Oklahoma 2012 Standard Medicare Supplement & Life Insurance Plans MSOK0112

Oklahoma 2012 Standard Medicare Supplement & Life Insurance Plans MSOK0112 2012 Standard Medicare Supplement & Life Insurance Plans You can rely on ...
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Oklahoma 2012 Standard Medicare Supplement & Life Insurance Plans MSOK0112

2012 Standard Medicare Supplement & Life Insurance Plans You can rely on Universal Fidelity’s Standard Medicare Supplement Plans to help pay your Medicare Part A and Medicare Part B charges that Medicare doesn’t cover. What’s more, you have: •Four plans from which to select the coverage that best meets your needs. •30 days to review your Policy; if you’re not happy with it, we’ll refund your premium. •Virtually no claims paperwork to file. •Your choice of physicians and specialists for your personalized care. •The option to use any hospital or medical facility. •Put a Universal Fidelity Standard Medicare Supplement Plan on your team today. The Universal Fidelity Standard Medicare Supplement insurance is underwritten by: Universal Fidelity Life Insurance Company Administrative Offices 815 W. Ash Duncan, Ok 73534 Choose the Universal Fidelity Standard Medicare Supplement Plan that’s right for you.

MSOK0112

Choose the Universal Fidelity plan that best fits your needs! MEDICARE PAYS

Medicare Part A hospital coverage Deductible First 60 days 100% Coinsurance 61All but $289 a day 90 days Coinsurance 91150 days (Lifetime Reserve)

All but $578 a day

Extended hospital coverage (up to an additional 365 days in your lifetime)

PLAN A PAYS

PLAN F PAYS

PLAN G PAYS

PLAN N PAYS

$1156.00

$1156.00

$1156.00

$289 a day

$289 a day

$289 a day

$289 a day

$578 a day

$578 a day

$578 a day

$578 a day

Eligible Expenses

Eligible Expenses

Eligible Expenses

Eligible Expenses

3 pints

3 pints

3 pints

Medicare copayment/ coinsurance

Medicare copayment/ coinsurance

Medicare copayment/ coinsurance

Up to $144.50 a day

Up to $144.50 a day

Up to $144.50 a day

Benefit for Blood All but 3 pints 3 pints Hospice Care All but limited coinsurance for Medicare outpatient drugs and copayment/ inpatient respite coinsurance care Skilled Nursing Facility Care First 20 Days 100% Coinsurance All but $144.50 a day 21-100 days Medicare Part B physician's services and supplies Deductible Coinsurance Generally 80% Generally 20% Excess Benefits Benefits for Blood

All but 3 pints

Other Benefits* Emergency Care received outside the USA

3 pints

$140 Generally 20% Generally 20% Generally 20% † 100% up to 100% up to Medicare’s limit Medicare’s limit 3 pints

3 pints

3 pints

80% to lifetime 80% to lifetime 80% to lifetime max of $50,000 max of $50,000 max of $50,000

*Refer to the next page and your outline of coverage for more information † Subject to copayment for office and emergency room visits.

Your Care Benefits Medicare Part A hospital coverage

The Universal Fidelity Standard Medicare Supplement Plan pays the $1,156 Part A (inpatient) deductible for Plans F, G and N for each benefit period. First 60 days – After the Part A deductible, Medicare pays all eligible expenses for services from your first through 60th day of hospital confinement. Services include semi-private room and board, general nursing and miscellaneous hospital services and supplies. Coinsurance – Plans A, F, G and N pay $289 a day when you are hospitalized from the 61st day through the 90th day. When you are hospitalized from the 91st day through the 150th day, the Plans pay $578 a day for each Lifetime Reserve day used. Extended hospital coverage – If you are in the hospital longer than 150 days during a benefit period and you have exhausted your 60 days of Medicare lifetime reserve, Plans A, F, G and N pay the Part A Medicare eligible expenses for hospitalization, paid at the Diagnostic Related Group (DRG) day outlier per diem or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days. Benefit for blood – Medicare has one calendar year deductible for blood that is the cost of the first three pints. Plans A, F, G and N pay the deductible. Skilled nursing facility care – Medicare pays all eligible expenses for the first 20 days. Coinsurance – Plans F, G and N pay up to $144.50 from the 21st through the 100th day during which you receive skilled nursing care. You must enter a Medicare certified skilled nursing facility within 30 days of being hospitalized for at least three days. Hospice care benefit – Plans A, F, G and N pay the copayment/coinsurance amount for all Part A Medicare eligible hospice care and respite care expenses.

Medicare Part B physician services and supplies

Deductible – Plan F pays the $140 calendar-year deductible. Coinsurance – After the Part B deductible, Plans A, F and G generally pay 20% of eligible expenses for

physician’s services, supplies, physical and speech therapy, and ambulance service. After the Part B deductible, Plan N generally pays 20% of the eligible expenses for physician’s services, supplies, physical and speech therapy, and ambulance services except up to a $20 copayment for office visits and up to a $50 copayment for emergency room visits. For hospital outpatient services, the copayment amount will be paid under a prospective payment system. If this system is not used, then generally 20% of eligible expenses will be paid. Excess benefits – Your bill for Part B services and supplies may exceed the Medicare eligible expense. When that occurs, Plan F and G will pay 100% up to the charge limitation established by Medicare. Benefit for blood – Medicare has one calendar year deductible for blood that is the cost of the first three pints. Plans A, F, G and N pay the deductible.

Other benefits*

Emergency care received outside the U.S. – After you pay a calendar-year deductible, Plans F, G and N pay

you 80% of eligible expenses incurred during the first 60 days of a trip up to a lifetime maximum of $50,000. Benefits are payable for medically necessary emergency care. *Refer to the next page and your Outline of Coverage for more information.

Universal Fidelity’s Standard Medicare Supplement Plans A Universal Fidelity Standard Medicare Supplement insurance policy helps pay eligible expenses not paid for by Medicare Part A and Medicare Part B. There may be charges that exceed what Medicare and your Standard Medicare Supplement insurance policy will pay. “Medicare Eligible Expenses” means expenses covered by Medicare to the extent recognized as reasonable and medically necessary by Medicare. Universal Fidelity Standard Medicare Supplement Plans will not pay for: • Any expense incurred before your Policy Date • Services for which no charge is made • Expenses paid by Medicare • Hospital or skilled nursing facility confinement charges incurred prior to the effective date of coverage of the policy • Loss or expense that is payable under any other Standard Medicare Supplement insurance policy or certificate Medicare Part A Eligible Expenses for hospital/skilled nursing facility care include expenses for semi-private room and board, general nursing and miscellaneous services and supplies. A Benefit Period begins the first full day you are hospitalized and ends when you have not been in a hospital or skilled nursing facility for 60 consecutive days. Medicare Part B Eligible Expenses for medical services include expenses for physician’s services, hospital outpatient services and supplies, physical and speech therapy, and ambulance service. Coinsurance is the portion of the eligible expense not paid by Medicare and paid by Standard Medicare Supplement Plans. Benefits are paid to you, your hospital or doctor. You have 31 days from your renewal date to pay your premium. Your policy will stay inforce during this 31day grace period. Your Policy is guaranteed renewable. Your policy cannot be cancel. It will be renewed as long as the premiums are paid on time and the information on your application is correct. You cannot be singled out for a rate increase no matter how many times you receive benefits. Your premium changes only (a) each year on the renewal date coinciding with or following the anniversary of your Policy Date until you reach age 99; and (b) when the same premium change is made on all inforce Universal Standard Medicare Supplement policies of the same form issued to persons of your classification in the same geographic area of your state. This is a brief description of your coverage. This brochure must be accompanied by the Outline of Coverage. For a complete description of benefits, exceptions and limitations, please read your Outline of Coverage and your Policy. Not connected with or endorsed by the United States government or the federal Medicare program. This is a solicitation of insurance and an agent will contact you by telephone. *Refer to the next page and your Outline of Coverage for more information.

Universal Fidelity Life Insurance Company / Administrative Office PO BOX 1565, Duncan, OK 73533 Outline of Standard Medicare Supplement Coverage ‐ Cover Page Benefit Plans A, F, G, & N Benefit Chart of Standard Medicare Supplement Plans sold for the effective dates on  or after November 1, 2011. This chart shows the benefits included in each of the  Standard Medicare Supplement Plans. Every company must make Plan “A” available.  Basic Benefit: Hospitalization:  Part A co‐insurance plus coverage for 365 additional days after Medicare benefits end.  Medical Expenses: Part B co‐insurance (generally 20% of Medicare‐approved expenses),  or co‐payment for hospital outpatient services.  Plan  d l ( ll f d d ) f h l l N requires insured to pay a portion or Part B co‐insurance or co‐payments.  Blood: First three pints of blood each year.  Hospice: Part A co‐insurance A 







F* 





p Hospitalization  Basic  and preventive  Basic  Basic  Basic  Basic  Basic including  including  care paid at  including  including  including  including  100% Part B  100% Part B  100% Part B  100% Part B  100% Part B   100% Part B   100%; other  co‐insurance co‐insurance co‐insurance co‐insurance co‐insurance co‐insurance basic benefits  paid at 50%  Skilled  Skilled  Skilled  50% Skilled  Skilled Nursing  Skilled Nursing 50% Skilled Nursing  Nursing  Nursing  N i N i N i Nursing Facility  Facility           Facility          Facility         Facility           co‐insurance  co‐insurance co‐insurance co‐insurance  co‐insurance Part A  Part A  Part A  50% Part A  Part A  Part A  Deductible  Deductible  Deductible  Deductible  Deductible  Deductible  Part B  Part B  deductible Deductible deductible  Deductible   Part B Excess  Part B Excess  (100%)   (100%)  Foreign  Foreign  Foreign Travel  Foreign Travel  Travel  Travel  Emergency  Emergency  Emergency  Emergency  * Plan F also has an option called a high deductible Plan F. This high deductible plan pays the  p g g p p y Out‐Of‐Pocket  same benefits as Plan F after one has paid a calendar year of $2,000 deductible.  Benefits from  limit $4620; paid high deductible Plan F will not begin until out‐of‐pocket expenses exceed $2,000.  Out‐of‐pocket at 100% after  expenses for this deductible are expenses that would ordinarily be paid by the policy. These  limit is reached   expenses include Medicare deductibles for Part A and Part B, but do not include the plan’s  separate foreign travel emergency deductible. 







p Hospitalization  and preventive  care paid at  100%; other  basic benefits  paid at 75% 

, gp Basic, including part  B co‐insurance  Basic  except up to $20 co‐ including  100% Part B  payment for office  co‐insurance  visit, and up to $50  co‐payment for ER  Skilled  75% Skilled  75% Skilled Nursing  Skilled Nursing  N i Skill dN i Nursing Facility  Facility co‐ Facility co‐insurance co‐insurance  insurance 75 %Part A  50% Part A  Part A Deductible  Deductible  Deductible

Foreign Travel Foreign Travel  Emergency Emergency  Out‐Of‐Pocket    limit $2310; paid   at 100% after  limit is reached 

PREMIUM INFORMATION Your premium will increase each year because of the increase in your attained age. We, Universal Fidelity Life Insurance Company, can also raise your premium if (a) we change the premium rates which apply to all policies of this form issued by us and in-force in your state; (b) coverage under Medicare changes; or (c) you move to a different ZIP code location. DISCLOSURES Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY This is only an outline, describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and Universal Fidelity Life Insurance Company. RIGHT TO RETURN POLICY If you find that you are not satisfied with you policy, you may return it to Universal Fidelity Life Insurance Company, PO Box 1565 Duncan, OK 73534. If you send this policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your premiums. POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE This policy may not fully cover all of your medical costs. Neither Universal Fidelity Life Insurance Company nor its agents are connected to Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult Medicare and You for more details. LIMITATIONS AND EXCLUSIONS Your Standard Medicare Supplement policy will not contain limitations and exclusions that are more restrictive than the limitations and exclusions contained in Medicare. The limitations and exclusions include: A. Expense incurred while your policy is not in force, except as provided in the Extension of Benefits section of your policy. B. Hospital or skilled nursing facility confinement charges incurred prior to the effective date of coverage of your policy. C. That portion of any expense incurred which is paid for by Medicare D. Services for non-Medicare Eligible Expenses, including, but not limited to , routine exams, take-home drugs and eye refractions. E. Services for which a charge is not normally made in the absence of insurance; or F. Loss or expense that is payable under any other Standard Medicare Supplement Insurance Policy or Certificate. REFUND OF PREMIUM This policy contains a provision providing for a refund or partial refund of premium upon your death or the surrender of the policy. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The Company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded.

Universal Fidelity Life Insurance Company Medicare Supplement ‐ Annual Rates ‐ Oklahoma Attained Age Rates ‐‐ Area I (732‐740, 742‐749) Non‐Smoker Plan A 2,045.77 870.48 909.53 960.48 984.24 1,008.83 1,034.12 1,057.65 1,082.12 1,106.83 1,132.36 1,158.36 1,161.18 1,186.95 1,201.65 1,228.36 1,255.65 1,283.42 1,299.53 1,328.24 1,357.89 1,374.83 1,401.18 1,428.12 1,455.53 1,483.65 1,498.12 1,531.06 1,564.95 1,599.30 1,634.59 1,655.18 1,690.48 1,726.48 1,763.06 1,800.59

Female Plan F Plan G

Plan N

1,046.95 1,094.00 1,154.95 1,183.77 1,213.18 1,243.77 1,272.36 1,301.53 1,331.30 1,362.00 1,393.30 1,400.36 1,435.30 1,457.06 1,493.42 1,530.95 1,569.06 1,592.95 1,632.83 1,673.53 1,699.30 1,741.77 1,785.30 1,830.00 1,875.77 1,904.71 1,952.24 2,000.95 2,051.06 2,102.36 2,134.95 2,188.36 2,243.06 2,298.95 2,356.59

764.24 798.59 843.18 864.12 885.77 908.00 928.71 950.12 971.89 994.24 1,017.06 1,022.24 1,047.77 1,063.65 1,090.24 1,117.53 1,145.42 1,162.95 1,192.00 1,221.77 1,240.48 1,271.53 1,303.30 1,335.89 1,369.30 1,390.36 1,428.95 1,468.59 1,509.30 1,551.18 1,579.42 1,621.65 1,664.95 1,709.30 1,755.06

879.42 918.83 970.12 994.36 1,019.18 1,044.83 1,068.59 1,093.30 1,118.36 1,144.00 1,170.24 1,176.24 1,205.65 1,224.00 1,254.71 1,285.89 1,318.00 1,338.24 1,371.53 1,406.00 1,427.30 1,466.71 1,506.83 1,548.12 1,590.48 1,618.95 1,663.30 1,708.83 1,755.89 1,803.89 1,836.12 1,887.42 1,940.24 1,994.36 2,050.24

Plan A 2,389.53 1,016.71 1,062.48 1,121.77 1,149.65 1,178.48 1,207.89 1,235.42 1,264.00 1,293.06 1,322.71 1,353.06 1,356.36 1,386.48 1,403.53 1,434.83 1,466.83 1,499.06 1,517.77 1,551.53 1,586.00 1,605.89 1,636.83 1,668.12 1,700.12 1,733.06 1,749.89 1,788.36 1,828.00 1,868.24 1,909.30 1,933.18 1,974.59 2,016.71 2,059.53 2,103.30

Smoker Male Plan F Plan G

Plan N

1,188.59 1,242.00 1,311.06 1,343.89 1,377.42 1,412.00 1,444.36 1,477.53 1,511.42 1,546.24 1,581.77 1,589.77 1,629.53 1,654.12 1,695.53 1,738.00 1,781.30 1,808.48 1,853.77 1,900.00 1,929.18 1,977.42 2,026.83 2,077.65 2,129.42 2,162.36 2,216.24 2,271.53 2,328.48 2,386.71 2,423.65 2,484.24 2,546.48 2,610.00 2,675.42

867.65 906.59 957.18 981.06 1,005.53 1,030.71 1,054.24 1,078.59 1,103.30 1,128.71 1,154.59 1,160.48 1,189.53 1,207.53 1,237.77 1,268.71 1,300.36 1,320.24 1,353.18 1,387.06 1,408.36 1,443.53 1,479.65 1,516.59 1,554.48 1,578.48 1,622.24 1,667.30 1,713.53 1,760.95 1,792.95 1,840.95 1,890.24 1,940.59 1,992.48

998.36 1,043.18 1,101.42 1,128.95 1,157.18 1,186.12 1,213.18 1,241.18 1,269.53 1,298.71 1,328.59 1,335.30 1,368.83 1,389.53 1,424.36 1,459.89 1,496.24 1,519.18 1,557.06 1,596.12 1,620.48 1,665.06 1,710.71 1,757.42 1,805.65 1,838.00 1,888.24 1,940.00 1,993.30 2,047.77 2,084.36 2,142.83 2,202.59 2,264.12 2,327.42

Attained  Age Under 65  65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99+

Plan A 2,355.18 1,002.12 1,047.18 1,105.65 1,133.18 1,161.53 1,190.59 1,217.65 1,245.89 1,274.48 1,303.65 1,333.53 1,336.83 1,366.48 1,383.42 1,414.24 1,445.65 1,477.53 1,496.00 1,529.18 1,563.18 1,582.71 1,613.18 1,644.12 1,675.65 1,708.12 1,724.71 1,762.59 1,801.77 1,841.30 1,881.77 1,905.42 1,946.12 1,987.65 2,029.89 2,073.06

Female Plan F Plan G

Plan N

1,205.30 1,259.53 1,329.65 1,362.83 1,396.83 1,431.89 1,464.71 1,498.36 1,532.71 1,568.00 1,604.12 1,612.24 1,652.48 1,677.42 1,719.42 1,762.48 1,806.48 1,834.00 1,879.89 1,926.71 1,956.36 2,005.30 2,055.42 2,106.95 2,159.42 2,192.83 2,247.53 2,303.53 2,361.30 2,420.36 2,457.89 2,519.18 2,582.36 2,646.83 2,713.06

879.89 919.42 970.71 994.83 1,019.77 1,045.30 1,069.18 1,093.89 1,118.83 1,144.59 1,170.95 1,176.83 1,206.36 1,224.59 1,255.18 1,286.59 1,318.71 1,338.83 1,372.24 1,406.59 1,428.12 1,463.89 1,500.48 1,537.89 1,576.36 1,600.71 1,645.06 1,690.71 1,737.65 1,785.77 1,818.24 1,866.95 1,916.83 1,968.00 2,020.59

1,012.48 1,057.89 1,116.95 1,144.83 1,173.42 1,202.83 1,230.24 1,258.71 1,287.42 1,316.95 1,347.30 1,354.12 1,388.12 1,409.06 1,444.48 1,480.48 1,517.42 1,540.59 1,579.06 1,618.71 1,643.30 1,688.59 1,734.83 1,782.24 1,831.18 1,863.89 1,914.95 1,967.42 2,021.42 2,076.59 2,113.77 2,172.95 2,233.65 2,296.00 2,360.24

Plan A 2,750.59 1,170.48 1,222.83 1,291.18 1,323.42 1,356.48 1,390.36 1,422.12 1,455.06 1,488.24 1,522.59 1,557.42 1,561.30 1,595.89 1,615.65 1,651.53 1,688.36 1,725.65 1,747.18 1,785.89 1,825.53 1,848.36 1,884.00 1,920.12 1,957.06 1,994.83 2,014.24 2,058.59 2,104.12 2,150.36 2,197.89 2,225.42 2,272.95 2,321.30 2,370.59 2,421.06

Male Plan F Plan G

Plan N

1,368.12 1,429.53 1,509.30 1,546.95 1,585.42 1,625.30 1,662.59 1,700.71 1,739.77 1,779.77 1,820.83 1,830.00 1,875.65 1,904.00 1,951.65 2,000.59 2,050.48 2,081.65 2,133.77 2,186.95 2,220.59 2,276.12 2,333.06 2,391.42 2,451.06 2,489.06 2,551.18 2,614.83 2,680.36 2,747.30 2,789.89 2,859.65 2,931.18 3,004.36 3,079.65

998.71 1,043.53 1,101.77 1,129.30 1,157.42 1,186.48 1,213.53 1,241.53 1,270.00 1,299.18 1,329.06 1,335.89 1,369.30 1,390.00 1,424.71 1,460.36 1,496.83 1,519.65 1,557.65 1,596.59 1,621.06 1,661.65 1,703.18 1,745.65 1,789.30 1,816.95 1,867.30 1,919.06 1,972.36 2,027.06 2,064.00 2,119.18 2,175.77 2,233.77 2,293.53

1,149.30 1,200.83 1,267.77 1,299.42 1,332.00 1,365.30 1,396.36 1,428.71 1,461.42 1,494.95 1,529.30 1,537.06 1,575.53 1,599.42 1,639.53 1,680.36 1,722.24 1,748.71 1,792.36 1,837.30 1,865.18 1,916.59 1,969.06 2,023.06 2,078.48 2,115.53 2,173.53 2,233.18 2,294.36 2,357.06 2,399.30 2,466.48 2,535.42 2,606.12 2,679.18

Policies may be issued on an annual, semi‐annual, quarterly or monthly mode.  To obtain semi‐annual premiums, multiply the above‐quoted premium by 0.515, for quarterly premiums, multiply the above‐quoted  premium by 0.2625 , for monthly premiums, multiply the above‐quoted premium by 0.085.  An annual policy fee of $48.00 will be added to the above premiums

Universal Fidelity Life Insurance Company Medicare Supplement ‐ Annual Rates ‐ Oklahoma Attained Age Rates ‐‐ Area II ( 730‐731, 741) Non‐Smoker Plan A 2,298.59 978.12 1,021.89 1,079.06 1,105.89 1,133.65 1,161.89 1,188.48 1,216.00 1,243.65 1,272.36 1,301.53 1,304.71 1,333.65 1,350.12 1,380.12 1,410.83 1,442.12 1,460.12 1,492.48 1,525.65 1,544.59 1,574.48 1,604.59 1,635.53 1,666.95 1,683.18 1,720.36 1,758.36 1,797.06 1,836.71 1,859.77 1,899.42 1,939.89 1,981.06 2,023.18

Female Plan F Plan G

Plan N

1,176.36 1,229.30 1,297.65 1,330.00 1,363.18 1,397.53 1,429.53 1,462.24 1,495.89 1,530.24 1,565.53 1,573.42 1,612.83 1,637.18 1,678.00 1,720.12 1,763.18 1,789.89 1,834.71 1,880.36 1,909.42 1,957.06 2,006.12 2,056.24 2,107.53 2,140.24 2,193.53 2,248.24 2,304.59 2,362.12 2,398.83 2,458.83 2,520.36 2,583.18 2,647.89

858.71 897.30 947.30 970.95 995.18 1,020.12 1,043.42 1,067.53 1,092.00 1,117.06 1,142.83 1,148.59 1,177.30 1,195.06 1,225.06 1,255.65 1,287.06 1,306.71 1,339.42 1,372.83 1,393.77 1,428.71 1,464.48 1,501.06 1,538.48 1,562.24 1,605.53 1,650.12 1,695.89 1,742.95 1,774.71 1,822.12 1,870.83 1,920.71 1,972.00

988.24 1,032.48 1,090.00 1,117.30 1,145.18 1,174.00 1,200.59 1,228.48 1,256.59 1,285.42 1,314.95 1,321.65 1,354.71 1,375.18 1,409.77 1,444.71 1,480.83 1,503.53 1,541.18 1,579.77 1,603.77 1,648.00 1,693.18 1,739.42 1,787.06 1,819.06 1,868.83 1,920.12 1,972.83 2,026.71 2,063.06 2,120.71 2,180.00 2,240.95 2,303.53

Plan A 2,684.95 1,142.48 1,193.65 1,260.36 1,291.77 1,324.24 1,357.30 1,388.36 1,420.24 1,452.59 1,486.12 1,520.24 1,524.00 1,557.77 1,577.06 1,612.12 1,648.00 1,684.36 1,705.53 1,743.30 1,781.89 1,804.24 1,838.95 1,874.24 1,910.36 1,947.18 1,966.00 2,009.42 2,053.89 2,099.06 2,145.42 2,172.36 2,218.59 2,265.89 2,314.00 2,363.18

Smoker Male Plan F Plan G

Plan N

1,335.42 1,395.42 1,473.18 1,510.00 1,547.65 1,586.59 1,622.83 1,660.12 1,698.24 1,737.30 1,777.30 1,786.24 1,830.95 1,858.59 1,905.06 1,952.83 2,001.53 2,032.00 2,082.95 2,134.71 2,167.65 2,221.77 2,277.42 2,334.36 2,392.59 2,429.65 2,490.24 2,552.48 2,616.36 2,681.65 2,723.30 2,791.42 2,861.30 2,932.59 3,006.12

974.83 1,018.59 1,075.53 1,102.24 1,129.89 1,158.12 1,184.59 1,211.89 1,239.65 1,268.24 1,297.30 1,303.89 1,336.59 1,356.71 1,390.71 1,425.53 1,461.06 1,483.42 1,520.48 1,558.48 1,582.36 1,621.89 1,662.48 1,704.00 1,746.59 1,773.53 1,822.71 1,873.30 1,925.30 1,978.71 2,014.71 2,068.48 2,123.77 2,180.48 2,238.71

1,121.77 1,172.12 1,237.53 1,268.36 1,300.24 1,332.71 1,362.95 1,394.59 1,426.48 1,459.30 1,492.83 1,500.36 1,538.00 1,561.30 1,600.48 1,640.24 1,681.06 1,706.95 1,749.53 1,793.42 1,820.59 1,870.83 1,922.12 1,974.83 2,028.83 2,065.06 2,121.65 2,179.77 2,239.53 2,300.83 2,342.00 2,407.53 2,474.83 2,544.00 2,615.18

Attained  Age Under 65  65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99+

Plan A 2,646.36 1,126.12 1,176.48 1,242.24 1,273.18 1,305.18 1,337.77 1,368.36 1,399.77 1,431.77 1,464.83 1,498.36 1,502.00 1,535.30 1,554.36 1,588.95 1,624.24 1,660.12 1,680.95 1,718.12 1,756.24 1,778.36 1,812.48 1,847.30 1,882.95 1,919.18 1,937.77 1,980.48 2,024.36 2,068.83 2,114.59 2,141.06 2,186.59 2,233.18 2,280.71 2,329.18

Female Plan F Plan G

Plan N

1,354.24 1,415.06 1,494.00 1,531.30 1,569.42 1,608.95 1,645.65 1,683.53 1,722.12 1,761.77 1,802.36 1,811.42 1,856.71 1,884.83 1,931.89 1,980.36 2,029.77 2,060.59 2,112.24 2,164.83 2,198.12 2,253.06 2,309.53 2,367.30 2,426.24 2,463.89 2,525.30 2,588.36 2,653.30 2,719.53 2,761.65 2,830.71 2,901.65 2,974.00 3,048.59

988.59 1,032.95 1,090.59 1,117.89 1,145.77 1,174.48 1,201.30 1,229.06 1,257.18 1,286.00 1,315.65 1,322.24 1,355.42 1,375.89 1,410.36 1,445.65 1,481.65 1,504.36 1,541.89 1,580.48 1,604.59 1,644.83 1,685.89 1,728.12 1,771.18 1,798.59 1,848.36 1,899.77 1,952.36 2,006.59 2,043.06 2,097.65 2,153.77 2,211.18 2,270.24

1,137.65 1,188.59 1,254.95 1,286.24 1,318.59 1,351.42 1,382.24 1,414.36 1,446.59 1,479.89 1,513.89 1,521.42 1,559.65 1,583.30 1,622.95 1,663.42 1,704.83 1,731.06 1,774.24 1,818.71 1,846.36 1,897.18 1,949.30 2,002.71 2,057.42 2,094.24 2,151.53 2,210.59 2,271.18 2,333.30 2,375.06 2,441.42 2,509.77 2,579.89 2,652.00

Plan A 3,090.59 1,315.06 1,374.00 1,450.71 1,486.95 1,524.12 1,562.36 1,597.89 1,634.83 1,672.12 1,710.71 1,750.00 1,754.24 1,793.18 1,815.30 1,855.77 1,897.06 1,938.95 1,963.18 2,006.71 2,051.18 2,076.83 2,116.71 2,157.30 2,199.06 2,241.42 2,263.06 2,312.95 2,364.24 2,416.24 2,469.53 2,500.59 2,553.89 2,608.12 2,663.53 2,720.36

Male Plan F Plan G

Plan N

1,537.18 1,606.36 1,695.77 1,738.12 1,781.42 1,826.24 1,868.00 1,910.95 1,954.83 1,999.77 2,045.77 2,056.12 2,107.53 2,139.30 2,192.95 2,247.77 2,303.89 2,338.83 2,397.53 2,457.30 2,495.06 2,557.42 2,621.42 2,687.06 2,754.00 2,796.59 2,866.48 2,937.89 3,011.53 3,086.95 3,134.71 3,212.95 3,293.53 3,375.65 3,460.24

1,122.24 1,172.48 1,237.89 1,268.83 1,300.59 1,333.18 1,363.53 1,395.06 1,426.95 1,459.77 1,493.30 1,500.95 1,538.48 1,561.77 1,600.95 1,640.95 1,681.77 1,707.53 1,750.12 1,793.89 1,821.42 1,866.95 1,913.53 1,961.42 2,010.48 2,041.42 2,098.12 2,156.36 2,216.12 2,277.65 2,319.06 2,381.06 2,444.59 2,509.77 2,576.95

1,291.42 1,349.18 1,424.48 1,459.89 1,496.59 1,534.00 1,569.06 1,605.30 1,642.00 1,679.77 1,718.36 1,727.06 1,770.24 1,797.06 1,842.24 1,888.00 1,935.18 1,964.95 2,013.89 2,064.36 2,095.89 2,153.42 2,212.36 2,273.06 2,335.42 2,376.95 2,442.24 2,509.06 2,578.00 2,648.48 2,695.77 2,771.18 2,848.71 2,928.24 3,010.24

Policies may be issued on an annual, semi‐annual, quarterly or monthly mode.  To obtain semi‐annual premiums, multiply the above‐quoted premium by 0.515, for quarterly premiums, multiply the above‐quoted  premium by 0.2625 , for monthly premiums, multiply the above‐quoted premium by 0.085.  An annual policy fee of $48.00 will be added to the above premiums

Plan A Medicare (Part A) – Hospital Services – Per Benefit Period * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days

MEDICARE PAYS

PLAN PAYS

YOU PAY

All but $1156

$0

All but $289 a day

$289 a day

$1156 (Part A deductible) $0

All but $578 a day

$578 a day

$0

$0 $0

100% of Medicare Eligible Expenses $0

$0**

Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days 21st thru 100th day 101st day and after

All approved amounts All but $144.50 a day $0

$0 $0 $0

$0 Up to $144.50 a day All Costs

Blood First 3 pints Additional Amounts

$0 100%

3 pints $0

$0 $0

All but very limited copayment/ co-insurance for outpatient drugs and inpatient respite care

Medicare co-payment/ co-insurance

$0

61st thru 90th day 91st day and after: • While using 60 lifetime reserve days • Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days

Hospice Care You must meet Medicare's requirements, including a doctor’s certification of terminal illness.

All Cost

**Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Plan A Medicare (Part B) – Medical Services – Per Calendar Year * Once you have been billed $140 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies , physical and speech therapy, diagnostic tests, durable medical equipment. First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts PART B EXCESS CHARGES (Above Medicare-approved amounts) BLOOD First 3 pints Next $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

CLINICAL LABORATORY SERVICES TEST FOR DIAGNOSTIC SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

$0

$0

$140 (Part B deductible)

Generally 80%

Generally 20%

$0

$0

All costs

$0 $0

All Cost $0

$0 $140 (Part B deductible)

80%

20%

$0

100%

$0

$0

PARTS A & B SERVICES HOME HEALTH CARE MEDICAREAPPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

MEDICARE PAYS

PLAN PAYS

YOU PAY

100%

$0

$0

$0

$0

$140 (Part B deductible)

80%

20%

$0

Plan F Medicare (Part A) – Hospital Services – Per Benefit Period * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days

MEDICARE PAYS

All but $1156

PLAN PAYS

YOU PAY

$0

All but $289 a day

$1156 (Part A deductible) $289 a day

All but $578 a day

$578 a day

$0

$0

$0**

$0

100% of Medicare Eligible Expenses $0

Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days 21st thru 100th day 101st day and after

All approved amounts All but $144.50 a day $0

$0 Up to $144.50 a day $0

$0 $0 All Costs

Blood First 3 pints Additional Amounts

$0 100%

3 pints $0

$0 $0

All but very limited co-payment/ co-insurance for outpatient drugs and inpatient respite care

Medicare co-payment/ co-insurance

$0

61st thru 90th day 91st day and after: • While using 60 lifetime reserve days • Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days

Hospice Care You must meet Medicare's requirements, including a doctor’s certification of terminal illness.

$0

All Cost

**Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Plan F Medicare (Part B) – Medical Services – Per Calendar Year * Once you have been billed $140 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES

MEDICARE PAYS

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies , physical and speech therapy, diagnostic tests, durable medical equipment. First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts PART B EXCESS CHARGES (Above Medicare-approved amounts) BLOOD First 3 pints Next $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

CLINICAL LABORATORY SERVICES TEST FOR DIAGNOSTIC SERVICES

PLAN PAYS

YOU PAY

$0

$140(Part B deductible)

$0

Generally 80%

Generally 20%

$0

$0

100%

$0

$0 $0

All Cost $140(Part B deductible)

$0 $0

80%

20%

$0

100%

$0

$0

PARTS A & B SERVICES

MEDICARE PAYS

HOME HEALTH CARE MEDICAREAPPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

PLAN PAYS

YOU PAY

100%

$0

$0

$0

$140(Part B deductible)

$0

80%

20%

$0

OTHER BENEFITS – NOT COVERED BY MEDICARE FOREIGN TRAVEL Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges

$0 $0

$0 80% to a lifetime maximum benefit of $50,000

$250 20% and amounts over the $50,000 lifetime maximum

Plan G Medicare (Part A) – Hospital Services – Per Benefit Period * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days

MEDICARE PAYS

All but $1156

PLAN PAYS

YOU PAY

$0

All but $289 a day

$1156 (Part A deductible) $289 a day

All but $578 a day

$578 a day

$0

$0

$0**

$0

100% of Medicare Eligible Expenses $0

Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days 21st thru 100th day 101st day and after

All approved amounts All but $144.50 a day $0

$0 Up to $144.50 a day $0

$0 $0 All Costs

Blood First 3 pints Additional Amounts

$0 100%

3 pints $0

$0 $0

All but very limited co-payment/ co-insurance for outpatient drugs and inpatient respite care

Medicare co-payment/ co-insurance

$0

61st thru 90th day 91st day and after: • While using 60 lifetime reserve days • Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days

Hospice Care You must meet Medicare's requirements, including a doctor’s certification of terminal illness.

$0

All Cost

**Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Plan G Medicare (Part B) – Medical Services – Per Calendar Year * Once you have been billed $140 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES

MEDICARE PAYS

MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies , physical and speech therapy, diagnostic tests, durable medical equipment. First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts PART B EXCESS CHARGES (Above Medicare-approved amounts) BLOOD First 3 pints Next $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts CLINICAL LABORATORY SERVICES TEST FOR DIAGNOSTIC SERVICES

PLAN PAYS

YOU PAY

$0

$0

$140 (Part B deductible)

Generally 80%

Generally 20%

$0

$0

100%

$0

$0 $0

All Cost $0

$0 $140 (Part B deductible)

80%

20%

$0

100%

$0

$0

PARTS A & B SERVICES

MEDICARE PAYS

HOME HEALTH CARE MEDICAREAPPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

PLAN PAYS

YOU PAY

100%

$0

$0

$0

$0

$140 (Part B deductible)

80%

20%

$0

OTHER BENEFITS – NOT COVERED BY MEDICARE FOREIGN TRAVEL Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges

$0 $0

$0 80% to a lifetime maximum benefit of $50,000

$250 20% and amounts over the $50,000 lifetime maximum

Plan N Medicare (Part A) – Hospital Services – Per Benefit Period * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days

MEDICARE PAYS

All but $1156

PLAN PAYS

YOU PAY

$0

All but $289 a day

$1156 (Part A deductible) $289 a day

All but $578 a day

$578 a day

$0

$0

$0**

$0

100% of Medicare Eligible Expenses $0

Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days 21st thru 100th day 101st day and after

All approved amounts All but $144.50 a day $0

$0 Up to $144.50 a day $0

$0 $0 All Costs

Blood First 3 pints Additional Amounts

$0 100%

3 pints $0

$0 $0

All but very limited co-payment/ co-insurance for outpatient drugs and inpatient respite care

Medicare co-payment/ co-insurance

$0

61st thru 90th day 91st day and after: • While using 60 lifetime reserve days • Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days

Hospice Care You must meet Medicare's requirements, including a doctor’s certification of terminal illness.

$0

All Cost

**Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Plan N Medicare (Part B) – Medical Services – Per Calendar Year * Once you have been billed $140 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies , physical and speech therapy, diagnostic tests, durable medical equipment. First $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts

PART B EXCESS CHARGES (Above Medicare-approved amounts) BLOOD First 3 pints Next $140 of Medicare-approved amounts* Remainder of Medicare-approved amounts CLINICAL LABORATORY SERVICES TEST FOR DIAGNOSTIC SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

$0

$0

$140 (Part B deductible)

Generally 80%

Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense

Up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense

$0

$0

All costs

$0 $0

All Cost $0

$0 $140 (Part B deductible)

80%

20%

$0

100%

$0

$0

PREMIUM INFORMATION Your premium will increase each year because of the increase in your attained age. We, Universal Fidelity Life Insurance Company, can also raise your premium if (a) we change the premium rates which apply to all policies of this form issued by us and in-force in your state; (b) coverage under Medicare changes; or (c) you move to a different ZIP code location. DISCLOSURES Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY This is only an outline, describing your policy’s most important features. The policy is you rinsurance contract. You must read the policy itself to understand all of the rights and duties of both you and Universal Fidelity Life Insurance Company. RIGHT TO RETURN POLICY If you find that you are not satisfied with you policy, you may return it to Universal Fidelity Life Insurance Company, PO Box 1565 Duncan, OK 73534. If you send this policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your premiums. POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received you new policy and are sure you want to keep it. NOTICE This policy may not fully cover all of you medical costs. Neither Universal Fidelity Life Insurance Company nor its agents are connected to Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact you local Social Security office or consult Medicare and You for more details. LIMITATIONS AND EXCLUSIONS Your Standard Medicare Supplement policy will not contain limitations and exclusions that are more restrictive that the limitations and exclusions contained in Medicare. The limitations and exclusions include: A. Expense incurred while your policy is not in force, except as provided in the Extension of Benefits section of your policy. B. Hospital or skilled nursing facility confinement charges incurred prior to the effective date of coverage of your policy. C. That portion of any expense incurred which is paid for by Medicare D. Services for non-Medicare Eligible Expenses, including, but not limited to , routine exams, take-home drugs and eye refractions. E. Services for which a charge is not Normally made in the absence of insurance; or F. Loss or expense that is payable under any other Standard Medicare Supplement Insurance Policy or Certificate.

Agent Checklist for Completing the Standard Medicare Supplement/ Life Insurance Application

This packet contains the following forms needed to complete an Application For Standard Medicare Supplement Insurance and Life Insurance. Please tear out the application and all pages marked "RETURN TO COMPANY "and leave the remaining pages with the applicant(s). Please review the following information carefully and complete all needed forms: ❑ Application For Standard Medicare Supplement Insurance and Life Insurance ■ Standard Medicare Supplement– If the applicant(s) is applying during Open Enrollment or a Guaranteed Issue period, Section 4 is not required to be completed ■ Life Insurance – Section 4 is required when the applicant(s) is applying for life insurance ■ Section 7 should be completed only if the applicant(s) would like his/her payments to be deducted automatically from his/her checking/savings account. This option applies only if premiums are paid monthly ❑ Agent Certification – This form must be signed by the agent and by the applicant(s). ❑ Calculate your premium – This form is used to calculate the correct life insurance premium and, in coordination with the Outline of Coverage, to calculate the correct Standard Medicare Supplement premium. This form must be returned with the application. ❑ Authorization to Release Confidential Medical Information – Must be completed only if applying outside Open Enrollment or a Guaranteed Issue period for Standard Medicare Supplement or if applying for life insurance. If both spouses are applying for coverage on the same application, then both must sign the form. ❑ Notice to Applicant Regarding Replacement of Standard Medicare Supplement Insurance or Medicare Advantage – This form must be completed if replacement of an existing Standard Medicare Supplement policy is involved. One signed copy must be returned to the Administrative Office and the other signed copy must be left with the applicant(s). ❑ Notice for Replacement of Life Insurance or Annuities - This form must be completed if replacement of existing life insurance is involved. One signed copy must be returned to the Administrative Office and the other signed copy must be left with the applicant(s). ❑ Investigative Consumer Report Notice to Applicant, Medical Information Bureau Disclosure Notice, Medicare Supplement/ Select Initial Premium Receipt, and Life Insurance Conditional Coverage receipt – The Initial/Conditional Premium Receipts must be left with the applicant(s) and the full modal premium is required with all applications. Please note, you are also required to provide the applicant(s) with the following items: ❑ Guide to Health Insurance for People with Medicare ❑ Outline of Coverage Premiums and policy fee Utilize the Universal Fidelity Life’s final expense premium chart to determine the correct monthly life insurance premium. Utilize the Outline of Coverage to determine Standard Medicare Supplement premiums. ■ Determine ZIP code where the client resides and find the correct rate page for that ZIP code ■ Determine Plan ■ Determine if tobacco or non-tobacco use ■ Find age/gender – Verify that the age and date of birth are the exact age as of the application date, this will be your base monthly premium ■ Use the Calculate your premium form to adjust the monthly premium for different modes and to add the policy fee

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453

Application For:

Medicare Supplement Coverage

Life Insurance

Medicare Supplement plan information (to be completed by Producer) NOTE: For ALL sections, ONLY complete the Applicant B information if to be insured.

APPLICANT A

APPLICANT B

Medicare Supplement Plan

Medicare Supplement Plan

(Circle One)

A

F

G

(Circle One)

N

A

Requested effective date: Month Day Year Mail policy to: insured agent Medicare Supplement premium collected $ Payment $ Payment mode A, S, Q, M (ACH only) ACH (bank draft)? 1. Please answer all questions completely.

F

G

N

Requested effective date: Month Day Year Mail policy to: insured agent Medicare Supplement premium collected $ Payment $ The Payment Mode Will be the Same as Applicant A

Applicant A

Applicant B

Name (First/Middle/Last)

Name (First/Middle/Last)

Residence Address

Residence Address

City

City

State ZIP Mailing Address (if different from residence address)

State ZIP Mailing Address (if different from residence address)

City

City

State

ZIP

State

ZIP

Home Phone No: (________)_______________

Home Phone No: (________)_______________

(area code)

(area code)

Current Age __________

Date of Birth ____________

Current Age __________

(MM/DD/YY)

Male

Female

State of Birth_________________

Date of Birth ____________ (MM/DD/YY)

Male

Female

State of Birth_________________

Social Security No: Medicare Health Insurance Card Number (if known or applicable)

Social Security No: Medicare Health Insurance Card Number (if known or applicable)

E-mail Address:

E-mail Address:

Height: Ft _______In ______ Weight :_______ Have you used tobacco in any form in the past 12 months...? Yes No

Height: Ft _______In ______ Weight :_______ Have you used tobacco in any form in the past 12 months...? Yes No

UFLCOMB1-OK Rev 09/11

Page 1 of 7

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453 2. Answer all of the following questions, if applying for Medicare Supplement. 1. Have you received a copy of the Guide to Health Insurance for People with Medicare and the Outline of Coverage? To the Best of Your Knowledge: 1. Are you covered under Medicare Part A? If “YES,” what is your Part A effective date?

____________/____________

If “NO,” what is your eligibility date

____________/____________

Applicant A Applicant A

If “NO,” indicate date you plan to enroll

____________/____________

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes Yes

No No

Yes Yes

No No

Applicant B Applicant B

3. Did you turn age 65 in the last six months? 4. Did you enroll in Medicare Part B in the last six months? If “YES,” indicate your effective date ____________/____________ Applicant A

Yes

Applicant B

____________/____________ Applicant A

Applicant B

Applicant B

2. Are you covered under Medicare Part B? If “YES,” what is your Part B effective date?

Applicant A

Applicant A

Applicant B

If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare Supplement insurance policy or certificate, or that you had certain rights to buy such a policy or certificate, you may be guaranteed acceptance in one or more of our Medicare Supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. Please circle “YES” or “NO” 3. FOR YOUR PROTECTION, the National Association of Insurance Commissioners requests that we ask the following questions about insurance policies or certificates you may have. To the Best of Your Knowledge: 1. Are you applying during a guaranteed issue period? (NOTE: If the answer above is “YES,” please attach proof of eligibility.) 2. Do you have another Medicare Supplement insurance policy or certificate in force? (a) If “YES,” with what company, and what plan do you have

Applicant A Yes No

Applicant B Yes No

Yes

Yes

Applicant A Applicant B Name of Company Name of Company Policy/Certificate Number Policy/Certificate Number Plan Plan Issue Date / / Issue Date / / (b) If “YES,” do you intend to replace your current Medicare Supplement policy/certificate Yes with this policy? (c) If “YES,” indicate termination date.

Applicant A

Yes

No

Yes

No

Yes

No

Applicant A

Applicant B

Start___/___/___

Start___/___/___

End___/___/____ Yes No

End___/___/____ Yes No

Yes

No

Yes

______________/_______________ Applicant A

Applicant B

______________/________________ Applicant A

UFLCOMB1-OK Rev 09/11

No

Applicant B

3. If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates. If you are still covered under this plan, leave “END” blank. (a) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare Supplement policy? (b) If “YES,” have you received a copy of the replacement notice?

(d) Planned date of termination/disenrollment?

No

_____________/_____________

(d) If “YES,” have you received a copy of the replacement notice? If you have had any other Medicare plan coverage as referenced below, not including Medicare Supplement, please complete questions (a-g) below. If not, skip to question #4.

(c) Reason for termination/disenrollment?

No

Applicant B Page 2 of 7

No

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453

Applicant A Applicant B (e) Was this your first time in this type of Medicare plan? Yes No Yes No (f) Did you drop a Medicare Supplement or Medicare select policy/certificate to enroll in this Medicare plan? Yes No Yes No (g) Is your former Medicare Supplement or Medicare select policy/certificate still available? Yes No Yes No 4. Have you had coverage under any other health insurance within the past 63 days? Yes No Yes No (For example, an employer, union, or individual non-Medicare Supplement plan.) (a) If “YES,” with what company and what kind of policy/certificate? (List below.) Applicant A Applicant B Name of Company Type of Policy/Certificate Name of Company Type of Policy/Certificate (b) What are your dates of coverage under the other policy/certificate? If you are still covered under this plan, leave “END” blank. START________________________END______________________/START__________________END_____________________ Applicant A

Applicant B

(c) Reason for termination/disenrollment?

______________________________/_________________________________ Applicant A Applicant B (d) Planned date of termination/disenrollment? _____________________________/__________________________________ Applicant A Applicant B 5. Are you covered for medical assistance through the state Medicaid program? Yes No Yes No (NOTE TO APPLICANT: If you are participating in a “Spend-Down Program” and have not met your “Share of Cost,” please answer “NO” to this question.) If “YES,” (a) Will Medicaid pay your premiums for this Medicare Supplement policy? Yes No Yes No (b) Do you receive any benefits from Medicaid OTHER THAN payment toward your Medicare Part B premium? Yes No Yes No 6. Producers shall list any other health insurance policies/certificates they have sold to the applicant. (a) List policies/certificates sold which are still in force. Applicant A Applicant B Name of Company Name of Company Policy/Certificate Number

Policy/Certificate Number

Description of Benefits

Description of Benefits

Effective Date of Coverage

Effective Date of Coverage

(b) List policies/certificates sold in the past five (5) years which are no longer in force. Applicant A Name of Company Name of Company

Applicant B

Policy/Certificate Number

Policy/Certificate Number

Description of Benefits

Description of Benefits

Effective Date of Coverage

Effective Date of Coverage

UFLCOMB1-OK Rev 09/11

Page 3 of 7

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453 4. IF APPLYING FOR MEDICARE SUPPLEMENT: • During Open Enrollment or a Guaranteed Issue period, SKIP SECTION 4 and GO TO SECTION 5. • NOT during Open Enrollment or a Guaranteed Issue period, PLEASE ANSWER ALL QUESTIONS. IF APPLYING FOR LIFE INSURANCE, PLEASE ANSWER ALL QUESTIONS If either you or Applicant B answer “YES” to any of the following questions 1-14, that person is not eligible for Medicare Supplement or Life Insurance coverage. 1. Are you currently hospitalized, confined to a nursing facility, receiving hospice or home Applicant A health care; or, are you bedridden or confined to a wheelchair? Yes No 2. Have you been diagnosed with emphysema, Chronic Obstructive Pulmonary Disease (COPD), or other chronic pulmonary disorders? Yes No 3. Have you been diagnosed with Parkinson’s Disease, Systemic Lupus, Myasthenia, Gravis, Multiple of Lateral Sclerosis, Osteoporosis with fractures, Cirrhosis, or kidney disease requiring dialysis? Yes No 4. Have you been diagnosed with Alzheimer’s Disease, Senile Dementia, or any other cognitive disorder? Yes No 5. Have you been diagnosed with or treated for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or the Human Immunodeficiency Virus (HIV)? Yes No 6. If you have diabetes, do you have any of the following conditions: diabetic retinopathy, peripheral vascular disease, neuropathy, any heart condition (including high blood pressure), or kidney disease? If you do not have diabetes, this question should be answered “NO”. Yes No 7. Do you have diabetes that has ever required more than 50 units of insulin daily? Yes No 8. Within the past two years have you been treated for or been advised by a physician to have treatment for internal cancer, alcoholism or drug abuse, mental or nervous disorder requiring psychiatric care, or have you had any amputation caused by disease? Yes No 9. Within the past two years have you been treated for or been advised by a physician to have treatment for heart attack, heart, coronary, or carotid artery disease (not including high blood pressure), peripheral vascular disease, congestive heart failure or enlarged heart, stroke, transient ischemic attacks (TIA), or heart rhythm disorders? Yes No 10. Within the past two years have you been treated for degenerative bone disease, crippling/disabling or rheumatoid arthritis, or have you been advised to have a joint replacement? Yes No 11. Have you been advised by a physician that surgery may be required within the next 12 months for cataracts? Yes No 12. Have you been advised by a physician to have surgery, medical tests, treatment, or therapy that has not been performed? Yes No 13. Have you been hospital confined three or more times in the last two years? Yes No 14. Have you had an organ transplant or been advised by a physician to have an organ transplant? Yes No 15. Are you taking or have you taken any prescription or over-the-counter medications within the past 12 months? If “YES,” please list Medication Name (as on the prescription bottle, Yes No frequency, dosage, condition for the medication in the table below). Medication: Frequency: Dosage: Medication: Frequency: Dosage: UFLCOMB1-OK Rev 09/11

Applicant B Yes No Yes

No

Yes

No

Yes

No

Yes

No

Yes Yes

No No

Yes

No

Yes

No

Yes

No

Yes

No

Yes Yes

No No

Yes

No

Yes

No

Page 4 of 7

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453

5. IF APPLYING FOR WHOLE LIFE INSURANCE, PLEASE COMPLETE ALL QUESTIONS NOTE: If you are in Open Enrollment or eligible for Guaranteed Issue for a Medicare Supplement policy and are applying for Whole Life Insurance, you must answer all the questions in Section 4 of the application. APPLICANT A APPLICANT B (If applying for coverage) Primary Beneficiary Name: Primary Beneficiary Name: Relationship to Applicant A:

Relationship to Applicant B:

Contingent Beneficiary Name:

Contingent Beneficiary Name:

Relationship to Applicant A:

Relationship to Applicant B:

Face Amount $5,000 $7,500 $10,000 Automatic Premium Loan Provision Yes Life Insurance Premium Collected: $ Mode: A, S, Q, M (ACH only)

Face Amount $5,000 $7,500 $10,000 Automatic Premium Loan Provision Yes Life Insurance Premium Collected: $

No

ACH (Bank Draft)?

No

The Payment Mode Will be the Same as Applicant A Applicant A Yes No

1. Are you a citizen of the United States?

Applicant B Yes No

2. List below all life insurance policies and/or annuity contracts that have terminated in the last 13 months, are now in force (including any that have been assigned or sold), or that are now pending. (This includes any life insurance policies and/or annuity contracts under a binding or conditional receipt or within an unconditional refund period.) If none, write none below: 3. List below if you have had or intend to have, any life insurance policies and/or annuity contracts replaced, converted, reduced, reissued, sold, subjected to borrowing, or otherwise discontinued because of this application. The Producer shall comply with any additional state and/or company replacement requirements. Company Policy or Face Pending? ADB 1035 To Be Assigned or Contract Amount Amount Exchange? Replaced or Sold? Number Converted? Applicant A Applicant B

Yes Yes

No No

Yes Yes

No No

Yes Yes

No No

Yes Yes

No No

6. BILLING INFORMATION I would like my payment to come from my (circle one) on the ________ day of the month: Checking (Please attach a voided check) Savings (Please ask your financial institution to verify that this EFT will be accepted and that the information below is correct.)

Financial Institution Name: Financial Institution Address: Transit Routing #:

Phone #: Account #:

I hereby request and authorize Universal Fidelity Life Insurance Co to initiate a charge to my account at the named Financial Institution to pay the Premium(s) due, after the first premium has been paid, on any policy issued in connection with this application. The term “charge” shall include items initiated by electronic means, checks, drafts or any other order. I have the right to stop payment of a charge by giving notice to Universal Fidelity Life or the Financial Institution in such time as to afford a reasonable opportunity to act prior to charging my account. I agree that Universal Fidelity Life’s rights in respect to each charge shall be the same as if it were a check made payable to Universal Fidelity Life and personally signed by me. If any charge is dishonored for any reason, Universal Fidelity Life Insurance shall not be under any liability even though such dishonor results in the forfeiture of insurance. ________________________________________________________ Signature as it appears on financial institution records

___________________________ Date

________________________________________________________ Print name of account owner (if other than proposed insured)

UFLCOMB1-OK Rev 09/11

Page 5 of 7

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453 7. PLEASE READ AND SIGN BELOW IMPORTANT STATEMENTS TO BE READ BY APPLICANT • You do not need more than one Medicare Supplement policy • If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need more than one type of coverage in addition to your Medicare benefits. • You may be eligible for benefits under Medicaid and may not need a Medicare Supplement policy. • If, after purchasing the policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare Supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicare Supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of suspension. • If you are eligible for, and have enrolled in a Medicare Supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare Supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare Supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare Supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstated within 90 days of losing your employer or union-based group health plan. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstated policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension. • Counseling services may be available in your state to provide advice concerning your purchase of Medicare Supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB). I understand the Company may obtain an investigative consumer report on me and a telephone interview may be necessary to verify or supplement information given to the Company on this application. I understand my right to request to be interviewed and that I may request a copy of the report if no personal interview is conducted. A photocopy of this form will be as valid as the original; this Authorization and Acknowledgment will be valid for 24 months after it is signed. Except to the extent that action has been taken in reliance on this authorization or the insurance company exercises a legal right to contest a claim or the policy itself, I may revoke the authorization at any time by sending a written revocation to the Company at P. O. Box 1565, Duncan OK 73533. WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information may be guilty of a felony. I wish to apply for a Medicare Supplement insurance policy. I represent that my answers and statements on this application are true and complete. I understand that, (a) upon acceptance of the completed application, each applicant will receive a separate policy; (b) my policy benefits can start no earlier than my Medicare effective date, my first month’s premium has been received and/or processed and my application has been approved by Universal Fidelity Life Insurance Company. I wish to apply for a Life insurance policy. I represent that my answers and statements on this application are true and complete to the best of my knowledge and belief. The life insurance policy applied for will not take effect until it is issued by us and all of the following requirements are met: (a) the policy is delivered to and accepted by the policy owner; (b) the first full premium has been paid according to the mode of payment specified in the application; ( c) the Proposed Insured is still alive; and (d) there has been no change in the Proposed Insured’s health or habits, or the answers to any of the questions in the application, from the date the application is approved by Universal Fidelity’s underwriting department to the date the policy is delivered and accepted by the policy owner. Dated at______________________, on______________________,______ City

State

Month

Day

Year

Dated at______________________, on______________________,______ City

State

Month

Day

Year

____________________________________ Applicant A’s Signature

____________________________________ Applicant B’s Signature

Premium Must Accompany Application I/We certify that during an interview with the proposed applicant, I/we have truly and accurately recorded in the application the information supplied by the applicant. __________________________________________ _______________________________________________ (Signature of Licensed Producer)

UFLCOMB1-OK Rev 09/11

Agent Number

(Signature of Licensed Producer)

Agent Number

Page 6 of 7

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453

Definitions of Eligible Person for Guaranteed Issue and Creditable Coverage Eligible Persons. An eligible person is an individual described in any of the following paragraphs: (1) The individual is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare, and the plan terminates, or the plan ceases to provide all such supplemental health benefits to the individual; or the individual is enrolled under an employee welfare benefit plan that is primary to Medicare and the plan terminates or the plan ceases to provide all health benefits to the individual because the individual leaves the plan. (2) The individual is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare and any of the following circumstances apply, or the individual is 65 years of age or older and is enrolled with a program of All-Inclusive Care for the Elderly (PACE) provider under section 1894 of the Social Security Act, and there are circumstances similar to the following that would permit discontinuance or the individual’s enrollment with such provider if such individual were enrolled in a Medicare Advantage plan: (a) The certification of the organization or plan has been terminated; or (b) The organization has terminated or otherwise discontinued providing the plan in the area which the individual resides; (c) The individual is no longer eligible to elect the plan because of a change in the individual’s place of residence or other change in circumstances specified by the Secretary, but not including termination of the individual’s enrollment on the basis described in Section 1851 (g)(3)(B) of the Social Security Act (where the behavior as specified in standards under section 1856), or the plan is terminated for all individuals within a residence area:; (d) The individual demonstrates, in accordance with guidelines established by the Secretary, that: 1. The organization offering the plan substantially violated a material provision of the organization’s contract under U.S.C Title 42, Chapter 7, Subchapter XVIII, Part D in relation to the individual, including the failure to provide an individual on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide such covered case in accordance with applicable quality standards; or 2. The organization, or agent or other entity acting on the organization’s behalf, materially misrepresented the plan’s provisions in marketing the plan or the individual; or (e)The individual meets such other exceptional conditions as the Secretary may provide. (3) The individual is enrolled with an entity listed in subparagraphs (A)-(D) of this paragraph and enrollment ceases under the same circumstances that would permit discontinuance of an individual’s election of coverage under paragraph (2) of this subsection: a. An eligible organization under a contract under section 1876 of the Social Security Act (Medicare cost)’ b. A similar organization operating under a contract under demonstration project authority, effective for periods before April 1, 1999; c. An organization under an agreement under section 1833(a)(1)(A) of the Social Security Act (health care prepayment plan); or d. An organization under a Medicare Select policy; and (4) The individual is enrolled under a Medicare Supplement policy and the enrollment ceases because: a. Of the insolvency of the issuer or bankruptcy of the non-issuer organization; or of involuntary termination of coverage of enrollment under this policy; b. The issuer of the policy is substantially violated a material provision of the policy; or c. The issuer, or an agent or other entity acting on the issuer’s behalf, materially misrepresented the policy’s provisions in marketing the policy to the individual; (5) The individual was enrolled under a Medicare Supplement policy and terminates enrollment and subsequently enrolls, for the first time, with any Medicare Advantage organization under a Medicare Advantage plan under Part C of Medicare, any eligible organization under a contract under section 1876 of the Social Security Act (Medicare cost), any similar organization operating under demonstration project authority, any PACE provider under section 1894 of the Social Security Act, or a Medicare Select policy; and the subsequent enrollment is terminated by the individual during any period within the first 12 months of such subsequent enrollment (during which the individual is permitted to terminate such subsequent enrollment under section 1851(e) of the Social Security Act); or (6) The individual, upon first becoming enrolled in Medicare part B for benefits at age 65 or older, enrolls in a Medicare Advantage plan under Part C of Medicare, or with a PACE provider under section 1894 of the Social Security Act, and disenrolls from the plan or program no later than 12 months after the effective date of enrollment. (7) The Individual enrolls in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D, was enrolled under a Medicare Supplement policy that cover outpatient prescription drugs and the individual terminates enrollment in the Medicare Supplement policy and submits evidence of enrollment in Medicare Part D with the application for a policy described in subsection (c)(4) of this section. (8) The individual loses eligibility for health benefits under Medicaid. Creditable Coverage means (a) a self-funded or self-insured employee welfare benefit plan that provides health benefits and that is established in accordance with the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.); (b) a group health benefit plan provided by a health insurance carrier or an HMO; (c) an individual health insurance certificate or evidence of coverage; (d) Part A or Part B of Title XVIII of the Social Security Act; (e) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928; (f) Chapter 55 of Title 10 (CHAMPUS); (g) a medical care program of the Indian Health Service or of a tribal organization; (h) a state or political subdivision health benefits risk pool; (i) a health plan offered under Chapter 89 of Title 5 (Federal Employees Health Benefits Program); (j) a public health plan (as defined in federal regulation); (k) a health benefit plan under section 5(e) of the Peace Corps Act (22 United States Code 2504(e)); or (l) short-term limited duration insurance.

UFLCOMB1-OK Rev 09/11

Page 7 of 7

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453

Agent Certification I the undersigned insurance agent certify; THAT, I have taken an application for: Applicant A Insured: Medicare Supplement

Applicant B: Medicare Supplement

Plan A Plan F Plan G Plan N

Plan A Plan F Plan G Plan N

Offered by UNIVERSAL FIDELITY LIFE INSURANCE COMPANY, To__________________________________________________________ (Applicant(s)), THAT, I have explained the provisions of the policy being applied for, including specifically, all the different benefits, exceptions, and limitations of the plan. THAT, I am a licensed agent of this insurance company and have given a company receipt for an initial premium in the amount of $___________________which has been paid to me by Check

Money Order

ACH (Bank Draft)

(Circle appropriate method of payment)

THAT, I have clearly explained any benefits of this plan are a supplement to any benefits that the applicant may be entitled to receive from the Medicare Program of the Federal Government. THAT, I have not made any representation to the applicant that there is any endorsement whatsoever by the Social Security Administration or the Centers for Medicare and Medicaid Services in connection with this insurance policy being applied for. ____________

_____________

Date

Agent Number

_________________________________________ Signature of Agent

I, the undersigned applicant, understand that I will receive a copy of this form when my policy is issued and delivered to me.

_________________________________________

_________________________________________

__________________________________________

Signature of Applicant

Name of Agency

Address of Agent/Agency

______________________________________

___________________________________________

Signature of Spouse if applying

Phone Number

UFLMED-CERT-OT-REV 09/11

RETURN TO COMPANY

Page 1of 1

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453

Medical Release AUTHORIZATION: In order to properly consider my application for life and/or health insurance, I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, pharmacy benefit managers, pharmacies, pharmacy-related facilities, the MIB, Inc. (“MIB”) or other organization, institution or person that has knowledge or records of me and my health to give such information to: (a) Universal Fidelity Life Insurance Company; and (b) its reinsurers. 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 I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization or the insurance company exercises a legal right to contest a claim or the policy itself. I may revoke the authorization by sending a written revocation to the Company address of PO Box 1565 Duncan, Oklahoma 73534. I understand that if I refuse to sign this authorization to release my complete medical records, my application for insurance with the Company will be rejected. All said sources, except the MIB, Inc., are authorized to give records or knowledge such as statements regarding hobbies, employment, criminal records or medical history that might be required to determine eligibility for insurance to any agency employed by the Company to collect and transmit data. I authorize Universal Fidelity Life Insurance Company to disclose any personal data gathered while processing this application to the following: (a) reinsuring companies; (b) the MIB, Inc.; (c) other persons or groups performing services in connection with this application; or (d) any others to whom it may be lawfully required or authorized. This authorization shall remain valid for two years from this date. A copy of this authorization shall be as valid as the original. I acknowledge receiving the Fair Credit Reporting Notice and the MIB Pre-Notice. Name(s) used for medical records if different than name(s) below. ___________________________/__________________________ Applicant A

X_______________________________

Applicant B

X _________________________________

Signature of Applicant A

Signature of Applicant B

Signed at

City____________________County___________________State_____________Date______________

UFLHIPAA-OT 09/11

RETURN TO COMPANY

Page 1of 1

Universal Fidelity’s Survivor Plan Final Expense Life Insurance

Universal Fidelity Survivor Plan is a whole life insurance product designed to help cover the loss of Social Security benefits due to the death of a spouse or final expenses such as cost associated with funeral and burial expenses. The Survivor product provides guaranteed, level premiums and uses the same simplified application as the Universal Fidelity Medicare Supplement Standard Plans. Graded Death Benefit Plan is available for those in poor health. If you qualify, and death occurs within the first two years, your beneficiary will receive all of the premiums paid plus 10% interest. After 2 years the full face value of the policy is payable upon death (as long as premiums are paid on time). ▼ Death benefit can be paid as a monthly benefit through one of the life settlement options. ▼ Builds Cash and Loan Values. ▼ Rates never increase and benefits never decrease (as long as premiums are paid on time). ▼ Minimum Face amount - $5,000.00 ▼ Maximum Face amount- $10,000.00 ▼ Policy is rated on age at last birthday. ▼ Please refer to Universal Fidelity’s height and weight chart for eligibility. ▼ Monthly bank draft rates are displayed on the rate chart. Other model premiums available are quarterly, semi-annual and annual. See rate chart for modal factors. ▼ Underwriting classes are smoker and non-smoker. A smoker is considered anyone who has used tobacco products in the past 12 mo. ▼ One check for both a Medicare Supplement and Survivor policy is acceptable. ▼ The Calculate your premium form must be completed and submitted with the application. ▼ Provide peace of mind that your death won’t cause a financial burden for the family you leave behind.

This is only a brief description of the policy guidelines, Please refer your additional questions to your licensed agent.

93322v2SurvivorPlan.indd 1

8/29/11 2:54 PM

Calculate Your Premium

Medicare Supplement

Standard Medicare Supplement Plan __________ Before you begin: If you’re not in your open enrollment or guarantee issue period, please go to page 2 to determine your eligibility for coverage.

Steps

Premium Write in your Standard Medicare Supplement plan’s premium from the Outline of Coverage table Payment Options To determine other payment schedules, multiply your monthly premium by: 3 to pay four times a year (quarterly) 6 to pay twice a year (semi-annually) 12 to pay once a year (annually)

Example Applicant A’s Rate displayed is used for calculation Premium purposes only. $ 87.47 monthly premium for age 70 Female Non Smoker Plan N

$87.47 Monthly Payment $262.41 Quarterly Payment $524.82 Semi-Annual Payment $1049.64 Annual Payment

Calculate Your Premium

Survivor Life Insurance

TO ADD SURVIVOR LIFE INSURANCE For total face amounts other than $5,000, $7,500 or $10,000, multiply the

Payment Options To determine other payment schedules, multiply your monthly premium by: 3 to pay four times a year (quarterly) 6 to pay twice a year (semiannually) 12 to pay once a year (annually) Add the Standard Medicare Supplement (from top section) and Life Insurance premiums (this section) together

Applicant B’s Premium

Monthly Premium on 5,000 for a Female Non Smoker age 70 $29.60 $88.80 $177.60 $355.20

$87.47 (Med Supp) + $29.60(Life Ins) = $117.07

One check payable to Universal Fidelity Life for $117.07

Applicant A’s Premium Calculation

Applicant B’s Premium Calculation

Survivor Series Monthly Bank Draft Premiums

Issue Age

Female Non Smoker 5,000

7,500

10,000

Female Smoker 5,000

7,500

10,000

Male Non Smoker 5,000

7,500

10,000

Male Smoker 5,000

7,500

10,000

62

$23.17 $33.70 $44.22 $29.59 $43.32 $57.06 $28.69 $41.97 $55.25 $37.98 $55.91 $73.84

63

$23.40 $34.03 $44.67 $29.90 $43.79 $57.68 $29.52 $43.21 $56.91 $39.38 $58.02 $76.65

64

$23.72 $34.52 $45.33 $30.34 $44.45 $58.56 $30.46 $44.63 $58.81 $40.91 $60.30 $79.70

65

$24.28 $35.35 $46.43 $31.05 $45.51 $59.98 $31.62 $46.37 $61.12 $42.59 $62.83 $83.07

66

$25.09 $36.58 $48.06 $32.11 $47.10 $62.10 $33.10 $48.59 $64.08 $44.63 $65.88 $87.14

67

$26.09 $38.07 $50.05 $33.42 $49.07 $64.71 $34.85 $51.21 $67.58 $46.99 $69.43 $91.86

68

$27.21 $39.75 $52.30 $34.86 $51.23 $67.60 $36.69 $53.97 $71.25 $49.39 $73.02 $96.66

69

$28.40 $41.54 $54.68 $36.33 $53.43 $70.54 $38.44 $56.60 $74.76 $51.54 $76.25 $100.96

70

$29.60 $43.33 $57.07 $37.71 $55.51 $73.31 $39.93 $58.84 $77.74 $53.15 $78.66 $104.17

71

$30.78 $45.11 $59.44 $38.98 $57.42 $75.85 $41.09 $60.58 $80.07 $54.06 $80.04 $106.01

72

$31.99 $46.93 $61.87 $40.22 $59.27 $78.31 $42.04 $62.00 $81.96 $54.48 $80.67 $106.85

73

$33.26 $48.84 $64.41 $41.45 $61.12 $80.79 $42.88 $63.26 $83.64 $54.64 $80.90 $107.15

74

$34.63 $50.89 $67.15 $42.75 $63.06 $83.37 $43.71 $64.51 $85.30 $54.74 $81.05 $107.36

75

$36.12 $53.13 $70.13 $44.14 $65.14 $86.15 $44.64 $65.90 $87.15 $55.02 $81.47 $107.92

76

$37.75 $55.56 $73.38 $45.63 $67.38 $89.13 $45.66 $67.43 $89.20 $55.48 $82.16 $108.84

77

$39.47 $58.15 $76.83 $47.19 $69.73 $92.26 $46.72 $69.01 $91.31 $55.97 $82.89 $109.82

78

$41.31 $60.90 $80.50 $48.82 $72.17 $95.52 $47.79 $70.63 $93.47 $56.48 $83.66 $110.84

79

$43.25 $63.81 $84.37 $50.52 $74.72 $98.93 $48.90 $72.30 $95.69 $57.03 $84.48 $111.93

80

$45.29 $66.88 $88.46 $52.29 $77.38 $102.46 $50.04 $74.00 $97.96 $57.60 $85.34 $113.08 Ages 81 & 82 eligible only for a Graded Death Benefit

81

$47.44 $70.10 $92.76 $54.12 $80.12 $106.13 $51.20 $75.74 $100.28 $58.18 $86.21 $114.24

82

$49.69 $73.48 $97.26 $56.02 $82.97 $109.93 $52.39 $77.53 $102.67 $58.76 $87.09 $115.41

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453 IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES This document must be signed by the applicant and the producer, 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 interest. 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 effects of replacements before you make your purchase decision and ask that you answer the following questions. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise 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 or contract? YES NO If you answered “yes” to either of the above questions, list each existing policy or contract you are contemplating replacing (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 NAME

CONTRACT OR POLICY #

INSURED OR ANNUITANT

REPLACED (R) OR 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__________

Producer’s Signature and Printed Name__________________________________________________________Date___________ I do not want this notice read allowed to me.________(Applicants must initial only if they do not want the notice read aloud.) REP REV 09/11

RETURN TO COMPANY

Page 1 of 1

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453 IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES This document must be signed by the applicant and the producer, 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 interest. 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 effects of replacements before you make your purchase decision and ask that you answer the following questions. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise 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 or contract? YES NO If you answered “yes” to either of the above questions, list each existing policy or contract you are contemplating replacing (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 NAME

CONTRACT OR POLICY #

INSURED OR ANNUITANT

REPLACED (R) OR 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__________

Producer’s Signature and Printed Name__________________________________________________________Date___________ I do not want this notice read allowed to me.________(Applicants must initial only if they do not want the notice read aloud.) REP REV 09/11

LEAVE WITH APPLICANT

Page 1 of 2

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 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 your 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 SURRENDERING 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?

REP REV 09/11

LEAVE WITH APPLICANT

Page 2 of 2

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453

Notice to Applicant regarding replacement of Medicare Supplement insurance or Medicare Advantage SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to your application, you intend to terminate existing Medicare Supplement insurance or Medicare Advantage and replace it with a policy to be issued by Universal Fidelity Life Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance available to you under the new policy. You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration and acceptance by replacing insurer, you find that the purchase of this Medicare Supplement coverage is a wise decision, you should terminate your present Medicare Supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy. STATEMENT TO APPLICANT BY ISSUER, AGENT I HAVE REVIEWED YOUR CURRENT MEDICAL OR HEALTH INSURANCE COVERAGE. To the best of your knowledge, this Medicare Supplement policy will not duplicate your existing Medicare Supplement or, if applicable Medicare Advantage coverage because you intend to terminate your existing Medicare Supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reasons: Additional benefits Same benefits but lower premiums Fewer benefits and lower premiums My plan has outpatient prescription drug coverage and I am enrolling in Part D; Disenrollment from a Medicare Advantage plan, please explain reason for disenrollment. _________________________________________________________________________________________ Other, (Please specify) __________________________________________________________________________

1.

2.

State laws provide that your replacement policy or certificate may not contain new pre-existing conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to pre-existing conditions, waiting periods, elimination periods or probationary periods in the new policy (or coverage) benefits to the extent such time was spent (depleted) under the original policy. If, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for any company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded

Do not cancel your present policy until you have received your new policy and are sure that you want to keep it. _____________________________________

__________________________________

____________________

Signature of Agent/Broker/Other Representative

Print Name and Address of Issuer/Agent/Broker

Agent Number

_____________________________________

__________________________________

Signature of Applicant A

Signature of Applicant B, if applying

__________________________________________ Date UFLMED-REP-OK 9/11

RETURN TO COMPANY

Page 1 of 1

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453

Notice to Applicant regarding replacement of Medicare Supplement insurance or Medicare Advantage SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to your application, you intend to terminate existing Medicare Supplement insurance or Medicare Advantage and replace it with a policy to be issued by Universal Fidelity Life Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance available to you under the new policy. You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration and acceptance by replacing insurer, you find that the purchase of this Medicare Supplement coverage is a wise decision, you should terminate your present Medicare Supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy. STATEMENT TO APPLICANT BY ISSUER, AGENT I HAVE REVIEWED YOUR CURRENT MEDICAL OR HEALTH INSURANCE COVERAGE. To the best of my knowledge, this Medicare Supplement policy will not duplicate your existing Medicare Supplement or, if applicable Medicare Advantage coverage because you intend to terminate your existing Medicare Supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reasons: Additional benefits Same benefits but lower premiums Fewer benefits and lower premiums My plan has outpatient prescription drug coverage and I am enrolling in Part D; Disenrollment from a Medicare Advantage plan, please explain reason for disenrollment. _________________________________________________________________________________________ Other, (Please specify) __________________________________________________________________________

1.

2.

State laws provide that your replacement policy or certificate may not contain new pre-existing conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to pre-existing conditions, waiting periods, elimination periods or probationary periods in the new policy (or coverage) benefits to the extent such time was spent (depleted) under the original policy. If, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for any company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded

Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.

_____________________________________

__________________________________

________________

Signature of Agent/Broker/Other Representative

Print Name and Address of Issuer/Agent/Broker

Agent Number

_____________________________________

__________________________________

Signature of Applicant A

Signature of Applicant B, if applying

__________________________________________ Date

UFLMED-REP-OK 9/11

LEAVE WITH APPLICANT

Page 1 of 1

Universal Fidelity Life Insurance Company Administrative Office P.O. Box 1565; Duncan, Oklahoma 73533 Phone: (800) 234-5453

CONSUMER REPORT NOTICE TO APPLICANT Federal law requires that notice of investigation be given to the person applying for insurance. In making this application for insurance to Universal Fidelity Life Insurance Company (the Company), it is understood that an investigative consumer report may be prepared whereby information is obtained through personal interviews with your neighbors, friends or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living (the term “mode of living” does not relate directly or indirectly to the sexual orientation of any proposed insured). You may request to be interviewed for the consumer report. You may, upon written request be informed whether or not the report was ordered, and if so, the name and address of the consumer reporting agency which made the report. Upon proper identification, you have the right to inspect and/or receive a copy of the report from the consumer reporting agency. You have the right to make a written request to the Company within a reasonable period of time to receive additional detailed information about the nature and scope of the investigation. Write to: Underwriting Department, Universal Fidelity Life Insurance Company, P.O. Box 1565, Duncan, OK 73533. MEDICAL INFORMATION BUREAU DISCLOSURE NOTICE Information regarding your insurability will be treated as confidential. Universal Fidelity Life Insurance Company (the Company) or its reinsurer(s) may, however, make a brief report thereon to the MIB, Inc., formerly known as Medical Information Bureau, a not-forprofit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information about you in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at 866-692-6901 (TTY 866-346-3642). If you question the accuracy of the information in MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of MIB’s information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734. The Company or its reinsurer(s) may also release information from its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at www.mib.com MEDICARE SUPPLEMENT INITIAL PREMIUM RECEIPT MAKE CHECK PAYABLE TO: UNIVERSAL FIDELITY LIFE INSURANCE COMPANY

Received from_______________________________________(Proposed Insured) an application for a Medicare Supplement Policy with Universal Fidelity Life Insurance Company (The Company), Duncan, OK and $_____________________for the initial premium. In the event the application is not accepted by the Company, the above amount will be refunded. No obligation is incurred by the Company unless said application is approved by the Company at its Administrative Office and a policy is issued. _________________________________ Agent’s Name (please print)

______________________________ Agent’s Signature

_____________________ Agent Number

_____________________ Date

LIFE INSURANCE CONDITIONAL COVERAGE RECEIPT (Void if altered or modified, or if check or draft given in payment is not honored. Note: Detach if full first life premium is not paid.) Received from _________________________________________$____________subject to the terms and conditions below, for the full first premium with the application bearing the date of this receipt. Coverage under any policy issued from an application bearing the date of this receipt will take effect on the later of the following dates: (1) the date of the application; or (2) the date of the last of any medical exams or tests, if required. Coverage will take effect only if each and every one of these conditions have been met: (1) all persons proposed for insurance are in good health; (2) the first full premium is paid on the date of the application; and (3) upon receipt of the application and of any further information required, all persons are insurable as of that date: (a) as determined by Universal Fidelity Life Insurance Company (Company) at its home office according to its rules and practices; and (b) at the standard rates for insurance exactly as applied for. The maximum amount of life insurance (excluding accidental death benefits) on the proposed insured (combined with any issued or pending with the Company) which will take effect under this receipt shall not exceed $10,000. Coverage under any policy not issued exactly as applied for or in excess of the maximum amounts stated above will only take effect: (1) when this policy is delivered to and accepted by the applicant; and (2) upon payment of the first premium for such coverage. This must occur during the lifetime and good health of all persons proposed for insurance (including accidental death benefits)). If a proposed insured dies by suicide while sane or self destruction while insane, we will pay only a refund of all premiums paid. Except as stated above, no insurance will take effect and the liability of the Company is limited to a refund of any amount paid. Any application not accepted or declined will be deemed declined on the 60th day after its date. _________________________________ Agent’s Name (please print)

UFLMED1-OT

______________________________ Agent’s Signature

_____________________ Agent Number

LEAVE WITH APPLICANT

_____________________ Date

Page 1 of 1

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