Preliminary Inquiry Not an application for life insurance.

This form is used exclusively to gather specific information on a proposed insureds medical history and other factors that may impact underwriting and rating classification. This is not an application for insurance and in no way guarantees a specific underwriting class or binds any insurance coverage with any insurance carrier.

Phone

PERSONAL HISTORY (this section must be completed)

Name Male City Female Social Security Number

Address

State

Zip

Date of Birth

Age

Height

Weight

Monthly Earned Income

Net Worth

Occupation

PRODUCER INFORMATION (this section must be completed)

Name Social Security Number Producer Number

Address

City

State

Zip

Phone

Fax

Email Address

Have you submitted this case previously?

Yes

No

GOALS OF THE CASE

What is the ultimate goal of the case? What premium is needed to place the case? Are you in competition? Yes No If in competition, with what companies?

Where has the case been shopped and list the outcome? Are there any carriers we shouldnt consider? Did you discuss this case with an Advanced Sales Associate? Did you discuss this case with an Underwriter? If yes, who? Is your client interested in the following? Annuities Disability Insurance Long Term Care Insurance Life Settlements Yes Yes No No Please check if applicable Business Planning Other Estate Planning Charitable Planning

All pages of the TimeSaverTM

Proposed Insured REQUESTED COVERAGE (this section must be completed)

Minimum Consideration: $500,000 face amount for permanent products $750,000 face amount for term products Face amount desired? Universal Life Variable Life Term, Level Period Will these premiums be financed? Yes

Social Security Number

Survivorship Whole Life

Yes No

No

Possibly

If you are replacing coverage, will there be any 1035 money with this replacement? Provide details on pending and in-force coverage: Company Policy/Application Date Amount

If yes, what amount will be carried over?

Class/Rating Issued

Current Premium

Do you intend to replace?

Life Settlements: Indicate any activity in the past five years

TOBACCO/NICOTINE USAGE (this section must be completed)

Have you ever smoked cigarettes: Yes No If yes, date of last usage: Yes No

Have you used other tobacco or nicotine containing products (examples: cigars, pipe, snuff, nicotine gum or patch) If yes, provide types and last date of use:

MEDICAL HISTORY (this section must be completed)

Doctors name, address, phone Who is your primary care physician? When did you last consult him/her? Why? Date Illness/Reason

What other physicians have you consulted during the past five years? Why? (do not include insurance examinations)

In what hospitals, clinics, or other health facilities have you ever been treated?

List all medications, including over-the-counter drugs and vitamins

FAMILY HISTORY (this section must be completed)

Have any immediate family members (parents, siblings) been diagnosed or died from heart disease or cancer? If yes, provide details below.
Relation (mother, father, brother, sister) Diagnosis Approximate age of disease onset

Yes

No

(if deceased) age at death

All pages of the TimeSaverTM must be completed. Inquiry cannot be considered unless authorization is signed by Proposed Insured.

Proposed Insured DRUG AND ALCOHOL USAGE QUESTIONNAIRE

Do you currently drink alcohol? Date of last consumption: Note amounts below: Type Beer Wine Liquor Have you ever consulted a doctor or received treatment because of alcohol use? Yes No Yes Amount per week Yes No

Social Security Number

check here if this section is not applicable Do you ever drink substantially more than present? If yes, when? Note amounts below: Type Beer Wine Liquor Have you ever been arrested for driving under the influence of alcohol? Yes No No If yes, provide date(s) Amount per week Yes No

Have you ever used illegal drugs or sought treatment because of drug use? If yes, provide details Type of drug(s) used Doctor/facility name and address

Date of last use

CORONARY

check here if this section is not applicable Number of diseased vessels

Date of diagnosis or first chest pain Dates/details of treatment/surgery (examples: Angioplasty, Bypass)

Date of last stress EKG Any pain since treatment/surgery?

Results

By whom?

CANCER

check here if this section is not applicable Stage and grade Date/details of treatment/surgery

Exact name and location of cancer Who would have the pathology report

DIABETES
Date of diagnosis

check here if this section is not applicable Treatment Results mg% Yes Yes No No Date Yes Yes Yes No No No High blood pressure Insulin reactions Yes Yes No No Heart trouble Neuritis/Neuralgia Diet only Oral medication Insulin Details Frequency

Do you regularly test your blood glucose? Yes No

Latest result of glycohemoglobin (A1C) test Have you ever had: Have you ever had: Eye trouble Kidney trouble

Have you been diagnosed with having protein and/or microalbumin in your urine?

HAZARDOUS ACTIVITIES
Are you a private pilot? If yes, provide details. Yes

check here if this section is not applicable No How many total hours have you flown as Pilot in Command? How many hours do you fly per year? Ultralight Flying Auto/Motorcycle Racing Do you have an IFR (instrument flight rating) Sky Diving Other Yes No

Do you participate in the following activities? (check those that apply) Scuba Diving Bungee Jumping Mountain Climbing Hang Gliding

Please refer to our website or contact your Sales Manager for additional questionnaires and information.
All pages of the TimeSaverTM must be completed. Inquiry cannot be considered unless authorization is signed by Proposed Insured.

AUTHORIZATION
INSURANCE CARRIERS
Allianz Life Insurance Company of New York Allianz Life Insurance Company of North America Allstate Life Insurance Company of New York American General Life American National Insurance Company Assurity Life Aviva Life and Annuity Company Aviva Life and Annuity Company of NY AXA-Equitable Banner Life Companion Life Insurance Company Fidelity Security First MetLife Investors Insurance Company First Symetra National Life Insurance Company of New York Genworth Life and Annuity Insurance Company Genworth Life Insurance Company Genworth Life Insurance Company of NY ING ReliaStar Life Insurance Company ING ReliaStar Life Insurance of NY ING Security Life of Denver John Hancock (USA) John Hancock Life Insurance Company of NY Liberty Life Assurance Liberty Life Insurance Company Lincoln Benefit Life Lincoln Financial Lincoln Life & Annuity of NY Lloyds of London MetLife Investors Metropolitan Life Insurance Company Minnesota Life* Mutual of Omaha National Life Insurance Company* Nationwide North American Life & Health Penn Mutual Presidential Life Insurance Company* Principal Life Insurance Company Principal National Life Insurance Company Protective Life Protective Life & Annuity Insurance Company Prudential Financial Security Mutual Life Sun Life Financial Sun Life Insurance & Annuity of NY Symetra Life Insurance Company Transamerica Financial Life Insurance Company Transamerica Life Insurance Company Union Central Life Insurance Company United of Omaha Life Insurance Company United States Life Insurance of NY West Coast Life William Penn Insurance Company of NY Zurich American*

*Limitations apply; see your Sales Manager for questions.

MEDICAL UNDERWRITING PREMIUM FINANCING ENTITIES

21st Medical RSA Services IBU, Inc. American Viatical Services, LLC Burgess Group C2 Cambridge Financing Company (CFC) Capital Management Strategies, Inc. (CMS) Credit Suisse

Deutsche Bank Enterprise Bank & Trust Examination Management Services, Inc. (EMSI) Fasano Associates, Inc. First Boston LLC First Choice Strategies First Insurance Funding

Goldman Sachs Heritage Labs International, LLC Insurative US (IPF) Northern Trust Ridge Capital Partners, LLC Sentinel Funding Group, LLC

Print Name of Proposed Insured

Proposed Insureds Signature (or that of Authorized Representative)

Date

All pages of the TimeSaverTM must be completed. Inquiry cannot be considered unless authorization is signed by Proposed Insured.

This Authorization is HIPAA compliant. This Authorization is HIPAA compliant

Proposed Insured: Proposed Insured: _____________________________________________________________________________________________________________________ Date of Birth: Social Security #: This Authorization

AUTHORIZATION

AUTHORIZATION

is HIPAA compliant.

Purpose: of Birth: _____________________________________________ Date Social Security # ________________________________________________________ The purpose of Insured: Authorization (the Authorization) is to permit Crump Life Insurance Services, Inc. and its affiliates to obtain non-public personal Proposed this HIPAA information about me, the Insured named above, for the purposes of (1) to determine my eligibility for and obtaining insurance products and services from one Purpose: or more of of Birth: this HIPAA Authorization (the Authorization) is to permit #: health or medical status and condition affiliates to obtain non-public personal The purpose of Date the insurance carrier or other entities; (2) to monitor, track, or verify my Social Security SouthCap Brokerage Group, Inc. and its in connection with any life insurance policy under which my life is insured, including named above, for the purposes of (1) to determine my eligibility for and obtaining insurance products and services from information about me, the Insured any conversions thereof or replacements therefore; and (3) to develop and use indices that do not personally identify individuals one actual of anticipated longevity, mortality, life expectancies, and/or similar measures. related toor moreandthe insurance carrier or other entities; (2) to monitor, track, or verify my health or medical status and condition in connection with any life Purpose: insurance policy this HIPAA my life is insured, including any conversions thereof or replacements therefore; and (3) to develop and use indices that do not The purpose of under which Information to be Released: Authorization (the Authorization) is to permit Crump Life Insurance Services, Inc. and its affiliates to obtain non-public personal personally identify individuals related to actual and for the purposes of (1) to determine my eligibilityand/or similar measures. anticipated longevity, mortality, life expectancies, for and obtaining insurance products and services information about me, the this Authorization refers The term Information as used inInsured named above, to the information to be released pursuant to this Authorization including but not limited to any from one or more of the insurance health information, records or data concerningverifypast,health or or future mental, physical orin connection with anycondition carrier or other entities; (2) to monitor, track, or my my present medical status and condition behavioral health or life insurance policy non-public personal, be Released: Information to financial, under which my life is insured, including any conversions thereof or replacements therefore; and (3) to and use indices that do (Information), to the extent permitted byAuthorization refers to the information to be released pursuantdevelopAuthorization including not personally identify individuals The term Information as used in this law. to this but not limited to any related to actual and anticipated longevity, mortality, life expectancies, and/or similar measures. non-public personal,includes all information, records or datadata concerning my past, or mental historymental, physical or behavioral health or condition financial, health information, records or relating to my: physical present or future or condition; medical treatment, diagnosis, or Specifically, Information Information to be Released: (Information), to the extent permitted to me; prognosis, including medications prescribed by law. other insurance coverage(s); hazardous activities; general character and general reputation; finances; The term Information as used hazardous hobbies; driving the information activities and pursuant to this Authorization including but not limited to occupation; avocation, including any in this Authorization refers torecords; aviation to be releasedother personal traits. The term Information does not include any Specifically,personal, financial, health information, records or data concerning my past, present orhistory or condition; medical treatment, diagnosis, or non-public Information includes all information, records or data relating to my: physical or mental future mental, physical or behavioral health or condition psychotherapy notes. prognosis, including medications prescribed to me; other insurance coverage(s); hazardous activities; general character and general reputation; finances; (Information), to the extent permitted by law. I understand thatavocation, including any hazardous hobbies; driving records; aviation activities and other personal traits. The term Information does not occupation; this Information may include results from blood, saliva, urine and other tests. Specifically, Information includes all information, records or data relating to my: physical or mental history or condition; medical treatment, diagnosis, or include psychotherapy notes. I further understand that this Information may, if applicable, include information regarding diagnosis, prognosis and treatment of: alcohol or drug abuse prognosis, including medications prescribed to me; other insurance coverage(s); hazardous activities; general character and general reputation; finances; (including records avocation, under federal law, 42 CFR Part 2); driving records; aviation activities infection, including traits. The term Information does not include protected including serious communicable disease or and other personal sexually transmitted diseases; HIV infection, Ioccupation; that this Information any hazardous hobbies; blood, saliva, urine and other tests. understand may include results from including medical test results. psychotherapy notes.

IIfurther understand that this Information may, if applicable, include saliva, urine and other tests. understand Authorization: that this Information may include results from blood, information regarding diagnosis, prognosis and treatment of: alcohol or drug abuse (including records protected medical practitioner, anyPart 2); clinic, or other health-related infection, including sexuallylaboratory, any insurer, any state CFR hospital, transmitted diseases; HIV I authorize anyunderstandor otherunder federal law, 42if applicable, serious communicable disease orfacility, any medicaland treatment of: alcohol or drug abuse I further physician that this Information may, include information regarding diagnosis, prognosis testing infection, including medical test results. motor vehicle department, my past or current employer(s), the Social serious communicable diseaseany infection, including sexually transmitted diseases; HIV infection, Security Administration, and or other organization, institution or person (an Authorized (including records protected under federal law, 42 CFR Part 2); HCP) that has Information about me to disclose any and all Information to Crump Life Insurance Services, Inc. and its agents and representatives. I also authorize my including medical test results. Authorization: Agent, named below, to receive Information to assist in the purpose of this Authorization to the extent permitted by law. I authorize any physician or other medical practitioner, any hospital, clinic, or other health-related facility, any medical testing laboratory, any insurer, any Authorization: state motor vehicle department, my past or current employer(s), the Social Security been subject to state and federal privacy laws and regulations. (an I understand that Information disclosed to Crump Life Insurance Services, Inc. may have Administration, and any other organization, institution or person Once I authorize any that Crump Life Insurance me to disclose hospital, Information to to those and and regulations. I understand I also Authorized HCP or Authorized HCP)physician or other medical Services, Inc., itany and longer or other SouthCaplaws its agents and representatives.that noauthorize my Information is disclosed tohas Information aboutpractitioner, anymay no allclinic,be subjecthealth-related facility, any medical testing laboratory, any insurer, any state motor vehicle department, my past or current enrollment, the Social for benefits on whether sign permitted by law. Agent, named below, to receive Information to assist in the purpose of this Authorization to the extent this Authorization. covered entity may condition my treatment, payment,employer(s), or eligibilitySecurity Administration, Iand any other organization, institution or person (an Authorized HCP) that has Information about me to disclose any and all Information to Crump Life Insurance Services, Inc. and its agents and representatives. I also authorize my A photocopynamed below, to receive Information to as thein thehaveI been subject to state thisto the extent permitted byregulations. Once Information is disIAgent, of this Authorization disclosed to SouthCap may purpose of this Authorization Authorization. laws and law. understand that Information shall be as valid assist original. will receive a copy of and federal privacy closed to SouthCap, may no longer be subject give, provide, and release any understand that no Authorized HCP federal placement of a life insurance I hereby further authorizeitCrump todiscloseddisclose,to those laws and Services, Inc.Imay have been subject connection with the privacy laws and regulations. Once I understand that Information deliver, to Crump Life Insurance regulations. and all Information in to state and or covered entity may condition my treatment, payment, enrollment, or eligibility for benefits on for the I sign this Authorization. policyInformationproduct to any insurance carrier or other entity whetherpurposes of health or medical information regulations. I understand that no Authorized HCP or or related is disclosed to Crump Life Insurance Services, Inc., it may no longer be subject to those laws and review or underwriting. covered entity may condition such insurance carriers enrollment, or eligibility for benefits on whetherTM sign I A partial list has been provided of my treatment, payment, and other entities on pagecopy of this Authorization. this Authorization. A photocopy of this Authorization shall be as valid as the original. I will receive a 4 of this TimeSaver . RightA photocopy of this Authorization shall be as valid as the original. I will receive a copy of this Authorization. to Revoke Authorization: I hereby further authorize SouthCaptwo (2) years after give, provide, and release any and all and understand that I may revoke placement of a life insurto deliver, disclose, This Authorization shall be effective for to deliver, disclose, the date signed below. I acknowledgeInformation in connection with thethis Authorization any time with I hereby further authorize Crump give, provide, and release any and all Information in connection with the placement of a life insurance ance any Authorized HCP by notifying such Authorized or other entity of the purposes of this Authorization and delivering my or underwriting. to respect to policy or related productanyany insurance carrierotherin writing formy revocation of health or medical information reviewrevocation by mail or personal policy or related product to insurance carrier or HCP entity for the purposes of health or medical information review or underwriting. delivery at such address designated to me by such Authorized HCP, provided that, any revocation of this Authorization shall not apply to the extent that the Authorized A partial action been provided of this Authorization prior and otherwritten notice of my4 this inquiry. A taken list has been provided such insurance carriers receiving entities on page 4 of this TimeSaverTM. HCP haspartiallist has in reliance upon of such insurance carriers and other entities on pageofrevocation. Right to Revoke Authorization: Right to Revoke Authorization: This Authorization shall be effective for two (2) years after the date signed below. I acknowledge and understand that I may revoke this Authorization any time with This Authorization shall be effective for two (2) years after the date signed below. I acknowledge and understand that I may revoke this Authorization any respect to any Authorized HCP by notifying notifying such Authorized HCP in writing of my of this Authorization and delivering delivering my revocation time with respect to any Authorized HCP by such Authorized HCP in writing of my revocationrevocation of this Authorization andmy revocation by mail or personal delivery at such address designated address such Authorized by such Authorized HCP, provided that, Authorization of this Authorization shall not apply by mail or personal delivery at such to me bydesignated to meHCP, provided that, any revocation of thisany revocationshall not apply to the extent that the Authorized Proposed Insureds that the Authorized HCP has taken action in reliance upon this Authorization prior receiving written notice of my revocation. Date HCP extent Signature (or that of Authorized Representative) to thehas taken action in reliance upon this Authorization prior receiving written notice of my revocation.

Proposed Insureds Signature (or that of Authorized Representative) Print Name of Proposed Insured

Date

Print Name of Proposed Insured If signed by Authorized Representative of Proposed Insured, describe authority, e.g., parent or guardian of minor child

If signed by Authorized Representative of Proposed Insured, describe authority, e.g., parent or guardian of minor child Print Name of Agent All pages of the TimeSaverTM must be completed. Inquiry cannot be considered unless authorization is signed by Proposed Insured.
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Print Name of Agent All pages of the TimeSaverTM must be completed. Inquiry cannot be considered unless authorization is signed by Proposed Insured.

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