FINAL EXPENSE OCCIDENTAL LIFE INSURANCE COMPANY OF NORTH CAROLINA

P.O. BOX 2595, WACO, TX 76702-2595  (254) 297-2775

LIFE INSURANCE APPLICATION (Please print in black ink) Telephone Case No:_________________________________

Proposed Insured _______________________________________________________ Telephone interview completed Yes No

(First) (Middle) (Last)
_________________ ________ am pm
Address (No. & Street)________________________________________________________ Phone Best time to call

City State Zip Code E-mail Address

Name/Address Secondary Addressee (for notice of possible lapse due to nonpayment of premiums):

Date of Birth Age State of Birth Social Security Number Height Weight
Male Female / / / / ft in lbs
Owner: Name_______________________________________________Relationship_____________________SS#______ /____/______
Address City/State/Zip
Primary Beneficiary Relationship Contingent Beneficiary Relationship

Plan: __________ Face Amount of Insurance $_________ Check here if you are willing to accept any plan for which you qualify based on
Immediate Death Benefit this application. The insurance for which you qualify may have a graded or return
Graded Death Benefit (Percentage of Face Amount) of premium death benefit for the first two (2) or three (3) years, a face amount
less than any indicated on this application, and riders may not be available.
Return of Premium Death Benefit
During the past 12 months have you used tobacco in any form (excluding occasional pipe and cigar use)? Yes No
Rider: Grandchild/Great Grandchild Coverage ____ Number of Children Applying ____ Units Other ________ Automatic Premium Loan
Child Rider* Units ADB* Amt $ (*not available on Return of Premium Death Benefit) Elected? Yes No
Mode: Bank Draft Draft 1st Prem on Req. Date CWA: E-Check Immediate 1st Prem Mail Policy To: Agent Insured Owner
Other Modal Prem $ Collected $ Requested Policy Date: / /
A. Do you have existing life insurance or an annuity contract? Yes No Company
B. Will you replace an existing life insurance policy or an annuity? Yes No Policy # Amount of Coverage $
Physician Name: City/State: Phone:
HEALTH INFORMATION
1. Are you currently hospitalized, confined to a nursing facility, a bed, or a wheelchair due to chronic illness or disease, currently
using oxygen equipment to assist in breathing, receiving Hospice Care or home health care, or had an amputation caused by
disease, or do you currently have any form of cancer diagnosed by a licensed medical professional (excluding basal cell skin
cancer), or do you require assistance (from anyone) with activities of daily living such as bathing, dressing, eating or toileting? Yes No
2. Have you had or been medically advised to have an organ transplant or kidney dialysis, or have you been diagnosed by a
licensed medical professional as having congestive heart failure (CHF), Alzheimer’s, dementia, mental incapacity,
Lou Gehrig’s disease (ALS), liver failure, respiratory failure, or any terminal illness or end-stage disease? ............................... Yes No
3. Have you tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the
HIV infection or other sickness or condition derived from such infection? ................................................................................ Yes No
If any answer to questions 1 through 3 is answered “Yes” the Proposed Insured is not eligible for any coverage.
4. Have you been diagnosed or treated by a licensed medical professional for complications of diabetes, including insulin shock,
diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50?....... Yes No
5. Have you been diagnosed or treated by a licensed medical professional or taken medication for renal insufficiency, kidney
failure, chronic kidney disease, or more than one occurrence of cancer in your lifetime (excluding basal cell skin cancer)? ...... Yes No
6. Within the past 2 years have you had any diagnostic testing (excluding tests related to Human Immunodeficiency Virus (HIV)),
surgery, or hospitalization advised by a licensed medical professional which has not been completed or for which the results
have not been received? .......................................................................................................................................................... Yes No
7. Within the past 2 years have you:
a. been diagnosed or treated by a licensed medical professional for angina (chest pain), stroke or TIA, cardiomyopathy, systemic
lupus (SLE), cirrhosis, Hepatitis C, chronic hepatitis, chronic pancreatitis, chronic obstructive pulmonary disease (COPD),
emphysema, chronic bronchitis, or required oxygen equipment to assist in breathing? .......................................................... Yes No
b. been diagnosed or treated by a licensed medical professional for a heart attack or aneurysm or been advised to have any
type of heart, brain or circulatory surgery (including, but not limited to a pacemaker insertion, defibrillator placement), or
any procedure to improve circulation? .................................................................................................................................. Yes No
c. been diagnosed by a licensed medical professional, or treated, or taken medication for any form of cancer (excluding basal
cell skin cancer)? ................................................................................................................................................................. Yes No
d. used illegal drugs, had or been recommended by a licensed medical professional or licensed counselor to discontinue the
use of alcohol or drugs or to have treatment or counseling for alcohol or drugs? .................................................................. Yes No
If any answer to questions 4 through 7 is answered “Yes” the Proposed Insured should apply for the Return of Premium Death Benefit Plan.
8. Within the past 3 years have you been diagnosed or treated by a licensed medical professional, or hospitalized for:
a. stroke, angina (chest pain), heart attack, aneurysm, heart or circulatory surgery or any procedure to improve circulation? ... Yes No
b. or taken medication for any form of cancer (excluding basal cell skin cancer), emphysema, chronic bronchitis, chronic
obstructive pulmonary disease (COPD), ulcerative colitis, cirrhosis, Hepatitis C, or liver disease? .......................................... Yes No
c. paralysis of two or more extremities or any neuro-muscular disease or disorder (including, but not limited to cerebral palsy,
multiple sclerosis, seizures, or Parkinson’s disease)? ............................................................................................................ Yes No
If any answer to question 8 is answered “Yes” the Proposed Insured should apply for the Graded Death Benefit Plan.
If all questions 1 through 8 are answered “No” the Proposed Insured should apply for the Immediate Death Benefit Plan.
Form No. OL9466-FL(Rev.1/15)
CHILD, GRANDCHILD, AND GREAT GRANDCHILD COVERAGE - Children Proposed for Insurance (list additional children on a separate sheet):
Proposed Insured Name Sex Birthdate Relationship Proposed Insured Name Sex Birthdate Relationship

I certify that I have legal guardianship for any children proposed for life insurance.
SIGNATURE:________________________________________________ DATE:_____________
PROPOSED CHILDREN’S HEALTH STATEMENT—To the best of my knowledge and belief, none of the children listed above for coverage have been treated
for, or diagnosed by a licensed medical professional that they have or had any of the following medical conditions: Hypertension, heart or circulatory disorder,
malignancy in any form, diabetes, sickle cell anemia, seizures, Down Syndrome, cystic fibrosis, cerebral palsy, hydrocephalus, paralysis, or hospitalized
for asthma or any respiratory disorder in past 12 months. List the names of children that are exceptions to PROPOSED CHILDREN’S HEALTH STATEMENT.
Children listed as an exception are excluded from the appropriate Child Rider Coverage. Exceptions are:____________________________
AGREEMENT—I agree with Occidental Life Insurance Company of North Carolina (the Company) as follows: (1) To the best of my knowledge and
belief, all answers and statements contained in this application are true, complete and correctly recorded; and (2) This application and any policy issued
on the basis of such application shall form the entire contract; and (3) No change in this contract shall be effected without my written consent with
regard to: (a) the amount of insurance; (b) age at issue; (c) classification of risk; (d) plan of insurance; or (e) benefits. If this application is declined by
the Company, I will accept the return of any premium paid.
AUTHORIZATION—In order to properly classify my application for life insurance, I authorize any and all physicians, medical practitioners, hospitals,
clinics, medical or medically-related facilities, health plans, pharmacy benefit managers, pharmacies or pharmacy-related facilities; insurance
companies and their business associates and those persons or entities providing services to the insurer’s business associates which are related in
any way to their insurance plans; the MIB, Inc. or other organization that has knowledge or records of me and my health to give such information to:
(a) Occidental Life Insurance Company of North Carolina; and (b) its reinsurers. I understand that any information that is disclosed pursuant to this
authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information. I understand that
I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization or the insurance
company exercises a legal right to contest a claim or the policy itself. I may revoke the authorization by sending a written revocation to the Company
address of 425 Austin Ave., Waco TX 76701. I understand that if I refuse to sign this authorization to release my complete medical records, my
application for insurance with the Company will be rejected.
All said sources, except the MIB, Inc., are authorized to give records or knowledge such as statements regarding hobbies, employment, criminal
records or medical history that might be required to determine eligibility for insurance to any agency employed by the Company to collect and transmit
data. l authorize Occidental Life Insurance Company of North Carolina to disclose any personal data gathered while processing this application. This
data may be released to the following: (a) reinsuring companies; (b) the MIB, Inc.; (c) other persons or groups performing services in connection with
this application; or (d) any others to whom it may be lawfully required or authorized. This authorization shall remain valid for two years from this date.
A copy of this authorization shall be as valid as the original.
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing
any false, incomplete, or misleading information is guilty of a felony of the third degree.
I acknowledge receiving the Fair Credit Reporting Act Notice, the MIB, Inc. Pre-Notice and the Terminal Illness Accelerated Benefit Rider Disclosure Form.
Signed at ____________________________________________ Date of Application _____________________________________
CITY STATE MONTH DAY YEAR
______________________________________________________ _____________________________________________________
SIGNATURE OF PROPOSED INSURED SIGNATURE OF OWNER (IF OTHER THAN PROPOSED INSURED)

AGENT’S REPORT
Does the proposed insured have any existing life insurance or annuity contract? ................................................................................. Yes No
Is the proposed insurance intended to replace or change any existing life insurance or annuity?.......................................................... Yes No
I certify that I have personally asked each question on this application to the proposed insured(s), I have truly and completely recorded on the
application the information supplied by him/her, and I witnessed their signature.
I certify that the Terminal Illness Accelerated Benefit Rider Disclosure Form has been presented to the applicant.
AGENT’S REMARKS:________________________________________________________________________________________________
_______________________________________ ______________ _______________________________________ ______________
AGENT’S PRINTED NAME DATE AGENT’S PRINTED NAME DATE
Agent _________________________________________________ Agent Printed Name _______________________________%______
SIGNATURE LICENSE IDENTIFICATION NUMBER
Agent _________________________________________________ Agent Printed Name _______________________________%______
SIGNATURE LICENSE IDENTIFICATION NUMBER

PREAUTHORIZATION CHECK PLAN - AUTHORIZATION TO HONOR CHARGE DRAWN

Insured______________________________________________________Account Holder________________________________________
Financial Institution__________________________________________Address_________________________________________________
Transit/ABA Number_________________Account Number_______________ Checking Savings Requested Draft Day (1st-28th)________
ATTACH VOIDED CHECK OR DEPOSIT SLIP
As a convenience to me, I hereby request and authorize you to pay and charge to my account amounts drawn on my account, whether by electronic
or paper means, by and payable to the order of Occidental Life Insurance Company of North Carolina, for the purpose of paying premiums on life
insurance policy, provided there are sufficient funds in said account to pay the same upon presentation. I agree that your rights with respect to each
such charge shall be the same as if it were signed personally by me. This authorization is to remain in effect until revoked by me in writing and
until you actually receive such notice. I agree that you shall be fully protected in honoring any such check. I further agree that if any such check be
dishonored, whether with or without cause, and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such
dishonor results in the forfeiture of insurance.
__________________________________________________ __________________________________________________
SIGNATURE (AS ON FINANCIAL INSTITUTION RECORDS) DATE
Form No. OL9466-FL(Rev.1/15)
 OCCIDENTAL LIFE INSURANCE COMPANY OF NORTH CAROLINA
P.O. BOX 2595, WACO, TX 76702-2595
CONDITIONAL RECEIPT
NO COVERAGE WILL BECOME EFFECTIVE PRIOR TO POLICY DELIVERY UNLESS AND UNTIL ALL CONDITIONS OF THIS RECEIPT ARE MET. NO AGENT HAS THE AUTHORITY
TO ALTER THE TERMS OR CONDITIONS OF THIS RECEIPT.
ALL PREMIUM CHECKS MUST BE PAYABLE TO THE COMPANY
DO NOT MAKE CHECK PAYABLE TO THE AGENT OR LEAVE PAYEE BLANK
Received of______________________________________the sum of $__________________________as first payment on this application.
Date___________________________________________________________Agent__________________________________________________________
If (1) an amount equal to the first full premium is submitted; and if (2) all underwriting requirements, including any medical examinations required by the Company’s
rules, are completed; and (3) the proposed insured is, on the date of application, a risk acceptable for insurance exactly as applied for without modification of plan,
premium rate, or amount under the Company’s rules and practices, then insurance under the policy applied for shall become effective on the latest of (a) the date
of application, or (b) the date of the latest medical exam required by the Company. THE AMOUNT OF LIFE INSURANCE, INCLUDING ANY AMOUNT IN FORCE OR BEING
APPLIED FOR, WHICH MAY BECOME EFFECTIVE PRIOR TO THE DELIVERY OF THE POLICY SHALL IN NO EVENT EXCEED $30,000.00 (INCLUDING LIFE INSURANCE AND
ACCIDENTAL DEATH BENEFITS).
If any of the above conditions are not met, the liability of the Company shall be limited to the return of any amount paid.

NOTICE
Printed in compliance with Public Law 91-508
Thank you for considering Occidental Life Insurance Company of North Carolina for your insurance needs. This is to inform you that as part of our procedure for
processing your insurance application, an investigative consumer report may be prepared whereby information is obtained through personal interviews with your
neighbors, friends, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation and personal characteristics. You
have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation.
MIB, INC. PRE-NOTICE
Information regarding your insurability will be treated as confidential. Occidental Life Insurance Company of North Carolina, or its reinsurers, may, however, make a brief
report thereon to the MIB, Inc., formerly known as Medical Information Bureau, a not-for-profit membership organization of life insurance companies, which operates an
information exchange on behalf of its members. If you apply to another MIB, Inc. member company for life or health insurance coverage, or a claim for benefits is submitted
to such a company, MIB, Inc., upon request, will supply such company with the information about you in its file.
Upon receipt of a request from you, MIB, Inc. will arrange disclosure of any information in your file. If you question the accuracy of information in MIB, Inc.’s file, you
may contact MIB, Inc. and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB, Inc.’s information
office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734.
Occidental Life Insurance Company of North Carolina, or its reinsurers, may also release information from its file to other insurance companies to whom you may apply for
life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB, Inc. may be obtained on its website at www.mib.com.