Western Reserve Life Assurance Co.

of Ohio Administrative Office: 4333 Edgewood Road NE Cedar Rapids, Iowa 52499 Home Office: Columbus, Ohio

May 31, 2012 CHRISTINA HIENG GAWRON 723 N IDAHO ST SAN MATEO, CA 94401-1120 USA

Policy Number: 013916070 Dear CHRISTINA HIENG GAWRON, Thank you for your recent inquiry to our Customer Service Department. Attached are the following documents, as requested: * Reinstatement CA We appreciate this opportunity to be of service. If there is anything else we can do to assist you, please call us at the number below. Thank you, Customer Service 800-851-9777

For your ease of reference, were providing this information from our records. We cannot assume responsibility for information that has not been provided to the Home Office, nor can we guarantee the validity or sufficiency of any documents, which have been provided to us. Western Reserve Life Assurance Co. of Ohio Cedar Rapids, IA 52499

MGIACOBBE

Western Reserve Life Assurance Co. of Ohio Administrative Office: 4333 Edgewood Road NE Cedar Rapids, Iowa 52499 Home Office: Columbus, Ohio

To:

Policy Services

From: Pages: Date:

Please Reply Please Recycle

Fax #: Re:

(727) 299-1620

REINSTATEMENT CA
For Review Please Comment

Urgent

Comments:

Western Reserve Life Assurance Co. of Ohio, P.O. Box 5068, Clearwater, Florida 33758

Application for Reinstatement and/or Policy Change

Policy Number:______________________ Insured Name _____________________________
If reinstatement is approved,the contestable p eriod will start ane w. This application must be a ccompanied by all r equired premiums.

PART 1. PROPOSED INSURED(S) INFORMATION

Last Name Primary Insur ed Spouse or 1 st OIR CIR or 2 nd OIR CIR or 3 rd OIR Telephone Number ( ) ____________________________ Best time to call s AM s PM _______________________ M.I. First name Birth Date Birth Place Height Ft. in. Weight Lbs. Sex

If additional space is necessary for CIRs, list childs name and date of birth on a separate sheet of paper.

PART 2. MEDICAL QUESTIONS

Has any proposed insured listed in Part 1 1) Within the last 5 years been treated for or been told by a member of the medical profession that they had heart disease or circulatory problems,stroke, cancer, diabetes, kidney or liver disorder, lung or respiratory disorder, Alzheimers Disease, mental or psychiatric disorder, alcohol or drug abuse? (Please circle the applicable ailments) 2) Within the last 5 years consulted a medical practitioner? 3) Within the last 5 years been diagnosed by a member of the medical profession as having AIDS (Acquired Immune Deficiency Syndrome), or been tested for the purpose of obtaining insurance and tested positive for HIV (Human Immunodeficiency Virus)? 4) Within the last 12 months used tobacco or other nicotine products in any form?

YES s YES s

NO s NO s

YES s YES s

NO s NO s

Give details to all YES answers above. Please indicate person(s) to which details apply, dates of visit, reason for visit and findings. Give us the doctor, hospital, clinic, or health care providers full name and address. Proposed Insured: Question number: Reason for visit: Dates of visits: Findings: Proposed Insured: Question number: Reason for visit: Dates of visits: Findings: Proposed Insured: Question number: Reason for visit: Dates of visits: Findings:

Dr./Clinics address:

Dr./Clinics address:

Dr./Clinics address:

RA00100-CA

PART 3. OCCUPATION AND MISCELLANEOUS QUESTIONS

5) Has any proposed insured listed in Part 1 had a change in occupation or income since the original application? YES s If yes, indicate whom and describe current occupation and income.__________________________________ ________________________________________________________________________________________ 6) State occupation and income for any adult applicant listed in Part 1 to be added to policy:________________ ________________________________________________________________________________________ 7) Has any proposed insured listed in Part 1 had their drivers license suspended, revoked, restricted, or been convicted of a moving violation in the last 12 months? If yes, provide Drivers License number, State of issue, and details. ___________________________________ ________________________________________________________________________________________ YES s NO s NO s

8) Does any proposed insured listed in Part 1 participate in aviation or any organized hazardous sport or activity? YES s If yes, complete an aviation or hazardous sports questionnaire and attach to application. 9) Will any proposed insured listed in Part 1 travel outside the United States within the next 12 months? If yes, provide details of when, where,and length of time._________________________________________ _______________________________________________________________________________________ YES s

NO s NO s

PART 4. REPRESENTATIONS
I represent that the statements and answers in this application are true and complete to the best of my knowledge and belief. It is agreed that: (a) The statements and answers given in this application, and any amendments or application supplements to it or statements made to the medical examiner, will be the basis of any reinstatement granted or insurance issued. (b) No agent or medical examiner has the autho rity to make or alter any contract for the Company. (c) No reinstatement will be effective or coverage provided until the date the application is approved by the company. (d) If a premium deposit is given, no insurance shall take effect until the application is approved by the company while all persons shown in Part 1 are living and their health remains as stated in the reinstatement and policy change application. (e) If a premium deposit is not given,no insurance shall take effect until the application is approved by the company and accepted by the owner, all premiums due have been paid and while all persons shown in Part 1 are living and their health remains as stated in the reinstatement and policy change application. (f) I further agree that this application will be attached and shall be ma de a part of the contract for insurance.

PART 5. AUTHORIZATION TO OBTAIN INFORMATION

I authorize any physician, medical professional, hospital, clinic, other medical care institution, the Medical Information Bureau, Inc., insurance company, consumer reporting agency, or employer having information available as to employment,other insurance coverage, medical care, advice or treatment with respect to any physical or mental condition regarding me or any of my minor children who are to be insured, to give such information to Western Reserve Life Assurance Co. of Ohio, its reinsurers, or any consumer reporting agency except the Medical Information Bureau, acting on Western Reserve Lifes behalf. I authorize Western Reserve Life Assurance Co. of Ohio to obtain an investigative consumer report on me and upon my request I am entitled to receive a free copy of this report. I authorize Western Reserve Life Assurance Co. of Ohio to obtain a motor vehicle report on me. I understand that this information will be used b y Western Reserve Life or its reinsurers, to determine eligibility for life insurance. I agree that this authorization is valid for two and one-half years from the date signed. I know that I or my authorized representative have a right to receive a copy of this authorization upon request.I agree that a photographic copy of this authorization is as valid as the original.

RA00100-CA

I also hereby authorize Western Reserve Life Assurance Co. of Ohio to provide its affiliated companies any and all information provided herein and obtained he reafter on me. This authorization shall be valid from the date signed below until affirmatively withdrawn in writing by myself. s I elect not to have personal information disclosed to non-affiliates of Western Reserve Life Assurance Co. of Ohio for marketing purposes. s I elect to be interviewed if an investigative consumer report is prepared in connection with this application. Signed at _____________________________________(city)________ (state)____________ on _________________(date)

__________________________________________________ Signature of Primary Insured or Proposed Insured (if over age 15 must sign) __________________________________________________ Signature of Spouse (if applicable)

__________________________________________________ Signature of Owner if other than proposed Insured

__________________________________________________ Signature of Other Insured age 15 or over

__________________________________________________ Signature of Other Insured age 15 or over

__________________________________________________ Signature of Licensed Agent Agent #

FAIR CREDIT REPORTING ACT

A routine investigative consumer report may possibly be made regarding your general reputation, character, mode of living and personal characteristics. This information may be obtained through personal interviews with your friends,neighbors and associates. Should you desire additional information on the nature and scope of such a report, you may write the Underwriting Department, Western Reserve Life Assurance Co. of Ohio, PO Box 9009, Clearwater, FL 33758. You may also request information concerning the nature and scope of the investigation to be performed.

THE MEDICAL INFORMATION BUREAU PRE-NOTICE

The Medical Information Bureau (MIB) is a non-profit organization of life insurance companies which operates as an information exchange for its members. We may make reports to the MIB regarding factors affecting your insurability. Underwriting decisions,however, are not reported to the MIB. If you apply to another Bureau member company for life or health insurance or submit a claim for benefits, the MIB will, upon request, provide that company with information in its file. Upon your written request, the MIB will arrange for disclosure to you of any information it has in your file. If you feel the information in the MIBs file is incorrect, you may contact the MIB and seek a correction in accordance with procedures outlined in the Federal Fair Credit Reporting Act. The address of the MIBs office is: MIB, Inc., P.O. Box 105, Essex Station, Boston, MA 02112. MIBs telephone number: (617) 426-3660. If you would like to know more about how we collect, evaluate and control information about you as one of our applicants for insurance,our sales representatives will be happy to assist you or you may contact us at our office.

RA00100-CA

Life Investors Insurance Company of America Monumental Life Insurance Company Stonebridge Life Insurance Company Transamerica Life Insurance Company Western Reserve Life Assurance Co. of Ohio
4333 Edgewood Road NE, Cedar Rapids, IA 52499

HIPAA Authorization for Release of HealthRelated Information

This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
Name of Primary Proposed Insured/Patient ______________________________________________________________ Name of Secondary Proposed Insured/Patient ______________________________________________________________ Name(s) of Unemancipated Minors Date of birth ________________________ Date of birth ________________________ Date(s) of birth Last four digits of SSN ____________________ Last four digits of SSN ____________________ Last four digits of SSN(s)

______________________________________________________________ ________________________ ____________________ I hereby authorize the use or disclosure of health information, as described below, about me or my above-named unemancipated minor children and revoke any previous restrictions concerning access to such information: 1. Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician, health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy, pharmacy benefit manager, insurance company [including the Companies noted above (the Companies)], insurance support organization such as MIB Group, Inc., or other medical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children. 2. Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The Companies, their affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize the Companies and their affiliates and reinsurers to redisclose the information to MIB Group, Inc., which operates an information exchange on behalf of life and health insurance companies. 3. Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health or that of my unemancipated minor children and my or my unemancipated minor childrens insurance policies and claims, including, but not limited to, information on the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental illness, communicable or infectious conditions, such as AIDS (except HIV exposure/testing), and use of alcohol, drugs and tobacco including alcohol or drug abuse treatment. This Authorization excludes psychotherapy notes that are separated from the rest of my medical records. 4. The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my insurance application with the Companies and, if a policy is issued, for evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy, for reinstatement of the policy or to contest a claim under the policy.

STATEMENTS OF UNDERSTANDING & ACKNOWLEDGMENT:

I understand that health information about me provided to the Companies may be protected by state and federal privacy regulations including the HIPAA Privacy Rule and that the Companies will only use and disclose such information as permitted by applicable regulations and as described in their privacy notices. However, I also understand that any information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations such as the HIPAA Privacy Rule governing privacy and confidentiality of health information. I understand that if I refuse to sign this authorization to release my health information or that of my unemancipated minor children, the Companies may not be able to process my application, or if coverage is issued may not be able to make any benefit payments. I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it, or to the extent that other law provides the Companies with the right to contest a claim under the policy or the policy itself, by sending a written revocation to the Companies Privacy Official at the address at the top of this form. I also understand that the revocation of this authorization will not affect uses and disclosures of my health information for purposes of treatment, payment and business operations, including agent commission statements. This authorization shall remain in force for 24 months from the date signed, regardless of my condition and whether living or deceased. I acknowledge I have received a copy of this authorization. ___________________________ Date ___________________________ Date

_____________________________________________________________________________ Signature of Primary Proposed Insured/Patient or Personal Representative _____________________________________________________________________________ Signature of Secondary Proposed Insured/Patient or Personal Representative

If signed by an individuals personal representative or the parent or guardian of an unemancipated minor, describe authority to sign on behalf of the individual: Parent Legal guardian Power of Attorney Other (please describe): _____________________________________ (NOTE: If more than one individual is named above, please specify the individual(s) to which the personal representative applies.) Policy or contract number (if known): ________________________________________________ A copy of this authorization will be considered as valid as the original.
HIP 1207 CA Please return this original copy to Company

Life Investors Insurance Company of America Monumental Life Insurance Company Stonebridge Life Insurance Company Transamerica Life Insurance Company Western Reserve Life Assurance Co. of Ohio
4333 Edgewood Road NE, Cedar Rapids, IA 52499

HIPAA Authorization for Release of HealthRelated Information

This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
Name of Primary Proposed Insured/Patient ______________________________________________________________ Name of Secondary Proposed Insured/Patient ______________________________________________________________ Name(s) of Unemancipated Minors Date of birth ________________________ Date of birth ________________________ Date(s) of birth Last four digits of SSN ____________________ Last four digits of SSN ____________________ Last four digits of SSN(s)

______________________________________________________________ ________________________ ____________________ I hereby authorize the use or disclosure of health information, as described below, about me or my above-named unemancipated minor children and revoke any previous restrictions concerning access to such information: 1. Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician, health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy, pharmacy benefit manager, insurance company [including the Companies noted above (the Companies)], insurance support organization such as MIB Group, Inc., or other medical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children. 2. Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The Companies, their affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize the Companies and their affiliates and reinsurers to redisclose the information to MIB Group, Inc., which operates an information exchange on behalf of life and health insurance companies. 3. Description of the information that may be used or disclosed: This authorization specifically includes the release of all information related to my health or that of my unemancipated minor children and my or my unemancipated minor childrens insurance policies and claims, including, but not limited to, information on the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental illness, communicable or infectious conditions, such as AIDS (except HIV exposure/testing), and use of alcohol, drugs and tobacco including alcohol or drug abuse treatment. This Authorization excludes psychotherapy notes that are separated from the rest of my medical records. 4. The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my insurance application with the Companies and, if a policy is issued, for evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy, for reinstatement of the policy or to contest a claim under the policy.

STATEMENTS OF UNDERSTANDING & ACKNOWLEDGMENT:

I understand that health information about me provided to the Companies may be protected by state and federal privacy regulations including the HIPAA Privacy Rule and that the Companies will only use and disclose such information as permitted by applicable regulations and as described in their privacy notices. However, I also understand that any information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations such as the HIPAA Privacy Rule governing privacy and confidentiality of health information. I understand that if I refuse to sign this authorization to release my health information or that of my unemancipated minor children, the Companies may not be able to process my application, or if coverage is issued may not be able to make any benefit payments. I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it, or to the extent that other law provides the Companies with the right to contest a claim under the policy or the policy itself, by sending a written revocation to the Companies Privacy Official at the address at the top of this form. I also understand that the revocation of this authorization will not affect uses and disclosures of my health information for purposes of treatment, payment and business operations, including agent commission statements. This authorization shall remain in force for 24 months from the date signed, regardless of my condition and whether living or deceased. I acknowledge I have received a copy of this authorization. ___________________________ Date ___________________________ Date

_____________________________________________________________________________ Signature of Primary Proposed Insured/Patient or Personal Representative _____________________________________________________________________________ Signature of Secondary Proposed Insured/Patient or Personal Representative

If signed by an individuals personal representative or the parent or guardian of an unemancipated minor, describe authority to sign on behalf of the individual: Parent Legal guardian Power of Attorney Other (please describe): _____________________________________ (NOTE: If more than one individual is named above, please specify the individual(s) to which the personal representative applies.) Policy or contract number (if known): ________________________________________________ A copy of this authorization will be considered as valid as the original.
HIP 1207 CA Applicants should retain this signed copy for their records