Affordable Dental Health Plan

Section F

DECLARATION AND AGREEMENT — I/We have personally completed and reviewed all of my/our answers to the questions in this Application and represent that all information I/we have provided is true, complete, and correctly recorded. I/We understand that this information will be used to determine each person’s eligibility for coverage under the Policy and any false statement or misrepresentation may result in loss of coverage or claim denial. The Applicant (and Spouse or Dependent if coverage elected) must be eligible based on the Company’s rules in effect on the date of Application and on the Policy Effective Date. Policy coverage (or Reinstatement of coverage), if issued and approved by the Company, will become effective on the date recorded in the Policy Schedule of Benefits and not the date this Application is signed. I/We understand that no agent or producer can accept risks, modify policies, or waive any rights or requirements of the Company. If this Application is completed electronically, I/we agree that my/our electronic signature serves as my/our original signatures.

ACKNOWLEDGEMENT — I/We understand that the coverage applied for provides limited benefits and is not a major medical or comprehensive medical benefit plan and is not a substitute for such coverage. The Policy is limited and is not designed to cover all medical expenses. I/We understand that no benefits are payable for sickness during the first 30 days following the Policy Effective Date and that pre-existing conditions are excluded for 12 months. If eligible for Medicare, I/we have received the Guide to Health Insurance for People with Medicare and the Important Notice to Persons on Medicare.

WARNING — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

THIS IS A LIMITED BENEFIT POLICY. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. PLEASE REVIEW THE POLICY CAREFULLY

Authorization to Obtain, Release and Disclose Medical Information

I/We hereby authorize any: physician, medical practitioner, hospital, clinic or other medical related facility, insurance company, insurance support organization, business partner, pharmacy, pharmacy benefit manager, government agency, group policyholder, employer, benefit plan administrator, MIB, Inc., the Department of Motor Vehicle Registration, and paramedical facility to provide to STANDARD LIFE AND ACCIDENT INSURANCE COMPANY, or to any agent, attorney, consumer reporting agency or independent administrator, including medical record retrieval services or pharmaceutical services, acting on STANDARD LIFE AND ACCIDENT INSURANCE COMPANY’S or its reinsurers’ behalf, information concerning advice, care or treatment sought by or provided to me and/or any other Proposed Insured for coverage, including information relating to medical history, medical conditions, treatment, hospitalizations or confinements, ailments, and/or drug, alcohol or tobacco usage of the Applicant or any Proposed Insured. It is understood that STANDARD LIFE AND ACCIDENT INSURANCE COMPANY underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation, or in response to litigation, summons, or subpoenas. I/We understand that after this information is disclosed, the recipient may redisclose it, resulting in loss of protection by federal regulations.

I/We understand that:

1. Such information will be used by STANDARD LIFE AND ACCIDENT INSURANCE COMPANY for underwriting and insurability determinations
2. I/We may refuse to sign this authorization and that my/our refusal to sign will affect my/our ability to obtain health insurance coverage
3. A picture copy or photocopy of this authorization shall be as valid as the original
4. I/We, or my/our authorized representative, am/are entitled to receive a copy of this authorization upon request.

This authorization is valid from the date signed for a duration of 24 months. I/We understand I/we may revoke the authorization at any time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Health Underwriting Department of STANDARD LIFE AND ACCIDENT INSURANCE COMPANY, P.O. Box 1991, Galveston, Texas 77553. I/We may inspect or copy any information used or disclosed under this authorization, if signed. If this application is taken over the phone, I/we agree that my/our electronic signature serves as my/our original signature.

If the Applicant or Proposed Insured holds one of these occupations, please check the box next to that individual’s name in the application. These individuals will not be eligible for coverage with the Standard Life product.

• Active Military Personnel
• Asbestos Workers
• Atomic or Nuclear Energy Workers
• Crop Dusters
• Explosive Workers/Pyrotechnical (dynamite, TNT, etc.)
• Hazardous Chemical Exposure Environment
• Offshore Workers (oil well drilling/operations)
• Professional Athletes (except golfers and bowlers)
• Quarry Workers
• Stunt Activity (flying, aerobatics)
• Toxic Waste Handlers
• Underground Miners
• Unemployed (Report this for the Primary Applicant only)

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