AMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 ALCOHOL USE QUESTIONNAIRE INSURED'S NAME, wwnwailife.com APPLICATION NUMBER Have you ever been charged with Driving While Intoxicated/Impaired? YES I yes, how many? Drivers License # Date(s) of arrest? No Do you currently Drink? Yes No If no longer drinking, date of last drink? DoJDid you drink? Almost Dally (Circle one) 1-2 Times a Week 4-2 Times a Month Less Often Than Above Approximately how many drinks in one day? Have you ever: A. Received treatment for alcohol use? Yes B, Been a member of A. A.? Yes I yes, to A above! Date or dates of treatment No No Facility where treated Were you confined? Inpatient Outpatient If s0, how long? If yes to A, of B. above, was this Voluntary Court Ordered Do you currently attend A. A. meetings? Yes No ‘Why did you have treatment or join A. A. Have you ever used street drugs or abused prescription drugs? I yes, complete the Drug Questionnaire also. x Proposed Insured’s Signature x (Agent's Signature) AG-2194 200 Yes No DateAmerican Income Life Insurance Company P.O. Box 2608 Waco, TX 76797 254-751-8600 ww ailife.com ARREST QUESTIONNAIRE (For Arrests other than DW1’s) Applicant’s Name _ Policy Number _ Date of arrest? Place (City, ST)?, Description of incident that led to arrest? Charge? Was this a Felom ora Misdemeanor? Were you convicted? Date of conviction? Length of Sentence? Any time served in jail? How long? _ Any time served in prison? How long?_ Paroled? Date? How long? Probation? Date, Began? How long?, Paid fine? Amount of fine? Any other arrests other than DWI?. (if yes, complete a separate Arrest Questionnaire for each arrest) Note: Information regarding arrests for DWI's should be provided on an Alcohol Use Questionnaire. (Proposed Insured’s Signature) x (Agent’s FORM AG-2195 201AMERICAN INCOME LIFE INSURANCE COMPANY Executive Office: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 wowaailife.com ARTHRITIS QUESTIONNAIRE INSURED'S NAME APPLICATION NUMBER, ‘TYPE OF ARTHRITIS: OSTEO. RHEUMATOID. DEGENERATIVE. INTERFERENCE WITH DAILY ACTIVITIES: NONE, SLIGHT SEVERE DISABLED WHICH JOINTS ARE AFFECTED: MEDICATIONS: DOSAGE: NAME/ADDRESS OF DOCTOR WITH CURRENT RECORDS OF YOUR ARTHRITIS: ADDITIONAL COMMENTS: x DATE PROPOSED INSURED’S SIGNATURE AG-2228 202AMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 wowwaailife.com AVIATION QUESTIONNAIRE INSURED'S NAME, APPLICATION NUMBER 4. WHAT TYPE OF FLYING DO YOU DO? PAY BUSINESS MILITARY PERSONAL PLEASURE OTHER TYPE(S) OF CERTIFICATE(S) HELD: ISSUE DATE: DO YOU HAVE AN IFR? ISSUE DATE: 2. 3 4, TYPE(S) OF AIRCRAFT USUALLY FLOWN: 5. TOTAL NUMBER OF SOLO HOURS FLOWN: 6. AVERAGE NUMBER OF HOURS FLOWN PER YEAR: 7 8. 9. DATE OF LAST FLIGHT: |. DO YOU FLY OUTSIDE THE CONTINENTAL UNITED STATES? YES NO. HAVE YOU EVER BEEN GROUNDED FOR VIOLATIONS? [| yes NO 10. WAS YOUR LICENSE GRANTED SUBJECT TO PHYSICAL WAIVER? YES No 11, HAVE YOU EVER BEEN IN AN AIRCRAFT ACCIDENT? YES No 12, DO YOU PLAN TO DO ANY FLYING IN THE FUTURE? YES No DETAILS OF ANY “YES” ANSWER: x DATE (PROPOSED INSURED’S SIGNATURE) x — (AGENT'S SIGNATURE) AG-2231 204AMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 www.ailife.com BACK/ JOINT QUESTIONNAIRE 1. INSURED'S NAME APPLICATION NUMBER 2, LOCATION OF INJURY? (back, knes, lef, right, etc?) WHAT WAS DOCTOR'S DIAGNOSIS? (E strain, sprain, muscle pull, pinched nerve, ruptured disc, etc?) 4. DATE OF INJURY 5. HOWLONG OFF WORK? 6 HOSPITALIZED? DATE? DURATION? NAME OF HOSPITAL? 7. ANY SURGERY ? DATE? 8 ANY PAIN, PROBLEMS OR MEDICATION SINCE THEN? IF YES, DATE & EXPLANATION? 9. NAME/ADDRESS OF DOCTOR WITH MOST RECENT RECORDS OF INJURY? 10. ARE YOU CURRENTLY DISABLED DUE TO THIS INJURY? 14, HAVE YOU EVER DISABLED DUE TO THIS INJURY? IF YES, PLEASE GIVE DETAILS AND DATES: (FOR BACKS ONLY:) 42, ARE YOU TREATED BY A CHIROPRACTOR? LAST SEEN? NAME/ADDRESS? x DATE Proposed Insured’s Signature 197 205AMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 wowwailife.com HIGH BLOOD PRESSURE QUESTIONNAIRE INSURED'S NAME, _APPLICATION NUMBER DATE DIAGNOSED? DO YOU TAKE MEDICATION? IF YES, NAMES: DOSAGE FREQUENCY NAME AND ADDRESS OF DOCTOR WITH CURRENT RECORDS OF BLOOD PRESSURE: DATE OF LAST VISIT: READING: IS BLOOD PRESSURE UNDER CONTROL? HAVE YOU EVER BEEN HOSPITALIZED DUE TO YOUR BLOOD PRESSURE? (IF YES PLEASE PROVIDE THE DATE(S) AND DETAILS), ADDITIONAL REMARKS: x DATE Proposed Insured's Signature (Agent's Signature) AG-200 214AMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 winw.ailife.com CANCER / TUMOR QUESTIONNAIRE PROPOSED INSURED'S NAME. APPLICATION NUMBER, 4, HAS ANY PROPOSED INSURED EVER HAD OR BEEN TREATED FOR A TUMOR OR CANCER? [_lves [_] no 2. WAS THE TUMOR DIAGNOSED AS CANCER? YES NO IF skin caNceR,Inoicate TPE: L_] sasa. [_] squamous | MELANOMA 3. WHERE WAS THE TUMORICANCER LOCATED? DID IT SPREAD TO ANY LYMPH NODES OR ANY OTHER LOCATION? Yes No IF YES, EXPLAIN: 4, WHEN WAS IT DIAGNOSED? _ 5, DID YOU HAVE SURGERY TO REMOVE THE TUMOR? YES No IF YES, WHEN? 6. WHAT WAS THE NAME AND ADDRESS OF THE HOSPITAL WHERE YOU HAD THE SURGERY? 7. DID YOU HAVE ICHEMOTHERAPY? RADIATION? |_IOTHER? (EXPLAIN) WHAT WAS THE DATE OF YOUR LAST TREATMENT? 8. HAVE YOU HAD ANY RECURRENCES OF THE TUMORICANCER? YES LJ no IF YES, EXPLAIN: 9. WHAT IS THE NAME, ADDRESS AND PHONE NUMBER OF THE DOCTOR WHO CHECKS YOU FOR POSSIBLE RECURRENCES OF THE TUMOR/CANCER? WHEN DID YOU LAST SEE THIS DOCTOR? x ATE (PROPOSED INSURED'S SIGNATURE) AG-2236 (RO495) ce 206American Income Life Insurance Company P.O. Box 2608 Waco, TX 76797 254-761-6400 Seana aliife.com CHILD COVERAGE QUESTIONNAIRE Name Application # PART A: GRANDPARENT APPLICATION - Where Does Child Live 41. Where/with whom does the child live? _ 2. If 1. is other then a parent, does the person with whom the child lives have custody of the child through Adoption, Guardianship, or some other form of custody? (CIRCLE ONE and provide an explanation if custody is “some other form”). 3, If 1, is a parent, list the name, address, and telephone number of the parent below: Parent's Name _ Address City, State, Zip - Telephone PART B: PARENT APPLICATION - Coverage on Other Family Members 1, Amount of Life Insurance coverage on the parents? Father $ Mother $. 2. List all children, showing their age and life insurance coverage, if any. Name Age Insurance 3. If all children do not have life insurance coverage, or are not applying for coverage, why is coverage being applied for on this child only? Date _ (Applicant's Signature) ~ (Agent's Signature) 207AMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 DEPRESSION QUESTIONNAIRE PROPOSED INSURED’S NAME APPLICATION NUMBER 4. HAVE YOU EVER HAD OR BEEN TREATED FOR ANY TYPE OF DEPRESSION, ANXIETY OR NERVOUS DISORDER? YES No [| 2. GIVE DATE OF DIAGNOSIS. 3, DO YOU CURRENTLY TAKE MEDICATION? yes(_| NO IF YES, MEDICATION: DOSAGE: MEDICATION: DOSAGE: MEDICATION: DOSAGE: 4, WERE YOU HOSPITALIZED? YES. no [_] IF YES, DATE(S) HOW LONG WERE YOU INTHE HOSPITAL? NAME/ADDRESS OF HOSPITAL: 5. HAVE YOU MISSED TIME FROM WORK? vyes| No IF YES, LENGTH OF TIME MISSED DATES 6. PHYSICAN NAME/ADDRESS WHO HAS TREATED THE CONDITION: - DATE LAST SEEN: 7. HAVE YOU EVER RECEIVED TREATMENT FROM A PSYCHOLOGIST OR PSYCHIATRIST? YES No NAME/ADDRESS | DATE FIRST SEEN: DATE LAST SEEN. x _ DATE _ (PROPOSED INSURED'S SIGNATURE) AG-2282 ne 208 cr]AMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 wwwwailife.com DIABETIC QUESTIONNAIRE INSURED'S NAME, APPLICATION NUMBER 1, DATE DIABETES DIAGNOSED? 2. INSULIN ~- DOSAGE ORAL MEDICATION — NAME & DOSAGE DIET ONLY 3. NAME AND ADDRESS OF THE DOCTOR WHO CURRENTLY TREATS YOUR DIABETES: PHONE NUMBER: 4, HOW LONG HAVE YOU BEEN UNDER THE ABOVE DOCTOR'S CARE? HOW OFTEN DO YOU SEE HIM? WHAT WAS YOUR LAST BLOOD SUGAR READING? DATE OF LAST VISIT? 5. HAVE YOU EVER BEEN HOSPITALIZED FOR YOUR DIABETES? YES. no [] WHEN AND WHERE: 6. ADDITIONAL REMARKS (INCLUDING NAMES OF DOCTORS SEEN PRIOR TO THE DOCTOR LISTED ABOVE): x DATE (PROPOSED INSURED'S SIGNATURE) AG-2230 ig 209 iAPPLICATION NUMBER DIGESTIVE TRACT QUESTIONNAIRE. AMERICAN INCOME re Pa HSURANCE COMPANY waco, ok 76197 PLEASE INDICATE APPROPRIATE APPLICANT'S NAME IN SHADED AREA i NAME E ‘Have you ever had or been Weated for [lulceratve coltis, ulcerative proctitis, ()Crotn’s disease (regional enters), Lispasticcoltis, iritable bowel syndrome (IBS), or Chother digestive tract disorder? (epecifyy Date Diagnosed = 2. Have you ever had a colonoscopy? = Yes ONo Date of your last colonoscopy: Name, address and phone number of facilty where performed: _ 3. Name, address and phone number of physician with curent records; 4, Have you ever had any type of surgery for digestive tract disorders? - Yes CNo List all surgeries: Type of Surgery Date Type of Surgery Date Type of Surgery Date Type of Surgery Date Type of Surgery — _Date Type of Surgery __Date 5. Was your colon removed? aYes CNo Wes your rectum removed? Yes ONo 6. Were you ever hospitalized for this condition (other than for surgery)?” Yes No Date hospitalized ration, Date hospitalized Duration Date hospitalized Duration In the past 2 years, have you had any of the folowing symptoms? Cleeding, Cweight loss, Citrequent diarrhea, Clabdominal pain, other - (specify) What are the frequency of your symptoms? 8. Are you currently taking any medications to control this condition? a UYes No Medications Dosage __ Frequency Medications Dosage _ Frequency Medications _ _ Dosage: Frequency 9, Have you missed time from work due to these symptoms? Yes ONo Date. _ ___ Length of time missed Date ___— Length of time missed _ Date a Length of time missed _ a 10. Do you suffer from any complications such as severe arthritis, cithosis or hepatitis? Yes ONo x _ a x - a Signature of Applicant Date ignature of Agent DateAMERICAN INCOME LIFE INSURANCE COMPANY Executive Office: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 ‘wwwilife.com, DISABILITY INCOME QUESTIONNAIRE Name Application # PART A: 4. What is your gross income? (hourly / monthly / annual ) 2. What is the average number of hours you work per week? 3. Do you have any other disability income insurance? ___ [ves [] no 1f“YES", name of company: Amount of benefit: (per week / month ) 4, Have you ever been disabled or applied for disability benefits? YES No If “YES”, give reason for disability and dates of disability 5. Other than sick leave, does your employer provide for continuation of your salary during illness? yes [] No IVES", for how long? What percentage of your salary is covered? PART B: (For Self- Employed Persons Only) 41. Do you have an office outside of your home? __ [] Yes [ ] No 2. Do you have any fulltime or regular part-time employees? (] ves No If“YES”, are these employees related to you? YES No 3. Is your business incorporated? _ YES No 4. Do you carry any business insurance other than homeowners or auto policies? _ YES No 5. Is your income subject to seasonal fluctuations? _ - yes|_] no 6. How long have you been self-employed? _. YES NO 7. How long have you been in your current profession? YES NO x Date (Proposed Insured’s Signature ) (Agent's Signature ) AG-2132 (R493) 210AMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 www.aili DRIVER’S LICENSE QUESTIONNAIRE PROPOSED INSURED APPLICATION NUMBER DRIVER'S LICENSE NUMBER STATE OF ISSUE DATE OF BIRTH NAME SHOWN ON LICENSE IF YOU DO NOT HAVE A LICENSE, PLEASE ANSWER THE FOLLOWING QUESTIONS: yes [] no HAVE YOU EVER BEEN A LICENSED DRIVER? IF NO GIVE REASON WHY AND SIGN BELOW IF YES, PLEASE ANSWER THE FOLLOWING QUESTIONS AND SIGN BELOW: HAS YOUR DRIVER'S LICENSE EVER BEEN susPENDED? [_] YES NO IF YES, WHY? (INCLUDE DATE OF VIOLATIONS) IF NO, WHY DO YOU CURRENTLY NOT HAVE A LICENSE? HAS YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED, REVOKED, OR NOT OBTAINED BECAUSE OF ALCOHOL RELATED PROBLEMS? L] ves LI no IF YES, PLEASE GIVE DETAILS: HAS YOUR DRIVER'S LICENSE EVER BEEN SUSPENDED, REVOKED, OR NOT OBTAINED BECAUSE OF HEALTH PROBLEMS? YES No IF YES, PLEASE GIVE DETAILS: IF LICENSE SUSPENDED FOR REASON OTHER THAN ALCOHOL OR HEALTH RELATED, PLEASE GIVE REASON FOR SUSPENSION BELOW. Details x DATE (PROPOSED INSURED S SIGNATURE) 211AMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas, 76797 (254) 751-8600 wwwilile.com DRUG QUESTIONNAIRE INSURED'S NAME APPLICATION NUMBER HAVE YOU EVER USED STREET DRUGS OR ABUSED PRESCRIPTION DRUGS? YES [|] NO DRUG USED DATE BEGAN CURRENT USE OR DATE DISCONTINUED. ** COMPLETE THE FOLLOWING FOR MARIJUANA IF USED WITHIN LAST 2 YEARS. DAILY USE 370 4 TIMES PER WEEK 1 TO 2 TIMES PER WEEK \_] LESS OFTEN THAN 1 TIME PER WEEK HAVE YOU EVER USED INTRAVENOUSLY INJECTED DRUGS? Yes[] NO IF YES, INDICATE TYPE OF DRUG USED. HAVE YOU EVER BEEN TREATED FOR DRUG ABUSE? YES No IF YES, TREATMENT DATE. HAVE YOU EVER BEEN TREATED FOR ALCOHOL ABUSE? YES. No IF YES, COMPLETE ALCOHOL USE QUESTIONNAIRE ALSO. (PROPOSED INSURED'S SIGNATURE) (DATE) AG-2199 me 212 rdAMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 HEART / CIRCULATORY QUESTIONNAIRE INSURED'S NAME APPLICATION NUMBER CHEST PAIN 1. HAVE YOU EVER HAD: A. cHEST PAN? ves of] 8, SHORTNESS OF BREATH? ves nol] 2, DATE OF OCCURRENCE (S) 3, WHEN DID THE PAIN OCCUR (AT REST OR AFTER EXERCISE)? __ 4. ID YOU CONSULT A PHYSICIAN OR WERE YOU HOSPITALIZED? vesL] no IF YES, WHAT IS THE NAME AND ADDRESS OF THE PHYSICIAN?, WHAT IS THE NAME AND ADDRESS OF THE HOSPITAL? 5, WHAT WAS THE PHYSICIANS DIAGNOSIS? HEART ATTACK QUESTIONNAIRE 4, HAVE YOU EVER BEEN DIAGNOSED WITH A HEART ATTACK? Yes No IF YES, PLEASE FURNISH NAME AND ADDRESS OF THE ATTENDING PHYSICIAN. WHAT IS THE NAME AND ADDRESS OF THE HOSPITAL WHERE CONFINED. HAVE YOU HAD MORE THAN ONE HEART ATTACK? Yes No 2. DATE OF HEART ATTACK (S) 3, HAVE YOU HAD ANGINA SINCE YOUR HEART ATTACK? yvesL_] no IF YES, HOW OFTEN TO YOU HAVE ANGINA? 4, DO YOU CURRENTLY TAKE MEDICATION FOR YOUR HEART? yes No \F YES, LIST ALL MEDICATION. 5, WHAT IS THE NAME AND ADDRESS OF THE PHYSICAN WHO CAN FURNISH RECORDS OF CONSULTATION AND TREATMENT SINCE THE DATE OF YOUR HEART ATTACK? 6. WHEN DID YOU RETURN TO FULL TIME EMPLOYMENT? _ (WOTOAYTYRY AG-2229 300CORONARY BY - PASS / ANGIOPLASTY QUESTIONNAIRE 4, HAVE YOU EVER HAD A CORONARY BY-PASS OPERATION OR ANGIOPLASTY PROCEDURE? (yes No IF YES, WHICH ONE? 2. DATE OF PROCEDURE. 3. HAVE YOU HAD ANGINA SINCE YOUR RECOVERY FROM surcerY? [lyes [] no 4, WHAT WAS THE NAME AND ADDRESS OF THE HOSPITAL WHERE THIS PROCEDURE WAS PERFORMED? WHAT IS THE NAME AND ADDRESS OF THE PHYSICIAN WHO CAN FURNISH RECORDS OF CONSULTATION AND TREATMENT SINCE THE OPERATION? DATE LAST SEEN? 5. WHEN WAS THE LAST EKG DONE? 6. WHEN DID YOU RETURN TO FULL TIME EMPLOYMENT? (MOT DATE7 YR) x DATE _ (PROPOSED INSURED'S SIGNATURE) (AGENT'S SIGNATURE) AG-2229 300APPLICATION NUMBER HEART MURMUR QUESTIONNAIRE AMERICAN INCOME LIFE INSURANCE COMPANY WACO, TX 76797 PLEASE INDICATE APPROPRIATE APPLICANT'S NAME IN SHADED AREA Er wy _ NAME = [ 1. Have you ever been diagnosed with @ heart murmur? - Yes CINo IF YES, any symptoms or treatment? 2. Do you have any exercise limitations? - Yes CNo IF YES, give details: a = _ = 3.Did the physician describe the murmur as Clfunctional or Corganic? Did he describe i as mitral valve prolapse? Yes No 4. Have you ever had theumatic fever? a Yes ONo IF YES, is the heart murmur @ result of rheumatic fever? Yes ONo 5, At what age was the murmur first diagnosed? 6, Are you required to be given antibiotics before surgery or dental work? _ Yes ONo 7. Have you ever had heart valve surgery? Yes CINo Date of Procedure: __ — Name, address and phone number of hospital: . 8, Name, address and phone number of physician with current records; __ Signature of Applicant ————«COiat Signature of Agent ~ DateAMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 www.ailife.com HEPATITIS HISTORY QUESTIONNAIRE PROPOSED INSURED'S NAME APPLICATION NUMBER 4, HAVE YOU EVER HAD OR BEEN TREATED FOR HEPATITIS? (1 Yes No 2. DATE DIAGNOSED? 3. INDICATE WHICH TYPE: HEPA HEP B HEP C CHRONIC OR OTHER (IF TYPE HEP A ONLY, NO FURTHER INFORMATION IS NEEDED.) 4, LIST MEDICATION(S) PRESCRIBED AND THE DATE BEGAN. MEDICATION DATE 5. DO YOU CURRENTLY TAKE MEDICATION FOR HEPATITIS? |_JYES NO MEDICATION DATE BEGAN, 6. WERE YOU HOSPITALIZED? Yes NO IF YES, DATE NAME AND ADDRESS OF HOSPITAL 7. ARE YOU FULLY RECOVERED? YES No 8. HAVE YOU HAD LIVER FUNCTION TESTS PERFORMED SINCE THE DIAGNOSIS OF HEPATITIS? Yes NO WERE THE RESULTS NORMAL? Yes NO WHAT WERE THE DATES OF THESE TESTS? HAVE YOU HAD A LIVER BIOPSY PERFORMED? Llyes [ino IF YES, WHAT WERE THE RESULTS? DATE? 9, DO YOU CURRENTLY DRINK ALCOHOL? (ives [Jno 10. HAVE YOU EVER USED IVDRUGS? ["] YES_-—[_] NO_IF YES, DATE 11, PHYSICIAN NAME/ ADDRESS WHO TREATED HEPATITIS? DATE LAST SEEN? x DATE (PROPOSED INSURED'S SIGNATURE) 213APPLICATION NUMBER INFANT QUESTIONNAIRE AMERICAN INCOME LIFE INSURANCE COMPANY PO BOX 2608 WACO, TX 76797 PLEASE INDICATE APPROPRIATE APPLICANT'S NAME IN SHADED AREA [ z, aa NAME 1. Name of chile: - Date of bith; Birth weight: Birth tength: 2, Wes binh premature? Yes CNo IFYES, by how much? 3, Were there any birth defects or medical problems? _DYes CINo IFYES, give detai _ 4, What isthe child's current weight? Current length? 5, Are there any current medical problems? — Yes CNo IFYES, give details: a 6, Name, address and phone number of hospital where child was born: = Date of discharge from hospital ater bith: Ir kept longer than 3 days, and child had no birth defects or medical problems, reason for extended hospitalization: 7.Was the child discharged with an Apnea Monitor, or any other type of monitor? Yes ONo IFYES, 's monitor currently being used? aes ONo Ir not currently using monitor, date discontinued: 8. Has the chitd been hospitalized since discharged at birth? _ Yes ONo Date Reason _ Duration Date Reason _ Duration 9.15 the child currently taking medication or have they ever taken medication on a long-term basis? Yes CNo Medications Dosage Frequency Duration _ Medications _____ Dosage Frequency Duration Medications Dosage Frequency Duration _ Name, address and phone number of prescribing physician 10, Nome, address and phone number of physician with current records: Signature of Appicant ——~—~—~ate Signature of Agent DaieAPPLICATION NUMBER KIDNEY QUESTIONNAIRE: AMERICAN INCOME LIFE INSURANCE COMPANY PQ BOX 2608 WACO, TX 76797 PLEASE INDICATE APPROPRIATE APPLICANT'S NAME IN SHADED AREA _ [ NAME T, Have you ever been diagnosed Dchronic kidney infections, Cinephritis, Ciglomeruionephritis, or Chad an abnormal renal function test? Date diagnosed Derails Date diagnosed Detats Date diagnosed : Details 2..Do you currenly take any medications for your kidneys? = Yes CN Medications Dosage _ Frequency Medications Dosage Frequency Medications Dosage Frequency 3.Have you ever had surgery or been hospitalized due to your kidneys? - Yes ONo Date Detaits Date Derails Date Details - 4, Have you ever had tests performed on your kidneys? —_ Yes GNo Date Detits Date Details —_ Date _ Detaits 5. Nome, address and phone number of physician with current records: 6.Have you ever had or been told you nected dialysis? on Yes CINo Date _ Details Dae Detais Date Details —_ THe you gion ago wth Cates, eat ease o EIN Dont pressure? (Iryes, complete appropriate questionnaires). 8.Have you ever had a kidney transplant? (It yes, complete following questions) a Yes ONo Date of surgery (surgery within the past year do not proceed) Name, address and phone number of hospital where confined: 9. Have you had any episodes of rejection? aes CNo It yes, how many? _ 10. Was the donor kidney from a living donor? Yes ONo TAs the physician who checks your kidneys a nephrologist? Yes GNo x x Signature of Applicant ——~—~=SCSC«OTe Signature of AgentAPPLICATION NUMBER PANCREATITIS. HASgeANE Cok AMERICAN INCOME, a ISURANCE COMPANY WACO, tk aaSI9T PLEASE INDICATE APPROPRIATE APPLICANT'S NAME IN SHADED AREA x NAME E 1, How many attacks of pancreatitis have you had? Give dates 1 2. — 4 2. Have you ever been hospitalized for pancreatitis? —_ _ aes CNo Dates: - 3, Name, address and phone number of hospital with records of pancreatitis: 4. Did the physician diagnose a cause for your pancreatitis? aes (No IF YES, what was the physicion's diagnosis? a 5, Have you ever been diagnosed or treated for diabetes? _ __ DYes CNo IFYES, complete Diabetic Questionnaire. 6.Have you in the past or do you currently take medication for your pancreas? __ ayes ONo Medications - _ Dosage - Frequency Duration Medications Dosage. Frequency Duration Medications Dosage. ___ Frequency Duration 7. Name, address and phone number of prescribing physician: —_— 8. Have you ever had surgery for your pancreatitis? Yes CINo Date of Procedure: — Name, address end phone number of hospital where confined: How long were you confined? 9. What was the nature of the surgery? = 10. At the time you were diagnosed with pancreatitis, did you drink alcohol? Yes CNo IF YES, was your pancreatitis related to your alcohol use? _ DYes CNo IF YES, do you currently drink alcohof? _ - ciYes No Signature of Applicant Date “Signawre of Agent —=SC*«~CS*S*«~SAMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O, Box 2608, Waco, Texas 76797 (254) 751-8600 wwwailife.com RACING QUESTIONNAIRE PROPOSED INSURED’S NAME. APPLICATION NUMBER AUTOMOBILE RACING LI MOTORCYCLE RACING MOTORBOAT RACING LI OTHER 1, NAME OF SANCTIONING ORGANIZATION RACING DIVISION VEHICLE CATEGORY AND CLASS (ENGINE SIZE) AVERAGE SPEED ‘TYPE OF TRACK (OVAL, SIMULATED ROAD, ECT.) AVERAGE NUMBER OF RACES PER YEAR DATE OF LAST RACE DO YOU PLAN TO CONTINUE RACING IN THE FUTURE? |_| YES No. DO YOU OWN YOUR OWN COMPETITIVE VEHICLE? YES NO TYPE?, © PrnNoaeen ADDITIONAL COMMENTS: x DATE (PROPOSED INSURED'S SIGNATURE) 52232 a AG-2232 fe 215APPLICATION NUMBER" RESIDENCY ADDENDUM FOR AMERICAN INCOME LIFE Ye COMPANY OX WACO, TX aigi97 PLEASE INDICATE APPROPRIATE APPLICANT'S NAME IN SHADED AREA NAMI x Ifthe Proposed Insured is not a citzen ofthe United States: 1. Under what authority are you ving in the United States? Please select one of the folowing i Aien Registration Receipt Card (INS Form 1181 or 551 Expiration Date 10. Unexpired Employment Authorization Document (INS Form |-688B) Expiration Date. - oe 1G Other Expiration Date 2. Ot what Country are you a citizen? 3, Have you been a resident of the United States for the last twelve consecutive months? Yes ONo 4, Do you plan to continue living in the United States? 7 —_ __Yes No 5, Have you traveled outside the United States any time during the last twelve months? Yes ONo Iryes, where? Signature of Appicant Date Signature of Agent DateAmerican Income Life Insurance Company P.O. Box 2608 Waco, TX 76797 254-751-8600 ‘wanwailife.com RESPIRATORY QUESTIONNAIRE Name Application # Asthma Allergies Bronchitis Emphysema Pneumonia Other (Please circle one of the above) When diagnosed: Do you take medication daily? Yes No Or only when you have a problem? Yes No List all medication(s) Dosage Frequency Name and address of treating doctor: Date of last attack/episode? How often do you have problems or attacks? Daily: Weekly: Monthly: Less than Monthly: Seasonal: Have you ever been hospitalized for this? Yes No IFYES, how many days were you hospitalized? _ When? Have you ever received treatment in an Emergency Room? Yes No yes, when? Name and address of facility: Have you smoked cigarettes within the last year? Yes No x Date (Proposed insured’s Signature) AG-2196 ic 203 rdAMERICAN INCOME LIFE INSURANCE COMPANY Executive Office: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 wwwwailife.com SCUBA DIVING QUESTIONNAIRE INSURED'S NAME, APPLICATION NUMBER: THIS QUESTIONNAIRE IS TO BE USED FOR THOSE PARTICIPATING IN SCUBA DIVING (USING A SELF- CONTAINED UNDERWATER BREATHING APPARATUS). IF YOU SKIN DIVE ONLY (USING A SNORKEL, MASK AND FINS), SIMPLY CHECK IN THE BOX BELOW AND SIGN AND DATE THE FORM AT THE BOTTOM: SKIN DIVE ONLY 4, ARE YOUACERTIFIED DIVER? [_] YES NO 2. WHERE DO YOU DIVE? RIVERS AND LAKES OCEAN BEACHES, BAYS AND INLETS [_] DEEP SEA 3. DO YOU DIVE: COMMERCIALLY [7] FOR THE MILITARY FOR PLEASURE ONLY IF COMMERCIAL OR MILITARY, WHAT IS THE PURPOSE OF THE DIVING? (EXAMPLES ARE CONSTRUCTION, SEARCH AND RESCUE, SCIENTIFIC RESEARCH, SEAFOOD GATHERING, SALVAGE) 4. TO WHAT DEPTH DO YOU DIVE? (EXPRESS IN FEET.) 5, HOW FREQUENTLY DO YOU DIVE? 6, DO YOU DO ANY CAVE DIVING? yes [_|NO 7. DO YOU DO ANY ICE DIVING? YES NO 8 DO YOU PLAN TO CONTINUE DIVING IN THE FUTURE? _ x DATE (PROPOSED INSURED’S SIGNATURE) (AGENT'S SIGNATURE) AG-2233 216AMERICAN INCOME LIFE INSURANCE COMPANY Executive Office: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 wawwailife.com SKY DIVING QUESTIONNAIRE INSURED'S NAME APPLICATION NUMBER 1,00 YOU BELONG TO A CLUB AFFILIATED WITH A PARACHUTE AssocIATION? [_]YES NO 2. DO YOU FOLLOW THE REGULATIONS AND SAFETY STANDARDS ESTABLISHED BY A PARACHUTE ‘ASSOCIATION? Clyes [Jno IF "NO" EXPLAIN 3, HOW LONG HAVE YOU BEEN SKY DIVING? 4, NUMBER OF JUMPS LAST 12 MONTHS? LAST 24 MONTHS? 5, DO YOU TAKE PART IN EXHIBITIONS, COMPETITIONS OR BASE JUMPING? YES No IF YES" DESCRIBE THE NATURE OF THESE EVENTS: 6.00 YourEceive pay For sky owncactiiTy? [_] ves L] no IF "YES" GIVE FULL DETAILS 7. ARE YOU AN AIRPLANE PILOT OR DO YOU INTEND TO BECOME ONE? yes [_]No 8. HAVE YOU EVER HAD ANY ACCIDENT ASSOCIATED WITH SKYDIVING? yes [_] No 9. DO YOU PLAN TO CONTINUE SKYDIVING IN THE FUTURE? yes |_| no x DATE - (PROPOSED INSURED'S SIGNATURE) AG-2 218‘APPLICATION NUMBER SLEEP APNEA QUESTIONNAIRE AMERICAN INCOME LIFE INSURANCE COMPANY WACO, TX 76797 PLEASE INDICATE APPROPRIATE APPLICANT'S NAME IN SHADED AREA NAME — = 1. Have you ever been diagnosed with sleep apnea? _ Yes CNo 2. Have you ever participated in a sleep study? _ Yes ONo IFYES, were the resuts C] normal or Cabnotmai? Nome, address and phone number of facility where study was conducted: 3.Was a C-PAP machine or any type of medical treatment or surgery recommended? ___ OYes ONo IFYES, what was recommended? _ - ee _ 4. lta C-PAP was recommended, do you use the C-PAP machine? ___ Yes No 5. lr medical treatment was recommended, did you follow through with the treatment? Yes No 6.Heve you ever had surgery for sleep apnea? CYes CINo Date of Procedure; Nome, address and phone number of physician andlor hospital: 7..Name, address and phone number of physician with current records; = Signature of Applicant _ Date Signature of Agent DateAPPLICATION NUMBER TROKE QUESTIONNAIRE AMERICAN INCOME ra INSURANCE COMPANY WACO, TX 76797 PLEASE INDICATE APPROPRIATE APPLICANT'S NAME IN SHADED AREA fa z= z ae NAME c E 1, Have you ever been diagnosed with a stroke or TIA (transient ischemic attack)? Yes CNo 2, What was the date of your stroke or TIA (transient ischemic attack)? __ 3. [sivas there any paralysis? _ - Yes ONo 4. Were you hospitalized? (Yes No How tong? Name, address and phone number of the hospital 5. Any physical or speech therapy needed? DYes CNo 6, Have you had more than one stroke or TIA (transient ischemic attack)? Yes No 7.Name, address and phone number of treating physician 8. When did you return to fulltime employment? _ x x - _ signature of Applicant Date signature of Agent Date‘APPLICATION NUMBER ULCER Ae nRURANC AMERICAN incon IFE INSURANCE COMPANY waco, a Tero PLEASE INDICATE APPROPRIATE APPLICANT'S NAME IN SHADED AREA TType of ulcer. CiPeptic CDuodenat (Gastric (Other __ - 2.Has any bleeding occurred? _ __0Yes CNo 3. Date diagnosed: _ 4. Have you ever had surgery for your ucer? Yes CNo Date of Procedwe: —___ Nome, address and phone number of hospital where confined: —_ How long were you confined? 5. Name, address and phone number of attending physician 6.o you currently take medication for your ulcer? _ . DYes ONo Medications Dosage Frequency Medications, __ Dosage __ Frequency Medications Dosage Frequency x Signature of Rppicant Date Signature of Agent DateAPPLICATION NUMBER RESIDENCY ADDENDUM FOR AMERICAN INCOME LIFE INSURANCE COMPANY PO BOX 2608 WACO, TX 76702 PLEASE INDICATE APPROPRIATE APPLICANT'S NAME IN SHADED AREA TaN NAME = IW the Proposed Insured is nota citizen of the Urited States: 1. Under what authority are you living in the United States? Please select one of the following: 11) Alien Registration Receipt Card (INS Form I-11 or 651, "Green Card") Expiration Date, - G Unexpired Employment Authorization Document (INS Form I-688B) Expiration Dato__ — Other a) Do you have a valid Government Issued ID? = TYes ONo ‘Type of 1D, Number and expiration date of ID_ b) Do you have a bank account? __ _ Yes (No Name of the Bank ‘Type of Account C1 Checking CI Savings ©) Do you have a valid Tax Identification Number? CYes (No TIN number 2, Of what Country are you a citizen? 3. List any family members living with you who are permanent residents or citizens of the United States: US. Citizen Pormanent Resident Expiration (Green Card) Date — oa o a ‘Spouse Name -_ o a Child Name ne o o tte Child Name - oo a a fot Child Name 4, Have you been living in the United States for the last twelve consecutive months? GYes CNo 6. Do you plan to continue living in the United States? - Yes CNo x_ - x ‘Signature of Applicant Dato ‘Signature of Agent Date AG-2464 (R16)AMERICAN INCOME LIFE INSURANCE COMPANY Executive Offices: P.O. Box 2608, Waco, Texas 76797 (254) 751-8600 swwwsilife,com SEIZURE QUESTIONNAIRE INSURED'S NAME APPLICATION NUMBER WHEN DIAGNOSED? HOW OFTEN DO YOU HAVE A SEIZURE? DATE OF YOUR LAST SEIZURE? TYPE OF SEIZURES: GRAND MAL PETIT MAL OTHER, DO YOU LOSE CONSCIOUSNESS? MEDICATIONS: DOSAGE: HAVE YOU EVER BEEN HOSPITALIZED FOR A SEIZURE? DATE: NAME / ADDRESS OF HOSPITAL: NAME AND ADDRESS OF DOCTOR WITH CURRENT RECORDS OF SEIZURES: ADDITIONAL REMARKS: x DATE (Proposed Insured’s Signature) (Agent's Signature) AG-2201 E 217 LCOMPANY jircom AIL AMERICAN INCOME LIFE INSURANC - Executive Office: P.O, Box 2 aco, Texas 76797 (25a) 71 DISABILITY INCOME QUESTIONNAIRE Name Application # oo PART A: 1, What is your gross income? ___( hourly / monthly / annual } 2. What is the average number of hours you work per week? 3. Do you have any other disability income insurance? res} [xo] If "YES", name of company: Amount of benefit: —_ (per week / month ) 4, Have you ever been disabled or applied for disability benefits? ves] [10] If “YES”, give reason for disability and dates of disability __ 5. Other than sick leave, does your employer provide for continuation of your —) j—) salory during illness? ves] [no] fF *YES®, for how tong? _ What percentage of your salary is covered? PART B: (For Self-Employed Persons Only) 1. Do you have an office outside of your home? yes} 2, 00 you have any full-time or regular part-time employees? es} If “YES”, are these employees related to you? ees] Is your business incorporated? t 4, Do you carry any business insurance other than homeowners or auto policies? y ry any Is your Income sulyect to seasonal fluctuations? 6. How long have you been self-employed? _ 7, How tong have you been in your current profession? __ x Dore (Proposed Insurea’s Signature) (Agent's Signature)American Income Life Insurance Company P.O. Box 2608 Waco, TX 76797 Assignment to Transfer Ownership Use this form only for an absolute transfer of ownership. Ifa collateral assignment for security purposes i intended, ‘use American Bankers assignment form No. 10. ‘The undersigned isthe present ovmer of the following American Income Life Insurance Company policy: Polley Number Name of Insured ‘The undersigned hereby assignee ownership of said policy to: “Assignee (new owner) ‘Relationship to Present Owner Dated at on 19 ‘Signatire of Present Owner CipiSiare ‘Signature of Witness ‘Signature of New Owner IF THERE IS A CHANGE IN PREMIUM PAYMENT, PLEASE COMPLETE THE FOLLOWING: Foture premium billings are to be sent t: Name ‘Address Gy State Zip PLEASE NOTE THAT THIS CHANGE HAS NO EFFECT ON THE BENEFICIARY DESIGNATION. IF A. (CHANGE OF BENEFICIARY IS DESIRED, THE NEW OWNER MUST NOTIFY THE COMPANY OF THE CHANGE. L-245(R589)AL, AMERICAN INCOME LIFE INSURANCE COMPANY PO Box 2608, Waco, TX 76797 (254) 761-6400 wwwailife.com Active Duty M: itary Thank you for your military service to our country. American Income recognizes and appreciates you. As a service to you, we wanted to make certain you were aware of coverage available to you through the Servicemen’s Group Life Insurance (SGLI) program. Often this coverage can be obtained at rates lower than you can obtain through an individual policy. SGLI coverage provides up to $400,000 of convertible term life insurance while you are in an “active” military status or serving as a “ready” reservist. This coverage is available at a cost as low as $.78 per $1,000 of coverage. If you have not taken advantage of this opportunity you may want to contact your local unit for details. Before we submit your application, we would like to confirm you are aware of SGLI benefits that may be available to you. Statement: {__) Yes, 1 am aware of other coverage available to me through the Servicemen’s Group Life Insurance and do wish to pursue coverage with American Income. Please proceed with evaluation of my application. Printed Name Applicant Signature Date Agent or Witness Signature Date