AMINDDI-APP-15 (NC) Page 1 of 3

PART A Amalgamated Life Insurance Company (the Company) Application for Please Use Black Ink 333 Westchester Avenue, White Plains, NY 10604 Disability Income Insurance 1. Proposed Insured’s Name - Last First Middle

2. Home Address - Street/Box No. City State Zip Home Phone Number

3. Mailing Address (if different) - Street/Box No. City State Zip

4. Social Security Number 5. Birthdate (Mo. Day Yr.) 6. Age Last Birthday 7. Gender Male Female

8. State of Birth

9. Name of Employer

10. Class 11. Occupation

12. Date of Employment (Mo. Day Yr.) / /

13. Duties 14. Average Monthly Earnings Last 12 Months $

15. Are you currently actively at work and able to perform the duties of your occupation? YES NO 16. To the best of your knowledge and belief: have you had a: a) heart attack; b) heart bypass; c) coronary artery

disease; d) stroke; e) cancer (other than basal or squamous cell skin cancer); and/or f) been treated or diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions? Yes No

Have you been hospitalized in the last 90 days (for any reason) or been recommended to seek: a) medical advice; b) treatment; c) care; and/or d) counseling that has not yet been performed? Yes No

SELECT THE COVERAGE YOU WANT BY SELECTING FROM BELOW: 17. BENEFIT PERIOD 19. BENEFITS WEEKLY PREMIUM

3 month 24 month 6 month 5 years 12 month

Monthly Disability Income: 24 hour coverage (check one box) off-the-job only coverage Benefit Amount: $ Riders:

Physical Therapy Rider Strike Waiver of Premium Rider Continuing Disability Rider

Elimination Period: 180 days Benefit Period: 6 months 18 months Benefit Amount: $

Catastrophic Loss Rider Elimination Period: 90 days 180 days Benefit Period: 12 mths 24 mths 36 mths Benefit Amount:$ Total Weekly Deduction:

$ $ $ $ $ $

18. ELIMINATION PERIOD

0/7 days 60/60 days 7/7 days 90/90 days 14/14 days 180/180 days 30/30 days

20. Primary Beneficiary Relationship to Insured D.O.B. Social Security Number Telephone Number Address

21. PRESENT INSURANCE: List all disability insurance you now have in force or are applying for with the Company or another company: Name of Company Policy No. Elimination Period

(days) Benefit Period

(Years) Total

Monthly Benefit Coverage to be

Replaced? Termination Date

Mo. - Yr.

ACKNOWLEDGEMENT: I understand and agree that: • The information in this application will be used to determine my eligibility for insurance; to the best of my knowledge

and belief, the statements and answers shown in this application (first page and, if applicable, the third page) are true and complete; the Company may rely upon such answers as the basis of my contract.

• No coverage will take effect until the application is approved by the Company without any modification as to plan, amount of premium, and further provided that the Company receives the first premium payment and a Policy is issued. If the first premium is not received within 30 days from the date hereof (or 90 days if premiums are paid by payroll deduction), no insurance will become effective. If the application is approved with any such modification, the insurance shall not take effect until the policy has been delivered to and accepted by me in writing and shall not take effect if there has been a change in the health of any person to be insured as stated since the date of the application.

• “Pre-existing conditions” diagnosed or treated before this coverage takes effect may not be covered; and I should read my Policy for a more detailed explanation of the pre-existing exclusion, if any.

• Insurance effective at any time on you under a like policy with the Company is limited to one such policy elected by the Insured. See the Policy for a more detailed explanation of this provision.

• I have received a copy of the Privacy Notice. • I authorize my employer to deduct the premium from my wages for remittance to Amalgamated Life Insurance

Company to provide the payments required to purchase this insurance coverage. This amount may be adjusted if my coverage or premium is changed.

AMINDDI-APP-15 (NC) Page 2 of 3

NOTICE TO CONSUMER: THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. ALSO, THE BENEFITS PROVIDED BY THIS POLICY CANNOT BE COORDINATED WITH THE BENEFITS PROVIDED BY OTHER COVERAGE. PLEASE REVIEW THE BENEFITS PROVIDED BY THIS POLICY CAREFULLY TO AVOID A DUPLICATION OF COVERAGE.

NOTICE: This policy may only be issued if you have minimum essential coverage within the meaning of section 5000A(f) of the Internal Revenue Code, or you are treated as having minimum essential coverage due to your status as a bona fide resident of any possession of the United States pursuant to Code section 5000A(f)(4)(B). If you have employer-sponsored coverage, COBRA coverage, insurance purchased from DC Health Link, or other similar insurance, you likely have minimum essential coverage. If your minimum essential coverage is terminated for any reason, you should notify the company immediately.

(1) Do you have comprehensive medical coverage including the minimum essential coverage required by the Affordable Care Act (ACA) or are you treated as having minimum essential coverage due to your status as a bona fide resident of any possession of the United States? YES NO

If you answered NO to question 1, you are not eligible for this policy, in the form of hospital or fixed

indemnity insurance. (2) Do you understand most supplemental only policies may not pay full benefits if your ACA compliant

minimum essential coverage plan is not in force? YES NO (3) Do you understand that the benefits provided under this policy may be limited? YES NO Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime, and may be subject to fines and confinement in prison. Dated at X (City and State) (Month) (Day) (Year) Proposed Insured’s Signature I, the undersigned agent, certify that: (1) I have personally interviewed the proposed insured; (2) I have accurately recorded the information supplied by the proposed insured. Dated at X (City and State) (Month) (Day) (Year) Agent’s Signature

AMINDDI-APP-15 (NC) Page 3 of 3

PART B To be completed when applying for simplified issue. 22. Name of Proposed Insured: Height: Weight: 23. To the best of your knowledge and belief: A. In the past 7 years have you ever had any known indication of or been told that you have:

(1) asthma/emphysema/lung/respiratory disorder or disease; (2) high blood pressure/heart/circulatory/blood disorder or stroke; (3) gastrointestinal/pancreatitis/liver disorder or disease; (4) diabetes; (5) leukemia/cancer/tumor or malignancy/lymphatic disorder or disease; (6) loss of consciousness/epilepsy/mental/nervous/neurological disease or disorder; (7) kidney/genito-urinary/rectal/reproductive/breast disease or disorder; (8) back/muscles/bone/joint disorder or disease; (9) paralysis or polio residuals; (10) lupus; (11) disorder of the eye? Yes No

B. In the past 7 years, have you: (1) been hospitalized or had hospitalization recommended; (2) had a physical examination or medical test with other than normal results? Yes No

C. Have you used on a regular basis or are you currently using or ever received treatment or

consultation for the use of drugs (prescription or non-prescription) or alcohol? Yes No D. Are you now taking medication (prescription or non-prescription) or under the care of a

medical practitioner or chiropractor? Yes No E. Any other medical treatment recommended, but NOT YET completed? Yes No 24. Details for questions 23 A, B, C, D or E answered “Yes”. Include question number.

Name Disease or Injury Date Details

AUTHORIZATION (NC)

AMALGAMATED LIFE INSURANCE COMPANY 333 WESTCHESTER AVENUE

WHITE PLAINS, NY 10604

DISCLOSURE AND AUTHORIZATION

I authorize any doctor or counselor; health practitioner; hospital, clinic or medical facility; insurer or

reinsurer, consumer reporting agency; Medical Information Bureau, Inc.; or employer, to give

Amalgamated Life Insurance Company (“the Company”) or its legal representative information about me.

This includes information about my physical or mental health (including history, condition, diagnosis and

treatment) except for drug and/or alcohol treatment records; other insurance coverage or employment

status. The Company will use the information to decide if and to what extent I am eligible for insurance

coverage or benefits under the Policy. This information will be treated as confidential.

I authorize any: doctor or counselor; health practitioner; hospital, clinic or medical facility; insurer or

reinsurer, consumer reporting agency; Medical Information Bureau, Inc.; or employer, to give the

Company or its legal representative information about me. This includes information about my: physical

or mental health (including history, condition, diagnosis and treatment); drug or alcohol use history; other

insurance coverage; or employment status. The Company will use the information to decide if and to what

extent I am eligible for insurance coverage or benefits under the Policy. This information will be treated

as confidential.

I understand the Medical Information Bureau, Inc. will release records or information only to the

Company. I authorize the Company to give information about me to: its reinsurer(s); the Medical

Information Bureau, Inc.; any other insurance company to whom I may apply for Life or Health Insurance;

or other persons or organizations handling a claim, underwriting coverage applied for or administering

coverage issued as a result of this application; or as required by law.

I understand that upon written request I may revoke this authorization except to the extent that action has already been taken in reliance on this authorization. This authorization expires 30 months from the date it is signed. I understand that a photocopy of this form is as valid as the original; and that I have a right to receive a copy of this form upon request. Please print Applicant’s Full Name (First and Last) Applicant’s Signature Date Signed

AMIACCAPP-14A (NC) 1

☐ New

AMALGAMATED LIFE INSURANCE COMPANY (the Company) Home Office: [333 Westchester Avenue, White Plains, NY 10604]

APPLICATION FOR ACCIDENT INSURANCE

☐ Add/Change

1. Applicant 2. Gender 7. Applicant (Spouse) 8. Gender (Spouse)

☐ M ☐ F ☐ M ☐ F

3. Date of Birth 4. Age

5. Place of Birth 6. Phone No. 9. Date of Birth (Spouse) 10. Age (Spouse)

/ / State: ( ) / /

As used in this application, “Spouse” means the lawful spouse of the Applicant. “Spouse” also refers to a partner in any relationship that provides substantially all of the same rights and benefits of marriage, including but not limited to civil union partnerships.

11. Present Residence

Address Apt # / PH City State Zip

12. Mailing Address (if different) 13. S. S. No (Applicant)

14. Are you actively at work? ☐ Yes ☐ No

15. Plan ☐ Applicant Only – [Weekly]

Premium

{ } ☐ Applicant/Children – [Weekly] Premium { }

(select one) ☐ Applicant/Spouse – [Weekly]

Premium

{ } ☐ Applicant/Spouse/Children – [Weekly]

Premium

{ }

16. ☐ Off the Job Only

☐ 24 Hour Coverage (on or off the job)

17. Beneficiary

Primary: Relationship to Insured:

Social Security No.: Date of Birth:

Address: Telephone No.:

If you have more than one beneficiary, list on a separate sheet of paper the name, address, telephone number, date of birth, social security number and relationship to you for each designated beneficiary. Date and sign the paper and attach it to this application. You may change your beneficiary at any time by notice to the Company.

18. Employer Date of Employment Employee No. (if any)

/ /

19. Dependents applying for Children’s coverage

Name Date of Birth Age Gender

(first) (last) Mo. Day Yr.

☐ M ☐ F

☐ M ☐ F

☐ M ☐ F

☐ M ☐ F

☐ M ☐ F

AMIACCAPP-14A (NC) 2

20. Other Information:

A. Do you or any person to be insured have any accident insurance, excluding an employer’s group plan, or any application for such insurance pending? ☐ Yes ☐ No

B. Will this insurance replace any other accident and sickness coverage? (if yes,

complete state replacement form if required) ☐ Yes ☐ No

If “YES” to A OR B, provide name of insurance company and type of insurance:

21. Special Requests

AGREEMENT AND DECLARATION – Read Carefully Before Signing I represent that the statements and answers written in this application and any supplements are complete and true to the best of my/our knowledge and belief, and it is agreed that: A. This application and any supplement shall form the basis for and become a part of any policy issued. B. The agent has no authority to waive the answer to any question in, or to modify, the application. C. No coverage will take effect until the application is approved by the Company without any modification as to plan,

amount of premium, and further provided that the Company receives the first premium payment [from my employer within 90 days from the date hereof] and a Policy is issued. If the first premium is not received [within 90 days], no insurance will become effective.

If the application is approved with any such modification, the insurance shall not take effect until the policy has been

delivered to and accepted by me and shall not take effect if there has been a change in the health of any person to be insured as stated since the date of the application.

D. I have received an Outline of Coverage. E. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime, and may be subject to fines and confinement in prison.

The policy applied for contains limited benefits. Review your policy carefully. I, the undersigned agent, certify that: (1) I have personally interviewed the proposed insured; (2) I have accurately recorded the information supplied by the proposed insured. _______________________________ Signature of

Applicant

_______________________________ Witness (Licensed Agent) Dated: / / at ___________________________________

(Month, Day, Year) City, State

AMINDDI-APP-15 (NC) Page 1 of 3

PART A Amalgamated Life Insurance Company (the Company) Application for Please Use Black Ink 333 Westchester Avenue, White Plains, NY 10604 Disability Income Insurance 1. Proposed Insured’s Name - Last First Middle

2. Home Address - Street/Box No. City State Zip Home Phone Number

3. Mailing Address (if different) - Street/Box No. City State Zip

4. Social Security Number 5. Birthdate (Mo. Day Yr.) 6. Age Last Birthday 7. Gender Male Female

8. State of Birth

9. Name of Employer

10. Class 11. Occupation

12. Date of Employment (Mo. Day Yr.) / /

13. Duties 14. Average Monthly Earnings Last 12 Months $

15. Are you currently actively at work and able to perform the duties of your occupation? YES NO 16. To the best of your knowledge and belief: have you had a: a) heart attack; b) heart bypass; c) coronary artery

disease; d) stroke; e) cancer (other than basal or squamous cell skin cancer); and/or f) been treated or diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions? Yes No

Have you been hospitalized in the last 90 days (for any reason) or been recommended to seek: a) medical advice; b) treatment; c) care; and/or d) counseling that has not yet been performed? Yes No

SELECT THE COVERAGE YOU WANT BY SELECTING FROM BELOW: 17. BENEFIT PERIOD 19. BENEFITS WEEKLY PREMIUM

3 month 24 month 6 month 5 years 12 month

Monthly Disability Income: 24 hour coverage (check one box) off-the-job only coverage Benefit Amount: $ Riders:

Physical Therapy Rider Strike Waiver of Premium Rider Continuing Disability Rider

Elimination Period: 180 days Benefit Period: 6 months 18 months Benefit Amount: $

Catastrophic Loss Rider Elimination Period: 90 days 180 days Benefit Period: 12 mths 24 mths 36 mths Benefit Amount:$ Total Weekly Deduction:

$ $ $ $ $ $

18. ELIMINATION PERIOD

0/7 days 60/60 days 7/7 days 90/90 days 14/14 days 180/180 days 30/30 days

20. Primary Beneficiary Relationship to Insured D.O.B. Social Security Number Telephone Number Address

21. PRESENT INSURANCE: List all disability insurance you now have in force or are applying for with the Company or another company: Name of Company Policy No. Elimination Period

(days) Benefit Period

(Years) Total

Monthly Benefit Coverage to be

Replaced? Termination Date

Mo. - Yr.

ACKNOWLEDGEMENT: I understand and agree that: • The information in this application will be used to determine my eligibility for insurance; to the best of my knowledge

and belief, the statements and answers shown in this application (first page and, if applicable, the third page) are true and complete; the Company may rely upon such answers as the basis of my contract.

• No coverage will take effect until the application is approved by the Company without any modification as to plan, amount of premium, and further provided that the Company receives the first premium payment and a Policy is issued. If the first premium is not received within 30 days from the date hereof (or 90 days if premiums are paid by payroll deduction), no insurance will become effective. If the application is approved with any such modification, the insurance shall not take effect until the policy has been delivered to and accepted by me in writing and shall not take effect if there has been a change in the health of any person to be insured as stated since the date of the application.

• “Pre-existing conditions” diagnosed or treated before this coverage takes effect may not be covered; and I should read my Policy for a more detailed explanation of the pre-existing exclusion, if any.

• Insurance effective at any time on you under a like policy with the Company is limited to one such policy elected by the Insured. See the Policy for a more detailed explanation of this provision.

• I have received a copy of the Privacy Notice. • I authorize my employer to deduct the premium from my wages for remittance to Amalgamated Life Insurance

Company to provide the payments required to purchase this insurance coverage. This amount may be adjusted if my coverage or premium is changed.

AMINDDI-APP-15 (NC) Page 2 of 3

NOTICE TO CONSUMER: THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. ALSO, THE BENEFITS PROVIDED BY THIS POLICY CANNOT BE COORDINATED WITH THE BENEFITS PROVIDED BY OTHER COVERAGE. PLEASE REVIEW THE BENEFITS PROVIDED BY THIS POLICY CAREFULLY TO AVOID A DUPLICATION OF COVERAGE.

NOTICE: This policy may only be issued if you have minimum essential coverage within the meaning of section 5000A(f) of the Internal Revenue Code, or you are treated as having minimum essential coverage due to your status as a bona fide resident of any possession of the United States pursuant to Code section 5000A(f)(4)(B). If you have employer-sponsored coverage, COBRA coverage, insurance purchased from DC Health Link, or other similar insurance, you likely have minimum essential coverage. If your minimum essential coverage is terminated for any reason, you should notify the company immediately.

(1) Do you have comprehensive medical coverage including the minimum essential coverage required by the Affordable Care Act (ACA) or are you treated as having minimum essential coverage due to your status as a bona fide resident of any possession of the United States? YES NO

If you answered NO to question 1, you are not eligible for this policy, in the form of hospital or fixed

indemnity insurance. (2) Do you understand most supplemental only policies may not pay full benefits if your ACA compliant

minimum essential coverage plan is not in force? YES NO (3) Do you understand that the benefits provided under this policy may be limited? YES NO Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime, and may be subject to fines and confinement in prison. Dated at X (City and State) (Month) (Day) (Year) Proposed Insured’s Signature I, the undersigned agent, certify that: (1) I have personally interviewed the proposed insured; (2) I have accurately recorded the information supplied by the proposed insured. Dated at X (City and State) (Month) (Day) (Year) Agent’s Signature

AMINDDI-APP-15 (NC) Page 3 of 3

PART B To be completed when applying for simplified issue. 22. Name of Proposed Insured: Height: Weight: 23. To the best of your knowledge and belief: A. In the past 7 years have you ever had any known indication of or been told that you have:

(1) asthma/emphysema/lung/respiratory disorder or disease; (2) high blood pressure/heart/circulatory/blood disorder or stroke; (3) gastrointestinal/pancreatitis/liver disorder or disease; (4) diabetes; (5) leukemia/cancer/tumor or malignancy/lymphatic disorder or disease; (6) loss of consciousness/epilepsy/mental/nervous/neurological disease or disorder; (7) kidney/genito-urinary/rectal/reproductive/breast disease or disorder; (8) back/muscles/bone/joint disorder or disease; (9) paralysis or polio residuals; (10) lupus; (11) disorder of the eye? Yes No

B. In the past 7 years, have you: (1) been hospitalized or had hospitalization recommended; (2) had a physical examination or medical test with other than normal results? Yes No

C. Have you used on a regular basis or are you currently using or ever received treatment or

consultation for the use of drugs (prescription or non-prescription) or alcohol? Yes No D. Are you now taking medication (prescription or non-prescription) or under the care of a

medical practitioner or chiropractor? Yes No E. Any other medical treatment recommended, but NOT YET completed? Yes No 24. Details for questions 23 A, B, C, D or E answered “Yes”. Include question number.

Name Disease or Injury Date Details

AUTHORIZATION (NC)

AMALGAMATED LIFE INSURANCE COMPANY 333 WESTCHESTER AVENUE

WHITE PLAINS, NY 10604

DISCLOSURE AND AUTHORIZATION

I authorize any doctor or counselor; health practitioner; hospital, clinic or medical facility; insurer or

reinsurer, consumer reporting agency; Medical Information Bureau, Inc.; or employer, to give

Amalgamated Life Insurance Company (“the Company”) or its legal representative information about me.

This includes information about my physical or mental health (including history, condition, diagnosis and

treatment) except for drug and/or alcohol treatment records; other insurance coverage or employment

status. The Company will use the information to decide if and to what extent I am eligible for insurance

coverage or benefits under the Policy. This information will be treated as confidential.

I authorize any: doctor or counselor; health practitioner; hospital, clinic or medical facility; insurer or

reinsurer, consumer reporting agency; Medical Information Bureau, Inc.; or employer, to give the

Company or its legal representative information about me. This includes information about my: physical

or mental health (including history, condition, diagnosis and treatment); drug or alcohol use history; other

insurance coverage; or employment status. The Company will use the information to decide if and to what

extent I am eligible for insurance coverage or benefits under the Policy. This information will be treated

as confidential.

I understand the Medical Information Bureau, Inc. will release records or information only to the

Company. I authorize the Company to give information about me to: its reinsurer(s); the Medical

Information Bureau, Inc.; any other insurance company to whom I may apply for Life or Health Insurance;

or other persons or organizations handling a claim, underwriting coverage applied for or administering

coverage issued as a result of this application; or as required by law.

I understand that upon written request I may revoke this authorization except to the extent that action has already been taken in reliance on this authorization. This authorization expires 30 months from the date it is signed. I understand that a photocopy of this form is as valid as the original; and that I have a right to receive a copy of this form upon request. Please print Applicant’s Full Name (First and Last) Applicant’s Signature Date Signed

AMINDDI-APP-15 (NC) Page 1 of 3

PART A Amalgamated Life Insurance Company (the Company) Application for Please Use Black Ink 333 Westchester Avenue, White Plains, NY 10604 Disability Income Insurance 1. Proposed Insured’s Name - Last First Middle

2. Home Address - Street/Box No. City State Zip Home Phone Number

3. Mailing Address (if different) - Street/Box No. City State Zip

4. Social Security Number 5. Birthdate (Mo. Day Yr.) 6. Age Last Birthday 7. Gender Male Female

8. State of Birth

9. Name of Employer

10. Class 11. Occupation

12. Date of Employment (Mo. Day Yr.) / /

13. Duties 14. Average Monthly Earnings Last 12 Months $

15. Are you currently actively at work and able to perform the duties of your occupation? YES NO 16. To the best of your knowledge and belief: have you had a: a) heart attack; b) heart bypass; c) coronary artery

disease; d) stroke; e) cancer (other than basal or squamous cell skin cancer); and/or f) been treated or diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions? Yes No

Have you been hospitalized in the last 90 days (for any reason) or been recommended to seek: a) medical advice; b) treatment; c) care; and/or d) counseling that has not yet been performed? Yes No

SELECT THE COVERAGE YOU WANT BY SELECTING FROM BELOW: 17. BENEFIT PERIOD 19. BENEFITS WEEKLY PREMIUM

3 month 24 month 6 month 5 years 12 month

Monthly Disability Income: 24 hour coverage (check one box) off-the-job only coverage Benefit Amount: $ Riders:

Physical Therapy Rider Strike Waiver of Premium Rider Continuing Disability Rider

Elimination Period: 180 days Benefit Period: 6 months 18 months Benefit Amount: $

Catastrophic Loss Rider Elimination Period: 90 days 180 days Benefit Period: 12 mths 24 mths 36 mths Benefit Amount:$ Total Weekly Deduction:

$ $ $ $ $ $

18. ELIMINATION PERIOD

0/7 days 60/60 days 7/7 days 90/90 days 14/14 days 180/180 days 30/30 days

20. Primary Beneficiary Relationship to Insured D.O.B. Social Security Number Telephone Number Address

21. PRESENT INSURANCE: List all disability insurance you now have in force or are applying for with the Company or another company: Name of Company Policy No. Elimination Period

(days) Benefit Period

(Years) Total

Monthly Benefit Coverage to be

Replaced? Termination Date

Mo. - Yr.

ACKNOWLEDGEMENT: I understand and agree that: • The information in this application will be used to determine my eligibility for insurance; to the best of my knowledge

and belief, the statements and answers shown in this application (first page and, if applicable, the third page) are true and complete; the Company may rely upon such answers as the basis of my contract.

• No coverage will take effect until the application is approved by the Company without any modification as to plan, amount of premium, and further provided that the Company receives the first premium payment and a Policy is issued. If the first premium is not received within 30 days from the date hereof (or 90 days if premiums are paid by payroll deduction), no insurance will become effective. If the application is approved with any such modification, the insurance shall not take effect until the policy has been delivered to and accepted by me in writing and shall not take effect if there has been a change in the health of any person to be insured as stated since the date of the application.

• “Pre-existing conditions” diagnosed or treated before this coverage takes effect may not be covered; and I should read my Policy for a more detailed explanation of the pre-existing exclusion, if any.

• Insurance effective at any time on you under a like policy with the Company is limited to one such policy elected by the Insured. See the Policy for a more detailed explanation of this provision.

• I have received a copy of the Privacy Notice. • I authorize my employer to deduct the premium from my wages for remittance to Amalgamated Life Insurance

Company to provide the payments required to purchase this insurance coverage. This amount may be adjusted if my coverage or premium is changed.

AMINDDI-APP-15 (NC) Page 2 of 3

NOTICE TO CONSUMER: THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. ALSO, THE BENEFITS PROVIDED BY THIS POLICY CANNOT BE COORDINATED WITH THE BENEFITS PROVIDED BY OTHER COVERAGE. PLEASE REVIEW THE BENEFITS PROVIDED BY THIS POLICY CAREFULLY TO AVOID A DUPLICATION OF COVERAGE.

NOTICE: This policy may only be issued if you have minimum essential coverage within the meaning of section 5000A(f) of the Internal Revenue Code, or you are treated as having minimum essential coverage due to your status as a bona fide resident of any possession of the United States pursuant to Code section 5000A(f)(4)(B). If you have employer-sponsored coverage, COBRA coverage, insurance purchased from DC Health Link, or other similar insurance, you likely have minimum essential coverage. If your minimum essential coverage is terminated for any reason, you should notify the company immediately.

(1) Do you have comprehensive medical coverage including the minimum essential coverage required by the Affordable Care Act (ACA) or are you treated as having minimum essential coverage due to your status as a bona fide resident of any possession of the United States? YES NO

If you answered NO to question 1, you are not eligible for this policy, in the form of hospital or fixed

indemnity insurance. (2) Do you understand most supplemental only policies may not pay full benefits if your ACA compliant

minimum essential coverage plan is not in force? YES NO (3) Do you understand that the benefits provided under this policy may be limited? YES NO Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime, and may be subject to fines and confinement in prison. Dated at X (City and State) (Month) (Day) (Year) Proposed Insured’s Signature I, the undersigned agent, certify that: (1) I have personally interviewed the proposed insured; (2) I have accurately recorded the information supplied by the proposed insured. Dated at X (City and State) (Month) (Day) (Year) Agent’s Signature

AMINDDI-APP-15 (NC) Page 3 of 3

PART B To be completed when applying for simplified issue. 22. Name of Proposed Insured: Height: Weight: 23. To the best of your knowledge and belief: A. In the past 7 years have you ever had any known indication of or been told that you have:

(1) asthma/emphysema/lung/respiratory disorder or disease; (2) high blood pressure/heart/circulatory/blood disorder or stroke; (3) gastrointestinal/pancreatitis/liver disorder or disease; (4) diabetes; (5) leukemia/cancer/tumor or malignancy/lymphatic disorder or disease; (6) loss of consciousness/epilepsy/mental/nervous/neurological disease or disorder; (7) kidney/genito-urinary/rectal/reproductive/breast disease or disorder; (8) back/muscles/bone/joint disorder or disease; (9) paralysis or polio residuals; (10) lupus; (11) disorder of the eye? Yes No

B. In the past 7 years, have you: (1) been hospitalized or had hospitalization recommended; (2) had a physical examination or medical test with other than normal results? Yes No

C. Have you used on a regular basis or are you currently using or ever received treatment or

consultation for the use of drugs (prescription or non-prescription) or alcohol? Yes No D. Are you now taking medication (prescription or non-prescription) or under the care of a

medical practitioner or chiropractor? Yes No E. Any other medical treatment recommended, but NOT YET completed? Yes No 24. Details for questions 23 A, B, C, D or E answered “Yes”. Include question number.

Name Disease or Injury Date Details

AUTHORIZATION (NC)

AMALGAMATED LIFE INSURANCE COMPANY 333 WESTCHESTER AVENUE

WHITE PLAINS, NY 10604

DISCLOSURE AND AUTHORIZATION

I authorize any doctor or counselor; health practitioner; hospital, clinic or medical facility; insurer or

reinsurer, consumer reporting agency; Medical Information Bureau, Inc.; or employer, to give

Amalgamated Life Insurance Company (“the Company”) or its legal representative information about me.

This includes information about my physical or mental health (including history, condition, diagnosis and

treatment) except for drug and/or alcohol treatment records; other insurance coverage or employment

status. The Company will use the information to decide if and to what extent I am eligible for insurance

coverage or benefits under the Policy. This information will be treated as confidential.

I authorize any: doctor or counselor; health practitioner; hospital, clinic or medical facility; insurer or

reinsurer, consumer reporting agency; Medical Information Bureau, Inc.; or employer, to give the

Company or its legal representative information about me. This includes information about my: physical

or mental health (including history, condition, diagnosis and treatment); drug or alcohol use history; other

insurance coverage; or employment status. The Company will use the information to decide if and to what

extent I am eligible for insurance coverage or benefits under the Policy. This information will be treated

as confidential.

I understand the Medical Information Bureau, Inc. will release records or information only to the

Company. I authorize the Company to give information about me to: its reinsurer(s); the Medical

Information Bureau, Inc.; any other insurance company to whom I may apply for Life or Health Insurance;

or other persons or organizations handling a claim, underwriting coverage applied for or administering

coverage issued as a result of this application; or as required by law.

I understand that upon written request I may revoke this authorization except to the extent that action has already been taken in reliance on this authorization. This authorization expires 30 months from the date it is signed. I understand that a photocopy of this form is as valid as the original; and that I have a right to receive a copy of this form upon request. Please print Applicant’s Full Name (First and Last) Applicant’s Signature Date Signed

AMIACCAPP-14A (NC) 1

☐ New

AMALGAMATED LIFE INSURANCE COMPANY (the Company) Home Office: [333 Westchester Avenue, White Plains, NY 10604]

APPLICATION FOR ACCIDENT INSURANCE

☐ Add/Change

1. Applicant 2. Gender 7. Applicant (Spouse) 8. Gender (Spouse)

☐ M ☐ F ☐ M ☐ F

3. Date of Birth 4. Age

5. Place of Birth 6. Phone No. 9. Date of Birth (Spouse) 10. Age (Spouse)

/ / State: ( ) / /

As used in this application, “Spouse” means the lawful spouse of the Applicant. “Spouse” also refers to a partner in any relationship that provides substantially all of the same rights and benefits of marriage, including but not limited to civil union partnerships.

11. Present Residence

Address Apt # / PH City State Zip

12. Mailing Address (if different) 13. S. S. No (Applicant)

14. Are you actively at work? ☐ Yes ☐ No

15. Plan ☐ Applicant Only – [Weekly]

Premium

{ } ☐ Applicant/Children – [Weekly] Premium { }

(select one) ☐ Applicant/Spouse – [Weekly]

Premium

{ } ☐ Applicant/Spouse/Children – [Weekly]

Premium

{ }

16. ☐ Off the Job Only

☐ 24 Hour Coverage (on or off the job)

17. Beneficiary

Primary: Relationship to Insured:

Social Security No.: Date of Birth:

Address: Telephone No.:

If you have more than one beneficiary, list on a separate sheet of paper the name, address, telephone number, date of birth, social security number and relationship to you for each designated beneficiary. Date and sign the paper and attach it to this application. You may change your beneficiary at any time by notice to the Company.

18. Employer Date of Employment Employee No. (if any)

/ /

19. Dependents applying for Children’s coverage

Name Date of Birth Age Gender

(first) (last) Mo. Day Yr.

☐ M ☐ F

☐ M ☐ F

☐ M ☐ F

☐ M ☐ F

☐ M ☐ F

AMIACCAPP-14A (NC) 2

20. Other Information:

A. Do you or any person to be insured have any accident insurance, excluding an employer’s group plan, or any application for such insurance pending? ☐ Yes ☐ No

B. Will this insurance replace any other accident and sickness coverage? (if yes,

complete state replacement form if required) ☐ Yes ☐ No

If “YES” to A OR B, provide name of insurance company and type of insurance:

21. Special Requests

AGREEMENT AND DECLARATION – Read Carefully Before Signing I represent that the statements and answers written in this application and any supplements are complete and true to the best of my/our knowledge and belief, and it is agreed that: A. This application and any supplement shall form the basis for and become a part of any policy issued. B. The agent has no authority to waive the answer to any question in, or to modify, the application. C. No coverage will take effect until the application is approved by the Company without any modification as to plan,

amount of premium, and further provided that the Company receives the first premium payment [from my employer within 90 days from the date hereof] and a Policy is issued. If the first premium is not received [within 90 days], no insurance will become effective.

If the application is approved with any such modification, the insurance shall not take effect until the policy has been

delivered to and accepted by me and shall not take effect if there has been a change in the health of any person to be insured as stated since the date of the application.

D. I have received an Outline of Coverage. E. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime, and may be subject to fines and confinement in prison.

The policy applied for contains limited benefits. Review your policy carefully. I, the undersigned agent, certify that: (1) I have personally interviewed the proposed insured; (2) I have accurately recorded the information supplied by the proposed insured. _______________________________ Signature of

Applicant

_______________________________ Witness (Licensed Agent) Dated: / / at ___________________________________

(Month, Day, Year) City, State

AMIACCAPP-14A (NC) 1

☐ New

AMALGAMATED LIFE INSURANCE COMPANY (the Company) Home Office: [333 Westchester Avenue, White Plains, NY 10604]

APPLICATION FOR ACCIDENT INSURANCE

☐ Add/Change

1. Applicant 2. Gender 7. Applicant (Spouse) 8. Gender (Spouse)

☐ M ☐ F ☐ M ☐ F

3. Date of Birth 4. Age

5. Place of Birth 6. Phone No. 9. Date of Birth (Spouse) 10. Age (Spouse)

/ / State: ( ) / /

As used in this application, “Spouse” means the lawful spouse of the Applicant. “Spouse” also refers to a partner in any relationship that provides substantially all of the same rights and benefits of marriage, including but not limited to civil union partnerships.

11. Present Residence

Address Apt # / PH City State Zip

12. Mailing Address (if different) 13. S. S. No (Applicant)

14. Are you actively at work? ☐ Yes ☐ No

15. Plan ☐ Applicant Only – [Weekly]

Premium

{ } ☐ Applicant/Children – [Weekly] Premium { }

(select one) ☐ Applicant/Spouse – [Weekly]

Premium

{ } ☐ Applicant/Spouse/Children – [Weekly]

Premium

{ }

16. ☐ Off the Job Only

☐ 24 Hour Coverage (on or off the job)

17. Beneficiary

Primary: Relationship to Insured:

Social Security No.: Date of Birth:

Address: Telephone No.:

If you have more than one beneficiary, list on a separate sheet of paper the name, address, telephone number, date of birth, social security number and relationship to you for each designated beneficiary. Date and sign the paper and attach it to this application. You may change your beneficiary at any time by notice to the Company.

18. Employer Date of Employment Employee No. (if any)

/ /

19. Dependents applying for Children’s coverage

Name Date of Birth Age Gender

(first) (last) Mo. Day Yr.

☐ M ☐ F

☐ M ☐ F

☐ M ☐ F

☐ M ☐ F

☐ M ☐ F

AMIACCAPP-14A (NC) 2

20. Other Information:

A. Do you or any person to be insured have any accident insurance, excluding an employer’s group plan, or any application for such insurance pending? ☐ Yes ☐ No

B. Will this insurance replace any other accident and sickness coverage? (if yes,

complete state replacement form if required) ☐ Yes ☐ No

If “YES” to A OR B, provide name of insurance company and type of insurance:

21. Special Requests

AGREEMENT AND DECLARATION – Read Carefully Before Signing I represent that the statements and answers written in this application and any supplements are complete and true to the best of my/our knowledge and belief, and it is agreed that: A. This application and any supplement shall form the basis for and become a part of any policy issued. B. The agent has no authority to waive the answer to any question in, or to modify, the application. C. No coverage will take effect until the application is approved by the Company without any modification as to plan,

amount of premium, and further provided that the Company receives the first premium payment [from my employer within 90 days from the date hereof] and a Policy is issued. If the first premium is not received [within 90 days], no insurance will become effective.

If the application is approved with any such modification, the insurance shall not take effect until the policy has been

delivered to and accepted by me and shall not take effect if there has been a change in the health of any person to be insured as stated since the date of the application.

D. I have received an Outline of Coverage. E. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime, and may be subject to fines and confinement in prison.

The policy applied for contains limited benefits. Review your policy carefully. I, the undersigned agent, certify that: (1) I have personally interviewed the proposed insured; (2) I have accurately recorded the information supplied by the proposed insured. _______________________________ Signature of

Applicant

_______________________________ Witness (Licensed Agent) Dated: / / at ___________________________________

(Month, Day, Year) City, State