Form 8235

GLOBE LIFE INSURANCE PRODUCTS

POLICY AND PROCEDURES

MANUAL FORCIVIL SERVICE EMPLOYEES

Rev. 0905

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Guidelines for the Civil Service Allotment ProgramPlans / Riders Available* Ages of Eligibility

Group Term to 100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 years - 80 yearsGroup Term — Paid up at 65 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 years - 55 yearsOrdinary Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 years - 80 yearsOrdinary Life — Paid up at 65 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 years - 55 yearsGraded Ordinary Life1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 years - 80 yearsGraded Ordinary Life — Paid up at 651 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 years - 55 yearsTerminal Illnedd Accelerated Benefit Rider . . . . . . (issued on standard policies only) 0 years - 80 yearsWaiver of Premium Disability Rider . . . . . . . . . . . . . (issued on standard policies only) 15 years - 55 yearsChildren's Term to 25 Rider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 days - 23 yearsAccidental Death Benefit Rider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 days - 55 years

* Plans and benefits may vary by state . (See Insert )

When completing your application, if the applicant will be having a birthday in the next 30 days, you should propose the policy at the higher age and list that age on the application . We will be issuing the policy at that next higher age . This only involves applications being submitted on payroll deduction . On bank drafts or direct pays you should give their exact age at the date you are writing the application .

ReplacementsAny replacement applications submitted without ALL required and completed forms will be declined, no exceptions . Also, failure to comply with replacement regulations could result in the revocation of your insurance license by the State Insurance Commissioner . Refer to ESD Replacement Form chart (See Insert) for the appropriate form for use in your state .

Eligible Family Members That May Apply for CoverageRegular full-time working2 employees of the Federal GovernmentSpouse of employeeChildren (30 days through age 23)Stepchildren (through age 23)Adopted Children (through age 23)Grandchildren (through age 23)

Minimum Face AmountsThe minimum face amount that will be issued is $1,000 .00 .

Child Rider Guidelines3

A maximum of $10,000 face amount per child may be written . Unmarried dependent children or legally adopted children of the employee who are standard risks and are between the ages of 30 days and 23 years may apply for the Child Rider . Regardless of the number of children covered under the rider, the total premium for each rider is $2 .00 weekly . This rider can be added to both the Term and Ordinary Life products and may be converted to an individual policy anytime before the child reaches age 25 . This rider can only be issued on the Ordinary Life paid up at 65 and the Term Life paid up at 65 . This rider is not available in Pennsylvania .

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1 Available to government employee and immediate family only .

2 Working means that the employee must actually be working each day at their duty work place and not on sick leave, with or without pay, annual leave pending retirement, temporary disabilities or any form of retirement .

3 The Child Rider Benefit must be applied for at the time of the original application . It can not be added to an existing policy at a later date .

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Accidental Death Benefit4

The Accidental Death Benefit (ADB) may be written on individual coverage for ages 30 days through 55 years, with the Term and Ordinary Life products, subject to the following rules:

1) ADB may be written on the employee only or on the employee and the spouse only, provided the minimum face amount applied for is $5,000 on each life .

2) ADB may also be written on other eligible family members as long as it is applied for on all other eligible family members and the minimum face amount applied for is $5,000 on each life . ADB cannot be placed on a child that is covered under the child rider .

For Example: If the ADB Rider is written on one child, it must be written on all other children in the family; minimum face amount is $5,000 on each child .

3) The minimum and maximum amount issued on an Ordinary Life guaranteed issue basis is 1 unit, $16,000 for $ .50 a week or 2 units, $32,000 for $1 .00 a week . Only one unit is available on Sub-Standard Policies . Maximum ADB with Globe Life is 2 units per person .

Maximum Guaranteed Insurability and Increase Options After Initial Enrollment (Immediate Family Members Only)

I . The minimum increase is based on the attained age using the minimum weekly enrollment premium . Increases may be granted after the first policy anniversary, subject to the following limitations:

1) One increase option per policy year will be allowed and each increase must be separated by a period of 12 months .

2) The amount of the increase with the face amount already in force may not exceed $75,000 on employee, $25,000 on a spouse and $7,000 on children .

3) If the maximum ADB was purchased on the previous policy(ies), no additional ADB benefit is available .

II . Insureds who have attained their 56th birthday but who have not reached their 65th birthday . Increases may be granted after the first policy anniversary, subject to the following limitations:

1) One increase option per policy year will be allowed and each increase must be separated by a period of 12 months .

2) The amount of the increase with the face amount already in force may not exceed $30,000 on employee and $10,000 on spouse .

III . If the civil service employee should resign, die or retire, any immediate family member who is insured at the time of the resignation, death or retirement shall be eligible for the regular increase options up to the maximum issue limits, subject to the initial enrollment guidelines for Sub-Standard . Such increases may be written on any mode of payment if a bank draft is authorized . Otherwise, the mode of payment must be made quarterly, semi-annually, or annually . If coverage lapses, any new requests for coverage will be processed as non-civil service business .

IV . A policy belongs to the Writing Agent for a period of two years as long as he is active with the company . If a new Agent increases this policy and it is within a 2-year period, the application will be returned .

4 The Accidental Death Benefit must be applied for at the time of the original application . It can not be added to an existing policy at a later date .

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Guidelines for Contract Labor

Globe Life will be accepting Contract Personnel on a guaranteed issue basis5 on the Ordinary Life product . They will fall under the same guidelines as the Federal Employees .

1) You must receive prior Home Office approval of the contractor .

2) A current (90 days) Leave and Earnings Statement must be sent in with each application . If Globe does not receive it, it will not be a guaranteed issue policy .

3) These policies should be written on a Bank Draft basis . In the event you can enroll ten or more employees, we will set up a list bill to the Employer .

4) Business must be submitted with contact person and phone number in order to verify the contract with the government .

Bank Drafts and Direct PaymentsThe minimum per individual for a monthly bank draft is $10 .00 . If the monthly bank draft is less than $10 .00, the applicant must pay quarterly, semi-annually or annually . Bank drafts must be sent in with at least one month’s premium and a voided check or deposit slip . Any direct payments must be at least a quarterly mode . We do not accept monthly direct payments . Advances are not paid on direct payment modes . All modes of payment will be made out to Globe Life And Accident Insurance Company . We will not accept Agent’s checks or cash . Any case submitted on Bank Draft with a Sub-Standard applicant must have a Leave and Earnings Statement submitted with the application .

CancellationsIf a policy is in force less than 60 days due to a cancellation or lapse, or if a policy is withdrawn due to the allotment never being received, a charge back of the full advance commission will be deducted from your weekly advance check .

Personal BusinessAdvances are not paid to an Agent when writing individual policies on himself or his family .

Ordinary Life Individual Guarantee Issue6 Maximums (Subject to Certain Limitations)The Maximum Individual Guarantee Issues6 are:

1) Up to $75,000 through age 55 (employee only)2) Up to $25,000 through age 55 (spouse of employee)3) Up to $30,000 for ages 56-65 (employee only)4) Up to $10,000 for ages 56-65 (spouse of employee)5) Up to $7,000 for children ages 0-2376) Up to $7,000 for parents of employee or spouse8

Face amount coverage exceeding these limits will be subject to the Company’s ordinary life underwriting rules . The Company reserves the right to request any evidence it deems necessary to qualify a risk .

Note: When writing a Sub-Standard premium on a spouse, you must write equal premium on healthy eligible family members.

5 Subject to certain limitations .

6 There is no guarantee issue policy in the states of Kansas, North Carolina, South Carolina, Texas or West Virginia .

7 Children age 24-30 can be issued up to $7,000 if in good health . The employee’s signature is all we need in these cases . We will issue $2 .00 weekly on children up to age 23 without any underwriting; however, it must be explained to the employee that the guaranteed amount is only $7,000 . We will never issue more than $25,000 on any child 18 or younger .

8 Parents will not be issued over $7,000 even if in good health . We will issue the policy if high blood pressure is controlled and/or diabetes that is not insulin injected .

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Ordinary Life — Government Employee and Family

Applying for Amounts in Excess of the Guaranteed Issue Limits If the proposed insured is assumed to be eligible for standard coverage, he/she may apply for coverage in excess of the guarantee issue limits (shown on page 3) in accordance with the following guidelines .

1) Complete application Form EGAP or IGAP . Questions 12 through 14 on the app must be answered and the Agent’s Report on the back of the application must also be completed . The application must be signed by the applicant .

2) You must also have the M .I .B . Authorization Form G1342N and the HIPAA form F3988 signed by the applicant . (Parent signs if child is age 17 or less .)

3) If 1 and 2 above are not properly completed, the application will automatically be reduced to the Guaranteed Issue Limit .

Non-Medical Limits Which Meet the Guaranteed Issue9 LimitsThese requirements apply to the total face amount applied for plus the total face amount in force with Globe Life .

Non-Medical Limits — GeneralIn determining Non-Medical Limits, all life insurance in force with Globe Life must be considered .

Even though an applicant falls within the Non-Medical Limits, the Company reserves the right to have the applicant examined .

N/M — non-medical N/M-GIL — non-medical, Guarantee Issue Limit A — simplified paramedical examination (includes medical history, height, weight, blood pressure, pulse and urinalysis) . B — A plus urine specimen, which is sent to the Home Office Reference Laboratory, Shawnee Mission, Kansas, plus blood profile, which includes Elisa-Screen and is sent to the Home Office Reference Laboratory, Shawnee Mission, Kansas . C — A plus B plus resting electrocardiogram .

All physical examinations required by the company to underwrite life insurance applications will be arranged for by the Home Office. The Agent should, however, inform the applicant that an examination will be required.

9 There is no guarantee issue policy in the states of Kansas and South Carolina .

AMOUNTS AGE 0-�0 AGE ��-�5 AGE �6-50 AGE 5�-55 AGE 56-65

0 — 5,000 N/M N/M N/M N/M N/M

5,001 — 20,000 N/M N/M N/M N/M N/M-GIL

20,001 — 40,000 N/M N/M N/M N/M-GIL A

40,001 — 50,000 N/M N/M N/M N/M-GIL A

50,001 — 100,000 N/M A A A A

100,001 — 150,000 B B B C C

150,001 — 250,000 B B B C C

+250,000 — not issued

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Term Policies Non-Guarantee Issue Policies:

Plans Available* Ages of EligibilityGroup Term to 100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 years - 80 yearsGroup Term — Paid up at 65 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 years - 55 yearsTerminal Illnedd Accelerated Benefit Rider . . . . (issued on standard policies only)

0 years - 55 years

Waiver of Premium Disability Rider . . . . . (issued on standard policies only) 15 years - 55 yearsChildren's Term to 25 Rider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 days - 23 yearsAccidental Death Benefit Rider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 days - 55 years

* Plans and benefits may vary by state .

Medical Limits (Non-Civil Service)These requirements apply to the total face amount applied for plus the total face amount in force with Globe Life .

Forms Required for Term Coverage and Non-Guaranteed IssueApplication Form EGA2MIB AuthorizationHIPAA Form F3988119910Bank Letter10Terminal Illness FormLeave and Earnings Statement10

If under 18, the owner signs the application . Exception: Indiana, Age 16 . If an allotment is not used in the mode of payment, payment must be bank draft, quarterly, semi-annually or annually . No C .O .D . unless allotment is used . Detach and furnish to the applicant the Notice Of Information Practices .

All modes of payment, except allotment, will be made out to Globe Life And Accident Insurance Company .

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N/M — non-medical A — simplified paramedical examination

B — A plus blood profile C — A plus B plus attending physician statement

10 Necessary if writing Term policy on allotments .

AMOUNTS AGE 0-�0 AGE ��-�5 AGE �6-50 AGE 5�-55 AGE 56-65

0 — 5,000 N/M N/M N/M N/M N/M

5,001 — 15,000 N/M N/M N/M N/M N/M

15,001 — 25,000 N/M N/M N/M N/M A

25,001 — 50,000 N/M N/M A A A

50,001 — 100,000 A A A A A

100,001 — 150,000 B B B B B

150,001 — 250,000 C C C C C

+250,000 — not issued

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Procedures For Paying Agents

Agents With Us For First Year1) Must have a Leave and Earnings Statement (must be 90 days current) - if not, it will be a P-411 . The 1199 will be

mailed and we will pay the Agent when we get the Leave and Earnings Statement or when the first allotment is received .

2) A Leave and Earnings Statement that reflects two allotments will be a P-4 when accompanied with an allotment to cancel .

3) Business submitted over the guarantee issue will be a P-4 . All non-civil service business will also be a P-4 .

4) Any case written over $20 .00 in weekly premium will be processed as a P-4 .

Agents In UnrecoverableIf an Agent’s Account goes into an Unrecoverable status, it is up to the Company’s discretion as to the amount of advances paid on any cases . An Agent will be notified on any changes in their pay status .

Rewrites on Withdrawals, Cancellations Or Lapses1) If a withdrawn policy is rewritten, it will be processed as a P-4 . If the Agent was charged back on the case, he will be

readvanced when the first allotment is received on the new case . If the Agent was not charged back, the new case will be processed as a P-3 .12

2) When a policy is being rewritten that has been lapsed or cancelled for less than a year, the new case will be a P-3 (no advance) .

PostalEase, Employee Express and MyPayESD Allotment Confirmation form F3326 must be received on all Postal and Employee Express business . If it is not received, the business will be P-4'd until it is received or the policy issued .

It is always up to the Company's discretion whether to advance on any application.

11 P-4 — will be paid when the case issues or when information needed is received .

12 P-3 — no advance .

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Submission of ApplicationComplete Enrollment Package

A complete enrollment with supporting forms should include:

11) Enrollment/Application Form EGAP/IGAP (Ordinary Life) or EGA2 (Term Life) . Refer to Insert for form approved for use in your state . Examples shown on pages 8-13 .

12) Allotment Form 1199A (for Postal Service, use form PS 1199-A) . Examples shown on pages 14-15 .

13) Bank Letter Form 4322 . Example shown on page 18 .

14) ESD Allotment Confirmation Form - F332613 . Example shown on page 16 .

15) Employee Leave and Earnings Statement — Must be a current statement within 90 days of the application being written .

16) Terminal Illness Rider Disclosure Form #GABR1D1 - (if approved in your state) . Example shown on page 17 .

17) HIPAA Form F3988 and MIB Authorization G1342N14 . Examples shown on pages 19-21 .

18) SAHB - Standard Application form for high blood pressure is only necessary if you want the company to underwrite the the high blood pressure for Standard Issue .

19) Replacement Forms — if replacing another company’s policy . See Insert for appropriate replacement forms by state .

10) Arbitration Form GARP03 required in Mississippi and Alabama on all applications .

If any other form of payment mode is used other than allotment, you will not need to send in supporting forms listed in 2 and 3 above .

If a bank draft payment is used, add Bank Draft Form 1080 along with one month’s premium and a voided check or deposit slip . Example shown on page 22 .

Failure to submit any of the above will cause the application to be returned to the writing agent as incomplete and unprocessable .

Note: When writing a Sub-Standard premium on a spouse, you must write equal premium on healthy family members.

13 This form must be completed on any allotments being initiated through an employee’s PIN number (Employee Express 1-800-525-9609, Postal Ease 1-877-477-3273, and MyPay 1-899-363-3677 . Contact Home Office for web site address .) . You will continue to submit the 1199 along with this form .

14 The two additional forms are needed on all Term Policies and any policies over the guarantee issue or non-civil service applicants . The MIB authorization is required on all applications in Arizona and California .

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Form EGAP — Ordinary Life Enrollment Form Refer to ESD Application / Enrollment Form Reference Chart (insert) for applicable form number for your state .

John L. Doe

John L. Doe

C/RC/RC/R

OL/CR

OL8.505.50

YES-1YES-1

X

X

X

X

XX

X

Mary C. DoeSusie R. DoeJim B. DoeJack G. Doe

5th 2001Oklahoma City Oklahoma

222 Elm Street Oklahoma City OK 73120

Tinker Air Force Base Midwest City, OK 123-45-6789 (405) 111-2222 (405) 111-2222 x34

M 6 5 55 46F 7 3 57 44F 4 10 85 16M 8 1 87 14M 2 15 90 11

Jim Smith 1211

X

John L. Doe

FMI-BSP

Aug

Questions 12-14 must be completed if over guarantee issue or non-civil service .

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Form EGAP(a) — Agent’s Report

Aug 5, 2001

John L. Doe

$28.00

Jim Smith

Form EGAP Ordinary Life Application Form Continued...

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Form IGAP — Ordinary Life Application Form Refer to ESD Application / Enrollment Form Reference Chart (insert) for applicable form number for your state .

John L. Doe

John L. Doe

C/RC/RC/R

OL/CR OL

8.505.50

YES-1YES-1

X

X

X

X

X

X

X

Mary C. DoeSusie R. DoeJim B. DoeJack G. Doe

5th 2001Oklahoma City Oklahoma

222 Elm Street Oklahoma City OK 73120

Tinker Air Force Base Midwest City, OK 123-45-6789 (405) 111-2222 (405) 111-2222 x34

M 6 5 55 46F 7 3 57 44F 4 10 85 16M 8 1 87 14M 2 15 90 11

Jim Smith 1211

X

John L. Doe

FMI-BSP

Aug

Questions 12-14 must be completed if over guarantee issue or non-civil service .

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Form SIGL — Agent’s Report

$28.00

Aug. 5, 2001

Jim Smith John L. Doe

Form IGAP Ordinary Life Application Form Continued...

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Form EGA� — Term Life Enrollment Form Refer to ESD Application / Enrollment Form Reference Chart (insert) for applicable form number for your state .

John L. Doe

John L. Doe

C/RC/RC/R

OL/CR

OL8.505.50

YES-1YES-1

X

X

X

XX

X

X

X

X

Mary C. DoeSusie R. DoeJim B. DoeJack G. Doe

5th 2001Oklahoma City Oklahoma

222 Elm Street Oklahoma City OK 73120

Tinker Air Force Base Midwest City, OK 123-45-6789 (405) 111-2222 (405) 111-2222 x34

M 6 5 55 46F 7 3 57 44F 4 10 85 16M 8 1 87 14M 2 15 90 11

Jim Smith 1211

X

John L. Doe

FMI-BSP

Aug

�3

Form EGA�(a) — Agent’s Report

X

X

X

X 7 p.m.

$28.00

Aug. 5, 2001

405 111-2222 x34

Tinker Air Force Base

6’2” 200 lbs.

Mary 5’6” 140 lbs. Spouse

Jim Smith John L. Doe

Form EGA� Term Life Enrollment Form Continued...

1 6

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Form ����-�0� — Allotment Form

Doe, John L.

Tinker Air Force Base Midwest City, OK 73145

8-8-01

John L. Doe

John L. Doe

Allotment $28.00

405-111-2222

123-45-6789

222 Elm StreetOklahoma City OK 73120

Use no correction fluid, erasure, write over or line through on any allotment form . This form must be correct and is not acceptable if altered in any way .

Social Security #

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PS Form ����-A — Allotment Form For Postal Service Employees

John L. Doe

John L. Doe

28

123-45-6789

4 5 6 7 8 9

222 Elm StreetOklahoma City, OK 73120

U.S.P.O.Oklahoma City, OK 73120

Aug. 8, 2001

Use no correction fluid, erasure, write over or line through on any allotment form . This form must be correct and is not acceptable if altered in any way .

ESD AllotmEnt ConfirmAtion

EmployEE ExprEss, postalEasE, mypay

Please check 1, 2 or 3, and fill in the aPProPriate information.

Employee Name (printed)

Employee ID/SSN

Employee Signature

Agent Name (printed)

Agent Signature

F3326 R0605

1 ■ Allotment has been initiated through employee’s PIN Number .

Postal Confirmation Number is:

Date of first allotment is:

2 ■ I have ordered a pin # and will follow-up in 10 days to make sure allotment is initiated .

3 ■ I need assistance from Globe Life home office in ordering my pin # . Globe Life will follow-up with me in initiating my allotment .

WHItE: Home office • yElloW: employee copy • pINK: file copy

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555-11-9999

Jim Smith

John L. Doe Jim Smith

Form F33�6 — ESD Allotment Confirmation

John L. Doe

GLOBE LIFE AND ACCIDENT INSURANCE COMPANYAdministrative Offices: P .O . Box 8080 • McKinney, Texas 75070-8080

TERMINAL ILLNESS ACCELERATED BENEFIT DISCLOSURE AND ACKNOWLEDGEMENT

The contract you have applied for contains a Terminal Illness Accelerated Benefit rider . We are required to provide you with this disclosure and obtain your signature, acknowledging your receipt and review of this document .

The Terminal Illness Accelerated Benefit rider on this contract allows the Insured to receive a portion of the contract’s Death Benefit upon our receiving due proof that the Insured has a Terminal Illness .

DEFINITION OF TERMINAL ILLNESS: The Insured has been diagnosed with a noncorrectable medical condition that, with reasonable medical certainty, will result in the Insured’s death within twelve (12) months from the date on which this benefit is requested .

AMOUNT OF THE BENEFIT: The amount of the Accelerated Benefit will be equal to 50% of the Death Benefit less 50% of any outstanding policy loan and loan interest .

“SAMPLE ILLUSTRATION:” The calculation of the Accelerated Benefit Amount and the effects on the remaining contract values are shown in the “sample illustration” below:

CONTRACT DEATH BENEFIT: $10,000CASH VALUE: 5,000POLICY LOAN: 2,500

ACCELERATED BENEFIT AMOUNT CALCULATION:

$10,000 X .50 = $5,000 Gross Amount 2,500 X .50 = - 1,250 Policy Loan $3,750 Amount Payable

CONTRACT VALUES AFTER ACCELERATED BENEFIT PAYMENT:

10,000 - 5,000 = $5,000 Death Benefit 5,000 - ( .50 X 5,000) = 2,500 Cash Value 2,500 - 1,250 = 1,250 Policy Loan

THIS FORM IS NOT A CONTRACT . IT IS INTENDED ONLY AS A SUMMARY OF THE RIDER PROVISIONS SHOWN . IN ALL CASES, CONSULT YOUR RIDER FOR FULL DETAILS AND RESTRICTIONS .

ANY ACCELERATED BENEFIT PAID UNDER THIS CONTRACT MAY BE TAXABLE . A PERSONAL TAX ADVISOR SHOULD BE CONSULTED .

PAYMENT OF ANY ACCELERATED BENEFIT MAY ALSO ADVERSELY AFFECT THE RECIPIENT’S ELIGIBILITY FOR MEDICAID AND OTHER GOVERNMENT BENEFITS OR ENTITLEMENTS .

I hereby acknowledge receipt of this disclosure form as evidenced by my signature below:

Signature of Applicant Date

_________________________________________________ ________________________

Signature of Agent Date

_________________________________________________ ________________________

Form GABR1D1

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Form GABR�D� — Terminal Illness Rider Disclosure Form

Aug 5, 01

Aug 5, 01

John L. Doe

Jim Smith

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Form �3�� — Bank Letter FormExplain and complete the form as shown . This form is not required when increasing the allotment . Have the employee sign and date .

Aug 5, 01John L. Doe

Jim Smith

____________________________________________________ ___________________ Nameofproposedinsured/patient(pleaseprint) Dateofbirth

Iauthorizeanyhealthplan,physician,healthcareprofessional,hospital,clinic, laboratory,pharmacy,medicalfacility,orotherhealthcareproviderthathasprovidedpayment,treatmentorservicestomeoronmybehalf(“MyProviders”)todisclosemyentiremedicalrecord andanyotherprotectedhealthinformationconcerningmetotheGlobeLifeAndAccidentInsuranceCompany(Globe)anditsagents,employees,andrepresentatives.ThisincludesinformationonthediagnosisortreatmentofHumanImmunodeficiencyVirus(HIV)infectionandsexuallytransmitteddiseases.Thisalsoincludesinformationonthediagnosisandtreatmentofmentalillnessandtheuseofalcohol,drugs,andtobacco,butexcludespsychotherapynotes.

Bymysignaturebelow,IacknowledgethatanyagreementsIhavemadetorestrictmyprotectedhealthinformationdonotapplytothisauthorizationandIinstructanyphysician,healthcareprofessional,hospital,clinic,medicalfacility,orotherhealthcareprovidertoreleaseanddisclosemyentiremedicalrecordwithoutrestriction.

This protected health information is to be disclosed under this Authorization so that Globe may: 1) underwrite myapplicationforcoverage,makeeligibility,riskrating,policyissuanceandenrollmentdeterminations;2)obtainreinsurance;3)administerclaimsanddetermineorfulfillresponsibilityforcoverageandprovisionofbenefits;4)administercoverage;and/or5)conductotherlegallypermissibleactivitiesthatrelatetoanycoverageIhaveorhaveappliedforwithGlobe.

This authorization shall remain in force for 24 months following the date of my signature below, and a copy of thisauthorization isasvalidastheoriginal. Iunderstandthat Ihavetherighttorevokethisauthorization inwriting,atanytime,bysendingawrittenrequestforrevocationtoGlobetotheattentionoftheUnderwritingDepartmentattheaboveaddress.IunderstandthatarevocationisnoteffectivetotheextentthatanyofMyProvidershavereliedonthisAuthorization,andthat, to theextent thatGlobehasa legal right tocontestaclaimunderan insurancepolicyor tocontestthepolicyitself,suchrevocationmaypreventGlobefromcompletingitsreviewofpolicyclaims.SuchrevocationshallnotapplytoanyuseordisclosureofmyprotectedhealthinformationspecificallyallowedwithoutauthorizationbyHIPAAandnoactionrelatingtothisauthorizationshallbeconstruedascreatinganyrestrictionontheusesthatHIPAAallowswithoutmyauthorization.Iunderstandthatanyinformationthatisdisclosedpursuanttothisauthorizationmayberedisclosedandnolongercoveredbyfederalrulesgoverningprivacyandconfidentialityofhealthinformation.

IunderstandthatMyProvidersmaynotrefusetoprovidetreatmentorpaymentforhealthcareservicesifIrefusetosignthisauthorization.IfurtherunderstandthatifIrefusetosignthisauthorizationtoreleasemycompletemedicalrecord,Globemaynotbeabletoprocessmyapplication,orifcoveragehasbeenissued,maynotbeabletoprocesspolicyclaims.IacknowledgethatIhavereceivedacopyofthisauthorization.

_________________________________________________________________ ___________________ SignatureofProposedInsured/PatientorPersonalRepresentative Date

___________________________________________________________________________________________DescriptionofPersonalRepresentative’sAuthorityorRelationshiptoPatient

Globe Life And Accident Insurance CompanyGlobe Life Center

Oklahoma City, Oklahoma 73184

Authorization for Release of Health-Related InformationThis authorization is intended to comply with the HIPAA Privacy Rule

SENDORIGINALWITHAPPLICATION•GIVECOPYTOPROPOSEDINSURED

F3988

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Form F3��� — HIPAA Consent Form This form is necessary on any applicant over the guarantee issue or non-civil service . *

* This form is required with ALL applications in Arizona and California

A. GlobeLifeAndAccidentInsuranceCompany(referredtoasGlobe),itsreinsurers,insurancesupportorganizations,andtheirauthorizedrepresentatives,mayobtainmedicalandotherinformationinordertoevaluatemy(our)applicationforLifeorHealthInsurance.

B. Anyphysician,practitioner,hospital,clinic,othermedicalormedicallyrelatedfacility,theVeteransAdministration,theMedicalInformationBureau,Inc.,myemployerandconsumerreportingagencyorinsurancecompanywhopossessinformationofcare,treatmentoradviceofmeormychildrenmayfurnishsuchinformationtoGlobeoritsrepresentativeuponpresentingthisauthorizationoraphotocopy.Tofacilitaterapidsubmissionofsuchinformation,Iauthorizeallsaidsources,exceptMIB,togivesuchrecordsorknowledgetoanyagencyemployedbytheinsurancecompanytocollectandtransmitsuchinformation.

C. Thisauthorizationincludesinformationaboutdrugs,alcoholismormentalillness.D. GlobeoritsreinsurersmaymakeabriefreportregardingmeormychildrentoothercompaniestowhomIhaveappliedormayapply.E. Thisauthorizationwillbevalidfromthedatesignedforaperiodoftwoandone-halfyears.F. IauthorizeGlobetoobtainaninvestigativeconsumerreportonme.G. IhavereadthisauthorizationandIknowthatImayrequestacopy.Iacknowledgereceiptofrequirednotices,formU-1342N.H. ❑Ielecttobeinterviewedifaninvestigativeconsumerreportispreparedinconnectionwiththisapplication.I. ❑Ielectnottohavepersonalinformationdisclosedtonon-affliliatesofGlobeformarketingpurposesandtoaffiliatesofGlobeforpurposesotherthanthe

marketingofinsuranceproductsandservice.

_________________________________ ______________________ ___________________________________ ___________________________________ DatedAt(City&State) DatedOn InsuredorJointInsuredA JointInsuredBorSpouse (Parentiftheaboveisunder15) Agent _______________________________________________________________ G-1342AR-2

Instructions to Agent:Thisauthorizationmust beobtainedwitheveryapplicationforinsuranceandtheattachedREQUIREDNOTICESTOAPPLICANTmustbedetachedandleftwiththeproposedInsured(or,inthecaseofaminor,withaparentorguardianoftheproposedInsured).

GLOBE LIFE AND ACCIDENT INSURANCE COMPANY AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

Your attending physician or treating medicalprofessional;

Personsororganizationsconductingbona fideactuarialorscientificresearchstudies,auditsorevaluations;

Persons or organizations who may wish to marketproductsorservices,includingaffiliatesofGlobeLifeAndAccidentInsuranceCompany.

Please be assured that the above describes some of thedisclosureswhichmaybemade,notdisclosureswhicharealways or even often made. In any event, the informationdisclosed without your authorization will be only as muchas is reasonably necessary to accomplish the intendedpurpose.

For example, we would ordinarily disclose only nameand address to a marketing firm, and perhaps additionalinformation relating to age, amounts of insurance andclaims experience to a scientific research organization.Information relating to physical condition or medicalhistorywouldordinarilybedisclosedonlytoyourattendingphysician or treating medical professional. In short, thetypesofinformationdisclosedwillvarydependingupontheneedsoftherecipientandthesensitivityofthedata.

Adescriptionofthecircumstancesunderwhichinformationaboutyoumightbedisclosedwithoutyourauthorizationtothetypesofpersonsandorganizationsreferredtoabovewillbesenttoyouuponrequest.

Access and Correction

In the event of an adverse underwriting decision, youhave a right to make a written request to receive detailedinformation of the specific reasons for the decision inwriting.

There are procedures by which you can obtain accessto personal information about you which appears in ourpolicyfiles,includinginformationcontainedininvestigativeconsumerreports.Wehavealsoestablishedproceduresbywhichyoumayrequestcorrection,amendmentordeletionof any information in our files which you believe to beinaccurateorirrelevant.Adescriptionoftheseprocedureswillalsobesenttoyouuponrequest.

OBTAINING ADDITIONAL INFORMATION

We at Globe Life And Accident Insurance Company hopethat you find this description of our information practiceshelpful. We take our responsibilities and your rights, veryseriously.Ifyouhaveanyfurtherquestionsabouttheitemsjust discussed, please write to us at Post Office Box 2440,McKinney,Texas75070.

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NOTICE REGARDING PUBLIC LAW 91-508

As part of the procedure for processing applications, aninvestigative consumer report may be prepared wherebyinformation is obtained through personal interviews withyour neighbors, friends, or others with whom you areacquainted. This inquiry includes information as to yourcharacter, general reputation, personal characteristics andmodeofliving. Youhavearighttomakeawrittenrequestwithin a reasonable period of time to receive additional,detailed information about the nature and scope of thisinvestigation.

NOTICE REGARDING USE OF MEDICAL INFORMATION BUREAU

Information provided in applications will be treated asconfidential except that the Globe Life And AccidentInsurance Company or its reinsurers may, however, makebrief report thereon to the Medical Information Bureau,a nonprofit membership organization of life insurancecompanies which operates an information exchange inbehalf of its members. Upon request by another memberinsurance company to which life or health insurance hasbeen applied for or to which a claim is submitted, theMedicalInformationBureauwillsupplysuchcompanywiththeinformationitmayhaveinitsfiles.

Uponreceiptofarequestfromyou,theMedicalInformationBureau will arrange disclosure of any information it mayhave in your file. (Medical information will be disclosedonly to your physician.) If you question the accuracy ofinformation in the Medical Information Bureau’s file, youmay contact the Medical Information Bureau and seek acorrection in accordance with the procedures set forth inthe Federal Fair Credit Reporting Act. The address of theMedical Information Bureau’s information office is PostOfficeBox105,EssexStation,Boston,Massachusetts,02112,TelephoneNumber(617)426-3660.

Globe Life And Accident Insurance Company or itsreinsurers,mayalsoreleaseinformationinthisfiletootherlife insurance companies to whom life or health insurancemaybeappliedfor,ortowhomaclaimforbenefitsmaybesubmitted.

GLOBE LIFE AND ACCIDENT INSURANCE COMPANY

P.O. Box 2440 3700 S. Stonebridge Dr. McKinney, Texas 75070

REQUIRED NOTICES

DESCRIPTION OF INFORMATION PRACTICES

ThisdescriptionoftheInformationPracticesofGlobeLifeAndAccidentInsuranceCompanyandyourGlobeAgentisbeingprovidedinaccordancewiththerequirementsoftheInsuranceInformationandPrivacyProtectionLawineffectinyourstateofresidence.

Collection of Information

In order to properly underwrite and administer yourinsurance coverage, we must collect a certain amountof necessary and helpful information. The amountand type of information collected may vary dependingon the amount and type of coverage applied for, but ingeneral we will be seeking information about your age,occupation, physical condition, health history, mode ofliving, avocations and other personal characteristics.In addition, your Globe Agent may collect informationintendedtoaidintheupdatingandimprovementofyourinsuranceprogram.

You are our most importantsource of information,butwemayalsocollectorverify informationbycontactingmedical professionals and institutions which haveprovidedcaretoyouormembersofyourfamilyproposedforcoverage,employersandbusinessassociates,friendsand neighbors, and other insurance companies towhich you have applied. We may collect informationby exchanges of correspondence, by phone or personalcontact.

In some cases, we may ask an insurance supportorganization to collect information and submit aninvestigativeconsumerreport tous. Thatorganizationmay retain a copy of the report and may disclose itscontentstoothersforwhomitperformssuchservices.

Disclosures by Globe Life And Accident Insurance Company

In some circumstances, Globe or your Globe Agentwill make disclosures of personal information, withoutyourauthorization,tothirdparties.Followingisabriefdescription of some of the persons or organizations towhomcertaininformationmightbedisclosed:

Personsororganizationswhichperformprofessional,business or insurance functions for us, such asindependent claim examiners or group planadministrators;

YourGlobeAgent,consumerreportingagencieshiredto prepare investigative reports, and other insurancecompaniestowhichyouhaveappliedforcoverageorbenefits;

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Form G�3�� — MIB Authorization Form

PLEASE INDICATE APPROPRIATE APPLICANT’S NAME IN THE SHADED AREA

HIGH BLOOD PRESSURE NAME:

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Form SAHB — Medical Addendum for High Blood Pressure

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Form �0�0 — Bank Draft Authorization

Aug 5, 01 John L. Doe