FORESTERS: COLUMBIAN FINANCIAL GROUP: Smart U.L. Strong Foundation. Safe Shield. After 5 years, without relapse, no current use: ACCEPT

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1 AI Alcoholism Within past 4 years: Within past 4 years: Within past 5 years: After 5 years, without relapse, no current use: Within past 10 years: Alcohol Abuse: After 5 years since last treatment and NO current use: Alzheimer s follow up: Amputation Disease: Disease: Injury: POSSIBLE Disease: Disease: Disease: Caused by injury: Due to disease: Injury: POSSIBLE Disease: Aneurysm Angina (Chest Pain) Angioplasty/Stent I plant follow-up: POSSIBLE After 10 years with no treatment/diagnosis: POSSIBLE Anxiety Mild >age 25, onset more than 1 year or later, no hospitalizations or time off work: If hospitalized within the past 10 years due to: Otherwise: 3 or more meds, or hospitalized: Arr thmia follow-up: POSSIBLE After 10 years with no treatment/diagnosis: POSSIBLE Arthritis Rheumatoid - minor no limitations: Severe: Other: POSSIBLE Rheumatoid - minor no limitations: Severe: Other: POSSIBLE Rheumatoid - Required follow-up ever: Other: Osteoarthritis: Rheumatoid - minor no limitations: Severe/Moderate (RX include Humira, Enbrel, Prednisone): Moderate/Severe rheumatoid arthritis treated with Humira, Enbrel or Methotrexate: Osteoarthritis: Rheumatoid: If treated with Enbrel, Remicade, Humira: If on disability: Simple A ma Mild, moderate, occasional, seasonal, allergic: If treated with steroids, tobacco use or hospitalization months: Mild, moderate, occasional, seasonal, allergic: If treated with steroids, tobacco use or hospitalization months: Tobacco use or moderate/severe or Mild: Moderate if build is 50 lbs lighter than the build chart: Severe ospitalization: Chronic or Severe: Hospitalization for 10+ days within the past year: Hospitalized within the past 2 years: Atrial Fibrillation (A-Fib) follow-up: POSSIBLE If diagnosed over 2 years ago, and current age is 50 or older: Otherwise: Bi olar Disorder If received diagnosis or required follow-up within the past 10 years: If taking 3+ medications or hospitalizations in past 2 years: Simple Blood Pressure (Hypertension) If controlled with 2 or less medications, provide current BP history. 3 or more medications: If controlled with 2 or less medications, provide current BP history. 3 or more medications: If controlled & MUST be 50 lighter than relative build chart: I Table 2 or higher build with multiple impairments or hospitalizations within past 10 years: Bronchitis Acute-Recovered: Chronic: Acute-Recovered: Chronic: If moderate to severe, if a smoker or any Acute: Chronic: If chronic and treated/ diagnosed within the past 5 years: By ass Surgery (CABG) follow-up: Possible if more than 10 years within the past 5 years C I 1

2 Cancer Melanoma/Skin/Basal/ Squamous treatment over 7 years ago: Basal/Squamous Carcinoma - Isolated occurrence: All others: treatment over 8 years ago: Basal/Squamous Carcinoma - Isolated occurrence: All others: More than 5 years since last diagnosis & treatment: POSSIBLE EVER Metastatic (spread), Hodgkin's Disease, Leukemia, Lymphoma, Liver, Lung or Pancreatic: treatment over 10 years ago or re ccurrence: Basal Cell: All others including Hodgkin's Lymphoma: treatment over 5 years ago: Basal Cell: Otherwise: Cardiomyopathy follow-up: POSSIBLE Crohn s Diagnosed prior to age 20 or within the past 12 months: Diagnosed prior to age 20 or within the past 12 months: If less than 3 years since last flare-up Crohn s Disease: >5 years in remission: Mild-Moderate: Hospitalizations or complications within the past year: Colitis Diagnosed within the past 12 months or prior to age 20: Diagnosed within the past 12 months or prior to age 20: Moderate to severe UC: Ulcerative: Mild-Moderate: Hospitalizations or complications within the past year: COPD (Chronic Obstructive Pulmonary Disease) Emphysema: Emphysema: If moderate to severe, if a smoker or any Otherwise: POSSIBLE Emphysema: Emphysema: Possible reasons for declination includes: Tobacco use within past 12 months; current oxygen treatment; or chronic oral steroids required CHF (Congestive Heart Failure) Cystic Fibrosis Depression Moderate to severe diagnosed within the past 3 years: Mild >age 25, onset more than 1 year or later, no hospitalizations or time off work: Severe, major depression, bipolar, schizophrenia (R include Lithium, Seroquel, Abilify, R e ): : Hospitalized within the past 10 years, or evere epression: If taking 3+ medications or hospitalizations in past 2 years: Dementia If treated within the past 5 years: Diabetes *Must be under TABLE 2 BUILD. Refer to diabetic build chart. Combined with verweight, gout, retinopathy, protein in urine, diagnosed prior to age 35, tobacco use months or uses insulin: Controlled with ral edications: Combined with verweight, gout, retinopathy, protein in urine, diagnosed prior to age 35, tobacco use months or uses insulin: Controlled with ral edications: Type - Any tobacco use, ratable table 2 build or higher, diabetic complications or Coronary Artery Disease: Type 2 - Any tobacco use age 50 and younger, ratable table 2 build or higher, diabetic complications or Coronary Artery Disease: Otherwise: POSSIBLE *Refer to underwriting guide for complete restrictions Treated with oral medication or diet. Good control. Nonsmoker or <1 pack/ day. Build does not exceed diabetic build chart: Otherwise: POSSIBLE *Call for risk assessment Diagnosed >age 50 with table 2 or higher build, tobacco use, or PVD: Otherwise: Between ages 18 & 35: Type or 2: POSSIBLE Using insulin in the last 5 years: Simple Otherwise: POSSIBLE Disabled/Disability Receiving disability income or payments: Receiving disability income or payments: If maternity, fractures, spinal or back disorders, hip or knee replacements: If currently disabled, or had been within the past 6 months or received any disability payments within the past 6 months: Simple Driving Record (Including DUI) License suspended or revoked. Past 3 years: DWI, or 2 or more accidents, or 3 or more driving violations or combination thereof: License suspended or revoked. Past 3 years: DWI, or 2 or more accidents, or 3 or more driving violations or combination thereof: License suspended or revoked. Past 3 years: DWI, DUI, 3 or more driving violations or combination thereof: Past 5 years: License suspended or revoked, 3 or more moving violations or 1 or more DUI: POSSIBLE Last 5 years: 4 or more moving violations, DUI, or wreckless driving convictions: Driver license suspended or revoked or any DUI violations within the past 3 years: If within the past 5 years: Simple Term DLX 2

3 Drug Abuse/Addiction past 4 years: past 4 years: In the past 5 years, used or had been treated for amphetamines, cocaine, narcotics, hallucinogens, or barbiturates: Other than occasional arijuana use (tobacco rates apply): Used or convicted unlawful drugs or prescription drugs other than as prescribed within the past 10 years: Less than 5 years from end of use/treatment: After 5 years: Within the past 12 months: Used any Illegal Drugs? If yes: Epilepsy Petit Mal: All others: Petit Mal: All others: With seizures in the past year: Controlled on meds, no seizures for 2 years, no POSSIBLE Unless diagnosed within the past year or hospitalized within the past two years: Severe: If seizures occurred within the past two years, uncontrolled: If more than 2 years since last seizure and controlled seizure disorder: Felony (Probation & Parole) Past 5 years: Probation or parole within past 6 months: Past 5 years: Probation or parole within past 6 months: Past 3 years: If on probation or parole: 1 year after probation: If jail time has been served, consider 5 years after parole. Past 10 years: Probation and Parole: POSSIBLE Past 5 years: Past 10 years: Fibromyalgia No depression and Gastric Bypass Surgery within past 1 year or with any complications post 1 year surgery date: After 1 year since surgery and NO Surgery within past 1 year or with any complications post 1 year surgery date: After 1 year since surgery and NO After 1 year, weight stabilized: After 1 year: Surgery > 6 months ago without US LL (Rate for build) Heart Attack Heart attack after 10 years may be considered, but may require medical records: POSSIBLE Heart Murmur History of treatment or surgery : History of treatment or surgery : follow-up: POSSIBLE Innocent and no symptoms: Heart Surgery follow-up: POSSIBLE Hepatitis History diagnosis of or treatment for B or C: History diagnosis of or treatment for B or C: A, recovered: B or C: A, recovered: B or C: A: POSSIBLE B or C: A (Acute) - Fully recovered: Otherwise: with B or C within the past 5 years: B C: HIV + VE Tested positive: Tested positive: Hyper/Hypo Thyroidism Treated, no symptoms: Kidney Disease/ Failure / Dialysis Kidney Stones Stones: Stones: Stones: Stones, acute infection: Stones: Stones: Stones: Leukemia Lupus Discoid: Discoid: Discoid: if diagnosed less than 5 years ago with medications: Discoid: Discoid: Discoid: Discoid: Accept in the past 5 years: Simple 3

4 Liver Disease/ Transplant Marijuana past 4 years: past 4 years: Possible obacco rates (occasional use only): Possible obacco rates (occasional use only): Used or convicted unlawful drugs or prescription drugs other than as prescribed within the past 10 years: Possible obacco rates: : If used within the past 12 months: Multiple Sclerosis (MS), received diagnosis of or required follow-up; progressive or relapsing: Under age 45: 45 and up: POSSIBLE Muscular Dystrophy (MD) If treated or diagnosed within the past 5 years: E LI E Oxygen se (excluding Sleep Apnea) Pacemaker follow-up: POSSIBLE Pancreatitis Chronic or multiple episodes: Chronic or multiple episodes: Single attack, acute >1 year ago, no alcohol related, no Single episode, fully recovered, no evidence of alcohol abuse: Alcohol related, chronic: Otherwise: Paralysis Includes Paraplegia or Includes Paraplegia or Any Paraplegia or Paraplegia or Any Paraplegia or Any Paraplegia or If any ADLs are impacted: Parkinson s Disease Moderate, Severe or Progressive: Peripheral Vascular Disease (PVD) If surgically corrected/ and or in multiple limbs, or tobacco use: Pregnancy Current, no Current, no Pulmonary Embolism N/A Two or fewer episodes, fully recovered: Otherwise: Sarcoidosis Pulmonary: Pulmonary: follow-up: Pulmonary: Localized, nonpulmonary: Mild (Stage 0 - Stage 1): All others: (moderatesevere) Schizophrenia follow-up: If diagnosed/treated Simple Sleep Apnea Combined with a history or overweight, poorly controlled high blood pressure, COPD, or heart arrhythmia: Combined with a history or overweight, poorly controlled high blood pressure, COPD, or heart arrhythmia: Treated and controlled: POSSIBLE 4

5 Stroke/CVA/TIA If less than 1 year of event, less than age 40 of event, or all ages with moderate to severe residuals: Suicide Attempt N/A N/A Transportation ssistance Permanent use: If any ADLs are impacted: If any ADLs are impacted: Weight SEE BUILD CHART SEE BUILD CHART SEE BUILD CHART SEE BUILD CHART OR DIABETIC BUILD CHART SEE BUILD CHART OR MULTIPLE IMPAIRMENT BUILD CHART(TABLE 2) SEE BUILD CHART SEE BUILD CHART 5

6 BUILD CHARTS - GENDER NEUTRAL Height AA/OCC AA/OCC *Table 2 CFG FORESTERS FORESTERS DIABETIC MUTUAL OF OMAHA MUTUAL OF OMAHA TABLE 2 PHOENIX UHL UHL DLX 4 8" " is meant to serve as a quick underwriting guide. It does not replace any carrier underwriting guidelines provided by each carrier. All underwriting decisions are at the sole discretion of each individual carrier. For additional underwriting assistance please contact the underwriting department at each carrier or Equis Agent Servic