KNIGHTS OF COLUMBUS Use space below for Agent’s Name and

Policy ID# 05270866 A FRATERNAL BENEFIT SOCIETY ID Number

1 Columbus Plaza Writing Agent 019977
Fast Form# 01001075 New Haven, CT 06510-3326 Servicing GA 016050
Policy Number Individual Life Insurance Application

Contract
□ GPO / YPO Contract Number _______________

Is the applicant a member of Knights of Columbus X□ Yes □ No If yes, indicate □ Associate Member or X
□ Insurance Member

A. APPLICANT / MEMBER

Name (First, Middle Initial, Last) Date of Birth (Mo - Day - Yr)
|__________________________________________________________________|
DENNIS H HAGENHOFF |__________________________|
06/17/1955

Street Address City State ZIP Code

|___________________________________________|
3632 COUNTY ROAD 4008 |____________________________|
HOLTS SUMMIT |_______|
MO |_____________|
65043-1954

SSN / TIN Member Number Council Number

|________________________________|
487-64-4414 |________________________________|
2579905 |____________________________|
08400

□ Yes □ No
Citizen of the United States X
If No |_____________________________________| |_________________________________|
United States

Country of Citizenship Country of Permanent Residence

Phone Number Email address
|__________________________|
(573) 291-8678 |___________________________________________________________________|
DHHAGENHOFF@[Link]

B. PROPOSED INSURED - A
Name (First, Middle Initial, Last) □ Male X
□ Female
|__________________________________________________________________|
Margaret Hagenhoff

Maiden Name Relationship to Applicant

| | | Spouse |
Street Address City State ZIP Code
|_________________________________________|
3632 County Rd 4008 |____________________________|
Holts Summit |_________|
MO |_____________|
65043

Date of Birth (Mo - Day - Yr) Issue Age □ Save Age Place of Birth (State/Country)
|_________________________|
10/31/1957 |________|
68 |_____________________________________|
United States
SSN / TIN
|_____________________________________|
488-70-1144 □ Yes □ No
Citizen of the United States X

If No |_____________________________________| |_________________________________|
United States
Country of Citizenship Country of Permanent Residence
Phone Number Email address
|________________________|
(573) 291-4744 |_____________________________________________________________________|
Occupation

□ Single X□ Married □ Widowed □ Divorced |________________________________________________|

RETIRED

ICC21 600D2 3-21 Page 1

 C. PROPOSED INSURED – B (Joint Insured/Spouse, if coverage is being applied for)
Name (First, Middle Initial, Last) □ Male □ Female
|__________________________________________________________________|
Maiden Name Relationship to Applicant
| | | |
Street Address City State ZIP Code
|_________________________________________| |____________________________| |_________| |_____________|
Date of Birth (Mo - Day - Yr) Issue Age Place of Birth (State/Country)
|_________________________| |_______| |_____________________________________________|
SSN / TIN
|_____________________________________| Citizen of the United States □ Yes □ No
If No |_____________________________________| |_________________________________|
Country of Citizenship Country of Permanent Residence
Phone Number Email address
|________________________| |_____________________________________________________________________|
Occupation
□ Single □ Married □ Widowed □ Divorced |________________________________________________|

D. OWNER Unless otherwise designated below, the owner of adult insurance is the proposed insured and the
owner of juvenile insurance is the applicant. In the event of the death of the owner prior to the
termination of the Contract, ownership shall pass to the contingent owner designated below:

Check if: □ Trust: Name of Trust |___________________________________________________________________ |

Name (First, Middle Initial, Last) □ Male X

□ Female Date of Birth/Date of Trust (Mo - Day - Yr)
|______________________________________________________________|
Margaret Hagenhoff |________________________________|
10/31/1957

Street Address City State ZIP Code

|_________________________________________|
3632 County Rd 4008 |____________________________|
Holts Summit |_________|
MO |_____________|
65043

SSN / TIN Owner’s Relationship to Insured

|______________________________________|
488-70-1144 | SELF |
□ Yes □ No
Citizen of the United States X
If No |_____________________________________| |_________________________________|
United States
Country of Citizenship Country of Permanent Residence
Phone Number Email address
|________________________|
(573) 291-4744 |_____________________________________________________________________|
Contingent Owner Contingent Owner’s Relationship to Insured
| | | |
Street Address City State ZIP Code
|_________________________________________| |____________________________| |_________| |_____________|

SSN / TIN |______________________________________|

Phone Number Email address

|________________________| |_____________________________________________________________________|
ICC21 600D2 3-21 Page 2
 E. PAYOR

Check if: □ Trust: Name of Trust |____________________________________________________________________|

Name (First, Middle Initial, Last) □ Male X

□ Female Date of Birth/Date of Trust (Mo - Day - Yr)

|________________________________________________________________|
Margaret Hagenhoff |________________________________|
10/31/1957

Street Address City State ZIP Code

|_________________________________________|
3632 County Rd 4008 |____________________________|
Holts Summit |_________|
MO |_____________|
65043

SSN / TIN |_______________________________________|

488-70-1144

Phone Number Email address

|________________________|
(573) 291-4744 |_____________________________________________________________________|

F. BENEFICIARY □ (Note: Check here if more than two beneficiaries and complete Form 113A)

If no principal beneficiary survives the Insured, then the death benefit will be divided equally among the surviving contingent
beneficiaries unless otherwise indicated.
Name (First, Middle, Last) / Name of Trustee □
X Primary □ Trust Date of Birth /Date of Trust

| DENNIS H HAGENHOFF | | 06/17/1955 |

Complete Name of Trust (If applicable) | |

Street Address City State ZIP Code

| 3632 COUNTY ROAD 4008 | | HOLTS SUMMIT | | MO | | 65043-1954 |

SSN / TIN Relationship to Insured Percentage

| 487-64-4414 | | SPOUSE | | 100 % | □ Per Stirpes

X
Phone Number Email address (Trustee’s if applicable)

|____________________________|
(573) 291-8678 |___________________________________________________________________|
DHHAGENHOFF@[Link]

Name (First, Middle, Last) / Name of Trustee □ Primary □ Contingent □ Trust Date of Birth/Date of Trust

| | | |

Complete Name of Trust (If applicable) | |

Street Address City State ZIP Code

| | | || | | |
SSN / TIN Relationship to Insured Percentage

| | | | | % | □ Per Stirpes

Phone Number Email address (Trustee’s if applicable)

|____________________________| |___________________________________________________________________|
X□ Death of Beneficiary within 30 days of insured’s death
(if this box is checked, no proceeds will be paid to any beneficiary who dies within 30 days of the date of the insured’s death.)

ICC21 600D2 3-21 Page 3

 G. CERTIFICATION OF TAXPAYER ID
By the signature below, under penalty of perjury, the Owner certifies that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to
me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified
by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest
or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Exemption from FATCA reporting code (if any) |_______|

Are you subject to backup withholding under section 3406(a)(1)(c)of the Internal Revenue Code. □ Yes X
□ No

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding.

| |
Owner Signature

ICC21 600D2 3-21 Page 4

H. PREMIUM AND PLAN DETAILS

Source of Funding: X□ E-Pay □ CWA/Check

□ Waiver Claim □ Death Claim □ Agent’s Salary Deduction
From Another Policy
□ Paid Up Additions □ Dividends On Deposit □ Loan
□ Annuity Values □ Settlement Option □ 1035 Exchange

$ | 100.00 | Amount Paid Herewith

1. Fixed Premium Life Insurance

100,000.00
Face Amount $ |__________________| OR Even Dollar Premium (solve for Face Amount) $ |_________________|

Premium Deposit Fund If applicable, Payment Years included with Amount Paid Herewith |________________|

X□ Whole Life (recurring premium) Plan 901

|_____________|
- Life Paid Up At - 32 Years

Paid-Up Age |____________| OR Payment Years |____________|

32

□ Single Premium Whole Life Plan |_____________|

□ Term Insurance Plan |_____________|

2. Flexible Premium Universal Life

Face Amount $ |_________________|

□ Single Life UL Plan |_____________|

□ Survivorship Universal Life Plan |_____________|

Planned Premiums:

Planned Modal Premium Amount $ |____________| (Payment Mode indicated below)

Planned Payment Years |____________|

Initial Dump-in Amount, if any $ |____________| (do not include pre-payment of planned modal premiums)

I. PAY MODE

□ Annual

□ Semi-Annual

□ Quarterly

X□ M.A.C/E.F.T. Monthly Withdrawal Date |_________|

4

Existing M.A.C Policies |____________________________________________________|

□ GPO Waiver

□ Military Allotment (branch of service) |_________________________________________________________|

□ Agent’s Salary Deduction

ICC21 600D2 3-21 Page 5

J. RIDERS

Elected Rider Rider Amount / Units (if applicable)

|____________________________________|
Chronic Illness Accelerated Death Benefit Rider |_____________________________________|

|____________________________________| |_____________________________________|

|____________________________________| |_____________________________________|

|____________________________________| |_____________________________________|

|____________________________________| |_____________________________________|

|____________________________________| |_____________________________________|

|____________________________________| |_____________________________________|

REMARKS: | |
| Chronic Illness Benefit % - 90; Chronic Illness Benefit Period - 50; Chronic Illness PUA Option - Yes; |
| |

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| |

| |

| |

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K. DIVIDENDS PROVISION

Any dividends payable under the insurance contract hereby applied for are to be:

□ Paid in Cash □ Applied to Purchase Paid up Additions (PUAs)

X
□ Applied to Reduce Premium □ Paid up Additions used as Inside Additions
□ Held at interest

In the event of a default in payment of any premium due on the insurance contract issued, shall the automatic premium
loan provision, if applicable, be effective in lieu of any non-forfeiture option? X□ Yes □ No

ICC21 600D2 3-21 Page 6

 FRATERNAL AGREEMENT – Before continuing, please read and agree to the following statement:
The Knights of Columbus is a fraternal organization and depends on information provided by you to offer
the best insurance products at competitive prices 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.

Do you agree to answer these questions truthfully, accurately, and completely, to the best of your knowledge and
belief? X□ Yes □ No

Name: |____________________________________
Margaret Hagenhoff | Insured Signature: |_______________________________________|

Do you agree to answer these questions truthfully, accurately, and completely, to the best of your knowledge and
belief? □ Yes □ No

Name: |____________________________________| Joint Insured/Spouse Signature: |____________________________|

(if applicable)

L. TOBACCO, ALCOHOL AND DRUGS DECLARATION

Please fill out the information below on the proposed insured.

Name (First, Middle, Last) □ Male X

□ Female Date of Birth (Mo - Day - Yr)

| Margaret Hagenhoff | | 10/31/1957 |

Height Weight Total Insurance in Force

| ________________ft.|
5 ft 8 in |_____________
170 lbs.| |__________________________________________________|
51,800.00

Has proposed insured ever used tobacco or tobacco substitutes? □ Yes X

□ No If yes, give dates of last use below.

□ Cigarettes Mo.-Yr. | | □ Cigar Mo.-Yr. | | □ Pipe Mo.-Yr. | |

□ Chewing Tobacco/Snuff Mo.-Yr. | | □ Patch/Gum/ Vapor or any nicotine substance Mo.-Yr. | |

□ Marijuana: □ Medical or □ Recreational Mo.-Yr. | |

What is the smoker class the insured is applying for? I Non-Tobacco I proposed insured initial here I I

Has the proposed insured ever been advised by a health professional to seek treatment for, been treated for the
excessive use of Alcohol, Narcotics or other habit forming Drugs or been convicted of or plead guilty to a drug or alcohol
related offense:

□ Drug □ Alcohol X□ Not applicable

| |

| |

ICC21 600D2 3-21 Page 7

 Please fill out the information below on the Joint Insured/Spouse, if coverage is being applied for

Name (First, Middle, Last) □ Male □ Female Date of Birth (Mo - Day - Yr)

| | | |

Height Weight Total Insurance in Force

| ________________ft.| |_____________lbs.| |__________________________________________________|

Has the Joint/Spouse Insured ever used tobacco or tobacco substitutes? □ Yes □ No If yes, give dates of last use below.

□ Cigarettes Mo.-Yr. | | □ Cigar Mo.-Yr. | | □ Pipe Mo.-Yr. | |

□ Chewing Tobacco/Snuff Mo.-Yr. | | □ Patch/Gum/ Vapor or any nicotine substance Mo.-Yr. | |

□ Marijuana: □ Medical or □ Recreational Mo.-Yr. | |

What is the smoker class the insured is applying for? I I Joint/Spouse insured initial here I I

Has the joint/spouse insured ever been advised by a health professional to seek treatment for, been treated for the
excessive use of Alcohol, Narcotics or other habit forming Drugs or been convicted of or plead guilty to a drug or alcohol
related offense:

□ Drug □ Alcohol □ Not applicable

| |

| |

M. SUPPLEMENTAL DECLARATION of INSURABILITY

If Payor Benefit is being applied for fill out the information below on the Payor.

Name (First, Middle, Last) □ Male □ Female Date of Birth (Mo - Day - Yr)

| | | |

Height Weight Total Insurance in Force

| ft.| | lbs.| | |

If the child term rider is being applied for fill out on children or stepchildren under the age of 18.

Child Name (First, Middle, Last) Sex Date of Birth SSN/TIN Height Weight Total Insurance in Force

ICC21 600D2 3-21 Page 8

 N. REPLACEMENT INFORMATION

Replace or replaced means that the insurance being applied for may replace or cause a change in any existing insurance or
annuity with any company, including the lapse or surrender of the existing policy, or the use of funds or values from the existing
policy to pay for the new policy.

1- a. Are there any existing life insurance or annuity contracts on the life of the:

Proposed Insured X□ Yes □ No

Joint Insured (if applicable) □ Yes □ No

b. Is the insurance applied for intended to replace any existing insurance or annuities with the Knights of Columbus or
another insurer:

Proposed Insured □ Yes X

□ No If yes, please indicate whether replacement is:
□ Internal OR □ External

Joint Insured (if applicable) □ Yes □ No If yes, please indicate whether replacement is:
□ Internal OR □ External

If the answer to either question 1 (a) or (b) is yes, submit a completed replacement form, and complete the following:

List all life insurance, annuities and long term care policies on any proposed insured (including pending
applications and reinstatements).

 Company/Person Insured Face Amount Accidental Death Amount

| Margaret Hagenhoff | | 5000 | |0 |

Year Issued List Contract Number if KofC

| 1985 | | 00A35200 |

 Company/Person Insured Face Amount Accidental Death Amount

|Margaret Hagenhoff | | 15000 | |0 |

Year Issued List Contract Number if KofC

| 2011 | | 04195162 |

 Company/Person Insured Face Amount Accidental Death Amount

| margaret hagenhoff | | 25000 | |0 |

Year Issued List Contract Number if KofC

| 1995 | | 0EC54510 |

 Company/Person Insured Face Amount Accidental Death Amount

| | | | | |
Year Issued List Contract Number if KofC

| | | |

ICC21 600D2 3-21 Page 9

 Medical Information for: | Margaret Hagenhoff | Policy Number: | 05270866 |

O. DECLARATION of INSURABILITY (DOI)

All Questions must be answered for each individual proposed insured if additional coverage is being requested. If Yes,
please provide details.

1- a. Are negotiations now pending for life or health insurance on any of the proposed insureds? □ Yes X□ No
| |

| |

b. Has any proposed insured been declined, postponed or rated for life or health insurance or reinstatement thereof?
□ Yes X□ No
| |

| |

c. Has any proposed insured ever made claim for sickness, accident or pension benefits in the last five years?
□ Yes X
□ No

| |

| |

d. Has any life, accident or health insurance policy issued on any proposed insured been cancelled by the issuer or
the renewal thereof been refused? □ Yes X□ No

| |

| |

2 - a. In the next two years, is any proposed insured contemplating making or in the past three years has the proposed
insured made flights as a pilot, student pilot, crew member, or flights in other than commercial planes? □ Yes X□ No
(If yes, complete Aviation Questionnaire.)

| |

| |

b. In the next two years, is any proposed insured contemplating engaging in or in the past three years has any proposed
insured engaged in any type of: □ Yes X□ No

□ Scuba Diving □ Sky Diving □ Racing □ Rodeo Activities □ Hang Gliding (If yes, complete questionnaire.)

| |

| |

c. In the past two years, has any proposed insured traveled overseas, or is foreign travel planned or contemplated in the
next two years? □ Yes X□ No

| |

| |

ICC21 600D2 3-21 Page 10

 3. Has any proposed insured ever been diagnosed, treated, tested positive for, or been given medical advice by a
member of the medical profession that such person has or had any of the following: (If Yes/Checked, please provide full
details)

a. □ Tuberculosis □ Asthma □ Emphysema □ COPD □ Pneumonia □ Other Lung Disease or Disorder? X□ None
| |

| |

b. □ Stroke □ Fainting Spells □ Epilepsy □ Paralysis □ Depression □ or other Psychiatric Diagnosis

□ Dementia □ Alzheimer’s □ Autism □ Nervous System or Other Brain Disorder □ None
X
| |

| |

c. □ Ulcers □ Colitis □ Rectal Disorder □ Indigestion □ Disorder of the Esophagus

□ Stomach Disorder □ Disorder of the Intestines □ Liver Disorder □ Gallbladder Disorder X□ None

| |

| |

d. □ Cancer □ Tumors □ Disorder of the Blood □ Lymph Glands Disorder □ Endocrine Disorder X□ None
| |

| |

e. □ Diabetes □ Sugar □ Albumin □ Pus or Blood in the Urine □ Other Kidney or Bladder Disorder X□ None

| |

| |

f. □ Disease of the Heart or Blood Vessels □ Chest Pains □ Shortness of Breath □ Heart Enlargement

□ High or Low Blood Pressure □ Abnormal Heart Rhythm □ Palpitations X□ None

| |

| |

g. □ Arthritis □ Gout □ Multiple Sclerosis □ Disorder of the Muscles or Bones X□ None

| |

| |

h. Disease or Disorder of the: □ Ears □ Eyes □ Nose □ Throat X□ None

| |

| |

ICC21 600D2 3-21 Page 11

 i. Disorder of the: □ Prostate □ Reproductive Organs □ Breasts X□ None
| |

| |

4. Has any proposed insured received treatment from any physician, or other practitioner for, or been told by any physician,
other practitioner or counselor that such person has or had:
□ Acquired Immune Deficiency Syndrome (AIDS) □ AIDS Related Complex (ARC)
□ any Disorder of the Immune System? X□ None
| |

| |

5. In the past five years has any proposed insured:

□ been hospitalized □ consulted a physician □ been treated, examined or advised by a member of the medical
profession for any illness, disease or syndrome not listed above
□ taken any medication not previously listed? X□ None
| |

6. Primary Care Physicians or Health Facilities:

 Name of Primary Care Physician or Facility

| Dr. Kaitlin Saucier |

Street Address City State ZIP Code

| 1241 W Stadium Blvd 1st Floor, | | Jefferson City | | MO | | 65109 |

Phone Number Date last seen (Mo - Day - Yr)

| (573) 635-5264 | | spring 2025 |

Reason last seen:

|__________________________________________________________________________________________________|
regular check up

|_______________________________________________________________________________________________________|

|__________________________________________________________________________________________________|

|__________________________________________________________________________________________________|

 Name of Specialist

| |

Street Address City State ZIP Code

| | | | | | | |

Phone Number Date last seen (Mo - Day - Yr)

| | | |

ICC21 600D2 3-21 Page 12

 Reason last seen:

|__________________________________________________________________________________________________|

|__________________________________________________________________________________________________|

|__________________________________________________________________________________________________|

| |

7. Family history: Has any parent or sibling been diagnosed or treated by a member of the medical profession for diabetes,
cancer, high blood pressure, heart, kidney disorder, mental illness or suicide? X□ Yes □ No

Father If Deceased
Age Illness or Disease (from above list) Age at Death Cause of Death
| | |________________________________________________________| |___________
87 | |________________________|
stroke

Mother If Deceased
Age Illness or Disease (from above list) Age at Death Cause of Death
| | |________________________________________________________| 81
|___________| |________________________|
natural causes

Siblings If Deceased
Age Illness or Disease (from above list) Age at Death Cause of Death
| | |________________________________________________________| |___________| |________________________|
Siblings If Deceased
Age Illness or Disease (from above list) Age at Death Cause of Death
| | |________________________________________________________| |___________| |________________________|
Siblings If Deceased
Age Illness or Disease (from above list) Age at Death Cause of Death
| | |________________________________________________________| |___________| |________________________|

8. Within the past five years, has any proposed insured had a license suspended or plead guilty to or been convicted
of any moving violations?
(a) Driver’s License Number: | R001292016 | □ Yes X
□ No

(b) State of License: | MO |

| |

9. Has the proposed insured ever plead guilty to or been convicted of a Felony or Misdemeanor or do they have such
charge currently pending against them?

If Yes please provide: □ Yes X□ No

(a) the nature of the plea, conviction or charge | |

(b) the date and State where the plea, conviction or charge occurred | |

(c) was time served in Prison? □ Yes □ No

| |

| |
ICC21 600D2 3-21 Page 13
 Additional remarks in answer to Question 1-9:

10. |______________________________________________________________________________________________________________|
ages 81-60, 8 siblings, 2-sisters remission of breast cancer, oldest blockage in arteries
|_________________________________________________________________________________________________|

|_________________________________________________________________________________________________|

|_________________________________________________________________________________________________|

11. All Present Occupations: Exact Duties in Each:

| RETIRED | | volunteers |

| | | |

| | | |

| | | |

12. Annual Income Net Worth

| $60,000.00 | | $500,000.00 |

ICC21 600D2 3-21 Page 14

 (1) I agree that the statements and answers contained in this application are representations and not warranties and are
complete and true to the best of my knowledge and belief. The Knights of Columbus shall not be bound by any
information that is not set out in writing in this application.

(2) I agree that the Charter, Constitution and Laws of the Knights of Columbus now in effect or hereafter enacted including
any change in the method or amount of insurance premiums, shall be binding upon me and the beneficiary.

(3) I agree that, except for coverage which may be provided in the Temporary Insurance Agreement, no insurance will be in
force because of this application until it has been approved and the minimum required premium has been paid to the Knights
of Columbus.

(4) I agree that the insurance hereby applied for shall be cancelled if the applicant is a candidate for membership and has
not been initiated into the Knights of Columbus within 90 days of the commencement of Temporary Insurance.

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.

Date: | |
Date (Mo – Day – Yr)

Signed at | | | | | 65043 |
City State Zip Code

| |
Applicant’s Signature

| |
Proposed Insured’s Signature (if other than applicant)

| |
Joint Insured/Spouse’s Signature (If coverage applied for)

| |
Owner’s Signature (If other than Applicant or Proposed Insured)

| | | 019977 |
Writing Agent’s Signature ID Number of Writing Agent

ICC21 600D2 3-21 Page 15

 KNIGHTS OF COLUMBUS
1 Columbus Plaza
New Haven, CT 06510-3326
RECEIPT
100.00
The Knights of Columbus received $_______________ Margaret Hagenhoff
from _____________________________________ on the date
shown below. This amount was paid when a life insurance application which bears the same date as this receipt was signed
Margaret Hagenhoff
in which ________________________________________________is named as the proposed insured. This receipt and
the Temporary Insurance Agreement set forth below are issued on the condition that any check, draft or other order or
authorization for payment of money is good and can be collected.

Date: ____________________________ ___________________________________________________Agent

(The above receipt must not be completed unless payment for the initial premium has been made at the time of application
or unless use of existing Knights of Columbus values has been authorized. The premium check, if any, must be made
payable to the Knights of Columbus. Do not make the check payable to the agent or leave the payee blank.)

TEMPORARY INSURANCE AGREEMENT

The Knights of Columbus agrees to provide Temporary Insurance as follows:
Payment of Temporary Insurance
The Temporary Insurance will be paid to the beneficiary named in the application if any person who is to be covered by the
Insurance contract applied for dies while the Temporary Insurance is in force.
Amount of Temporary Insurance
This Agreement provides Temporary Insurance for any person who is to be covered by the insurance contract applied for
in the amount applied for on that person or $300,000, whichever is less. (See Special Limitation 1 below.)
Commencement of Temporary Insurance
The Temporary Insurance will start when all medical exams, paramedical exams, telemedical exams, laboratory tests and
reports required at time of application are completed. If no exams, tests or reports are required, the Temporary Insurance
will start on the date of the above Receipt.
Duration of Temporary Insurance
Unless this Temporary Insurance ends sooner for one of the three reasons listed in the Termination of Temporary Insurance
section below, it will end 90 days after it starts.

Termination of Temporary Insurance

1. The Temporary Insurance will end when the Knights of Columbus issues the insurance contract as applied for.
2. The Temporary Insurance will end when the Knights of Columbus issues an insurance contract other than as applied for,
and the contract is accepted by the contract owner.
3. The Temporary Insurance will end when the Knights of Columbus refunds the initial premium or restores the existing
values used to pay the initial premium

Special Limitations Applicable to Temporary Insurance Agreement

1. In the event that more than one Temporary Insurance Agreement is in force at the time of a proposed insured’s death,
the maximum total amount payable under all such Agreements will be $300,000.
2. If any proposed insured dies by suicide, the liability of the Knights of Columbus under this Agreement is limited to a
refund of the payment made.
3. No Temporary Insurance will be provided with respect to a child to be insured under the insurance contract applied for or
under a Family Insurance Rider or Children’s Insurance Rider, if death occurs while such child is less than 15 days old.
4. No Temporary Insurance will be provided with respect to any proposed insured who is to be insured under an insurance
contract applied for under the provisions of a Guaranteed Purchase Option Rider or a Youth Purchase Option Rider.
5. No Temporary Insurance will be provided for any insurance coverage paid for by funds transferred from another insurer
as part of a Section 1035 exchange.
6. Fraud or material misrepresentation in the application invalidates this Agreement. In the event of fraud or material
misrepresentation, the liability of the Knights of Columbus is limited to a refund of any payment made.
7. No change may be made in the terms and conditions of this Agreement. No statement which claims to make such
a change will bind the Knights of Columbus.

ICC20 600D2 TIA-REC 5-20

 AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

A. To assist the Knights of Columbus in underwriting an application for insurance, I hereby

authorize those persons or organizations listed in section B of this Authorization who possess
protected health information and/or medical or non- medical information concerning me or
my children and stepchildren to permit the Knights of Columbus, its reinsurers or its
representatives, including, but not limited to: physicians, paramedics, tele-underwriters and
consumer reporting agencies; to view, to copy, to be furnished a copy or to be given details
of all such information, including my entire medical record, prescription history and
medications prescribed. In addition to other medical or non- medical information, this
Authorization applies to any information about psychiatric, drug or alcohol abuse treatment
and includes information on the diagnosis or treatment of Human Immunodeficiency Virus
(HIV), as well as the testing, diagnosis, and/or treatment of communicable diseases. Knights
of Columbus may release this information to other person or organizations who must perform
business or legal services connected with my application or claim. Please note that the term
“non-medical information” consists of information obtained from a consumer
investigative report which would pertain to such items as: confirmation of age,
residence, marital status, employment, information as to character, general reputation,
personal characteristics, avocation and mode of living.

B. Those persons or organizations authorized to disclose protected health information and/or

medical or non-medical information concerning me or my children and stepchildren are: any
member of the medical profession, licensed physicians, medical practitioners, paramedics,
tele-underwriters, hospitals, clinics, pharmacy, pharmacy benefit manager or other medical
or medically related facilities, government agencies regulating motor vehicles, insurance and
reinsurance companies, consumer reporting agencies and MIB, LLC or any other person or
organization that has any records or knowledge of me or my mental health, employment,
finances transactions or other information relevant to my insurability.

C. Notwithstanding the provisions of sections A and B of this Authorization, MIB, LLC may
release information only to the Knights of Columbus, its reinsurers and their authorized
representatives.

D. I also authorize the Knights of Columbus to disclose any information regarding me, my
children and stepchildren or our health, including but not limited to protected health
information, to: MIB, LLC; any company to which my application form is submitted for
reinsurance purposes; my Knights of Columbus agents; and to other life insurance companies
with whom I have policies or to whom I may apply for insurance, or to whom a claim for
benefits may be submitted. I understand that any information that is disclosed pursuant to
this authorization may be re-disclosed and no longer covered by federal rules governing
privacy and confidentiality of health information. I understand that while my insurance
application may not be able to be approved/processed, if I do not sign this authorization, that
treatment cannot be conditioned upon my signing.

E. I authorize the Knights of Columbus to obtain an investigative consumer report on me. I

understand that I may request to be interviewed in connection with the preparation of such a
report.

MIB 4-22
Page 1
F. I acknowledge receiving and reading the notices regarding the Fair Credit Reporting Act,
MIB, LLC and Description of Information Practices.

G. This Authorization shall be valid for 24 months after it is signed or the time limit, if any,
permitted by applicable law in the state where the policy is delivered or issued for delivery.
A photographic copy of this authorization shall be as valid as the original. I understand that I
may revoke this authorization at any time by written notification to Knights of Columbus;
however, any action taken prior to receipt of notification will not be affected. I understand
that authorizing the disclosure of this health information is voluntary. I can refuse to sign this
authorization.

Date (Mo - Day - Yr)

| |

Signed by:

| | | |
Insured / Parent Spouse/Joint Insured or Payor
(if any proposed insured(s) is/are (if coverage applied for)
under the age of 18)

| | | 019977 |
Writing Agent’s Signature ID Number of Writing Agent

MIB 4-22
Page 2
 KNIGHTS OF COLUMBUS
A FRATERNAL BENEFIT SOCIETY
1 Columbus Plaza
New Haven, CT 06510-3326

CHRONIC ILLNESS ACCELERATED DEATH BENEFIT RIDER

SUPPLEMENT TO INDIVIDUAL LIFE APPLICATION

Margaret Hagenhoff
Proposed Insured ______________________________________________________
(First, Middle, Last)

Questions 1 AND 2 must be answered by the Proposed Insured if Chronic Illness Accelerated Death Benefit Rider is being
requested.

1. During the last 12 months, have you:

a. Required assistance or supervision of any kind to perform an activity of daily living (ADLs) which consist of:
Mobility, taking medications, dressing, eating, walking, bathing, or toileting? □ Yes X□ No
b. Been advised by a licensed health care practitioner to use any of the following: Catheter, motorized scooter,
walker, chair lift, oxygen equipment, wheelchair, dialysis, respirator, or a quad or three-pronged cane?
□ Yes X
□ No
c. Been advised to enter, reside in, or require any of the following: Nursing home, long-term care facility, adult
day care, assisted living facility, residential care facility, skilled nursing facility, or continuing care retirement
community (CCRC), continuing care at home (CCAH)? □ Yes X□ No

2. Have you EVER been diagnosed with, been treated for, tested positive for, or received medical advice from a licensed
health care practitioner for any of the following conditions:
a. Alzheimer’s Disease; Dementia; Memory Loss? □ Yes X□ No

If any answer to the above Questions 1 or 2 was answered Yes, the rider is not available for the Proposed Insured
and this supplemental application should not be completed or submitted.

If all answers to the above Questions 1 or 2 were answered No, the Proposed Insured must complete the
following questions:
(If Yes to any question below, give reason(s) in Remarks section)

3. Do you have a handicap sticker, handicap placard, or handicap license plate? □ Yes X
□ No

4. In the past 24 months, have you had to limit or been advised by a licensed health care practitioner to limit, reduce,
discontinue, or restrict any activities or hobbies? □ Yes X □ No

5. In the past 12 months, have you been treated by, examined by, or consulted with a licensed health care practitioner due
to falls?
□ Yes X □ No

6. In the past 24 months, have you required assistance with any Instrumental Activities of Daily Living (IADL’s) which
consist of: shopping, arranging transportation, housekeeping, cooking, laundry, meal preparation, managing finances,
managing medications, using the telephone or used a straight cane? □ Yes X □ No

7. Within the past 5 years, have you received any Long-term care benefits; Social Security Disability Income Benefits;
or Disability Income Benefits? □ Yes X
□ No

8. Within the past 5 years, have you been declined for Long term care insurance; Long term care insurance rider or
Accelerated Death Benefit Rider attached to a life insurance policy or an annuity contract? □ Yes X □ No
(If yes, please provide the name of the company, date, and the reason for decline, if known)

ICC25 CI SUPP Page 1

 Remarks in answer to Questions 3-8:
|_____________________________________________________________________________________________________________|

|_____________________________________________________________________________________________|

|_____________________________________________________________________________________________|

|_____________________________________________________________________________________________|

|_____________________________________________________________________________________________|

|_____________________________________________________________________________________________|

|_____________________________________________________________________________________________|

|_____________________________________________________________________________________________|

|_____________________________________________________________________________________________|

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.

Date: | |
Date (Mo – Day – Yr)

| |
Proposed Insured’s Signature

Date: | |
Date (Mo – Day – Yr)

019977
| | | |
Writing Agent’s Signature ID Number of Writing Agent

ICC25 CI SUPP Page 2

 Electronic Funds Transfer (EFT) Authorization Form
[For Use with Electronic Applications (E-App) Only]

Policy/Contract number(s): 05270866

Type of Request: X Initiate a one-time EFT in the following amount:

☐ $100.00
X (MO) Monthly ☐ (QT) Quarterly ☐ (SA) Semi-Annual ☐(AN)Annual
☐
☐ Establish EFT for recurring premium payment to be withdrawn on the
following day of the month: X th
☐4 ☐ 10th ☐ 16th ☐ 25th

Bank Account Owner Name (Payor)

First Name Middle Name Last Name

Margaret Hagenhoff

Business Entity (if applicable)

Street Address
3632 County Rd 4008

City State Zip Code

Holts Summit MO 65043

Relationship of Bank Account Owner (Payor) to Insurance/Annuity Contract Owner

Self

Banking Information: Account Type: ☐

X Checking ☐ Savings

Bank Institution Routing Number

086500634

(Re-enter) Bank Institution Routing Number

086500634

Bank Account Number

003704610

(Re-enter) Bank Account Number

003704610

Name of Bank

Central Bank

Street Address of Bank Bank City Bank State Bank Zip Code

Jefferson City MA 65102

 [For Use with Electronic Applications (E-App) Only]

Authorization Agreements and Signatures

• I/we authorize the Knights of Columbus to initiate debit entries from my/our bank account for a
one-time EFT in the amount specified on this form and/or establish EFT for monthly recurring
premium payments on the policy(ies) or contracts as on the specified day of the month.
• I/we understand that payment due notices will not be sent on policy(ies) or contracts setup on EFT
for monthly recurring premium payments.
• If EFT for monthly recurring premium payments is elected and the payment dates fall on a weekend
or holiday, I/we understand that the payment may be executed on the next business day.
• I/we understand that if corrections in the debit amount are necessary, it may involve an adjustment
(credit or debit) to my/our bank account.
• I/we understand that if any such EFT is dishonored by my/our bank and any premium amounts due
to the Knights of Columbus is not paid within the allowable grace period, the policy(ies) or contracts
shall become null and void except as otherwise indicated in the contract language.
• I/we understand that any changes to my/our bank or bank account will require me/us to submit a
new EFT authorization form to Knights of Columbus. Knights of Columbus must be notified of any
bank account closures or changes at least 10 days in advance.
• I/we understand if premiums are being withdrawn from my/our savings account, due to federal
regulations my/our financial institution may limit the number of transfers from my/our savings
account to six (6) transfers each month. I understand if I/we exceed that limit my/our financial
institution may reject the transfer.
• I/we understand this authorization shall remain in effect until such time that the Knights of
Columbus terminates the agreement, or I/we notify the Knights of Columbus to terminate the
agreement, or the policy(ies) or contracts are no longer inforce, or the bank account is no longer
active.
• I/we certify that I/we are the owners or authorized signer(s) on the bank account listed above and
are authorized to enter into this agreement.

Signature of Bank Account Owner Signature of policy/contract Owner (if different)

Date Date
 KNIGHTS OF COLUMBUS
IMPORTANT NOTICE
REPLACEMENT OF LIFE INSURANCE OR ANNUITIES
This document must be signed by the applicant and the agent, 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 this purchase,
premium payments on an existing policy or contract are discontinued, 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 the policy or contract. You may be able to make changes
to the existing policy or contract to meet your needs at less cost. A financed purchase will reduce the value
of an existing policy and may reduce the amount paid upon the death of the insured.
We want you to understand the effect of replacement 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. Does the proposed insured or annuitant have at least one existing life insurance policy or annuity
contract on his or her life? ____YES
X ____NO (If you answered “no”, skip 2-5.)
2. Are you considering discontinuing premium payments, surrendering, forfeiting, assigning to the insurer,
or otherwise terminating an existing policy or contract? ____ YES ____
X NO
3. Are you considering using funds from an existing policy or contract to pay premiums due on the new
policy or contract? ____ YES ____
X NO
4. If you answered “yes” to either question 2 or question 3, list each existing policy or contract you are
contemplating replacing (include the name of the insurer, the insured and the contract number if
available) and whether the policy will be replaced or used as a source of financing:
INSURER CONTRACT INSURED REPLACED (R)
NUMBER FINANCING (F)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. The existing policy or contract is being replaced because _____________________________________
______________________________________________________________________________________
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 disclosure document 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.
I certify that the above responses herein are, to the best of my knowledge, accurate:
____________________________________________________________________________________
Margaret Hagenhoff
Applicant’s Signature and Printed Name and Date
____________________________________________________________________________________
MITCHELL W RADEMAN
Agent’s Signature and Printed Name and Date
I do not want this notice read aloud to me. ________ (Applicants must initial only if they do not want this
document read aloud.)

APPLICANT COPY

1080 IA 7-00
A replacement may not be in your best interest, or a decision to replace existing coverage could be a good
one. You should make a careful comparison of the costs and benefits of the existing policy or contract and
the proposed policy or contract. One way to do this is to ask the company or agent that sold the existing
policy or contract to provide information concerning it. This may include an illustration of how the 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?
Are premiums higher for the proposed new policy?
How long will premiums have to be paid 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 expense and sales charges will be paid on the new policy?
Does the new policy provide more insurance coverage?

INSURABILITY
If health conditions have changed since the old policy was purchased, the new policy could cost more, or
your application could be rejected.
A medical exam may be needed 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 the 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 surrender charges be paid on the old contract?
What are the interest rate guarantees for the new contract?
Hare 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?
Is the existing insurer willing to modify the old policy?
How does the quality and financial stability of the Knights of Columbus compare with the existing company?

1080 IA 7-00
Margaret Hagenhoff MITCHELL RADEMAN
Summary and Disclosure Notice
Terminal Illness Accelerated Death Benefit Rider

Knights of Columbus
One Columbus Plaza • New Haven, CT 06510-3326

This summary and disclosure notice describes features of the Terminal Illness Accelerated Death Benefit
Rider. This is not an insurance contract, but only a summary of the coverage provided by the rider. It is,
therefore, important that, when presented to you for delivery, you read your policy carefully.

Your policy may contain the Terminal Illness Accelerated Death Benefit Rider described in this summary
and disclosure notice. You should check your policy to determine if the rider has been attached to your
policy.

The Terminal Illness Accelerated Death Benefit Rider provides the option to have part of the policy’s
death benefit paid to you prior to the insured’s death. The death benefit that would have been paid to
the beneficiary after the death of the insured will be reduced by the amount of the accelerated benefit.
You will not receive the full amount of the accelerated death benefit, but rather a reduced amount
called the Accelerated Benefit payment.

Receipt of an Accelerated Benefit may be a taxable event. You should consult a tax advisor regarding
the tax status of any benefit paid to you under these riders. Receipt of accelerated benefits may
affect your eligibility for Medicaid, supplemental security income, or other government benefits or
entitlements.

There is no additional premium required for this rider.

An administrative fee will be deducted from the Accelerated Benefit Payment.

Accelerated Benefit Rider for Terminal Illness provides acceleration of a portion of the death benefit if
the Insured has a terminal illness. A terminal illness is a medical condition that:
1) Is first diagnosed by a legally qualified physician; and
2) With reasonable medical certainty, will result in death within 12 months after the date the
legally qualified physician certifies the diagnosis; and
3) Is not curable by any means available to the medical profession.

The Accelerated Benefit Payment will be equal to the portion of the eligible death benefit requested,
less the actuarial discount and an administrative charge. For policies with outstanding policy debt at the
time of acceleration, the Accelerated Benefit Payment will also be reduced by a proportionate amount
of the existing policy debt. The Accelerated Benefit Payment will never be less than the portion of the
cash surrender value of the policy associated with the accelerated death benefit.

After the accelerated benefit payment is made, the policy will remain in force. Any riders not included
in determining the eligible amount will not be affected; they will continue in accordance with their term.

SDN-TI-ADB 1-25
For any other riders and for the base policy, the amounts of insurance and all policy values will be
subject to pro-rata reductions based on the percentage decrease in the death benefit provided by the
rider or policy. Premiums for the base policy and any accelerated riders will also be subject to pro-rata
reductions based on the percentage decrease in the death benefit provided by the rider or policy.

This is a disclosure statement only. Detailed information is contained in the issued rider. The terms of
the issued rider takes precedence over the information in this disclosure statement.

Please date and sign as indicated and keep a copy. Send the original copy to Knights of Columbus with
the insurance application.

I have read this Summary and Disclosure Notice on (Date)

Margaret Hagenhoff MITCHELL W RADEMAN

Applicant (print name) Agent (print name)

x x
Applicant Signature (owner) Agent Signature (witness)

SDN-TI-ADB 1-25
 NOTICE AND CONSENT FOR TESTING OF BIOLOGICAL SPECIMENS
TO INCLUDE HIV (AIDS VIRUS) TESTING
EXAMINER _____________________________ INSURER KNIGHTS OF COLUMBUS
ADDRESS _____________________________ ADDRESS One Columbus Plaza
_____________________________ New Haven, CT 06510
_____________________________
To determine your insurability, the Insurer named above (the Insurer) has requested that you provide a bio-
logical specimen for testing and analysis. All tests will be performed by a licensed laboratory.
Unless precluded by law, tests will be performed to determine the presence of HIV (the AIDS virus), its
component parts, or its antibodies. These tests are extremely reliable. Other tests which may be performed
include determinations of cholesterol and related lipids (fats), cotinine, cocaine, and screening for liver or kidney
disorders, diabetes, and immune disorders.
All test results will be treated confidentially. They will be reported by the laboratory to the Insurer. When
necessary for business reasons in connection with insurance you have or have applied for with the Insurer, the
Insurer may disclose test results to others such as its affiliates, reinsurers, employees or contractors. If a biolog-
ical specimen other than blood is tested to determine the presence of HIV virus, its component parts, or its anti-
bodies, the Insurer may at a later time request a specimen of your blood for further HIV testing. If you choose to
decline that request, the results of all testing which has been performed will be provided to the physician which
you have designated to receive such results. In addition, if the insurer is a member of MIB, Inc. and you choose
to decline the request that you submit a blood specimen for further HIV testing, the Insurer will report to MIB,
Inc. a generic code which specifies only a non-specific blood test has been ordered and not received. Regardless
of the number of tests requested, if the final HIV testing results (including the results of any confirmatory tests
dictated by standard medical practice) are other than normal, the Insurer will report to MIB, Inc. a generic code
which signifies only a non-specific test abnormality. If your final HIV testing results are normal, no report will be
made about it to MIB, Inc. Other test results may be reported to MIB, Inc. in a more specific manner. The orga-
nizations described in this paragraph may maintain the test results in a file or data bank. There will be no other
disclosure of test results or even that the tests have been done except as may be required or permitted by law or
as authorized by you.
If your HIV tests are normal, no routine notification will be sent to you. If the HIV test results are other than
normal, the Insurer will contact you. The Insurer may also contact you if there are other abnormal test results
which, in the Insurer’s opinion, are significant. The Insurer may ask you to confirm the name of a physician to
whom you authorize disclosure and with whom you may wish to discuss the results. If you are a resident of
Missouri and your HIV test(s) indicates confirmed infection with HIV and you have not provided the Insurer with
the name of a physician to whom you authorize disclosure of test results, the Insurer will disclose test results to
the Missouri Department of Health as required by law.
Positive HIV test results or other significant abnormalities detected by additional tests of biological speci-
mens will adversely affect your application for insurance. This means that your application may be declined, that
an increased premium may be charged or that other policy changes may be necessary.
Physician __________________________________ Address _________________________________________
_________________________________________
_________________________________________
I have read and I understand this Notice of Consent for Testing of biological specimens, which includes HIV
testing. I voluntarily consent to provide biological specimen(s) for testing, to the testing of such specimen(s) and
the disclosure of the test results as described above. I understand that I have the right to request and receive a
copy of this information. A photocopy of this form will be as valid as the original.
Margaret Hagenhoff
__________________________________________ 10/31/1957
___________________________________
Proposed Insured (Print) Date of Birth

MO
__________________________________________ _________________ ___________________________________
Signature of Proposed Insured Date State of Residence

__________________________________________
Signature of Witness

HIV-MO 6-98
KNIGHTS OF COLUMBUS COPY
 INFORMATION ON THE TRANSMISSION OF HIV
HIV, the virus that causes AIDS, is transmitted from one person to another through blood, semen, and
vaginal fluids. The disease is spread primarily during anal, vaginal, or oral intercourse, the sharing of needles
and syringes used for shooting drugs, or from a mother to her unborn child. HIV is not spread through casual
contact, such as eating with or touching a person infected with the virus. There is no medical evidence that
HIV is spread by kissing.
Persons most at risk of contracting HIV are men who have sex with other men; intravenous (“IV”) drug
users; prostitutes (male or female); persons who have had many sexual partners since 1977; persons who
received transfusions of blood or blood products prior to March, 1985; the sexual partners of persons in any of
these groups; and infants born to infected mothers.
Persons who have a history of high risk behavior should change these behaviors to prevent getting or giving
AIDS, regardless of whether they are tested. Specific important changes in behavior include safe sex practices
(including condom use for sexual contact with someone other than a long-term monogamous partner) and not
sharing needles. HIV infected persons have a responsibility not to knowingly infect others.

HIV ANTIBODY TEST

HIV testing means the performing of a serological test or other tests upon a biological specimen to determine
the presence of HIV or its antibodies in the specimen. The HIV test is actually a series of tests designed to detect
the presence of antibodies to the AIDS virus rather than detect the virus itself. Antibodies to the AIDS virus are
found in the blood of most patients with AIDS and AIDS-related complex (ARC), and can be found in people who
do not have AIDS or ARC but have been exposed to the virus.
Your blood sample or other biological specimen will first be subjected to a test known as ELISA
(enzyme-linked immunosorbent assay). If the result of this test is positive, the ELISA test will be repeated. If
this repeat ELISA test is also positive, your blood sample or other biological specimen will then be subjected
to another, more specific technique called the Western blot test, for confirmation. Your test result is consid-
ered positive only after positive results are obtained on two ELISA tests and a Western blot test.
Positive Test Results. In general, if you receive such a positive result, there is a high probability that you
have HIV antibodies in your blood. However, there is a risk that a person who has not been exposed to this virus
will be incorrectly classified by the test as having a positive test result. This is called a “false positive” result.
People who are not in one of the “high risk” groups listed above who get a positive test result are much more
likely to receive a “false positive” than those who are in a high risk group.
A positive test result does not mean that you have AIDS. The diagnosis of AIDS is established using a
patient’s history, symptoms and physical examination. A positive test result does mean, however, that you are
at risk of developing AIDS or AIDS-related conditions. It also means that, without taking precautions, you may
transmit the virus to other people. Therefore, the following steps are recommended to limit the spread of
AIDS: (1) stop donating blood; (2) limit sexual contacts and follow “safe sex” practices; (3) inform your sexual
partners; (4) notify your doctor; and (5) if you are considering having a child, carefully evaluate the risks to
the fetus.
Negative Test Results. If your result is not positive, you most likely have not been infected by the virus.
However, it is possible to have been infected with the virus within the past year and not yet have developed
antibodies that cause a positive test result. Thus, it is possible to receive a “false negative” result.

For further information on HIV Infection/AIDS you may contact:

CDC National HIV & AIDS Hotline (800) 342-2437 or
Missouri – AIDS Infoline Hotline (800) 533-2437
Margaret Hagenhoff
 KNIGHTS OF COLUMBUS
1 COLUMBUS PLAZA, NEW HAVEN, CT 06510

ELECTRONIC SIGNATURE PROCEDURE NOTICE

By recording your signature electronically on the application or related policy documents,

you declare that you have read each question and section that requires your signature,
understood each and agree with the statements therein. You are also acknowledging your
electronic signature, consenting to do business electronically, including receiving any
required disclosures electronically at the time of solicitation or delivery and authorizing the
Knights of Columbus to electronically stamp or sign related policy documents in all areas
that require your acknowledgement and signature, including, but not limited to, owner
insured/annuitant, applicant and/or payor with a single electronic signature in order to
process your application or related policy documents. These documents require your
signature for the products and/or services for which you have applied or are making
changes to after they are issued.

Signatures will be displayed in real time and bound in a single record. Encryption and
storage of your signature is automatic. Your electronic signature will automatically be purged
from the file once the policy has been issued or the related policy documents have been
processed. This prevents use of the signature for any other purpose than those specific to
the issuance of the policy or processing of the related policy documents.

Please review your application and/or related policy documents completely before signing,
paying attention to areas that require your signature, including, but not limited to, areas
where your signature was electronically signed or stamped as owner, insured, annuitant,
applicant and/or payor.

A copy of your completed application and related policy documents (including any applicable
disclosures) will be provided to you electronically following your signature. Please review
the signatures on the application and related policy documents for accuracy and contact us
immediately if you feel there are any discrepancies regarding the use of your electronic
signature.

In order to conduct business with Knights of Columbus you will need to meet the
following system requirements:

• Internet Access
• Minimum Screen Resolution 1024x768
• 128MB of RAM, Cookies and Javascript Enabled
• Web Browser, Latest Versions of Internet Explorer, Microsoft Edge, Mozilla Firefox,
Safari, Google Chrome
• IPad tablet running iOS7+, Tablets running Android OS 4+

I have read and understand this Notice:

______________________________________ ______________________________________
Insured Date Owner Date

______________________________________ ______________________________________
Applicant Date Spouse Date

______________________________________ ______________________________________
Payor Date Joint Insured Date

_____________________________________ _____________________________________
Translator Date Witness Date
 KNIGHTS OF COLUMBUS ● 1 COLUMBUS PLAZA ● NEW HAVEN, CONNECTICUT 06510-3326 ● 1-800-380-9995

Foreign Language Translation Statement of Understanding

Policy Number __________________

05270866

Do the proposed insureds/annuitants/owners speak/read English? X Yes No

If yes, you can skip sections A – E and complete section F.

If no, please complete sections A - E and section G.

To be completed by all proposed insureds/annuitants and owners whose primary/native language is other than English

A. INSURED/ANNUITANT
Name (First, Middle, Last) Insured/Annuitant’s Native Language(s)

| | | |

B. JOINT INSURED/ANNUITANT
Name (First, Middle, Last) Joint Insured/Annuitant’s Native Language(s)

| | | |

C. OWNER Check if same as insured/annuitant

Name (First, Middle, Last) Owner’s Native Language(s)

| | | |

D. JOINT OWNER Check if same as joint insured/annuitant

Name (First, Middle, Last) Joint Owner’s Native Language(s)

| | | |

E. INTERPRETER Check if Agent

Name (First, Middle, Last) Relationship to insured/owner

| | | |

Native Language(s)

| |

Interpreter’s Address City State Zip Code Telephone Number

| | | | | | | || |

P a g e |1 Form #: FLTS - 124

 KNIGHTS OF COLUMBUS ● 1 COLUMBUS PLAZA ● NEW HAVEN, CONNECTICUT 06510-3326 ● 1-800-380-9995

F. Statement of English Understanding

I certify that I can read, speak, and understand English. All discussions and questions related to the solicitation and sale, and
all documents related to the solicitation and sale including this form, the application, any notices and authorization forms and
all other forms required in connection with my application were completed without the assistance of translation.

________________________ _______ _________________________________________ _______

Insured/Annuitant’s Signature Date Owner’s Signature (if other than Insured/Annuitant) Date

I certify that the proposed insureds/annuitants/owners can read, speak, and understand English.

_________________________ __________________
019977 _______

Agent Signature Agent ID Date

G. Insured/Annuitant/Owner Statement of Understanding:

• I understand that I have signed an application and all related forms, including any required notices and authorization
forms, for the following Knights of Columbus product(s) (Check all that apply):

Life Insurance Annuity Long-Term Care Insurance Disability Income Insurance

• I understand and agree that I authorized the above-named interpreter to interpret for me during the solicitation and
sale of the Knights of Columbus product[s] indicated above. This authorization shall remain valid for 12 months. I
understand that I may revoke this authorization at any time by written notification to Knights of Columbus.
• I have communicated with the above-named interpreter, and I am satisfied he/she can speak and understand a
language that I speak.
• I understand that if one of the above products is issued, the contract and all correspondence I receive from Knights
of Columbus in connection with the contract will be written in English. This includes but is not limited to applications,
illustrations, letters, legal notices, premium notices, lapse notices, annual statements, change of beneficiary forms,
other transaction forms and claim forms.
• I agree to be bound by the terms of the contract and by all documents I receive or sign, even though they are in
English. I understand I have the right to have these documents translated for me at my own expense.
• If I call or correspond with Knights of Columbus on any matter related to my policy, I agree to do so in English, using
a translator if necessary.
• During the solicitation and sale of the above product(s), the above-named interpreter has interpreted in their entirety
all discussions and questions related to the solicitation and sale, and all documents related to the solicitation and
sale including this form, the application, any notices and authorization forms and all other forms required in
connection with my application for the above-selected product(s). The application(s) and questions were fully
explained to me by the Field Agent through the above-named interpreter.
• I fully understand that such statements above will be the basis of any product issued, and that nondisclosure,
incomplete or incorrect statements could result in denial of a claim.

My signature below attests to my agreement to this Statement of Understanding.

________________________ _______ _________________________________________ _______

Insured/Annuitant’s Signature Date Owner’s Signature (if other than Insured/Annuitant) Date

P a g e |2 Form #: FLTS - 124

 KNIGHTS OF COLUMBUS ● 1 COLUMBUS PLAZA ● NEW HAVEN, CONNECTICUT 06510-3326 ● 1-800-380-9995

H. Interpreter’s Statement of Understanding:

• I speak, read and understand fluently both English and the non-English language indicated above spoken by the
Insured/Annuitant/Owner and know from speaking with the person(s) listed in sections A, B, C and/or D of this form
that we understand each other.
• I have interpreted accurately, literally, and fully this form, all discussions, questions, and documents used during the
solicitation and sale of the above product including the application, all related forms including any notices and
authorization forms required in connection with the application for the above-selected product(s).
• I fully understand that such statements above will be the basis of any product issued, and that nondisclosure,
incomplete or incorrect statements could result in denial of a claim.

My signature below attests to my agreement to this Statement of Understanding.

_________________________ _______

Interpreter Signature Date

P a g e |3 Form #: FLTS - 124

 NOTICE TO PROPOSED INSURED

Fair Credit Reporting Act

Federal and state laws require us to notify you that, in connection with our consideration of
this application, we may request and obtain an investigative consumer report. In addition,
such a report may be requested subsequently to update our records. We may also request
one, if you apply for more coverage.

The report may contain information as to character, general reputation, personal

characteristics and mode of living and driving record. It may be obtained through an
interview with: you, an adult member of your family, friends, neighbors, business
associates, other persons with whom you are acquainted, or government agencies
regulating motor vehicles. The report will also consist, when applicable, of a confirmation
of your age, residence, marital status, employment and the like.

You have the right, upon written request, to be informed whether or not an investigative
consumer report was obtained by us. Send your request to: Medical Director, Knights of
Columbus, P.O. Box 1670, New Haven, Connecticut 06510- 3326. If it was obtained, we
are required to furnish the name and address of the consumer reporting agency and to
furnish detailed information concerning the nature and scope of the report. Where the
name and address of the consumer reporting agency are furnished, the report may be
inspected and a copy may be obtained by contacting the agency.

NOTICE REGARDING MIB, LLC (MIB)

MIB operates as an information exchange on behalf of insurance companies that are

members of MIB Group, LLC. The Knights of Columbus is a member of MIB Group, LLC.

We make reports to MIB on factors affecting your insurability. We will not inform them of
our decision on your applications. If you subsequently apply to another MIB member
company for life or health insurance or submit a claim for benefits, MIB will, upon request,
supply that company with information in its files. The Knights of Columbus or its
reinsurer(s) may also release information in its files 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.

Upon written request, MIB will arrange disclosure of any information it may have on you in
its file. If you feel the information in the MIB file is not correct, you may contact MIB and
seek a correction in accordance with procedures outlined in the Federal Fair Credit
Reporting Act.

MIB’s address is: MIB, LLC, 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734.
MIB’s telephone number is: (866) 692-6901. MIB’s web address is: [Link]

FCRA 4-22
 DESCRIPTION OF INFORMATION PRACTICES

Collection of Information

In order to properly underwrite your insurance coverage, we must collect a certain amount of necessary and
helpful information. The amount and type of information collected may vary depending on the amount and type of
coverage applied for. In general, we may seek information about: your age, occupation, physical condition, health
history, mode of living, avocations and other personal characteristics.

You are our most important source of information, but we may also collect or verify information by contacting:
medical professionals and institutions which have provided care to you or members of your family proposed for
coverage, employers and business associates, friends and neighbors, and other insurance companies you have
applied to. We may collect information by exchanges of correspondence, by phone, or by personal contact.

In some cases, we may ask an insurance support organization to collect information and submit an investigative
consumer report to us. That organization may retain a copy of the report and may disclose its contents to others
for whom it performs such services.

Disclosure of Information

In some circumstances, the Knights of Columbus will make disclosures of personal information to third parties.
Following is a brief description of some of the persons or organizations to whom certain items of information might
be disclosed: MIB, LLC, our reinsurers, our agents, and other insurance companies to which you have applied for
coverage or benefits.

The above describes some of the disclosures which may be made, not disclosures which are always or even
often made. In any event, the information disclosed will be only as much as is reasonably necessary to
accomplish the intended purpose.

Access and Correction

There are procedures by which you can obtain access to personal information about you appearing in our files,
including information contained in investigative consumer reports. We have also established procedures by which
you may request correction, amendment or deletion of any information in our files which you believe to be
inaccurate or irrelevant. A description of these procedures will also be sent to you upon request.

Obtaining Additional Information

We hope that you find this description of our information practices helpful. We take our responsibilities, and your
rights, very seriously. If you have any further questions about the items just discussed please write to us at: P.O.
Box 1670, New Haven, Connecticut 06510-3326.

DOIP 4-22