American-Amicable Application

Proposed Insured Information

Proposed Insured Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

E-mail Address(Required)

Phone(Required)

By checking this box, I agree to receive calls and text messages, including marketing and informational messages, from Insurance By Heroes at 855-434-3500 or 443-214-3500 about my insurance quote, application, policy, or appointment, even if my number is listed on a state, federal, internal, or any other Do Not Call list. Message frequency varies. Message and data rates may apply. Reply STOP to opt out of texts and HELP for help. Consent is not a condition of purchase. We will not share mobile information with third parties or affiliates for promotional or marketing purposes. See Terms and Conditions and Privacy Policy.

Sex(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

State of Birth(Required)

Social Security Number(Required)

Driver License Number(Required)

State of Issue (DL)(Required)

Height(Required)

Weight (lbs)(Required)

Occupation/Duties(Required)

Annual Salary(Required)

Owner / Payor

Owner & Payor information

Same as Proposed Insured

Owner Name(Required)

Owner SSN(Required)

Owner Address(Required)

Payor Name(Required)

Payor SSN(Required)

Payor Address(Required)

Beneficiaries

Primary Beneficiaries(Required)

Full Name

SSN

Relationship

Share %

Contingent Beneficiaries (optional)

A backup beneficiary who only receives the death benefit if your primary beneficiary is no longer living when a claim is paid. Optional but recommended — common choices include children, siblings, or a trust.

Full Name

SSN

Relationship

Share %

Plan Details

Term Length(Required)

Face Amount(Required)

Tobacco Status(Required)

Tobacco/nicotine past 12 months?(Required)

Yes

Tobacco/nicotine past 36 months?(Required)

Yes

Payment Mode

When should we draft your first premium?(Required)

Immediately (as soon as possible)

Wait until my requested draft date

Modal Premium ($ per draft)

The dollar amount that will be drafted from your bank account each cycle (monthly). If you're unsure of the exact amount, your agent will provide this — you can enter an estimate or leave 0.00 and we'll fill it in.

Requested Draft Date(Required)

MM slash DD slash YYYY

Physician Information

Physician Name(Required)

City/State(Required)

Physician Phone(Required)

Current prescribed medications(Required)

SECTION A: Health Questions

Answer Questions 1 through 4 for the Proposed Insured.

1. Within the past 10 years, have you been treated for, or tested positive for, or been diagnosed by a medical professional with:

a. high blood pressure, high cholesterol, heart attack, angina (cardiac chest pain), angioplasty, bypass surgery or stent, pacemaker or defibrillator, cardiomyopathy, congestive heart failure (CHF), irregular heartbeat, peripheral vascular disease (PVD), carotid artery disease, or any heart or circulatory disease or disorder?(Required)

Yes

b. stroke, transient ischemic attack (TIA), amputation caused by disease, aneurysm, hemophilia, or anemia?(Required)

Yes

c. diabetes, cirrhosis, hepatitis, pancreas disorder, Crohn's disease, ulcerative colitis, or any digestive or liver disease or disorder?(Required)

Yes

d. asthma, emphysema, chronic obstructive pulmonary disease (COPD), sleep apnea, or any respiratory or lung disease or disorder?(Required)

Yes

e. cancer in any form, Hodgkin's disease, leukemia, lymphoma, multiple myeloma, or organ transplant?(Required)

Yes

f. migraine headaches, seizures, bi-polar disorder, schizophrenia, Alzheimer's, memory loss, dementia, anxiety or depression, mental retardation, mental incapacity, mental or nervous disorder, psychiatric disorder, or a suicide attempt?(Required)

Yes

g. any disease or disorder of the kidneys, urinary bladder, prostate, breast, reproductive organs, or sexually transmitted disease?(Required)

Yes

h. connective tissue disease, systemic lupus (SLE), multiple sclerosis, Parkinson's, cerebral palsy, muscular dystrophy, cystic fibrosis?(Required)

Yes

i. arthritis, paralysis of two or more extremities or any disorder of the back, joints, muscles, or nervous system?(Required)

Yes

j. any other disease or disorder, injury, surgery, birth defect, or deformity?(Required)

Yes

k. Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or any immune deficiency related disorder or the Human Immunodeficiency Virus (HIV)?(Required)

Yes

2. Are you currently unemployed due to medical reasons or been prohibited from actively working full time (30 hours or more per week) at your regular occupation due to any illness, injury, or health related problem, or are you currently receiving benefits, compensation, or pension for disability?(Required)

Yes

3. Are you currently hospitalized, confined to a nursing facility, receiving Hospice Care or home health care, or do you require assistance (from anyone) with activities of daily living such as bathing, dressing, eating or toileting?(Required)

Yes

4. Within the past 12 months, have you:

a. consulted a medical professional, had surgery, or been hospitalized, or had diagnostic tests (excluding HIV/AIDS) such as EKG, Xray, MRI, CAT scan?(Required)

Yes

b. had any diagnostic testing (excluding HIV/AIDS), surgery, or hospitalization recommended by a medical professional which has not been completed or for which the results have not been received, or been referred to a medical professional?(Required)

Yes

c. been declined, postponed, rated, or modified for life or medical insurance?(Required)

Yes

If you answered Yes to anything above, please add a row for each condition:

List current medications here too. Use the Comments box on the next page if you need more space.

Condition

Date(s)

Treatment

Doctor / Hospital + Phone

SECTION C: Additional Questions

Answer Questions 1 through 5 for Proposed Insured. If you answer Yes to any question, please add the relevant detail in the COMMENTS box below.

1. Have you had a natural parent or sibling diagnosed or treated by a licensed medical professional for diabetes, kidney disease, require a major organ transplant, or been medically diagnosed with heart disease, cerebrovascular disease, internal cancer prior to age 60? (If yes, list in COMMENTS section: name, relationship, age at onset, medical condition, age if living or age at death.)(Required)

Yes

2a. Within the next 24 months, do you intend to work, travel, or reside outside of the U.S. for more than 30 days?(Required)

Yes

If yes, where?(Required)

2b. Within the past 24 months, have you made or contemplated making any flights as a pilot, student pilot, or crew member of any aircraft?(Required)

Yes

3a. Within the past 5 years, have you pled guilty to or been convicted of a felony or misdemeanor (including DUI or DWI) or do you have such charge currently pending against you or have you had a driver's license suspended or revoked, any motor vehicle violations or within the past 6 months, have you been on probation or parole?(Required)

Yes

3b. Within the past 5 years, participated in motorized racing, hang gliding, rock or mountain climbing, rodeo events, sky diving, or skin or scuba diving?(Required)

Yes

4. Within the past 10 years, have you used illegal drugs, or abused alcohol or drugs, or had been recommended by a medical professional or a licensed counselor to discontinue the use of alcohol or drugs or to have treatment or counseling for alcohol or drugs?(Required)

Yes

5. Do you have any existing life or disability insurance or annuity contract?(Required)

Yes

If yes - Company(Required)

Policy #(Required)

Coverage Amount(Required)

Will you replace an existing life or disability insurance policy or an annuity?(Required)

Yes

Family History — list each affected parent or sibling:(Required)

From Section C Q1: list name, relationship, age at onset, medical condition, and age (if living or at death) for each family member.

Name

Relationship

Age at Onset

Medical Condition

Age (if living, or at death)

Addendum to Application for COVID-19

1. Within the past 12 months, have you been advised by a medical professional to be quarantined, for any period of time for the novel coronavirus (COVID-19)?(Required)

Yes

2. Within the past 12 months, have you been treated for, examined for, diagnosed with, or tested positive for the novel coronavirus (COVID-19) by a medical professional?(Required)

Yes

3. Within the past 30 days, have you been advised by a medical professional to get specified medical care (such as any diagnostic testing or hospitalization) which was not completed; as result of fever, cough, shortness of breath, fatigue (excluding HIV/AIDS)?(Required)

Yes

Bank Draft Authorization

Bank Name(Required)

Bank Address(Required)

Transit/ABA Number(Required)

Account Number(Required)

Account Type(Required)

Coincide with Social Security payment schedule?(Required)

American-Amicable can time your draft to your Social Security payment date. Social Security pays on the 2nd, 3rd, or 4th Wednesday of the month depending on your birth date. If you select Yes, we'll skip the calendar-day draft date and use your Social Security Wednesday instead.

Yes

N/A — I do not draw Social Security

Requested Draft Date (1st-28th)(Required)

When is your Social Security paid?(Required)

SSI (Supplemental Security Income): 1st of the month. Started benefits before May 1997 or receive both SSI and SS: 3rd of the month. Born 1st–10th: 2nd Wednesday. Born 11th–20th: 3rd Wednesday. Born 21st–31st: 4th Wednesday.

Agreement, Authorization & Certification

Please read the following carefully, then check the acknowledgment box below.

AGREEMENT — I agree with American-Amicable Life Insurance Company of Texas (the Company) as follows: (1) To the best of my knowledge and belief, all answers and statements contained in this application are true, complete and correctly recorded; (2) I will notify the Company of any changes in the statements or answers given in this application between the time of application and delivery of the policy; and (3) This application and any policy issued on the basis of such application shall form the entire contract; and (4) No change in this contract shall be effected without my written consent with regard to: (a) the amount of insurance; (b) age at issue; (c) classification of risk; (d) plan of insurance; or (e) benefits. If this application is declined by the Company, I will accept the return of any premium paid. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

AUTHORIZATION — In order to properly classify my application for life insurance, I authorize any and all licensed physicians, medical practitioners, hospitals, clinics, medical or medically-related facilities, health plans, pharmacy benefit managers, pharmacies or pharmacy-related facilities; insurance companies and their business associates and those persons or entities providing services to the insurer's business associates which are related in any way to their insurance plans; the MIB, Inc. or other organization that has knowledge or records of me and my health to give such information to: (a) American-Amicable Life Insurance Company of Texas; and (b) its reinsurers. I understand that any information that is disclosed pursuant to this authorization may be 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 this authorization by sending a written revocation to the Company address of 425 Austin Ave., Waco TX 76701. 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 American-Amicable Life Insurance Company of Texas to disclose my personal data gathered while processing this application. This data may be released 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 the time limit, if any, permitted by applicable law in the state where the policy is delivered or issued for delivery. A copy of this authorization shall be as valid as the original.

CERTIFICATION — I hereby certify that, under penalties of perjury, that (1) the social security number indicated above is my correct taxpayer identification number and (2) that I am not subject to backup withholding under Section 3406 (a) (1) (c) of the Internal Revenue Code. The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.

I acknowledge receiving the Fair Credit Reporting Act Notice and the MIB, Inc. Pre-Notice. I acknowledge receiving the Accelerated Living Benefit Rider Disclosure Form, the Terminal Illness Accelerated Benefit Rider Disclosure Form, the Accelerated Benefit Rider-Confined Care Rider and Chronic Illness Accelerated Death Benefit Rider Disclosure Forms if applicable.

DECLARATION — By signing below, I certify that the answers provided in this application are true, complete, and correctly recorded to the best of my knowledge and belief. I understand that any misrepresentation or omission of material fact may result in the denial of a claim or cancellation of the policy.

TCPA / COMMUNICATIONS CONSENT — By agreeing and submitting your online insurance quote request to Insurance By Heroes, you are agreeing by your electronic signature to give Insurance By Heroes and it’s partners, your prior express written consent and continuing established business relationship permission to call and/or text message you at each cell and residential phone number you provided in your online quote request, as well as to email you at any provided email address, and any other subscriber or user of these phone numbers, using an automatic dialing system and pre-recorded and artificial voice messages any time from and after your inquiry to Insurance By Heroes for purposes of all federal and state telemarketing and Do-Not-Call laws and your prior affirmative written consent to email you at the email address(s) you provided in your online quote request, in each case to market our products and services to you and for all other purposes. Message and data rates may apply. Message frequency varies. You may text "HELP" for assistance and you can opt out at any time by replying "STOP". Additional privacy policy information may be found at the bottom of insurancebyheroes.com. Your consent is not required to get a quote or purchase anything from Insurance By Heroes, and you may instead reach us by phone. For clarity, your consent includes calls and text messages from Insurance By Heroes at 855-434-3500 or 443-214-3500, even if your number is listed on a state, federal, internal, or any other Do Not Call list.

COVID-19 ADDENDUM ACKNOWLEDGMENT — This Addendum to Application amends and is made a part of my individual life insurance application. To the best of my knowledge and belief, all answers and statements contained in this application are true, complete, and correctly recorded. I will notify the Company of any changes in the statements or answers given in this application between the time of application and delivery of the policy.

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

Acknowledgment(Required)

I have read and acknowledge the Agreement, Authorization, Certification, and Declaration above.

Signed at — City(Required)

Signed at — State(Required)

Date of Application(Required)

MM slash DD slash YYYY

Applicant Signature(Required)