STANDARD STATES - SIMPLIFIED ISSUE - 5Star Life with Quality of Life Benefits

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Employee: YESEmployee: NOSpouse YES (if applicable)Spouse NO (If applicable)

*Hospitalized is defined as an admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long-term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.

Employee: YESEmployee: NOSpouse YES (if applicable)Spouse NO (If applicable)

In the past 5 years, has any Applicant:

Employee: YESEmployee: NOSpouse YES (if applicable)Spouse NO (If applicable)

This will be divided into your paychecks evenly.

5Star Life with Quality of Life Benefits

Statement of Insurability

DETERMINING YOUR COVERAGE