HIPAA Authorization for

Release of Health-
Related Information

Transamerica Life Insurance Company

Home Office: 6400 C Street SW, Cedar Rapids, IA 52499

This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

Name of Primary Proposed Insured/Patient Date of birth Last four digits of SSN

Name of Secondary Proposed Insured/Patient Date of birth Last four digits of SSN

Name(s) of Unemancipated Minors Date(s) of birth Last four digits of SSN(s)

I hereby authorize the use or disclosure of health information, as described below, about me or my above-named
unemancipated minor children and revoke any previous restrictions concerning access to such information:
1. Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician,
health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy,
pharmacy benefit manager, insurance company [including the Companies noted above (the “Companies”)], insurance
support organization such as MIB Group, Inc., or other medical practitioner or health care provider that has provided
payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children.
2. Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The
Companies, their affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize
the Companies and their affiliates and reinsurers to redisclose the information to MIB Group, Inc., which operates an
information exchange on behalf of life and health insurance companies.
3. Description of the information that may be used or disclosed: This authorization specifically includes the release
of all information related to my health or that of my unemancipated minor children and my or my unemancipated
minor children’s insurance policies and claims, including, but not limited to, information on the diagnoses, prognoses,
treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental
illness, communicable or infectious conditions, such as HIV or AIDS, and use of alcohol, drugs and tobacco. This
Authorization excludes psychotherapy notes that are separated from the rest of my medical records.
4. The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my
insurance application with the Companies, to support the operations of our business, and, if a policy is issued, for
evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy, for reinstatement
of the policy or to contest a claim under the policy.
STATEMENTS OF UNDERSTANDING & ACKNOWLEDGMENT:
• I understand that health information about me provided to the Companies may be protected by state and federal privacy
regulations including the HIPAA Privacy Rule and that the Companies will only use and disclose such information as
permitted by applicable regulations and as described in their privacy notices. However, I also understand that any infor-
mation disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected
by federal regulations such as the HIPAA Privacy Rule governing privacy and confidentiality of health information.
• I understand that if I refuse to sign this authorization to release my health information or that of my unemancipated
minor children, the Companies may not be able to process my application, or if coverage is issued may not be able to
make any benefit payments.
• I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been
taken in reliance on it, or to the extent that other law provides the Companies with the right to contest a claim under the
policy or the policy itself, by sending a written revocation to the Companies’ Privacy Official at the address at the top
of this form. I also understand that the revocation of this authorization will not affect uses and disclosures of my health
information for purposes of treatment, payment and business operations, including agent commission statements.
• This authorization shall remain in force for 24 months (12 months in Kansas) from the date signed, regardless of my
condition and whether living or deceased.
• I acknowledge I have received a copy of this authorization.

ICC16HIPAA Please return this original copy to Company Page 1 of 2

Rev 0122
Signature of Primary Proposed Insured/Patient or Personal Representative Date

Signature of Secondary Proposed Insured/Patient or Personal Representative Date

If signed by an individual’s personal representative or the parent or guardian of an unemancipated minor, describe
authority to sign on behalf of the individual:

l Parent l Legal guardian l Power of Attorney l Other (please describe):

(NOTE: If more than one individual is named above, please specify the individual(s) to which the personal representative
applies.)

Policy or contract number (if known):

A copy of this authorization will be considered as valid as the original.

ICC16HIPAA Please return this original copy to Company Page 2 of 2

 HIPAA Authorization for
Release of Health-
Related Information

Transamerica Life Insurance Company

Home Office: 6400 C Street SW, Cedar Rapids, IA 52499

This authorization complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

Name of Primary Proposed Insured/Patient Date of birth Last four digits of SSN

Name of Secondary Proposed Insured/Patient Date of birth Last four digits of SSN

Name(s) of Unemancipated Minors Date(s) of birth Last four digits of SSN(s)

I hereby authorize the use or disclosure of health information, as described below, about me or my above-named
unemancipated minor children and revoke any previous restrictions concerning access to such information:
1. Person(s) or group(s) of persons authorized to use and/or disclose the information: Any health plan, physician,
health care professional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy,
pharmacy benefit manager, insurance company [including the Companies noted above (the “Companies”)], insurance
support organization such as MIB Group, Inc., or other medical practitioner or health care provider that has provided
payment, treatment or services to me or on my behalf or to or on behalf of my unemancipated minor children.
2. Person(s) or group(s) of persons authorized to collect or otherwise receive and use the information: The
Companies, their affiliates and reinsurers, and their agents, employees, or other representatives. I further authorize
the Companies and their affiliates and reinsurers to redisclose the information to MIB Group, Inc., which operates an
information exchange on behalf of life and health insurance companies.
3. Description of the information that may be used or disclosed: This authorization specifically includes the release
of all information related to my health or that of my unemancipated minor children and my or my unemancipated
minor children’s insurance policies and claims, including, but not limited to, information on the diagnoses, prognoses,
treatments, prescription drug information, and information regarding diagnosis, prognosis and treatment of mental
illness, communicable or infectious conditions, such as HIV or AIDS, and use of alcohol, drugs and tobacco. This
Authorization excludes psychotherapy notes that are separated from the rest of my medical records.
4. The information will be used or disclosed only for the following purpose(s): For the purpose of underwriting my
insurance application with the Companies, to support the operations of our business, and, if a policy is issued, for
evaluating contestability and eligibility for benefits, for the continuation or replacement of the policy, for reinstatement
of the policy or to contest a claim under the policy.
STATEMENTS OF UNDERSTANDING & ACKNOWLEDGMENT:
• I understand that health information about me provided to the Companies may be protected by state and federal privacy
regulations including the HIPAA Privacy Rule and that the Companies will only use and disclose such information as
permitted by applicable regulations and as described in their privacy notices. However, I also understand that any infor-
mation disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected
by federal regulations such as the HIPAA Privacy Rule governing privacy and confidentiality of health information.
• I understand that if I refuse to sign this authorization to release my health information or that of my unemancipated
minor children, the Companies may not be able to process my application, or if coverage is issued may not be able to
make any benefit payments.
• I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been
taken in reliance on it, or to the extent that other law provides the Companies with the right to contest a claim under the
policy or the policy itself, by sending a written revocation to the Companies’ Privacy Official at the address at the top
of this form. I also understand that the revocation of this authorization will not affect uses and disclosures of my health
information for purposes of treatment, payment and business operations, including agent commission statements.
• This authorization shall remain in force for 24 months (12 months in Kansas) from the date signed, regardless of my
condition and whether living or deceased.
• I acknowledge I have received a copy of this authorization.

ICC16HIPAA Applicants should retain this signed copy for their records Page 1 of 2
Rev 0122
Signature of Primary Proposed Insured/Patient or Personal Representative Date

Signature of Secondary Proposed Insured/Patient or Personal Representative Date

If signed by an individual’s personal representative or the parent or guardian of an unemancipated minor, describe
authority to sign on behalf of the individual:

l Parent l Legal guardian l Power of Attorney l Other (please describe):

(NOTE: If more than one individual is named above, please specify the individual(s) to which the personal representative
applies.)

Policy or contract number (if known):

A copy of this authorization will be considered as valid as the original.

ICC16HIPAA Applicants should retain this signed copy for their records Page 2 of 2
 Reset Form

TRANSAMERICA LIFE INSURANCE COMPANY

Individual Whole Life Insurance Application
Home Office: Cedar Rapids, IA Administrative Office: 6400 C Street SW, Cedar Rapids, IA 52499
“Company,” “We,”“Our,” and “Us” all refer to Transamerica. Unless otherwise stated, “You” refers to the Proposed Primary Insured.

1. PROPOSED PRIMARY INSURED PERSONAL INFORMATION

Legal First Name Middle Name Legal Last Name Suffix Gender
Male Female
Social Security Number/ITIN Date of Birth (mm/dd/yyyy) Place of Birth (State / Territory, Country)

Physical Address (No P.O. Boxes) Apartment / Unit

City U.S. State / Territory Zip Code Country

Phone Number Mobile Email Address

2. COVERAGE ELIGIBILITY
I confirm that I have not been diagnosed with, treated for, tested positive for, or been given medical advice by a member of
the medical profession for any of the following:
Alzheimer’s Disease or any type of Dementia/organic brain syndrome, cognitive impairment, memory loss, or mental incapacity; Amyotrophic Lateral Sclerosis (ALS or Lou
Gehrig’s disease) or other motor neuron disease; amputation (other than due to accident/ trauma); metastatic, recurrent cancer, or multiple cancers, or cancer (any type other
than basal cell of skin) within the last 2 years; Cerebral Palsy; Down Syndrome; Pulmonary Fibrosis; Sickle Cell Anemia; currently bedridden, residing in a nursing home, assisted
or long term care facility, or receiving hospice, palliative, or home health care.
Eligibility for coverage is not available if any of the above listed conditions apply. Please proceed to the following section only if the box is checked.

3. PERSONAL HISTORY
A. Have you received or been advised to seek medical treatment or counseling for the use of, or been advised to discontinue the
use of alcohol or drugs, by a member of the medical profession; or joined an organization for dependence or abuse in the past
0–2 years?, 2–4 years?, 4–10 years?, none of these?

Have you used narcotics, barbiturates, amphetamines, hallucinogens, heroin, opiates, cocaine, or any habit forming drugs except as
prescribed by a member of the medical profession in the past 0–2 years?, 2–4 years?, 4–10 years?, none of these?

Have you been convicted of or pleaded no contest to reckless driving or operating a vehicle while impaired (DWI/OWI/DUI) in the
past 0–2 years?, 2–5 years?, none of these? Number of these offenses in the past 5 years:

Have you been convicted of or pleaded no contest to a felony or do you have such charge currently pending against you in the past
0–3 years?, 3–5 years?, 5–10 years?, none of these?
Total number of felonies, convicted or pleaded no contest to in the past 10 years:

B. Height (feet and inches) C. Current Weight (pounds)

D. Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical
profession for any of the following: (Select all that apply)
Heart Disease Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure (CHF) or any respiratory disorder or disease (excluding
allergies or mild Asthma) “Mild” asthma is
Transient Ischemic Attack (TIA) or Stroke/ categorized as: no daily symptoms, no limitations
Cerebrovascular Accident (CVA) to daily activities, no reduced lung function, no
Disease or disorder of the kidneys including Polycystic regular use of oral steroids, and no ER visits or
Kidney Disease (PKD) or Neurogenic Bladder (not hospitalizations due to asthma in the last five years.
Kidney Stones unless diagnosed a “Stone Former”) Cancer or malignancy of any kind (exclude benign or
Disease or disorder of the liver or Hepatitis non-melanoma skin cancers or fatty tumors)
Diabetes (other than during pregnancy) None of the above

1
ICC22 T-AP-WL11IC-0822 FE
3. PERSONAL HISTORY (Continued) Yes No
E. During the last 3 months, have you been on treatment for anemia (lower than normal number of red blood cells)?
Include diet, iron pills, iron shots, infusions as treatment.
In the last 12 months, were you a patient in a hospital overnight? (Do not include hospitalization due to child birth
without complications or an overnight stay in an emergency room.)
Have you ever been diagnosed by a member of the medical profession or tested positive for any of the following:
Acquired Immune Deficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV), and/or tested positive on an
AIDS/HIV related test?
Have you ever used nicotine in any form? This includes cigarettes, e-cigarettes/vapes, chewing tobacco/smokeless
tobacco, pipe, cigar, nicotine gum/patch, or other nicotine delivery system. If “Yes,” date of last use:
In a typical week, do you perform any intentional physical activity such as yard work, walking, exercising, or playing
sports for at least 10 consecutive minutes? Days:
Is the Owner employed by any cannabis related business?

4. U.S. CITIZENSHIP
United States citizens and valid Green Card holders are eligible.
Are you a U.S. citizen? Green Card
Yes No

Green Card Number and Expiration Date Country of Citizenship

5. OTHER INSURANCE Yes No

1. Do you have any pending applications or existing life insurance or annuities with the company or any other company?

2. Will the insurance applied for discontinue, replace, or change any existing life or annuity coverage?

If “Yes” to questions 1 or 2, please provide details below and complete state required forms, if applicable.
For Internal Replacements, complete the Withdrawal/Surrender Form.

Types of coverage include: Personal, Business, Employer-Provided, Group

Type of Coverage Company Policy Number Face Amount Replacement Pending Application
$ Yes No Yes No
$ Yes No Yes No
$ Yes No Yes No

6. OWNER
Complete this section only if the owner is not the Proposed Primary Insured.
If there is a Contingent Owner, complete the Contingent Owner Form.

Legal First Name Middle Name Legal Last Name Suffix Gender
Male Female
Social Security Number/ITIN Date of Birth (mm/dd/yyyy) Place of Birth (State / Territory, Country)

Physical Address (No P.O. Boxes) Apartment / Unit

City U.S. State / Territory Zip Code Country

Phone Number Mobile Email Address

2
ICC22 T-AP-WL11IC-0822 FE
6. OWNER (Continued)
Owner’s relationship to Proposed Primary Insured
Spouse Child Parent Grandparent Domestic Partner Other

Are you a U.S. citizen? Green Card

Yes No

Green Card Number and Expiration Date Country of Citizenship

7. BENEFICIARIES
Total between all primary beneficiaries must equal 100%. Total between all contingent beneficiaries must equal 100%. If you
need space for more beneficiaries, complete the Beneficiary Supplement.

Beneficiary Information
Primary First & Last Name Date of Birth (mm/dd/yyyy) Phone Number Relationship Benefit %

Mailing Address Social Security Number/ITIN

Primary First & Last Name Date of Birth (mm/dd/yyyy) Phone Number Relationship Benefit %
or
Contingent
Mailing Address Social Security Number/ITIN

Primary First & Last Name Date of Birth (mm/dd/yyyy) Phone Number Relationship Benefit %
or
Contingent
Mailing Address Social Security Number/ITIN

8. PRODUCT DETAILS
Product Name Coverage Amount (This is the amount of life insurance Planned Premium Amount
coverage you are applying for.)
$ $
Rate Class Applied for:
Preferred Non-tobacco Preferred Tobacco Request to backdate the policy to ‘Save Age’
Standard Non-tobacco Standard Tobacco Graded
If a policy cannot be issued as applied for, Adjust face amount to premium?
would you accept a modified rate class Yes No
and/or plan? if “Yes” Yes No

Automatic Premium Loan (subject to policy loan provisions): Elect Do Not Elect

ADDITIONAL BENEFITS

Benefit Amount
Accidental Death Benefit Rider Coverage amount equal to policy face amount

Child/Grandchild Rider (If elected, complete supplement form) $

By checking this box, I attest that no child listed on the supplemental application has been diagnosed by a
member of the medical profession with a terminal illness expected to result in death within 24 months, and I
am the parent/guardian of each child listed or the legal guardian has approved the application for insurance.

I agree that if (1) the proposed insured does not qualify for the rate class above, I am applying for the best rate class available; (2) the proposed insured qualifies for the
rate class but the premium amount paid or authorized with this application is not sufficient, the Company shall issue the policy for a reduced coverage amount modified
according to the applicable rates for that coverage amount. If the planned premium amount shown in this application is other than the amount required for the policy issued,
the Company will increase or decrease the coverage amount for that policy. If the proposed insured qualifies for the Graded rate class, no riders will be issued.

3
ICC22 T-AP-WL11IC-0822 FE
9. PAYMENT OPTIONS
Choose the premium payor, payment type and mode, and complete the Payment Authorization form.
Premium Payor: Proposed Primary Insured Owner Other (if chosen, complete Premium Payor Supplement)
Payment Type: Bank Draft Credit/Debit Card Social Security Benefits Billing Direct Bill
Payment Mode: Annual Semi-Annual Quarterly Monthly

10. AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

Each of the undersigned hereby certifies and represents as follows: such credit reporting agency, and do consent to such use of my information.
The statements and answers given on this application are true and complete to the I hereby expressly consent to receive calls about my application from the Company
best of my knowledge and belief. I agree (A) this application shall consist of the or its representatives that involve the use of an automatic telephone dialing system
Individual Life Insurance Application, the Individual Life Insurance Application - and/or an artificial or prerecorded voice. This authorization will be valid for 30
Personal History, and any required application supplement(s)/amendment(s), and months, or the period permitted by applicable law in the state where the policy is
shall be the basis for any contract issued on this application; (B) that the Producer delivered or issued for delivery, if shorter. Information released shall comply with
does not have the authority to waive any question on this application, to decide if the time limit, if any, permitted by applicable law in the state where the policy is
insurance will be issued, or to modify any term or provision of any insurance which delivered or issued for delivery. I understand that I may revoke it at any time by
may be issued based on this application, only a writing signed by an officer of the giving written notice to the Company at the above address. I understand that there
Company can change the terms of this application or the terms of any insurance are limitations on my right to revoke this authorization. Any action taken in reliance
issued by the Company; (C) no policy applied for shall take effect until after all of on this authorization will be valid if such action has been taken prior to receipt of
the following conditions have been met: 1) the minimum initial premium must be notice of revocation. If this authorization is used to collect information in connection
received by the Company; 2) the Owner must have personally received and accepted with a claim for benefits, it will be valid for the duration of the claim. If the law of
the policy during the lifetime of each Insured and there must have been no change my state so provides, my authorization may not be revoked during a contestable
in the insurability of any Insured; and 3) on the date of the later of either 1) or 2) investigation. I also understand that my revocation of this authorization will not
above, all of the statements and answers given in this application must be true and result in the deletion of codes in the MIB database if such codes are reported by the
complete. Unless otherwise stated, the undersigned Insured is the premium payor Company (or the Company becomes obligated to report such codes to MIB) while
and Owner of the policy applied for. this authorization is in force. I understand the Company may use the information
I hereby authorize any licensed physician, medical practitioner, pharmacy and collected via this authorization: (1) to underwrite my insurance application, (2) to
pharmacy benefit managers, hospital, clinic or other medical or medically related support the operations of the Company’s business, (including performing actuarial
facility, wellness/fitness, financial services or insurance company, MIB, LLC (“MIB”), or internal business studies, research and analytics and other analysis), or (3) if a
consumer reporting agency, data aggregator, or any other organization, institution policy is issued, to evaluate contestability and eligibility for benefits, the policy’s
or person, that has any records or knowledge of me or my health/fitness, finances, continuation or replacement, the policy’s reinstatement, or to contest a claim under
credit history, credit standing, credit capacity, life activities or purchase history, the policy.
to give to the Company, or its reinsurers, any such information. This may include The Company shall have 60 days from the date hereof within which to consider and
information on the diagnosis and treatment of mental illness, alcohol, and drug use. act on this application and if within such period a policy has not been received by the
This also may include information on the diagnosis, treatment, and testing results Owner or if notice of approval or rejection has not been given, then this application
related to HIV, AIDS, and sexually transmitted diseases, unless otherwise restricted shall be deemed to have been declined by the Company.
by state law. I authorize the Company, or its reinsurers, to make a brief report of I acknowledge receipt of the Notice of Disclosure for (1) Notice to Persons
my personal health information to MIB. A photographic copy of this authorization Applying for Insurance Regarding Investigative Report, (2) MIB Pre-
shall be as valid as the original. I understand a credit report may be requested in Notification, and (3) Notice of Insurance Information Practices.
connection with this authorization. I also understand that any credit reporting
agency contacted in connection with this authorization may retain and use any I understand that any omissions or misstatements in this application could
information provided about me to the credit reporting agency to the extent that the cause an otherwise valid claim to be denied under any insurance issued from
information is in addition to or more current than the information currently held by this application.

The USA PATRIOT ACT requires all financial institutions to obtain, verify, and maintain information that identifies each person who opens a new account with the Company,
or assumes ownership of an existing policy or contract. To meet this federal obligation, we will ask for your name, address, date of birth, or articles of incorporation or similar
documents and other information, including a driver’s license or other government-issued identification that will allow us to verify your identity. This process may include the
use of third-party sources to verify the information provided.

FRAUD WARNING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a
criminal offense and subject to penalties under state law.

Signature of Proposed Insured Date City U.S. State / Territory

Signature of Applicant/Owner Date City U.S. State / Territory

(If other than Proposed Insured)

Print Producer Name Producer Number Producer Signature

4
ICC22 T-AP-WL11IC-0822 FE
NOTICE OF DISCLOSURE
Please provide a copy of these notices to the applicant and to any proposed Insureds not living in the household.
NOTICE TO PERSONS APPLYING FOR INSURANCE REGARDING INVESTIGATIVE REPORT
To proposed Insured: In connection with this application, an investigative consumer report may be prepared about you. Such reports are part of the process of
evaluating risks for life and health insurance. Typically, this report will contain information about your character, general reputation, personal characteristics, and mode
of living. The information in the report may be obtained by talking with you or members of your family, business associates, financial sources, neighbors, and others
you know. You may ask to be interviewed in connection with the preparation of any such report. Also, we may have the report updated if you apply for more coverage.
Upon your written request, we will let you know whether a report was prepared and we will give you the name, address, and telephone number of the
agency preparing the report. By contacting that agency and providing proper identification, you may obtain a copy of the report.
MIB PRE-NOTIFICATION
Proposed Insured and other persons proposed to be insured, if any: Information regarding your insurability will be treated as confidential. The Company or its
reinsurers may, however, make a brief report thereon to MIB, a not-for-profit membership organization of insurance companies, which operates an information
exchange on behalf of its Members. If you apply to another MIB Member company for life or health insurance coverage, or a claim for benefits is submitted to such a
company, MIB, upon request, will supply such company with the information in its file.
Upon receipt of a request from you MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 866-692-6901 (TTY 866-346-3642).
If you question the accuracy of information in MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair
Credit Reporting Act ([Link]). The address of MIB’s information office is 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734.
The Company, or its reinsurers, may also release information in its file to other insurance companies to whom you may apply for life or health insurance, or to whom a
claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at [Link].
NOTICE OF INSURANCE INFORMATION PRACTICES
To proposed Insured: Personal information may be collected from persons other than the individual(s) proposed for coverage. Such information as well as other
personal or privileged information subsequently collected by us or our producer may in certain circumstances be disclosed to third parties without authorization.
Upon request, you have the right to access your personal information and ask for corrections. You may obtain a complete description of our Information Practices by
writing to: Transamerica Life Insurance Company, Attn: Director of Underwriting, 6400 C Street SW, Cedar Rapids, Iowa 52499.

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ICC22 T-AP-WL11IC-0822 FE
 Reset Form

AGENT’S REPORT

Agent Name Agent Number Profile Number % of Agent’s Split

Producer 1

Producer 2

Producer 3

Producer 4

2. AGENT DISCLOSURE
How long have you known the Proposed Primary Insured? Relationship to Proposed Primary Insured:

Yes No
Does the Proposed Insured have existing life insurance policies or annuity contracts with the company
or any other company?

Will the policy applied for discontinue, replace, or change any existing life insurance policy or annuity?
If replacement of existing insurance is involved, have you complied with all state requirements, including any Disclosure
and Comparison Statements?
If “No,” explain.

Has any application for life, health, disability, or long term care insurance been declined,withdrawn, postponed, rated,
modified, issued with an exclusion rider, canceled, or renewed?

Are you financially responsible for the Proposed Primary Insured?

Are you or any of your family members named as a beneficiary on this policy application?
If “Yes,” what insurable interest do you/your family member have in the life of the insured(s)?

Do you intend to submit multiple applications on any of the proposed insureds?

Is the Agent or Split Agent also the Insured, Owner, Applicant or Payor?

Is the Proposed Primary Insured or Owner related to any affiliated Broker/Dealer office or employee?
If “Yes,” name and address of Broker/Dealer

City U.S. State / Territory Zip Code

Did you provide the “Notice of Disclosure” to the Proposed Primary Insured? Yes No N/A
How was this sale taken?
In Person Phone or Video Call Other
Was the identification of the Proposed Primary Insured Type of government-issued photo ID
verified during the sale? Yes No

Issuer of Identification Document Number Expiration Date

AR2022 NF 1
3. CORRESPONDENCE INFORMATION

Case Manager Name (if applicable)

Agent/Case Manager Email Office ID

Agent/Case Manager Phone Number Agent/Case Manager Fax Number

4. SIGNATURE
I submit this application assuming full responsibility for delivery of any coverage issued and for immediate transmittal to the Company of the first premium when collected.
I certify that I reviewed the photo identification of each person seeking to open this policy and verified that each person seeking to open this policy is the same person in the
documents reviewed. I certify that I used only company approved sales materials and copies of all sales materials used during the solicitation were provided to the Applicant.
I attest that neither I nor the beneficiary translated, the translator is fluent in both languages involved, the Applicant and/or Proposed Insured fully understood everything
translated, and that a similarly disinterested translator will participate through to policy delivery. I understand that misrepresentations in connection with this and other
certifications in the Company’s application documents may result in disciplinary action, termination, civil action, or prosecution for violation of state or federal criminal laws.
As part of the application review, I discussed with the Applicant the possibility to designate a secondary addressee and the Applicant declined to designate a secondary
addressee.
Payment with application not accepted if: (1) the Proposed Insured does not reside in the U.S., or (2) the Proposed Insured has been treated for or experienced,
within the last 12 months, any disorder of the heart, stroke or other vascular disease, cancer, or HIV infection.

Signature of Writing Agent/Registered Representative Date (mm/dd/yyyy)

AR2022 NF 2
 Reset Form

Payment Authorization Form

Policy Number (for existing policies only)

Introduction

Instructions: Questions?
Use this form to choose the initial
premium payment method on your Contact your
application for insurance or to Return Completed Form To: Financial
update how you pay for an existing Transamerica Life Insurance Company Professional
policy. Take care to fill in each field Transamerica Financial Life Insurance Company
accurately so letters and numbers 6400 C St. SW
Visit us at:
cannot be misinterpreted and Cedar Rapids, IA 52499
attach a separate sheet if there is [Link]
more than one policy number. Note
that not all payment options are Or fax it to us at: Call us at:
available on all products. 1-800-235-4782 1-800-797-2643

Insured First Name Insured Last Name

Policy Owner First Name Policy Owner Last Name

Draft Date (MM/DD, 1st through 28th only)

If you select an initial premium draft date in the future, it cannot be greater than 30 days after the
application date, and you will not have potential coverage until that date under the Conditional Receipt.

Leave the above blank to have Recurring Payment Frequency (choose one) Total Premium
initial and recurring premiums Monthly Semiannually
drafted on day policy is issued. Quarterly Annually
$ , .
Please select your preferred payment type/s by checking the box for initial and/or recurring payments next to the
option you favor. (Ex: I want to make my initial payment by check and recurring payments with my credit card.)

Payment Type Options Initial and/or Recurring Payment Form Information

Bank Draft (ACH/ EFT) Initial Recurring Complete the ACH payment section below

Complete the SSB Option info on the next

Social Security page. To pay by SSB Card, tokenize the card
Benefits Billing (SSB) Initial Recurring # and fill out the Credit Card Payment section;
or for direct SSB account draft, fill out the
Bank Draft Payment section.

Credit Card Initial Recurring Tokenize your card number, and complete the
Credit Card Payment section below

No additional form required; mail your check

Check Initial
to the address at the top of this form

No additional form required; this method only

Direct Bill Recurring
available quarterly, semiannually, or annually.

PAY2022ALL Transamerica Life Insurance Company I Transamerica Financial Life Insurance Company Page 1 of 3
Home Office: Cedar Rapids, IA Home Office: Harrison, NY
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If using Social Security Benefits for either form of payment, please enter payer date of birth and then select one:
Payer date of birth

Beneficiary receiving Supplemental Security Income (SSI) Benefit Paid on Second Wednesday (Option C)
1st of the month (Option A)
Benefit Paid on Third Wednesday (Option D)
Benefit Paid on 3rd of each month, started receiving SS
benefits prior to May 1997 or receiving both SS benefits Benefit Paid on Fourth Wednesday (Option E)
and SSI payments (Option B)

Credit Card Payment Information

Credit Card Type: VISA MasterCard Create your PCI token at: [Link]-
[Link] (Reminder: When you enter your credit
PCI Token # card information on the Token website, your unique
number will start with a “T”. Be sure to write the full
number, including the T, on the line at left.)
Cardholder First Name Cardholder Last Name

Card [Link] Payment Amount The cardholder is the (choose one):

$ , . Insured Owner Spouse Other:
Cardholder Address City

State Zip Cardholder Phone Number

Cardholder Signature:
X
By signing I acknowledge that I have read and agreed to all of the following consents that pertain to my preferred
premium payment method.
Bank Draft (ACH/EFT) Payment Information
Account Type: Checking Savings
Account Holder First Name Account Holder Last Name

Trust or Entity (if entity, add the title of officer and name of entity; if trust, add trustee’s name)

Financial Institution Name

Financial Institution City State Zip

Routing Number Account Number

The account holder is the (choose one):

Insured Owner Spouse Other:

Account Holder Signature:

X
By signing I acknowledge that I have read and agreed to all of the following consents that pertain to my preferred
premium payment method.

PAY2022ALL Transamerica Life Insurance Company I Transamerica Financial Life Insurance Company Page 2 of 3
Home Office: Cedar Rapids, IA Home Office: Harrison, NY
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 Consents

If a conditional receipt was issued along with this authorization, initial premium will be withdrawn/cashed upon receipt
of the application by the Company. Unless a conditional receipt was issued along with this authorization, I/we agree
this authorization shall not become effective for payment of the initial premium unless and until after a contract is
issued and all other conditions of coverage set forth in the application have been met.

As a convenience to me, I request and authorize the Company named above to make withdrawals, by draft or
electronic transfer, from my account with the financial institution named for: (1) premiums becoming due (including
premiums which have increased from the initial payment amount under the terms of the policy(ies) or due to changes
made to the policy(ies)); (2) other amounts due under the policy(ies) listed above (including any amendments,
endorsements, riders, or amounts past due); (3) loan payments if authorized above or later agreed to by me; and/or
(4) such other payments as I may authorize the Company to make. I request that this authorization, unless previously
revoked, continue to apply to any conversion, renewal, or change later made to the policy(ies). I understand that if a
withdrawal is not honored for payment by the financial institution, with or without cause and whether intentionally or
inadvertently, and the premiums are not otherwise paid within the grace period allowed by a policy, the policy may
terminate.

As a convenience to me, I hereby request the financial institution named above (and its successors and assigns)
to accept and honor the draft or transfer withdrawals made by the Company from my account. I agree the financial
institution shall be fully protected in honoring such draft or transfer.

This authorization shall take effect when recorded and processed by the Company and financial institution and will
remain in effect until I notify the Company or the financial institution in writing to terminate and the Company or
financial institution has a reasonable time to act on the termination request. I hereby terminate any prior authorization
of the Company to initiate charges to this account for the above policy(ies) effective the date on which the initial
charge is made under this authorization. I also understand and agree that if a withdrawal is not honored by the
financial institution for any reason, the Company may cease attempting to make withdrawals through the use of this
authorization.

Bank Account Will be Subject to Identity Verification

To help ensure the security of your funds, if bank account information is provided, the Company may obtain a
consumer report from a Consumer Reporting Agency (“CRA”) to help verify the validity and accuracy of the account
information provided. If I have provided the company with bank account information, I authorize the Company to
obtain a consumer report from the CRA as described above, and acknowledge that I: (1) understand that in order
for the CRA to verify my account information, some of my personal information will be shared with the CRA; and (2)
consent to such sharing, retention, and use.

PAY2022ALL Transamerica Life Insurance Company I Transamerica Financial Life Insurance Company Page 3 of 3
Home Office: Cedar Rapids, IA Home Office: Harrison, NY
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 Accelerated Death Benefit Rider Disclosure

Transamerica Life Insurance Company

Home Office: 6400 C Street SW, Cedar Rapids, IA 52499

Receipt of the Accelerated Death Benefit may adversely affect the recipient’s eligibility for Medicaid or other
government benefits or entitlements. In addition, receipt of the Accelerated Death Benefit may be taxable and
assistance should be sought from a personal tax advisor.
Description of Benefit: Upon receipt of proof acceptable to us of the Insured’s Qualifying Event, the Owner may choose
to receive the Accelerated Death Benefit while the Insured is alive and the Rider is In Force.
Qualifying Event: An event defined in the Rider, which allows for payment of the Accelerated Death Benefit.
Accelerated Death Benefit Amount: The Accelerated Death Benefit shall be equal to:
1. the Policy Death Benefit that would be In Force at the end of the 12 month period following the Acceleration
Date, before deduction of any outstanding Loan Balance; less
2. a discount on the Accelerated Death Benefit calculated for the 12 month period using the current interest rate;
less
3. any outstanding policy loans, including accrued interest until the end of the 12 months following the Accelera-
tion Date; less
4. any premiums which would be required to keep the Policy In Force for the 12 month period following the Ac-
celeration Date for the Policy Amount of Insurance reduced by an appropriate discount using the current interest
rate.
Termination of Coverage: The Accelerated Death Benefit Rider will automatically terminate when the Policy to which it
is attached terminates or lapses or matures or is continued under one of the nonforfeiture options; or when the Acceler-
ated Death Benefit is paid; whichever occurs first.
Impact on the Policy’s Death Benefit: The Policy to which the Rider is attached will terminate on the date the Acceler-
ated Death Benefit is paid.

By signing below, you agree that you have read and received a copy of this summary and disclosure statement at the time of
application.

Date Owner’s (Applicant’s) Signature

Date Agent’s Signature

ICC18 ACC-DISC LR
 Important Notice
Replacement of
Life Insurance or Annuities

Transamerica Life Insurance Company

Home Office: 6400 C Street SW, Cedar Rapids, IA 52499

This document must be signed by the applicant and the producer, if there is one, and a copy left with the applicant.

You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may
involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases
are also considered replacements.
A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue
making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited,
assigned to the replacing insurer, or otherwise terminated or used in a financed purchase.
A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the
withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing
policy, to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement.
You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there
may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing
policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing
policy and may reduce the amount paid upon the death of the insured.
We want you to understand the effects of replacements before you make your purchase decision and ask that you
answer the following questions and consider the questions on the back of this form.

1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to
the insurer, or otherwise terminating your existing policy or contract? ___ YES ___ NO

2. Are you considering using funds from your existing policies or contracts to pay premiums due on the
new policy or contract? ___ YES ___NO

If you answered “yes” to either of the above questions, list each existing policy or contract you are contemplating
replacing (include the name of the insurer, the insured or annuitant, and the policy number or contract number if
available) and whether each policy or contract will be replaced or used as a source of financing:
INSURER CONTRACT OR INSURED REPLACED (R) OR
NAME POLICY # FINANCING (F)
1.
2.
3.
Make sure you know the facts. Contact your existing company or its agent for information about the old policy
or contract. [If you request one, an in-force illustration, policy summary or available disclosure documents must be sent
to you by the existing insurer.] Ask for and retain all sales material used by the agent in the sales presentation. Be sure
that you are making an informed decision.
The existing policy or contract is being replaced because _______________________________________.
I certify that the responses herein are, to the best of my knowledge, accurate:
_______________________________________________________ __________________________
Applicant’s Signature and Printed Name Date
_______________________________________________________ __________________________
Producer’s Signature and Printed Name Date
_______ I do not want this notice read aloud to me. (Applicants must initial only if they do not want the notice
read aloud.)

LREP-00-0917 Rev 0122

A replacement may not be in your best interest, or your decision could be a good one. You should make a careful
comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way
to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information
concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is
working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be
used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine
whether replacement or financing your purchase makes sense:

PREMIUMS:
Are they affordable?
Could they change?
You’re older – are premiums higher for the proposed new policy?
How long will you have to pay premiums on the new policy? On the old policy?

POLICY VALUES:
New policies usually take longer to build cash values and to pay dividends.
Acquisition costs for the old policy may have been paid; you will incur costs for the new one.
What surrender charges do the policies have?
What expenses and sales charges will you pay on the new policy?
Does the new policy provide more insurance coverage?

INSURABILITY:
If your health has changed since you bought your old policy, the new one could cost you more, or you
could be turned down.
You may need a medical exam for a new policy.
[Claims on most new policies for up to the first two years can be denied based on inaccurate statements.
Suicide limitations may begin anew on the new coverage.]

IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY:
How are premiums for both policies being paid?
How will the premiums on your existing policy be affected?
Will a loan be deducted from death benefits?
What values from the old policy are being used to pay premiums?

IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT:

Will you pay surrender charges on your old contract?
What are the interest rate guarantees for the new contract?
Have you compared the contract charges or other policy expenses?

OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS:

What are the tax consequences of buying the new policy?
Is this a tax-free exchange? (See your tax advisor)
Is there a benefit from favorable “grandfathered” treatment of the old policy under the federal tax code?
Will the existing insurer be willing to modify the old policy?
How does the quality and financial stability of the new company compare with your existing company?

30 DAY RIGHT TO CANCEL

In the event of a replacement transaction, you may cancel this policy by delivering or mailing a written request to the
Company. You must return the policy to the Company before midnight of the thirtieth day after the day you receive it.
You will receive an unconditional full refund of all premiums or considerations paid on it, less any withdrawals and
indebtedness, including any policy fees or charges or, in the case of a variable or market value adjustment policy,
payment of the cash surrender value provided under the policy plus the fees and other charges deducted from the gross
premiums or considerations or imposed under the policy. Your written request given by mail and return of the policy by
mail are effective on being postmarked, properly addressed and postage prepaid.

LREP-00-0917
TRANSAMERICA LIFE INSURANCE COMPANY
Premium Payor Supplement
Home Office: Cedar Rapids, IA Administrative Office: 6400 C Street SW, Cedar Rapids, IA 52499
“Company,” “We,” “Our,” and “Us” all refer to Transamerica. Unless otherwise stated, “You” refers to the Payor.
This form is only required when the Premium Payor is not the Insured or Owner.
1. PAYOR INFORMATION
Name (first, middle, last) Policy Number (if available)

Social Security Number/ITIN Date of Birth (mm/dd/yyyy)

Physical Address Apartment/Unit

City U.S. State/Territory Zip Code Country

Phone Number Mobile Email Address

Payor’s Relationship to Insured:

Spouse Parent Child Grandparent Domestic Partner Other:

Are you a U.S. citizen? Green Card

Yes No

Green Card Number and Expiration Date Country of Citizenship

2. AUTHORIZATION AND SIGNATURE

As a convenience to me, I request and authorize the Company name above to make This authorization shall take the effect when recorded and processed by the
withdrawals, by draft or electronic transfer, from my account with the financial Company and financial institution and will remain in effect until I notify the
institution name for: (1) premiums becoming due (including premiums which have Company or the financial institution in writing to terminate and the Company
increased from the initial payment amount under the terms of the policy(ies) or due or financial institution has a reasonable time to act on the termination request. I
to changes made to the policy(ies)); (2) other amounts due under the policy(ies) hereby terminate any prior authorization of the Company to initiate charges to this
listed above (including any amendments, endorsements, riders, or amounts past account for the above policy(ies) effective the date on which the initial charge is
due); (3) loan payments if authorized above or later agreed to by me; and/or (4) made under this authorization. I also understand and agree that if a withdrawal is
such other payments as I may authorize the Company to make. I request that this not honored by the financial institution for any reason, the Company may cease
authorization, unless previously revoked, continue to apply to any conversion, attempting to make withdrawals through the use of this authorization.
renewal, or change later made to the policy(ies). I understand that if a withdrawal Bank Account Will Be Subject to Identity Verification
is not honored for payment by the financial institution, with or without cause and To help ensure the security of your funds, if bank account information is provided,
whether intentionally or inadvertently, and the premiums are not otherwise paid the Company may obtain a consumer report from a Consumer Reporting Agency
within the grace period allowed by a policy, the policy may terminate. (“CRA”) to help verify the validity and accuracy of the account information
As a convenience to me, I hereby request the financial institution named above provided. If I have provided the company with bank account information, I authorize
(and its successors and assigns) to accept and honor the draft or transfer the Company to obtain a consumer report from the CRA as described above, and
withdrawals made by the Company from my account. I agree the financial acknowledge that I: (1) understand that in order for the CRA to verify my account
institution shall be fully protected in honoring such draft or transfer. information, some of my personal information will be shared with the CRA; and (2)
consent to such sharing, retention, and use.

The USA PATRIOT ACT requires all financial institutions to obtain, verify, and maintain information that identifies each person who opens a new account with the Company,
or assumes ownership of an existing policy or contract. To meet this federal obligation, we will ask for your name, address, date of birth, or articles of incorporation or similar
documents and other information, including a driver’s license or other government-issued identification that will allow us to verify your identity. This process may include the
use of third-party sources to verify the information provided.

Payor Signature Date

ICC22 T-SU-WL13IC-0822 FE
 Schedule of Social Security Benefit Payments 2023
JANUARY 2023 FEBRUARY 2023 MARCH 2023
S M T W T F S S M T W T F S S M T W T F S
1 2 3 4 5 6 7 1 2 3 4 1 2 3 4
8 9 10 11 12 13 14 5 6 7 8 9 10 11 5 6 7 8 9 10 11
15 16 17 18 19 20 21 12 13 14 15 16 17 18 12 13 14 15 16 17 18
22 23 24 25 26 27 28 19 20 21 22 23 24 25 19 20 21 22 23 24 25
29 30 31 26 27 28 26 27 28 29 30 31

APRIL 2023 MAY 2023 JUNE 2023

S M T W T F S S M T W T F S S M T W T F S
1 1 2 3 4 5 6 1 2 3
2 3 4 5 6 7 8 7 8 9 10 11 12 13 4 5 6 7 8 9 10
9 10 11 12 13 14 15 14 15 16 17 18 19 20 11 12 13 14 15 16 17
16 17 18 19 20 21 22 21 22 23 24 25 26 27 18 19 20 21 22 23 24
23 24 25 26 27 28 29 28 29 30 31 25 26 27 28 29 30
30
JULY 2023 AUGUST 2023 SEPTEMBER 2023
S M T W T S F S M T W T F S S M T W T F S
1 1 2 3 4 5 1 2
2 3 4 5 6 7 8 6 7 8 9 10 11 12 3 4 5 6 7 8 9
9 10 11 12 13 14 15 13 14 15 16 17 18 19 10 11 12 13 14 15 16
16 17 18 19 20 21 22 20 21 22 23 24 25 26 17 18 19 20 21 22 23
23 24 25 26 27 28 29 27 28 29 30 31 24 25 26 27 28 29 30
30 31
OCTOBER 2023 NOVEMBER 2023 DECEMBER 2023
S M T W T F S S M T W T F S S M T W T F S
1 2 3 4 5 6 7 1 2 3 4 1 2
8 9 10 11 12 13 14 5 6 7 8 9 10 11 3 4 5 6 7 8 9
15 16 17 18 19 20 21 12 13 14 15 16 17 18 10 11 12 13 14 15 16
22 23 24 25 26 27 28 19 20 21 22 23 24 25 17 18 19 20 21 22 23
29 30 31 26 27 28 29 30 24 25 26 27 28 29 30
31
Benefits paid on Birth date on If you don’t receive your
Supplemental Security Income (SSI) payment on the expected
Second Wednesday 1st – 10th If you received Social Security before date, please allow
Third Wednesday 11th – 20th May 1997 or if receiving both Social three additional mailing
Security & SSI, Social Security is days before contacting
Fourth Wednesday 21st – 31st paid on the 3rd and SSI on the 1st. Social Security.

Social Security Administration

[Link] Publication No. 05-10031
January 2022 (Recycle prior editions)
Schedule of Social Security Benefit Payments 2023
Produced and published at U.S. taxpayer expense