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(~ ASSURANT Health Assurant Health

501 W. Michigan Street

P.O. Box 624
Milwaukee, WI 53201-0624

HealthyDiscount Questionnaire - Your opportunity to save up to 10%

Policy number:
Insured name: Renewal date: ~2010

Congratulations! You're a HealthyDiscount candidate. HealthyDiscount is your opportunity to change your

renewal premium from $398.28 monthly to $358.44 monthly.

To determine your eligibility for HealthyDiscount, follow these simple instructions:

1. Answer all six questions below. Please consider the last 12 months when answering these questions.
2. Read and sign the Statement of Understanding and Authorization.
3. Promptly1ax the questionnaire to us at 414-299-8493 or call us at-BOO-596-0045. We must have your
response by 10/12/2010.

In the last 12 months, has anyone covered on the policy:

Yes No
1. Been recommended or scheduled for surgery that has not been completed?

/{ Been recommended to have or is anyone contemplating infertility treatment or been

treated for infertility?

~. Received or been recommended to have any treatment for alcoholism, alcohol or drug
abuse or addiction or mental or nervous conditions?

7: 4. Been cited for operating a moving vehicle under the influence of alcohol or drugs?

-;; Received a diagnosis for any serious medical condition such as heart disease, stroke,
cancer, diabetes, HIV, AIDS, or any other progressive disabling condition?

~6. Been incapacitated or hospitalized due to an accident or illness?

If you're approved, you'll receive a letter confirming your approval and your premium of$358.44 monthly
will be effective on 08/13/2010. Be sure to answer all six questions, or the offer will not be valid. If you have
------;q"u"e""'stions wfi:l1efIlhng oan 1 form, call ar8()(J-59l}-O()t5. •

Statement of Understanding and Authorization

I understand that Assurant Health will rely upon answers to the questions in this questionnaire to determine
whether to issue a premium discount. I understand that omissions and/or misstatements regarding any
medical history could cause the premium discount to be removed retroactively.
To the best of my knowledge and belief, any statements and answers made related to this questionnaire are
true, complete and correctly recorded.

Date Si ned

Assurant Health is the brand name for products underwritten and issued by Time Insurance Company.