Branch/Order # 439-045939

Exam Appointment InformationConsumer Information

Customer Information

FAST: Yes (Account) Delivery InstructionsOriginal Exam Paperwork

ExamForm Goes To: AGENCY - ECG Goes To: AGENCY -

Application Packet Copy of ExamMailing Address:

Fax:

FMS Instructions

Service to Perform

Form Information

Lab Information

Fasting 12 Hours Preferred (No fasting required if applicant is diabetic or pregnant.), Number of BP Recordings: 1,,

Order Date: 2/26/2015 Print Date: 2/26/2015

Delivery CommentsCompleted paperwork is to be mailed to the brokerage. Please obtain the address when taking the order.

State Instructions

Service Code Instructions Interpretation Instructions

Scheduling Instructions

Packet Instructions

Carrier: SBLI Address: 1 Linscott Rd Woburn, MA 01801 Woburn MA 01801-0000 Account: SBLI-MA-BROKERAGE Address:

Policy Amount: $300000Policy Type: LifePolicy Number: Smoker: No

Ordering Customer: Li, YaleiAgent Name: Li, YaleiAgent Code: PendingAgency Name: 3MarkAgency Code: OC Associations:

003 - EXAM, URINE/BLOOD-VENIPUNCTURE072 - STATE REQUIRED CONSENT FORM/SPCL HNDLING108 - BLOOD PROFILE KIT

Lab: Lab One/Quest Lab Code: BYYLab Slip: , Courier: Fasting: Preferred (12 Hours)

Write "SBLI-MA-BROKERAGE" in the name field on lab slip.

Document - FAST CoverSheet, Basic exam form - A-92 (02 2009) & A-92E - A-92 (02 2, Continuation form - Continueform.tif - Continuefo, HIV Consent Form - A57 TX 12 2012, HIPAA - MD-342.tif,

Name: Caisia GaoDOB: 9/23/1963 Nearest Age: 51 Gender: F

Home Address: 5827 Camelia Evergreen Ln , Richmond, TX, 77407 Home: Work: Extn: Cell: (832)436-8858 Other:

Exam Appointment Date/Time: Friday 02/27/2015 at 12:00 PM

FMS Name: My M Nguyen

Exam Location: Other10333 Harwin Dr Ste 460H Houston TX 77036

A-57 TX Page 1 of 2 (12/2012)

The Savings Bank Life Insurance

Company of Massachusetts One Linscott Road, Woburn MA 01801

Telephone (800) 694-7254 ~ www.sbli.com

NOTICE AND CONSENT FOR HIV-RELATED TESTING

To evaluate your insurability, the Insurer named above (the Insurer) has requested that you provide a sample of your blood, oral fluid extracted from cheek and gum tissue, or urine for testing and analysis to determine the presence of human immunodeficiency virus (HIV) antibodies. By signing and dating this form you agree that this test may be done and that underwriting decisions will be based on the test result. A series of three tests will be performed by a licensed laboratory through a medically accepted procedure. Pre-Testing Considerations: Many public health organizations have recommended that before taking an HIV-related test a person seek counseling to become informed concerning the implications of such a test. You may wish to consider counseling, at your expense, prior to being tested. Meaning of Positive Test Result: The test is not a test for AIDS. It is a test for antibodies to the HIV virus, the causative agent for AIDS, and shows whether you have been exposed to the virus. A positive test result does not mean that you have AIDS but that you are at significantly increased risk of developing problems with your immune system. The test for HIV antibodies is very sensitive. Errors are rare, but they do occur. Your private physician, a public health clinic, or an AIDS information organization in your city might provide you with further information on the medical implications of a positive test. Positive HIV antibody test results will adversely affect your application for insurance. This means that your application may be declined, that an increased premium may be charged, or that other policy changes may be necessary. Confidentiality of Test Results: All test results are required to be treated confidentially. They will be reported by the laboratory to the Insurer. The test results may be disclosed as required by law or may be disclosed to employees of the Insurer who have the responsibility to make underwriting decisions on behalf of the Insurer or to outside legal counsel who needs such information to effectively represent the Insurer in regard to your application. The results may be disclosed to a reinsurer, if the reinsurer is involved in the underwriting process. The test may be released to an insurance medical information exchange under procedures that are designed to assure confidentiality, including the use of general codes that also cover results of tests for other diseases or conditions not related to AIDS, or for the preparation of statistical reports that do not disclose the identity of any particular person. Notification of Test Result: If your test results are negative, no routine notification will be sent to you. If your test results are reported by the laboratory to the Insurers as being positive, you will receive written notification of such results from a physician you have designated or, in the absence of such designation, from the Texas Department of Health. Because a trained person should deliver that information so that you can understand clearly what the test result means, please list your private physician so that the Insurer can have him or her tell you the test result and explain its meaning. Name of physician for reporting a possible positive test result: ____________________________________________________ Address: ____________________________________________________________________________________ In the event the test is positive and you are denied coverage because of that fact and you request the reason for the denial, the insurer may require you to name a physician at that time in order to receive the information. If the test indicates a positive result, but you do not designate a private physician, the test results will be provided to you by a representative of the Texas Department of Health.

A-57 TX Page 2 of 2 (12/2012)

Consent: I have read and I understand this Notice and Consent for HIV-Related Testing. I voluntarily consent to the collection of a sample of blood, oral fluid extracted from cheek and gum tissue, or urine from me, the testing of that sample, and the disclosure of the test results as described above. I have read the information on this form about what a test result means. I understand that I have the right to request and receive a copy of this authorization. A photocopy of this form will be as valid as the original. _________________________________ _____________________________________ ___________ Print Name of Proposed Insured Signature of Proposed Insured or Parent/Guardian Date

Address: ___________________________________________________________________________

___________________________________________________________________________

The Savings Bank Life Insurance Company of Massachusetts One Linscott Road, Woburn MA 01801

Telephone (800) 694-7254 ~ www.sbli.com

A-92A Page 1 of 1 (03-08)

SUPPLEMENT TO

LIFE INSURANCE APPLICATION

Part IIThe Savings Bank Life Insurance Company of MassachusettsP.O. Box 4048, Woburn, MA 01888Telephone (800) 694-7254 www.sbli.com

Name of Proposed Insured Date of Birth Social Security Number Date of Application

I hereby request that the application on the life of the Proposed Insured be amended to include the following:

C. DETAILS For any “Yes” answers. Please identify applicable Question.State conditions, diagnoses, dates, durations, treatments, tests, medications prescribed and names, phone numbers and addresses of all careproviders and treatment facilities.

To the best of my knowledge and belief, I hereby represent that the above answers and statements are complete, correct and true. I agree that SBLI,believing them to be complete, correct and true, shall rely and act on them. I agree that they shall be a part of my application for insurance or policychange request.

Signature of Proposed Insured Date City, State

If Producer recorded information:Signature of Writing Producer Date City, State

If Tele-interviewer recorded information:Name Date

If Paramedical recorded information:Examiner’s Name Date Phone Number

A-92 Page 1 of 4 (02-09)

LIFE INSURANCE

APPLICATION

Part IIThe Savings Bank Life Insurance Company of MassachusettsP.O. Box 4048, Woburn, MA 01888Telephone (800) 694-7254 www.sbli.com

Professional health care provider (“care provider”) means persons licensed as: medical physicians; chiropractors; physical therapists; psychologists;and drug, alcohol, or mental health counselors. Professional health care treatment facility (“treatment facility”) includes: hospitals; clinics; drug oralcohol treatment or consultation facilities; nursing homes; mental health facilities; ambulatory care centers; and facilities or offices staffed or run by careproviders.

A. PROPOSED INSURED INFORMATION1. Full Name (First, Middle, Last) 2.Date of Birth (mm/dd/yyyy) 3. SSN

B. MEDICAL HISTORY Please answer ALL medical history questions. Do not leave any questions blank. Explain “Yes” Answers in DETAILS1. Primary Care Provider (“PCP”)Provide name, address and phone number of your PCP. For the past 5 years, describe dates, reasons consulted, and any treatments or medicationsprescribed in Section C, DETAILS, below. (If no PCP, provide names, addresses and phone numbers of care providers last seen, dates and thereasons for the visits. If none, state “NONE”).

Name and address of PCP(or other care provider)

Phone NumberDates

ConsultedReasons for Consultation

Treatments and MedicationsPrescribed

2. Builda. Height

ft. in.b. Weight

lbs.c. Have you had any weight change in excess of 10lbs. in the past year? Yes No

3. Personal Health History (For any “Yes” answers, provide details in Section C, DETAILS, below)a. Have you ever had, been treated for, or been medically advised to be treated for any of the following?

Yes No Yes No Yes No1. Anemia or other Blood Disorder 16. Dizziness/Fainting 31. Paralysis 2. Angina/Chest Pain 17. Emphysema 32. Pituitary Disorder 3. Anxiety/Depression/Mental

Disorder 18. Epilepsy/Seizures 33. Prostate Disorder

4. Asthma 19. Gastrointestinal/EsophagealDisorder/Ulcer

34. Respiratory Disorder, ChronicCough, Spitting up Blood

5. Backache or Sciatica 20. Genito-urinary Disorder 35. Any Sexually Transmitted Disease 6. Bone, Joint or Arthritis 21. Heart Attack or Heart Disease 36. Shortness of Breath 7. Bronchitis 22. Heart Murmur/Rheumatic Fever 37. Skin Disorder 8. Cancer 23. Hepatitis 38. Sleep Apnea 9. Chronic Headaches 24. High Blood Pressure 39. Stroke 10. Circulatory Disorder 25. Kidney Disorder 40. Sugar, Protein, or Blood in Urine 11. Clotting Disorder 26. Lupus(SLE)/Scleroderma 41. Suicide Attempt 12. Colitis/Ileitis 27. Lymph Gland Disorder 42. Thyroid Disorder 13. Diabetes 28. Multiple Sclerosis 43. Tuberculosis 14. Disease of the Brain or Nervous

System 29. Palpitations/Arrhythmia 44. Tumor, Mass or Lump

15. Disease of the Liver orGallbladder

30. Pancreatitis or other Disorder ofthe Pancreas

b. In the past 5 years, have you:1. consulted with or received treatment from a care provider or treatment facility?...................................................................................... Yes No2. had an EKG, X-ray, or other diagnostic test, other than an AIDS-related test?........................................................................................ Yes No3. been advised to have any diagnostic test, other than an AIDS-related test, hospitalization or surgery that was not completed?............ Yes No4. had medication prescribed for any other condition not listed in question 3(a), above?............................................................................. Yes No5. ever received or claimed disability or hospital indemnity benefits or pension for any injury, sickness, disability or impaired condition?. Yes No

A-92 Page 2 of 4 (02-09)

___________________________________Name of Proposed Insured

c. Have you ever:1. sought or received advice, counseling or treatment by a care provider for the use of alcohol or drugs, including prescription drugs?.... Yes No2. used cocaine, marijuana, heroin, narcotics, stimulants, sedatives, hallucinogens, controlled substance or any other drug,

except as legally prescribed by a physician?................................................................................................................................................. Yes No3. been diagnosed as having or been treated by a care provider for AIDS Related Complex (ARC) or Acquired Immune

Deficiency Syndrome (AIDS)? ...................................................................................................................................................................... Yes No4. used alcoholic beverages? ...........................................................................................................................................................................

If “Yes”, type: Frequency: Amount:Yes No

d. Do you have any symptoms or knowledge of any other conditions that are NOT disclosed above? ..……………………………………… Yes No

4. Family History

a. Is there a history of diabetes, cancer, high blood pressure, heart or kidney disease, cardiovascular disease, alcoholism, mental illness,or suicide in your family?..............................................................................................................................................................................

b. Please complete the following:Yes No

Age ifLiving

State ofHealth

Age ofDeath

Cause of Death History of diabetes, cancer, heart disease or cardiovascular disease?

FatherYesNo ______________ ____________________________________

Age of Onset Type

MotherYesNo ______________ ____________________________________

Age of Onset Type

Brother

Sister

YesNo ______________ ____________________________________Age of Onset Type

Brother

Sister

YesNo ______________ ____________________________________Age of Onset Type

Brother

Sister

YesNo ______________ ____________________________________Age of Onset Type

Brother

Sister

YesNo ______________ ____________________________________Age of Onset Type

Brother

Sister

YesNo ______________ ____________________________________Age of Onset Type

Brother

Sister

YesNo ______________ ____________________________________Age of Onset Type

C. DETAILS For any “Yes” answers. Identify applicable question. If additional space is needed, use overflow form.State conditions, diagnoses, dates, durations, treatments, tests, medications prescribed and names, phone numbers and addresses of all care providersand treatment facilities.

A-92 Page 3 of 4 (02-09)

___________________________________Name of Proposed Insured

D. AGREEMENT AND SIGNATURESI, the Proposed Insured signing below, agree that I have read all of the statements contained in this entire application, or they have been read to meI understand and agree that no Producer is authorized to (a) accept risks or pass upon insurability; (b) make or modify contracts; (c) waive theCompany’s rights or requirements; or (d) waive any information the Company requests.

I represent: (1) the statements and answers given in the entire application are true, complete, and correct to the best of my knowledge and belief; (2) thatThe Savings Bank Life Insurance Company of Massachusetts, believing the statements and answers to be true, complete, and correct, shall rely and acton them, and (3) the insurance being applied for is suitable for the Owner’s insurance needs.

I acknowledge that I have received a copy or I have been read a copy of the Notice to Proposed Insured and Owner.

I agree that:(a) I will notify the Company if any statement or answer given in the entire application changes prior to policy delivery; and(b) except as provided in the Conditional Receipt Agreement (CRA), I understand and agree that even if I paid a premium, no insurance will bein effect under this application, or under any new policy or any rider(s) issued by the Company, unless the following three conditions are allmet:

(1) the policy has been delivered and accepted;(2) the full first modal premium for the delivered policy has been paid in full; and(3) there has been no change in the health of the Proposed Insured that would change the answers to any questions in the application,

or any amendments thereto, before conditions (1) and (2) above have occurred.

I understand and agree that if all three conditions are not met:- no insurance coverage will become effective; and- the Company’s liability will be limited to a refund of any premiums paid, regardless of whether loss occurs before premiums are refunded.

Signature of Proposed Insured

X________________________________________________________

Date City, State

E. SIGNATURE(S) OF INTERVIEWER(S) – TO BE SIGNED BY ALL INTERVIEWERS, AS APPLICABLE

I certify that the information supplied by the Proposed Insured has been truthfully and accurately recorded on the Part II application.

If Producer recorded information:

Writing Producer Name Date Writing Producer Number

Writing Producer Signature

X_________________________________________________________

Countersigned (Licensed resident Producer if state required)

X________________________________________________

If Tele-interviewer recorded information:

Name Date

If Paramedical recorded information:

Examiner’s Name Date Phone Number

Signature of Examiner

X_______________________________________________________

Date City, State

A-92 Page 4 of 4 (02-09)

___________________________________Name of Proposed Insured

F. CUSTOMER IDENTITY INFORMATION :To be completed by Producer or Paramed in physical proximity to the Proposed Insured (and Owner if different than Insured).

II have reviewed the Proposed Insured and Owner’s (if applicable) identity document presented and recorded the following information:

Proposed Insured (and Owner if applicable) Name:

Street Address: City and State: Zip Code:

Type of ID (Individual) (e.g. Drivers License):

Type of ID Document (Corporation/Trust) (e.g. Certificate of Good Standing or Trust):

ID Number: Expiration Date:

Signature of Producer or Paramed Authenticating Customer’s Identity:

X_________________________________________________________________________________________

Producer/ Paramed Number: Date:

The Savings Bank Life Insurance Company of MassachusettsP.O. Box 4048, Woburn, MA 01888Telephone (800) 694-7254 www.sbli.com

A-94 (09-08)

LIFE INSURANCE

APPLICATION

PART III – Completed by Examiner

Insured’s Name:

Insured’s Social Security Number: EKG required: No Yes – attach to this form

How have you identified the person being examined? Drivers License Other (specify)

Can the Proposed Insured speak and understand English? Yes No – Language spoken:

WWas an Interpreter present?

SECTION A: Complete for ALL applicants:

1. Males only: Chest measurement: in. Waist measurement: in.

2. Blood Pressure: If over 135/85, repeat x2, three minutes apart:SystolicDiastolic

3. Pulse: Rate Quality Irregularities/Minute(if over 90, repeat) Rate Quality Irregularities/Minute

4. Measured Height (In stocking feet): ft., in. Weight: lbs. (weigh applicant – normal street clothes)5. Females only: Menstruating at time of exam? Yes No6. Did you observe any indication of physical or mental impairment or abnormality not indicated in Part 2?

Yes No If “Yes”, explain:

SECTION B: Complete for PHYSICIAN’S EXAM ONLY: (Paramedic Examiner continue to Section C)

1. Is there, upon examination, any abnormality of the following:

a. eyes, ears, nose, mouth, pharynx? (If vision or hearing markedly impaired,indicate degree and correction.) Yes No

b. skin (include scars), lymph nodes, varicose veins, or peripheral arteries? Yes Noc. nervous system (include reflexes, gait and paralysis)? Yes Nod. respiratory system? Yes Noe. abdomen (describe scars)? Yes Nof. genitourinary system? Yes Nog. endocrine system (include thyroid)? Yes Noh. musculoskeletal system (include spine, joints, amputations and deformities)? Yes No

2. Are there any hernias? Yes No3. Are you aware of additional medical history? Yes No4. For the heart, is there any:

Enlargement? Yes No Dyspnea? Yes NoEdema? Yes No Murmur? Yes No

Location: First murmur Second murmurConstant Inconstant Transmitted Localized Systolic Presystolic Diastolic Soft (Gr.1-2) Mod. (Gr. 3-4) Loud (Gr.5-6)

SECTION C: Complete for ALL applicants:

I have personally seen the person whose name appears above and in Part 2. I am satisfied as to the identity of that person. I certify that Ipersonally weighed and measured the proposed Insured, and that the answers in Part 2 were correctly recorded by me.

ExaminerDate: Signature:

Printed Name: Sent to Lab: Urinalysis Blood Sample

Do not write in this space

Paramed Stamp

Provide details to each “Yes” answer.Identify question #. Use reverse side, orAttach additional sheet, if needed.

PORTAMEDIC • HERITAGE LABS • HEALTH & WELLNESS • UNDERWRITING SOLUTIONS6914-4 1/09

Continuation of Exam

Insurance Co.: Account number: Overflow Page of

Applicant: Date of Birth: / / Last First Middle

Agent: Policy Number:

Question # Diagnosis: Date:

Doctor:

Name:

Address:

Phone:

Treatment/Meds:

Duration:

Disposition:

Question # Diagnosis: Date:

Doctor:

Name:

Address:

Phone:

Treatment/Meds:

Duration:

Disposition:

Question # Diagnosis: Date:

Doctor:

Name:

Address:

Phone:

Treatment/Meds:

Duration:

Disposition:

Question # Diagnosis: Date:

Doctor:

Name:

Address:

Phone:

Treatment/Meds:

Duration:

Disposition:

Signature of Applicant: Date:

Signature of Examiner: Date:

Branch Address:

6919-2 6/08 PORTAMEDIC • HERITAGE LABS • CLAIMS SERVICES • HEALTH & WELLNESS • UNDERWRITING SOLUTIONS

No Show/No Image Available Form

Branch # Branch Name

Order # Applicant

Appointment No Show

Date/Time Applicant Missed Appointment

Reason

Description of appointment address:

Image Not Available

Originals sent to

Verified originals received YES NO

Date

Branch Mgr Signature

Fill out this form and fax wth the original FAST cover page and Order Ticket to HHQA at 1-877-220-9277 as notification an imaged copy is unavailable.