Street Address *

City *

State *

Country *

Postal code *

Within the past five years has any person proposed for insurance been diagnosed with, received treatment for, or been prescribed medication for any of the following conditions? a. Alcoholism, Alcohol, Chemical Dependency, or Drug or Alcohol Abuse b. Autism Spectrum Disorders, Autism, Asperger’s Disorder, Rett’s Syndrome, Pervasive Developmental disorders, or Pervasive Developmental Delay c. Heart Disorder, Heart Disease, Heart Attack, Coronary Bypass d. Peripheral Vascular Disease or Peripheral Arterial Disease e. Crohn’s Disease or Ulcerative Colitis f. Kidney disorders, excluding Kidney Stone g. Osteomyelitis h. Rheumatoid Arthritis i. Stroke, Transient Ischemic Attack (TIA) or Brain Aneurysm j. Basal Cell or squamous cell carcinoma with recommended surgery that has not been completed k. Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Fibrotic Lung Disease, or Primary Pulmonary Hypertension l. Liver disorders, excluding fully recovered Hepatitis A m. Diabetes (Type I or Insulin controlled) n. Hernia Uncorrected o. Lupus p. Paralysis q. Sickle cell anemia r. Tuberculosis (TB) *

Yes

I hereby authorize any licensed physician, medical practitioner, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager or other medical facility, insurance or reinsurance company, MIB, Inc. (MIB), Division of Motor Vehicles, the Veterans Administration or other medical or medically-related facility, insurance company or other organization, institution or person, that has any records or knowledge of me or my health or having any non-medical information concerning me to give to the ManhattanLife Insurance and Annuity Company (the Company) or its reinsurers, any such information. I understand that there is a possibility of redisclosure of any information disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by federal law governing privacy and confidentiality. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization.

I authorize ManhattanLife Insurance and Annuity Company, or its reinsurers, to make a brief report of my protected health information to MIB, Inc.

I understand that I am authorizing the Company to receive my health information, prescription drug usage history and my non-medical information. I understand that prescription drug usage may be used to verify the presence of certain medical conditions and that such history will not be used to decline coverage. These medical conditions will be confirmed by a telephone interview prior to being used in the underwriting process. The released information received by the Company will remain protected by federal and/or state regulations.

I understand that the information requested is necessary for evaluation and underwriting of my application for the Policy for which I have applied; to determine eligibility for insurance, risk rating or policy issue determinations; obtain reinsurance; administer claims and determine or fulfill responsibility for coverage and provision of benefits; and to conduct other legally permissible activities that relate to any coverage I have, or have applied for, with the Company.

I understand that telephone interviews may be a part of the application process and that any information obtained from such telephone interviews may be used to decline my application for coverage. I understand that failure to provide the authorization to the Company will result in the rejection of the Insurance Policy coverage.

I understand that I may revoke this authorization at any time by notifying the Company in writing at their Administrative Office: 10777 Northwest Freeway, Houston, Texas 77092. I understand that such revocation will not have any effect on actions the Company took prior to their receiving the revocation notice.

I understand that this authorization will be valid for twenty-four (24) months from the date signed if used in connection with an application for an insurance policy, reinstatement of an insurance policy, change in policy benefits, or, for the duration of a claim if used for the purpose of collecting information with a claim for benefits under a policy. A photocopy of this authorization will be treated in the same manner as the original.

To the best of my knowledge and belief, all of the answers to the questions contained in this application are true and complete, and I understand and agree that: (a) the insurance shall not take effect unless and until the application has been accepted and approved by the Company, the full first premium has been paid, and the policy has been delivered to the applicant; and (b) oral statements between the agent and myself are not binding on the Company unless accepted by the Company in writing. I am aware that the company may terminate this insurance at the end of any period for which the premium has been paid.

I, the undersigned applicant, represent that I have read, or had read to me, the completed application and that I realize that any false statements or misrepresentations therein material to the risk may result in loss of coverage under the policy to which this application is a part. I understand that statements in this application are representations and not warranties. I have received a copy of the outline of coverage.

THE EFFECTIVE DATE OF THE POLICY WILL BE THE DATE RECORDED BY THE ADMINISTRATIVE OFFICE. IT IS NOT THE DATE THIS APPLICATION IS SIGNED.

THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE.

WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

I agree to terms & conditions provided by the Company. By providing my phone number, I agree to receive text messages from the business. I give written consent to the Company to communicate with me by email and further agree to indemnify and hold harmless the Company for any action or loss arising from any incorrect or false email address(s). I acknowledge that, should I desire to revoke this written authorization, I will inform the Company, in writing, of such revocation.

I (we) hereby authorize the Insurance and Annuity Company, hereinafter called COMPANY, to initiate debit entries to the account and depository, hereinafter called DEPOSITORY, to debit the same to such account. This authority is to remain in full force and effect until COMPANY and DEPOSITORY have received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.