDERWRITING SOLUTIONS