Atlantic Insurance Brokerage

1265 Cottage Drive

Harrisburg, PA 17112
P 877.561.2422
F 888.228.7570

INFORMAL INQUIRY - This Preliminary Application is used specifically to gather underwriting information relating to an
insureds medical history and other factors that may have an impact on an underwriting classification.

PERSONAL HISTORY
Name (First)_____________________________(Last)_____________________________ Date of Birth _____________________

Social Security # _____________________________ Male Female Age ________ Height _________ Weight __________

Address ___________________________________________ City ________________________ State ______ Zip ____________

TOBACCO USAGE
Do you use any nicotine products? Yes No If yes, what type? Cigarettes Cigar Pipe Snuff

If other, please describe_________________________________ Frequency of Use ____________________________________

Have you ever used nicotine products? Yes No If yes, date of last usage__________________________________________

PLAN OF INSURANCE
Universal Life Whole Life Variable Survivorship Term desired guaranteed period ____________________

Face Amount __________________________________ Premium Amt/UW Class Needed_________________________________

Have competing offers been made? Yes No If so, indicate company/offer _________________________________________

INFORCE COVERAGE
Carrier Face Amount Replacing?

AVOCATIONS
Any hazardous activities? (rock climbing, scuba diving, hang gliding, pilot, etc) Yes No If yes, please specify which activity
_________________________________________________________________________________________________________

FAMILY HISTORY
Has any immediate family member (parents or siblings) died prior to age 60? Yes No If so, please indicate which family
member, cause, and age of death.
_________________________________________________________________________________________________________

HISTORY OF MEDICAL CONDITIONS

Impairment Date of Onset Treatment
Cancer
Diabetes
Cardiac
Stroke
Hepatitis
Sleep Apnea
Other:

AGENT INFORMATION

Name _________________________________________ Social Security # ____________________ Date of Birth _____________

Address _________________________________________ City ___________________________ State _______ Zip __________

Phone _______________________ Fax _______________________ Email Address ____________________________________

1
 REQUEST FOR ATTENDING PHYSICIAN INFORMATION

The following information is needed to help expedite the medical underwriting process. Please list all of the physicians that the
client has seen within the last 5 years and the reason for each visit. If the client does not have a personal physician, please state so
below.

Who is your primary care physician? Doctors address and phone number Date last seen and reason why

Other physicians seen? Doctors address and phone number Date last seen and reason why

Any hospitalizations? Hospital name, address, phone number Date and reason why hospitalized?

Please list all current medications (including over-the-counter):

LIFESTYLE QUESTIONNAIRE

Proposed Insured __________________________________________________________________________________________

1. Do you work? Yes No If yes, where and how often ________________________________________________________

2. Do you volunteer? Yes No If yes, where and how often _____________________________________________________

3. Are you married? Yes No Highest level of education?_______________________________________________________

4. Do you exercise? Yes No If yes, what type and how often ___________________________________________________

5. Hobbies and Interests?___________________________________________________________________________________

6. Do you travel? Where to? Reason business/pleasure? How often? Future plans?
________________________________________________________________________________________________________

7. Do you use any assisted devices (walker, cane, etc)? Yes No If so, please describe _______________________________

8. Do you have a pet? Yes No If so, please describe your daily activities with your pet
________________________________________________________________________________________________________
________________________________________________________________________________________________________
9. Do you handle your own financial affairs such as:

Balance your own checkbook? Yes No

Pay your own bills? Yes No

10. Do you drive an automobile? Yes No If you have had any accidents in the last three years, please explain
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

2
 Atlantic Insurance Brokerage
1265 Cottage Drive
Harrisburg, PA 17112
P 877.561.2422
F 888.228.7570

HIPAA Authorization for Release of Health Related Information

This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

I hereby authorize the use, disclosure, or sharing of health information, as described below, about me and revoke any
previous restrictions concerning access to such information:

1. The information will be used, disclosed, or shared only for the following purpose(s): For the purpose of conducting a
formal or informal inquiry regarding my eligibility for life insurance products or related services, underwriting my
insurance application(s) 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.

2. Persons or entities authorized to use, disclose, and/or share 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, 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.

3. Persons or entities authorized to collect or otherwise receive, use, and share the information: The life insurance
companies and servicing agencies listed on this form in section 5, along with their affiliates and reinsurers, and their
agents, employees, or other representatives (the Authorized Entities). I further authorize the Authorized Entities to
redisclose the information to, and discuss the information with, each other and to redisclose the information to MIB
Group, Inc., which operates an information exchange on behalf of life and health insurance companies.

4. Description of the information that may be used, disclosed, or shared: This authorization specifically includes the
release of all information related to my health to the extent allowed by law, including, but not limited to, information on
the diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosis
and treatment of mental illness, suicidal disorders, communicable or infectious conditions, such as Human
Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), and use of alcohol, drugs and
tobacco. This authorization excludes separate psychotherapy notes.

3
5. Authorized Life Insurance Companies and Servicing Agencies:

3 Mark Financial Mass Mutual Union Central

Accordia Life & Annuity Metropolitan Life United of Omaha
Advantage Insurance Network Metropolitan Life of New York US Life in the City of New York
AIG/American General Minnesota Life VOYA
American-Amicable Nationwide William Penn
Atlantic Insurance Brokerage National Life Ins. Co. Zurich American Life Ins. Company
Allianz Nationwide Financial Zurich American Life Ins. Co. of NY
American National Ins. Co. New York Life Additional: _____________________
Americo North American Co. for Life & Health Ins Additional:
Assurity Old Mutual Additional:
AXA/MONY Pacific Life Additional: _____________________
Athene Pan American
Banner Penn Mutual
Berkshire Phoenix Life
Companion Life Presidential Life
EMSI Principal Life Insurance
Express Imaging Services, Inc. Principal National Life Insurance
Fidelity Life Protective
Fidelity Security Protective Life & Annuity
Foresters Prudential
Genworth Financial Companies Reliance Standard
Guardian Reliastar Life
Illinois Mutual Royal Neighbors of America
ING Sagicor
John Hancock Savings Bank Life Insurance
Lafayette Life Securian
Life Ins. Co. of the Southwest Security Life of Denver
Lincoln Benefit Standard
Lincoln Financial Group Symetra Life
Lloyds of London Transamerica

4
 STATEMENTS OF UNDERSTANDING & ACKNOWLEDGMENT

I understand that health information about me provided to the Authorized Entities may be protected by state
and federal privacy regulations including the HIPAA Privacy Rule and that the Authorized Entities will only use,
disclose, and share such information as permitted by applicable regulations and as described in their privacy
notices.

I 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, the Authorized Entities
may not be able to determine my eligibility for life insurance products or related services, process any
application submitted by me, 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 Authorized Entities with the
right to contest a claim under the policy or the policy itself, by sending a written revocation to the address at the
top of this form. I understand that if I signed any other authorizations, these must be revoked separately.

This authorization shall remain in force for 24 months from the date signed, regardless of my condition and
whether living or deceased.

A copy of this authorization will be considered as valid as the original.

I acknowledge I have read and received a copy of this authorization.

_______________________________________ _______________________________________

Printed Name of Proposed Insured Date

_______________________________________ _______________________________________

Signature of Proposed Insured Printed Name of Witness (if available)

_______________________________________ _______________________________________

Proposed Insureds Date of Birth Signature of Witness (if available)

5
 Authorization and Acknowledgement www.accordia.com

Mail or fax completed form to: Accordia Life and Annuity Company
Accordia Life and Annuity Company 215 10th Street, Suite1100, Des Moines, IA 50309
P.O. Box 305030, Nashville, TN 37230-5030
Contact us:
Customer Contact Center Tel: 877 462 8992 Fax: 800 262 6976

Any alteration of this form will not be accepted.

This authorization complies with the HIPAA Privacy Rule.
Name of Proposed Insured Birth Date (mm/dd/yy)
/ /
A. AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
I authorize the Accordia Life and Annuity Company (the Company), its reinsurers, or its authorized representatives, to obtain
from MIB, Inc. or any other consumer reporting agency or employer one or more consumer reports including, but not limited to,
a credit report, about me, which may include information about my physical or mental health.
I understand that an investigative consumer report may be prepared in connection with this application. I authorize the
Company, its reinsurers, or its authorized representatives, to prepare or obtain from any consumer reporting agency one or
more investigative consumer reports about me. With the exception of Arizona residents, I understand that an investigative
consumer report involves personal interviews with sources such as neighbors, friends, or associates, and may include information
as to my character, general reputation, personal characteristics, and mode of living. For residents of Arizona, I understand
that an investigative consumer report involves personal interviews with sources such as neighbors, friends, or associates, and
may include information as to my character and general reputation. I understand these investigative consumer reports contain
information regarding income, net worth, business information, hazardous sports, avocations, driving history, occupation, credit
history, or criminal history.
This authorization shall remain in force for 24 months following the date of my signature on this form.
For residents of all states, I understand that I may request to be personally interviewed if an investigative consumer report
is prepared or obtained in connection with this application. I further understand that, if an investigative consumer report is
prepared or obtained, I have the right to request in writing, within a reasonable time, a complete and accurate disclosure of the
nature and scope of the investigation, a copy of the investigative consumer report, and a summary of my rights under the Fair
Credit Reporting Act.
I authorize the Company, its reinsurers, or its authorized representatives, to release information obtained in connection with this
application including, but not limited to, any consumer reports, investigative consumer reports, or personal health information
to reinsurers, the MIB, Inc. or other persons or organizations performing business or legal services in connection with my
application, claim, or as may be permitted or required by law, or as I may further authorize.
B. AUTHORIZATION for release of personal health information
To evaluate my eligibility for insurance coverage, I authorize any licensed physician, health care professional, hospital, clinic,
laboratory, pharmacy, medical facility, health care provider, health plan, insurer, and/or any other entity subject to the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) that has provided treatment service, payment, or coverage to me
within the past 10 years to disclose my entire medical record and any other protected health information concerning me to
the Company, its agents/producers, employees, representatives, insurance support organizations, and reinsurers. Protected
health information includes but is not limited to: hospital records, treatment records/office notes, consultation reports, workers
compensation information, diagnosis, prescriptions, and test results. It also includes information concerning the diagnosis or
treatment of Human Immunodeficiency Virus (HIV) infection (see below for state-specific exclusions concerning disclosure of
HIV-related information), sexually transmitted diseases, and information on the diagnosis and treatment of mental illness and
the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes.
FOR RESIDENTS OF MAINE: This authorization excludes the disclosure of the result of a test for HIV if the applicant has tested
HIV positive but has not developed symptoms of the disease AIDS. Such tests shall not be discovered or published. Nothing in
this caveat will prohibit this authorization from including the fact that the applicant has AIDS.

18769 Page 1 of 2
FOR RESIDENTS OF MINNESOTA: This authorization excludes the release of information about HIV (AIDS) virus tests which
were administered (1) to a criminal offender or crime victim as a result of a crime that was reported to the police; (2) to a patient
who received the services of emergency medical services personnel at a hospital or medical care facility; (3) to emergency
medical personnel who were tested as a result of performing emergency medical services. The term emergency medical
personnel includes individuals employed to provide pre-hospital emergency services; licensed policeE officers, firefighters,
paramedics, emergency medical services; crime lab personnel, correctional guards, including security guards at the Minnesota
security hospital, who experience a significant exposure to an inmate who is transported to a facility for emergency medical care;
and other persons who render emergency care or assistance at the scene of an emergency, or while an injured person is being
transported to receive medical care and who would qualify for immunity under the good samaritan law.

FOR RESIDENTS OF VERMONT: This authorization EXCLUDES the release of any information relating to ANY previously
administered tests for the HIV antibody, T-Cell counts, AIDS, or ARC. Further, the results from any new test requested of me by
the Company will NOT be forwarded to any outside, non-affiliated company or to any entity not under specific contract with the
Company to perform underwriting services.

FOR RESIDENTS OF WISCONSIN: The reporting of AIDS/HIV test results is limited only to the results of FDA-licensed tests and
that the consumer need not report the results of the tests conducted at an anonymous counseling testing site, or home test kit.

By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not
apply to this authorization and I instruct any physician, health care professional, hospital, clinic, laboratory, pharmacy, medical
facility, health care provider, health plan, insurer, and/or other entity subject to HIPAA to release and disclose such information.
I understand that, unless prohibited by state and/or federal law, the protected health information is to be disclosed under this
authorization so that the Company may: 1) underwrite my application for coverage, make eligibility, risk rating, policy issuance
and enrollment determinations; 2) obtain reinsurance; 3) administer claims and determine or fulfill responsibility for coverage
and provision of benefits; 4) administer coverage; and 5) conduct other legally permissible activities that relate to any coverage
I have, have applied for, or may in the future apply for with the Company. I understand any information disclosed under this
authorization may no longer be covered by federal rules governing privacy and confidentiality of health information and may
be subject to redisclosure (For residents of Colorado, the Company will not redisclose information received pursuant to this
authorization without my written authorization)
This authorization shall remain in force for 24 months following the date of my signature on this form (Except for residents
of Arizona, authorization to disclose HIV-related information is valid for 180 days from the date of the signature below). If
this authorization is signed and the Company is collecting information in connection with a claim for life insurance benefits,
this authorization shall remain valid for no longer than the duration of the claim. A copy of this authorization is as valid as the
original. I understand that I have the right to revoke this authorization at any time. The request for revocation must be in writ-
ing and sent to the attention of the Underwriting Department of the Company at the address listed above. I understand that
the request for revocation may be a basis for denying an application or a claim for benefits. I also understand that a revocation
is not effective to the extent that the Company has already relied on this authorization or to the extent that has a legal right to
contest a claim under an insurance policy or to contest the policy itself. Such revocation shall not apply to any use or disclosure
of my protected health information specifically allowed without authorization by HIPAA and no action relating to this authoriza-
tion shall be construed as creating any restriction on the uses that HIPAA allows without my authorization.
I understand that failure to sign this authorization may impair the ability of a regulated insurance entity to evaluate claims or
process applications and may be a basis for the Company to deny an application or claim for benefits. By signing below, I ac-
knowledge that I have received a copy of this authorization.

Signature of Proposed Insured or Personal Representative Date (mm/dd/yy)

/ /
X

If you are the Personal Representative of the Proposed Insured, describe the scope and/or basis of your authority to act on the
Insureds behalf:

18769 Page 2 of 2
 Principal Life Insurance Company P.O. Box 10431 Authorization for
Principal National Life Insurance Company Des Moines, IA 50306-0431 Release of Personal
Members of Principal Financial Group Health Information
All States
(Applicable to Individual
Only one company is the issuer and responsible for obligations of any given Life and Disability
policy and is hereinafter referred to as the Company. Insurance Customers)

This authorization complies with the HIPAA Privacy Rule and permits health care providers and other covered
entities to disclose personal health information.
/ /
Name of Proposed Insured/Patient (please print) Date of Birth
I authorize any physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, health care provider, health
plan, insurer, and/or any other entity subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that has
provided treatment, service, or coverage to me within the past 10 years to disclose my entire medical record to the Company, its
agents, employees, insurance support organizations, reinsurers, and their representatives. This includes information concerning the
diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes
information on the diagnosis and treatment of mental illness (excluding psychotherapy notes as defined under HIPAA) and the use of
alcohol, drugs, and tobacco. Statements required by 164.508(c)(1)(ii), (c)(1)(iii).
I understand my personal health information may be used or disclosed as set forth by this authorization. Protected health information
includes information created or received by the Company. Protected health information also includes but is not limited to: hospital
records, treatment records/office notes, alcohol or drug abuse treatment, consultation reports, workers compensation information,
diagnosis, prescriptions, test results, vocational testing/counseling information, benefit information, claims information, demographic
information, and claims payment information. Statement required by 164.508(c)(1)(i).
By my signature, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this
authorization and I instruct any physician, health care professional, hospital, clinic, medical facility, other health care provider or
health plan, insurer, or other entity subject to HIPAA to release and disclose my medical record without restriction. I understand that my
personal information, including my protected health information disclosed under this authorization, will be incorporated into and made a
part of any life and/or disability insurance policy(s) issued by the Company in connection with the application(s) for insurance that I have
submitted to the Company. I further understand that the policy(s) will be delivered to the policy owner, which may be my employer or other
party. The information included and forming a part of such policy(s), including my protected health information, may be disclosed to the
policy owner.
I understand that unless prohibited by state and/or federal law the protected health information is to be disclosed under this
authorization so that the Company may: 1) underwrite my application for coverage, make eligibility, risk rating, policy issuance and
enrollment determinations; 2) obtain reinsurance; 3) administer claims and determine or fulfill responsibility for coverage and
provision of benefits; 4) administer coverage; and 5) conduct other legally permissible activities that relate to any coverage I have,
have applied for, or may in the future apply for with the Company. Statement required by 164.508(c)(1)(iv).
The following groups of persons employed or working for the Company may use my personal health information which is described
above: employees of the underwriting, administration, claim or legal departments and any other personnel of the Company, and its
authorized representatives, and business associates that perform functions or services that pertain to any coverage I have, have applied
for, or may in the future apply for with the Company. Statement required by 164.508(c)(1)(ii).
I understand any information disclosed under this authorization may no longer be covered by the privacy provisions of HIPAA and
may be subject to redisclosure. Statement required by 164.508(c)(2)(iii).
This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this authorization is as
valid as the original. Statement required by 164.508(c)(v). I understand that I have the right to revoke this authorization at any time.
The request for revocation must be in writing and sent to: Life and Disability Underwriting, Life and Health Segment, Principal Life
Insurance Company and/or Principal National Life Insurance Company, Des Moines, IA 50392-1780. I understand that a revocation is
not effective if the Company has relied on the protected health information disclosed to it or has a legal right to contest a claim under an
insurance policy or to contest the policy itself. Statement required by 164.508(c)(2)(i). Such revocation shall not apply to any use or
disclosure of my protected health information specifically allowed without authorization by HIPAA and no action relating to this
authorization shall be construed as creating any restriction on the uses that HIPAA allows without my authorization.
I understand that if I refuse to sign this authorization to release my complete medical record, the Company may not be able to process
my application for life and/or disability coverage, or if coverage has been issued, may not be able to make any such benefit payments.
Statement required by 164.508(c)(2)(ii). Upon receipt of your signed authorization, a copy will be provided to you. Statement
required by 164.508(c)(4). Any alteration of this form will not be accepted.

/ /
Signature of Proposed Insured/Patient or Personal Representative Date

If you are the personal representative of the proposed insured/patient, describe the scope of your authority to act on this individuals
behalf (parent, legal guardian, power of attorney, etc.) on the line above. Statement required by 164.508(c)(1)(vi).
DD 6000 UND-2 Insurance products from the Principal Financial Group(The Principal) are issued by Page 1 of 1
Principal National Life Insurance Company (except in New York) and Principal Life Insurance Company.
This completed document is for restricted use only. No part may be copied nor disclosed without prior consent of The Principal. 03/2009
 Life Tips for Ensuring Accurate
Underwriting Paramed Results

Having your clients follow some simple guidelines prior to their Paramed examination is key to ensuring accurate
results. Not to mention, it may improve their underwriting rating, possibly save them money, increase their
insurance coverage, AND youll be looked upon as a true insurance expert.

Following these tips will help your clients attain the most If your client has experienced one of the following
favorable and accurate exam results impairments, follow these additional guidelines:

Fast for 4-8 hours prior to the exam and try to schedule the HYPERTENSION
exam for first thing in the morning, prior to eating Avoid stimulants (caffeine, alcohol, cigarettes)
Limit salt and high-cholesterol foods 24 hours prior to the Schedule a morning exam
exam Have the examiner take blood pressure after the client
Refrain from drinking alcoholic beverages for at least 24 has had a chance to relax three attempts at 10 minute
hours prior to the exam (can increase fat in blood and liver intervals
functions) Take usual medications
Limit caffeine and nicotine 24 hours prior to the exam (can
increase blood pressure, cholesterol) DIABETES
Smokers should not smoke 30 minutes prior to exam (tends Schedule the exam for 2 hours after a meal (no sweets or
to constrict artery walls and elevate blood pressure) sugars after the meal), but if blood is being drawn, fast for
Drink a glass of water one hour prior to the exam 4-8 hours prior to the exam
Get a good night of sleep prior to the exam Empty bladder right after meal
Drink 1-2 glasses of water before the exam
Helpful reminders
Be prepared with a photo ID at the time of the exam URINARY SPECIMEN PROBLEMS (albumin, Red Blood Cells
Provide names and dosages of current medications [RBCs], sugar, etc.)
Provide any history of problems associated with providing a Empty bladder right after meal
blood sample Drink 2-3 glasses of water before the exam
Women should mention to the examiner if mensturating at Avoid sweets or foods with sugar content before the exam
the time of exam (can caues blood in the urine specimen) Avoid strenuous exercise, such as running, for 24 hours prior
Have information cards available, including member to the exam
numbers, for any current health insurance
Have available names, addresses and phone numbers of any CORONARY, EKG PROBLEMS
doctors or clinics visited in the last five years Avoid stimulants (caffeine, alcohol, cigarettes)
Tell the examiner if exercise is a regular activity
Tell the examiner if vitamins or aspirin are taken on a daily
basis