UNIVERSAL LIFE INSURANCE

Underwritten by Transamerica Life Insurance Company, Cedar Rapids, Iowa.

Protection for Your Plans With benefits like the Terminal Illness rider,

life insurance proceeds can also be used to

cover costs associated with terminal illnesses.

Coverage up to $500,000 .> Guaranteed 4% Interest Rate . Terminal Illness Benefit

No Physicals or Blood work' .> Cash Values .> Level Death Benefit

Dependent Coverage Available • Convenient Payroll Deduction .> Layoff Provision'

What are your plans? Depending on your unique life and future plans, you may apply for group universal life insurance exclusively through your employer from

$5,000 up to $500,000. Premiums are based upon age and tobacco use. The minimum premium is $4 per week.

Benefits that work. TransLegacy's benefits work to help provide protection while you work to plan your future.

.> Accelerated Death Benefit for Terminal Illness 2 Rider (Form Series CRABT1003)

Tap into your life insurance in the event of a future terminal illness diagnosis and still provide a benefit for your beneficiary.

0)- Waiver of Monthly Deductions due to Layoff Rider (Form Series CRULWT00°)

Protects your life insurance coverage from lapsing for up to six months if involuntarily laid off from your full-time job.

Who can apply for coverage?

APPLICANT

AGE COVERAGE

Employee

16-70

$5,000-500,000

Spouse or equivalent by state law

16-65

$5,000-50,000

Child

15 DAYS- 17

$10,000 Level Term Rider

Child or Grandchild

15 DAYS-24

$25,000 UL Contract ..IWWWMRMR,f.m',°m•PSM.,

1 Acceptance based on answers to questions on your applications for coverage. 2 Accelerated Death Benefit for Terminal Condition Rider in Pennsylvania. 3 Not available in Massachusetts. 4 Not available in Massachusetts, Maryland, New Jersey, Tennessee, Vermont, or Washington.

TRANSAMERICA WORKSITE MARKETING

Policy form numbers CPGLDU00 and CCGLDU00.

CLGO1 C. 1 2 IC Forms and definitions may vary, coverage available where product is approved.

25 MONTHS

50 MONTHS

confinement in a licensed nursing or assisted living facility

receiving home health care or adult day careOR

GROUP UNIVERSAL LIFE INSURANCE Underwitten by Transamerica Life Insurance Company, Home Office, Cedar Rapids, Iowa.

Accelerated Death Benefit for Long-Term Care Rider with Extension of Benefits Rider Helping You Keep Your Plans. This rider allows an insured (not available to children) to take an advance against the life insurance death benefit to help pay for long-term care.

Activation of the Accelerated Death Benefit for Long-Term Care Rider

Benefits under this rider can only be triggered by a diagnosis certified by a licensed physician that you are chronically ill. A chroniically ill individual means:

a) being unable to perform, without substantial human assistance, at least two of the six activities of daily living (ADLs)—bathing, conti-nence, dressing, eating, toileting and transferring—for a period of at least 90 days; or

b) being so cognitively impaired that the insured requires substantial supervision to protect them from threats to their health and safety.

Under the Accelerated Death Benefit for Long-Term Care Rider, the percentage of death benefit available each month is:

When benefits are paid under this rider, the face amount, accumulation value, surrender charge and outstanding loan balance, if any, are reduced proportionately to reflect the new death benefit. The balance will be paid to the beneficiary after the death of the insured. Monthly deductions will be waived for each contract month or partial contract month that you receive these rider benefits.

35 year old, non-smoker with $50,t 00 of coverage:

$2,000 12 MONTHS reduces the face amount by $24,000 remaining death benefit: $26,000OR

$1,000 12 MONTHS reduces the face amount by $12,000 remaining death benefit: $38,000

When a claim is filed, an expense charge will be deducted from the first and each subsequent claim payment.'

Extension of Benefits Rider If the insured's entire face amount under the Accelerated Death Benefit for Long Term Care Rider has been paid and the insured continues to be chronically ill, the Extension of Benefits Rider (EBR) allows an insured to have extended benefits. The face amount will be increased by 4% of the rider face amount. If this increased death benefit is depleted and the insured continues to be chronically ill, the contract is eligible for another 4% increase. Increases will not exceed 100% of the rider face amount as of the contract date at the time of the first accelerated death benefit under the Accelerated Death Benefit for Long-Term Care Rider was paid.

For example, if the insured is still confined in a licensed nursing or assisted living facility after the first 25 months (or home health care or adult day care after the first 50 months), and the death benefit has been depleted, the Extension of Benefits Rider will extend the acceler-ated death benefit by an amount equal to 4% of the rider face amount on a month-to-month basis (as the insured continues to meet the requirements) for up to an additional 25 months (or home health care or adult day care for an additional 50 months). When the insured depletes all of the death benefit in the additional months, coverage will end.

Continued on the back. 1 Varies by state.

TRANSAMERICA WORKSITE MARKETING The Accelerated Death Benefit for Long-Term Care and the Extension of Benefits Rider (Form Series CRABLTOO and CREXTB00) is

available on TransLegacy Universal Life Insurance contracts. Forms may vary, coverage available where product is approved. CLGO3C4-1609

Paid-up Life Benefit

In addition, this rider will also provide a paid-up life insurance contract equal to 25% of the original face amount prior to accelerated pay-ments for Long Term Care. In the example above, in addition to receiving the additional benefit of 4% per month, as of the first payment extended under the EBR, the owner receives a paid up life insurance contract of 25% of the pre-accelerated death benefit to be paid to the beneficiary upon death.

Activating Multiple Accelerated Death Benefits

The maximum we will pay under any ADB rider (critical care, long-term care or terminal illness) is 100% of the death benefit for any one insured.

non-smoker with $50,000 of coverog

4% $2000 3 MONTHS reduces the face amount by $6,000 remaining death benefit: $44,000AND

ACTIVATE 50% CCR OR TI RIDERS reduces the face amount by $22,000 remaining death benefit: $22,000

This Rider will terminate on the earliest of the following dates or events:

1. The date the cumulative payments of the monthly accelerated death benefit amount equal 100% of the face amount of this rider; 2. The date the rider or the contract lapses for failure to pay premiums, subject to the grace period of the contract; 3. The date the owner requests termination; 4. The date of the insured's death; 5. The date the contract terminates; 6. The date a nonforfeiture option under the contract, if any, becomes effective.

Tax Qualification Notice

This rider is intended to provide a qualified accelerated death benefit excluded from gross income for Federal Income Tax purposes under the applicable provisions of the Internal Revenue Code in existence at the time this rider is issued. The provisions of this rider and the contract are to be interpreted to ensure or maintain such tax qualification, notwithstanding any other provisions to the contrary. We reserve the right to amend this rider or the contract to reflect any clarifications that may be needed or are appropriate to maintain tax qualification or to conform this rider or the contract to any applicable changes in such tax qualification requirements. We will send you a copy of any amendments and if you refuse such an amendment, it must be by written notice, and may result in adverse tax consequences. Whether any tax liability may be incurred when benefits are paid under this rider may depend on who is insured and how the IRS interprets applicable provisions of the Internal Revenue Code. As with any tax matter, recipients of this benefit should each consult a tax advisor regarding any tax impact of this benefit.

Contact the Medicaid Unit of the local Department of Public Welfare and Social Security Administration Office for more information on how receipt of an accelerated death benefit MAY AFFECT MEDICAID and SUPPLEMENTAL SECURITY INCOME (SSI).

This option must be exercised to affect eligibility for these government programs. Exercising this option before applying for these programs, or while receiving government benefits, may affect eligibility.

This is a brief summary of the Accelerated Death Benefit for Long Term Care with Extension of Benefits. Limitations and exclusions may apply. Refer to the rider and contract certificate for complete information.

I • I 2

TRANSAMERICA 0 LIFE INSURANCE COMPANY

Transamerica Life Insurance Company ("Insurer') Home Office: Cedar Rapids, IA Administrative Office: P.O. Box 8063 Little Rock, AR 72203-8063

Universal Life Application

n First Application n Add Dependents - Contract # n Increase Coverage - Contract # Group Name State of Louisiana Group Number Location

Applicant (Last, First, M.I.)

q Male n Female

Social Security No. Date of birth Date of marriage -

Spouse** (Last, First, M-1.)

n Male q Female

Social Security No Date of birth

Date of hire Avg hours worked per week Annual salary Occupation Applicant ID

Have you or your spouse -used tobacco products in the last year? Yes

Home phone Work phone/ext. Applicant n No n Yes Spouse" n No n

Home address City State Zip code

Life insurance certificate/policy owner (Last, First) (If different than applicant)

Address Relationship Social Security No.

Primary Beneficiary: (Last, First, MI)

Relationship:

Contingent Beneficiary: (Last, First, M.I.)

Relationship:

Applicant will be the beneficiary for any spouse** andlor child(ren) coverage

Payroll Mode: q Weekly q Bi-Weekly q Semi-Monthly al Monthly n Other

I Am Applying For: Universal Life: Benefit Option n A (level) n B (increasing) Automatic Increase

0 ion RiderLevel Term Rider

Face Amount* Premium per pay period* Face Amount* Rider Length Premium per pay period*

n Applicant ,;2,5' coat, If 93 Yes • No • 1 Oyr n 20yr • Spouse'" • Yes n No • 10yr n 20yr n Child(ren) Child Level Term Rider

List Name(s) of All Child(ren)2 Date of Birth Tobacco User? Add child level term rider to: qApplicant n Spouse" n Yes n No Number of Units: Premium:

n Yes n No Number of Children:

n Yes n No if increasina coveraae. enter the TOTAL Face Amount and Premium.Spouse- may apply for Universal Life coverage OR a Level Term Rider attached to the applicant's policy, but not both.

2 List ALL children to be insured, either by Universal Life coverage OR by Child Term Rider, but not both.

Eligibility Questions 1 . Are you actively at work on a full time basis and able to perform the regular duties of your occupation?

If "No", you and your dependents are not eligible for coverage. 2 If applying for spouse and/or child(ren) coverage, is any proposed insured currently disabled?

If "Yes", List name(s) , who will be excluded from coverage.

q Yes q No

q Yes q No

Evidence of Insurability Questions - Part 1

In the six months prior to the application date, has any proposed insured been hospitalized (inpatient or outpatient) or missed more than five consecutive days of work due to any of the conditions listed in Question # 6? If "Yes", List name(s) , who will be excluded from coverage.

4 Has any proposed insured had an actual diagnosis of or treatment by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or sexually transmitted disease? If "Yes", List name(s) , who will be excluded from coverage.

q Yes q No

q Yes q No

5. Indicate height and weight for Applicant 1 I Spouse"

6. In the ten years prior to the application date, has any proposed insured been treated for, been diagnosed as having, or had any indication, sign or symptom of having any heart, brain, lung, circulatory, respiratory, blood, vascular, kidney, liver, digestive, neurological, rheumatoid, or other major organ disorders, blood transfusion, diabetes, drug addiction, alcoholism, cancer or malignancy in any form (except non-melanoma skin cancer)? If "Yes", List name(s)

7. Do you or any proposed insured have high blood pressure that is controlled by more than two medications? If "Yes". List name(s) who will be excluded from coveracie

, who will be excluded from coverage. q Yes q No

q Yes q No

APPLICANT'S STATEMENTS AND AGREEMENTS:

Replacement question for residents of AL, AK, AR, AZ, CO, HI, IA, LA, MD, ME, MS, MT, NE, NC, NH, NJ, NM, OH, OR, RI, SC, TX, UT, VA, VT, WI I or WV: Do you currently have any other existing life insurance policies or contracts? q Yes q No

If "Yes", complete the replacement form(s) provided by your agent and return with this application. Replacement question for residents of all other states:

Is the insurance being applied for intended to replace or change any existing life insurance coverage? q Yes q No If "Yes", list name of company , Policy/certificate # , complete the Replacement form(s) provided by your agent and return with this application.

I Accelerated Death Benefit Disclosure Acknowledoement: If applying for an Accelerated Death Benefit Rider, did you receive the applicable Disclosure if required in your state? Long Term Care Rider q Yes q

Illustration Acknowledgement for all applicants: I certify that a life insurance illustration showing non-guaranteed values q was q was not used during the sale of the insurance coverage I am applying for on this application. I understand that if my application is approved, an illustration conforming to the policy/certificate as issued will be delivered to me no later than when I receive my policy/certificate. I understand that any non-guaranteed elements contained in any illustration are subject to change and could be either higher or lower and that they are not guaranteed. I will review the illustration, sign the acknowledgment, and will return a copy of the signed illustration to the Insurer.

I represent that all statements and answers made on or attached to this application are true to the best of my knowledge and belief, and realize that any false statements herein which materially affect the acceptance of the risk or the hazard assumed may result in loss of coverage under the policy/certificate to which this application is attached. I understand that 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.. I also understand that coverage will become effective only after all of the following conditions have been met: a) I must be a member of an eligible class: b) I must have satisfied the policyholder waiting period; c) group must have met the Insurer's minimum participation requirement; d) I must satisfactorily answer all questions on this form; e) I must be actively at work, and for my dependents, they must not be disabled (unless included by special endorsement), on the effective date (according to the Insurer's rules); and f) the first month's premium must have been received by the Insurer at its administrative office. Lastly, I understand that completion of this application in no way implies that I will be accepted for insurance coverage. I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medical ly-related facility, insurance company, the Medical Information Bureau*, or other organization, institution or person, that has any records or knowledge of me or my health, to give to Insurer, or its reinsurers, any such information. I understand the information obtained by use of this Authorization will be used by Insurer to determine eligibility for insurance. Any information obtained will not be released by Insurer to any person or organization except to reinsuring companies, the Medical Information Bureau*, or other persons or organizations performing business or legal services in connection with my application, claim, or as may be otherwise lawfully required or as I authorize. I know that I may request to receive a copy of this Authorization. I agree that a photographic copy of this Authorization shall be as valid as the original. I agree that this Authorization shall be valid for two years from the date shown below.

Signed in (City/State)

This

Day of (MonthNear)

Applicant's Signature X

Spouse's** Signature (if applicable)

AGENT'S STATEMENTS AND AGREEMENTS: I hereby certify that I have accurately recorded in this application all of the information supplied by the applicant. The applicant has read or had read to him/her the completed application. I also certify that this insurance q does q does not replace or change any existing life insurance coverage. I further certify that a life insurance illustration q was q was not (but a company-provided Rate Sheet may have been used and no non-guaranteed values were shown to the applicant) used in connection with this application.

Licensed Representative's Name David B. Deade Agent # BUO61 9

Licensed Representative's Signature Date

*Information regarding your insurability will be treated as confidential. The Insurer, or its reinsurers, may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members.' lfyou apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the Bureau, upon request, will supply such company with the information in its file. Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau's file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the Bureau's information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-

8734, telephone number 866-692-6901 (TTY 866-346-3642 for hearing impaired). Insurer, or its reinsurers, may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.

TRANSAMERICA ® LIFE INSURANCE COMPANY

Transamerica Life Insurance Company ("Insurer') Home Office: Cedar Rapids, IA Administrative Office: P.O. Box 8063

Little Rock, AR 72203-8063

Supplemental Application for Accelerated Death Benefit

for Long Term Care Rider

This is a supplement to the Application for Life Insurance by the Proposed Insured listed below.

Proposed Insured (Last, First, M.I.)

q Male q Female

Social Security No. Date of birth Policy Number

Home address City State Zip code

This address is a: q Personal Private Residence q Residence of Friend or Relative q Other (please explain)

Phone Number Best Time to Call

q Day q Evening

Height Weight

Protection against unintended lapse: I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this long term care insurance rider for nonpayment of premium. I understand that notice will not be given until thirty days after premium is due and unpaid. Secondary Addressee Name Home Address City State Zip code

q I elect NOT to designate any person to receive such notice.

1. Do you have any impairment, whether physical or mental, for perform everyday living activities, such as dressing, eating, activities, or taking medication?

2. Are you currently confined to a hospital or nursing home, or care or home health care?

3. Do you use a wheelchair, walker or cane, oxygen, catheter, taking any prescribed or over the counter medication?

4. During the past five (5) years, have you been confined to a hospital, day care or home health care, or has such confinement, resident

5. Within the past five (5) years, have you been treated for or been depression, Alzheimer's disease, Parkinson's Disease or any

Medical Questionsassistance or supervision of any kind to

(getting in and out of bed), toilet

facility, or are you receiving adult day

mechanical device or are you currently

assisted living facility, or received adult

profession that you had dementia,

which you need or receive walking, bathing, transferring

residing in an assisted living

dialysis machine or other

a nursing home or an or care been recommended? told by a member of the health

other mental illness?

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

6. Do you contract)?

7. Did you If so, name

8. Is the Proposed

9. Do you intend

10. Has any than applied

have another long term care insurance

have another long term care insurance of company

Non-Medical Questionshealth care

months? date lapsed

with this rider?

declined, postponed

service contract or HMO

.

policy or certificate in

policy or certificate in force

force (including

during the last twelve If policy lapsed,

coverage

for ever been

q Yes q No

q Yes q No

Insured currently covered by Medicaid?

to replace any of your medical, health or long term care insurance

health insurance, nursing home or home health care coverage applied for?

or offered other

q Yes q No

q Yes q No

q Yes q No

Please list any health insurance policies that are still in force or policies purchased in the past five years that are no longer in force.

Please provide details of all "Yes" answers. Use additional paper

Details

if needed.

Question # Name

CUL-AP-01-LA-Supp

Any changes made to the application will require the changes to be dated and initialed by Applicant. Page 1 of 2

APPLICANT'S STATEMENTS AND AGREEMENTS:

I, the Proposed Insured, understand and acknowledge that I have provided authorizations to Transamerica Life Insurance Company (the Company) to obtain non-public personal financial and health information about me. I understand and agree that information obtained in accordance with such authorizations may be used by the Company in determining whether to issue an Accelerated Death Benefit Long-Term Care Rider to me.

I, the Proposed Insured, understand and agree that:

1. The coverage I am applying for provides benefits for the Proposed Insured only.

2. Any benefits available to me under this rider will end when I die and/or when my Policy terminates.

3. This Supplemental Application will become a part of the Application for Life Insurance.

4. The rider applied for herein is not intended to replace any long term care/health insurance coverage.

5. Having read the above answers and statements, I declare that they are true and complete to the best of my knowledge and belief.

6. No agent has any authority to waive a question or to determine insurability.

Warning: 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 ay be subject to fines and confinement in prison.

CAUTION: IF YOUR ANSWERS ON THIS APPLICATION ARE INCORRECT OR UNTRUE, TRANSAMERICA LIFE INSURANCE COMPANY HAS THE RIGHT TO DENY BENEFITS OR RESCIND YOUR RIDER.

Signed in (City/State) This Day of (Month/Year)

Policy Owner's Signature Proposed Insured's Signature

AGENT'S STATEMENTS AND AGREEMENTS: List any other health insurance policies you have sold to the applicant that are still in force

List any other health insurance policies you have sold to the applicant in the past 5 years that are no longer in force

I hereby certify that I have accurately recorded in this application all of the information supplied by the applicant. I further certify that the information provided is true and complete to the best of my knowledge.

Agent's Name Agent #

Agent's Signature Date

Agent's License ID Number Agent's SSN

CUL-AP-01-LA-Supp

Any changes made to the application will require the changes to be dated and initialed by Applicant. Page 2 of 2

SED-4 (R 09/11)

Transamerica Life Insurance Company

State of Louisiana Employee Payroll Deduction Authorization Employee Name Soc.

11

Sec.

11

No. Employee No. (for agency use)

Agency No. Department/Agency/Section Name

I hereby authorize my employer to deduct Transamerica Life Insurance . A TOTAL

a total of $ , monthly rate, from my salary until further of $ represents

notice and remit one half of the total

the vendor. It is the responsibility between

policy. Cancellation signed SED-4 stopping

deductions that are the employee's responsibility

employee and the

same to monthly premium

responsibility of the the employee

Semi-Monthly Deduction in the amount

employing agency are not representatives a payroll deduction with of address and/or

of any payroll deduction is correct and request to both the vendor and his/her

can be stopped in the LaGov HCM any wages, or not being paid enough

of the payroll system are not pre-taxed. in this section have been read, are

required for the coverage(s) detailed The Office of State Uniform Payroll employee to notify each vendor

below. and the

he/she has the amount in a written

the deduction not being due

made outside the statements

or agents of the employee or name changes. It is solely the

is properly credited to the appropriate agency's payroll office. An employee

payroll system. Statewide vendor wages to take the deduction are

By signing this form, both the understood and are agreed upon.

and the vendor to ensure that of a policy must the

not taken due to to pay

vendor

be submitted by the employee deduction may be required before an employee being on LWOP. directly to the vendor. Payments representative acknowledge that

DEDUCTION DETAIL (Product Names & Codes, 125 Eligible, Premium Amts.) MENU ELECTIONS

PRODUCT NAME

PLAN PART

125 ELIG MO PREM.PAYROLL

CODE

INELIGIBLE & NON-PART Semi-Mo.

ELIGIBLE PART Semi-Mo. CD YES NO

Cancer 25 N Y $ NA $ Cancer 25 P Y $ PA $ Heart 16 N Y $ NC $ Heart 16 P Y $ PC $

SUBTOTALS Non-Part. - Part. $ $

Universal Life 32 N N $ NR $

Accident 27 N N $ NT S

Cancer-C/V-N/S 80 N N $ NM $ Heart-C/V-N/S 82 N N $ NP $

Total Mo. Prem. $ PP Begin Date

Total Semi-Mo. Ineligible

Total Semi-Mo. Non-Part.

$

$ Date Authorized

By:

Total Semi-Mo. Part. $

TOTAL SEMI-MONTHLY $ Employee Signature

(THIS FORM SUPERSEDES

Presentation an deduction authorization processed by:

AND REPLACES ALL OTHER AUTHORITY FOR DEDUCTIONS FOR THIS VENDOR)

Transamerica Life Insurance Representative Phone Date

Company Address

Original: HR Payroll

Yellow: Home Office

Pink: Customer