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INFORMAL INQUIRY - This Preliminary Application is used specifically to gather underwriting information relating to an insured’s  medical  history  and  other  factors  that  may  have  an  impact  on  an  underwriting  classification. PERSONAL HISTORY

Name (First)_____________________________(Last)_____________________________ Date of Birth _____________________ Social Security # _____________________________ Male Female Age ________ Height _________ Weight __________ Address ___________________________________________ City ________________________ State ______ Zip ____________ TOBACCO USAGE

Do you use any nicotine products? Yes No If yes, what type? Cigarettes Cigar Pipe Snuff If other, please describe_________________________________ Frequency of Use ____________________________________ Have you ever used nicotine products? Yes No If yes, date of last usage__________________________________________ PLAN OF INSURANCE

Universal Life Whole Life Variable Survivorship Term – desired guaranteed period ____________________ Face Amount __________________________________ Premium Amt/UW Class Needed_________________________________ Have competing offers been made? Yes No If so, indicate company/offer _________________________________________ INFORCE COVERAGE

Carrier Face Amount Replacing?

AVOCATIONS Any hazardous activities? (rock climbing, scuba diving, hang gliding, pilot, etc) Yes No If yes, please specify which activity

_________________________________________________________________________________________________________ FAMILY HISTORY Has any immediate family member (parents or siblings) died prior to age 60? Yes No If so, please indicate which family member, cause, and age of death. _________________________________________________________________________________________________________ HISTORY OF MEDICAL CONDITIONS

Impairment Date of Onset Treatment Cancer Diabetes Cardiac Stroke Hepatitis Sleep Apnea Other:

AGENT INFORMATION Name _________________________________________ Social Security # ____________________ Date of Birth _____________ Address _________________________________________ City ___________________________ State _______ Zip __________ Phone _______________________ Fax _______________________ Email Address ____________________________________

Atlantic Insurance Brokerage 1265 Cottage Drive Harrisburg, PA 17112 P – 877.561.2422 F – 888.228.7570

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REQUEST FOR ATTENDING PHYSICIAN INFORMATION

The following information is needed to help expedite the medical underwriting process. Please list all of the physicians that the client has seen within the last 5 years and the reason for each visit. If the client does not have a personal physician, please state so below. Who is your primary care physician?

Doctor’s  address  and  phone  number Date last seen and reason why

Other physicians seen?

Doctor’s  address  and  phone  number Date last seen and reason why

Any hospitalizations?

Hospital name, address, phone number Date and reason why hospitalized?

Please list all current medications (including over-the-counter):

LIFESTYLE QUESTIONNAIRE

Proposed Insured __________________________________________________________________________________________ 1. Do you work? Yes No If yes, where and how often ________________________________________________________ 2. Do you volunteer? Yes No If yes, where and how often _____________________________________________________ 3. Are you married? Yes No Highest level of education?_______________________________________________________ 4. Do you exercise? Yes No If yes, what type and how often ___________________________________________________ 5. Hobbies and Interests?___________________________________________________________________________________ 6. Do you travel? Where to? Reason –business/pleasure? How often? Future plans?

________________________________________________________________________________________________________

7. Do you use any assisted devices (walker, cane, etc)? Yes No If so, please describe _______________________________ 8. Do you have a pet? Yes No If so, please describe your daily activities with your pet

________________________________________________________________________________________________________

________________________________________________________________________________________________________

9. Do you handle your own financial affairs such as: Balance your own checkbook? Yes No

Pay your own bills? Yes No 10. Do you drive an automobile? Yes No If you have had any accidents in the last three years, please explain

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

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Atlantic Insurance Brokerage1265 Cottage DriveHarrisburg, PA 17112P – 877.561.2422F – 888.228.7570

HIPAA Authorization for Release of Health Related Information

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

I hereby authorize the use, disclosure, or sharing of health information, as described below, about me and revoke anyprevious restrictions concerning access to such information:

1. The information will be used, disclosed, or shared only for the following purpose(s): For the purpose of conducting aformal or informal inquiry regarding my eligibility for life insurance products or related services, underwriting myinsurance application(s) and, if a policy is issued, for evaluating contestability and eligibility for benefits, for thecontinuation or replacement of the policy, for reinstatement of the policy or to contest a claim under the policy.

2. Persons or entities authorized to use, disclose, and/or share the information: Any health plan, physician, health careprofessional, hospital, clinic, long-term care facility, medical or medically-related facility, laboratory, pharmacy,pharmacy benefit manager, insurance company, insurance support organization such as MIB Group, Inc., or othermedical practitioner or health care provider that has provided payment, treatment or services to me or on my behalf.

3. Persons or entities authorized to collect or otherwise receive, use, and share the information: The life insurancecompanies and servicing agencies listed on this form in section 5, along with their affiliates and reinsurers, and theiragents, employees, or other representatives (the “Authorized Entities”). I further authorize the Authorized Entities toredisclose the information to, and discuss the information with, each other and to redisclose the information to MIBGroup, Inc., which operates an information exchange on behalf of life and health insurance companies.

4. Description of the information that may be used, disclosed, or shared: This authorization specifically includes therelease of all information related to my health to the extent allowed by law, including, but not limited to, information onthe diagnoses, prognoses, treatments, prescription drug information, and information regarding diagnosis, prognosisand treatment of mental illness, suicidal disorders, communicable or infectious conditions, such as HumanImmunodeficiency Virus (“HIV”) and Acquired Immune Deficiency Syndrome (“AIDS”), and use of alcohol, drugs andtobacco. This authorization excludes separate psychotherapy notes.

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5. Authorized Life Insurance Companies and Servicing Agencies:

3 Mark Financial

Guardian Principal National Life Insurance Accordia Illinois Mutual Protective Advantage Insurance Network ING Protective Life & Annuity AIG/American General John Hancock Prudential American-Amicable Lafayette Life Reliance Standard Atlantic Insurance Brokerage Life Ins. Co. of the Southwest Reliastar Life Allianz Lincoln Benefit Royal Neighbors of America American National Ins. Co. Lincoln Financial Group Savings Bank Life Insurance Americo Lloyds of London Securian Assurity Mass Mutual Security Life of Denver AXA/MONY Minnesota Life Standard Athene Nationwide Symetra Life Banner National Life Ins. Co. Transamerica Berkshire Nationwide Financial Union Central Brighthouse Life Ins. Co. New York Life United of Omaha Companion Life North American Co. for Life & Health Ins US Life in the City of New York EMSI Old Mutual VOYA Express Imaging Services, Inc. Pacific Life William Penn Fidelity & Guarantee Life Pan American Zurich American Life Ins. Company Fidelity Life Penn Mutual Zurich American Life Ins. Co. of NY Fidelity Security Phoenix Life Additional: Foresters Presidential Life Additional: Global Atlantic Financial Group Principal Life Insurance Additional:

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STATEMENTS OF UNDERSTANDING & ACKNOWLEDGMENT

I understand that health information about me provided to the Authorized Entities may be protected by stateand federal privacy regulations including the HIPAA Privacy Rule and that the Authorized Entities will only use,disclose, and share such information as permitted by applicable regulations and as described in their privacynotices.

I understand that any information disclosed under this authorization may be subject to redisclosure by therecipient and may no longer be protected by federal regulations such as the HIPAA Privacy Rule governingprivacy and confidentiality of health information.

I understand that if I refuse to sign this authorization to release my health information, the Authorized Entitiesmay not be able to determine my eligibility for life insurance products or related services, process anyapplication submitted by me, 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 hasalready been taken in reliance on it, or to the extent that other law provides the Authorized Entities with theright to contest a claim under the policy or the policy itself, by sending a written revocation to the address at thetop of this form. I understand that if I signed any other authorizations, these must be revoked separately.

This authorization shall remain in force for 24 months from the date signed, regardless of my condition andwhether living or deceased.

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

I acknowledge I have read and received a copy of this authorization.

_______________________________________

Printed Name of Proposed Insured

_______________________________________

Signature of Proposed Insured

_______________________________________

Proposed Insured’s Date of Birth

_______________________________________

Date

_______________________________________

Printed Name of Witness (if available)

_______________________________________

Signature of Witness (if available)

Any alteration of this form will not be accepted.This authorization complies with the HIPAA Privacy Rule.

Name of Proposed Insured Birth Date (mm/dd/yy)

A. AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

I authorize the Accordia Life and Annuity Company (the “Company”), its reinsurers, or its authorized representatives, to obtain from MIC, Inc. or other any consumer reporting agency or employer one or more consumer reports including, but not limited to, a credit report, about me, which may include information about my physical or mental health.I understand that an investigative consumer report may be prepared in connection with this application. I authorize the Company, its reinsurers, or its authorized representatives, to prepare or obtain from any consumer reporting agency one or more investigative consumer reports about me. With the exception of Arizona residents, I understand that an investigative consumer report involves personal interviews with sources such as neighbors, friends, or associates, and may include information as to my character, general reputation, personal characteristics, and mode of living. For residents of Arizona, I understand that an investigative consumer report involves personal interviews with sources such as neighbors, friends, or associates, and may include information as to my character and general reputation. I understand these investigative consumer reports contain information regarding income, net worth, business information, hazardous sports, avocations, driving history, occupation, credit history, or criminal history. This authorization shall remain in force for 24 months following the date of my signature on this form.For residents of all states, I understand that I may request to be personally interviewed if an investigative consumer report is prepared or obtained in connection with this application. I further understand that, if an investigative consumer report is prepared or obtained, I have the right to request in writing, within a reasonable time, a complete and accurate disclosure of the nature and scope of the investigation, a copy of the investigative consumer report, and a summary of my rights under the Fair Credit Reporting Act.I authorize the Company, its reinsurers, or its authorized representatives, to release information obtained in connection with this application including, but not limited to, any consumer reports, investigative consumer reports, or personal health information to reinsurers, the MIB, Inc., or other persons or organizations performing business or legal services in connection with my application, claim, or as may be permitted or required by law, or as I may further authorize.

B. AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION

To evaluate my eligibility for insurance coverage, I authorize any licensed physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, health care provider, health plan, insurer, and/or any other entity subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that has provided treatment service, payment, or coverage to me within the past 10 years to disclose my entire medical record and any other protected health information concerning me to the Company, its agents/producers, employees, representatives, insurance support organizations, and reinsurers. Protected health information includes but is not limited to: hospital records, treatment records/office notes, consultation reports, workers’ compensation information, diagnosis, prescriptions, and test results. It also includes information concerning the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection (see below for state-specific exclusions concerning disclosure of HIV-related information), sexually transmitted diseases, and information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes.

FOR RESIDENTS OF MAINE: This authorization excludes the disclosure of the result of a test for HIV if the applicant has tested HIV positive but has not developed symptoms of the disease AIDS. Such tests shall not be discovered or published. Nothing in this caveat will prohibit this authorization from including the fact that the applicant has AIDS.

18769 (11-16)

Authorization and Acknowledgement

Page 1 of 2

Accordia Life and Annuity Company 215 10th Street, Suite1100, Des Moines, IA 50309

Mail or fax completed form to:Accordia Life and Annuity Company P.O. Box 305030, Nashville, TN 37230-5030

Contact us:Customer Contact Center – Tel: 877 462 8992 Fax: 800 262 6976

FOR RESIDENTS OF MINNESOTA: This authorization excludes the release of information about HIV (AIDS) virus tests which were administered (1) to a criminal offender or crime victim as a result of a crime that was reported to the police; (2) to a patient who received the services of emergency medical services personnel at a hospital or medical care facility; (3) to emergency medical personnel who were tested as a result of performing emergency medical services. The term “emergency medical personnel” includes individuals employed to provide pre-hospital emergency services; licensed police officers, firefighters, paramedics, emergency medical services; crime lab personnel, correctional guards, including security guards at the Minnesota security hospital, who experience a significant exposure to an inmate who is transported to a facility for emergency medical care; and other persons who render emergency care or assistance at the scene of an emergency, or while an injured person is being transported to receive medical care and who would qualify for immunity under the good samaritan law.

FOR RESIDENTS OF VERMONT: This authorization EXCLUDES the release of any information relating to ANY previously administered tests for the HIV antibody, T-Cell counts, AIDS, or ARC. Further, the results from any new test requested of me by the Company will NOT be forwarded to any outside, non-affiliated company or to any entity not under specific contract with the Company to perform underwriting services.

FOR RESIDENTS OF WISCONSIN: The reporting of AIDS/HIV test results is limited only to the results of FDA-licensed tests and that the consumer need not report the results of the tests conducted at an anonymous counseling testing site, or home test kit.

By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct any physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, health care provider, health plan, insurer, and/or other entity subject to HIPAA to release and disclose such information. I understand that, unless prohibited by state and/or federal law, the protected health information is to be disclosed under this authorization so that the Company may: 1) underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; 2) obtain reinsurance; 3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer coverage; and 5) conduct other legally permissible activities that relate to any coverage I have, have applied for, or may in the future apply for with the Company. I understand any information disclosed under this authorization may no longer be covered by federal rules governing privacy and confidentiality of health information and may be subject to redisclosure (For residents of Colorado, the Company will not redisclose information received pursuant to this authorization without my written authorization)

This authorization shall remain in force for 24 months following the date of my signature on this form (Except for residents of Arizona, authorization to disclose HIV-related information is valid for 180 days from the date of the signature below). If this authorization is signed and the Company is collecting information in connection with a claim for life insurance benefits, this authorization shall remain valid for no longer than the duration of the claim. A copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization at any time. The request for revocation must be in writ-ing and sent to the attention of the Underwriting Department of the Company at the address listed above. I understand that the request for revocation may be a basis for denying an application or a claim for benefits. I also understand that a revocation is not effective to the extent that the Company has already relied on this authorization or to the extent that has a legal right to contest a claim under an insurance policy or to contest the policy itself. Such revocation shall not apply to any use or disclosure of my protected health information specifically allowed without authorization by HIPAA and no action relating to this authoriza-tion shall be construed as creating any restriction on the uses that HIPAA allows without my authorization.

I understand that failure to sign this authorization may impair the ability of a regulated insurance entity to evaluate claims or process applications and may be a basis for the Company to deny an application or claim for benefits. By signing below, I ac-knowledge that I have received a copy of this authorization.

Signature of Proposed Insured or Personal Representative

X

Date (mm/dd/yy)

If you are the Personal Representative of the Proposed Insured, describe the scope and/or basis of your authority to act on the Insured’s behalf:

18769 (11-16) Page 2 of 2

DD 6000 UND-3 Insurance products from the Principal Financial Group® (The Principal®) are issued by Page 1 of 1 Principal National Life Insurance Company (except in New York) and Principal Life Insurance Company.

This completed document is for restricted use only. No part may be copied nor disclosed without prior consent of The Principal®. 05/2017

Principal Life Insurance CompanyPrincipal National Life Insurance Company Members of Principal Financial Group®

P.O. Box 10431Des Moines, IA 50306-0431

Authorization forRelease of Personal Health Information –All States

Only one company is the issuer and responsible for obligations of any given policy and is hereinafter referred to as “the Company”.

(Applicable to Individual Lifeand Disability Insurance Customers)

This authorization complies with the HIPAA Privacy Rule and permits health care providers and other covered entities to disclose personal health information.

Name of Proposed Insured/Patient (please print) Date of Birth

I authorize any physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, health care provider, health plan, insurer, and/or any other entity subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that has provided treatment, service, or coverage to me within the past 10 years to disclose my entire medical record to the Company, its agents, employees, insurance support organizations, reinsurers, and their representatives. This includes information concerning the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness (excluding psychotherapy notes as defined under HIPAA) and the use of alcohol, drugs, and tobacco. Statements required by §164.508(c)(1)(ii), (c)(1)(iii). I understand my personal health information may be used or disclosed as set forth by this authorization. Protected health information includes information created or received by the Company. Protected health information also includes but is not limited to: hospital records, treatment records/office notes, alcohol or drug abuse treatment, consultation reports, workers’ compensation information, diagnosis, prescriptions, test results, vocational testing/counseling information, benefit information, claims information, demographic information, and claims payment information. Statement required by §164.508(c)(1)(i). By my signature, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct any physician, health care professional, hospital, clinic, medical facility, other health care provider or health plan, insurer, or other entity subject to HIPAA to release and disclose my medical record without restriction. I understand that my personal information, including my protected health information disclosed under this authorization, will be incorporated into and made a part of any life and/or disability insurance policy(s) issued by the Company in connection with the application(s) for insurance that I have submitted to the Company. I further understand that the policy(s) will be delivered to the policy owner, which may be my employer or other party. The information included and forming a part of such policy(s), including my protected health information, may be disclosed to the policy owner. I understand that unless prohibited by state and/or federal law the protected health information is to be disclosed under this authorization so that the Company may: 1) underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; 2) obtainreinsurance; 3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4) administer coverage; and 5) conduct other legally permissible activities that relate to any coverage I have, have applied for, or may in the future apply for with the Company. Statement required by §164.508(c)(1)(iv). The following groups of persons employed or working for the Company may use my personal health information which is described above: employees of the underwriting, administration, claim or legal departments and any other personnel of the Company, and its authorized representatives, and business associates that perform functions or services that pertain to any coverage I have, have applied for, or may in the future apply for with the Company. Statement required by §164.508(c)(1)(ii). I understand any information disclosed under this authorization may no longer be covered by the privacy provisions of HIPAA and may be subject to redisclosure. Statement required by §164.508(c)(2)(iii). This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this authorization is as valid as the original. Statement required by §164.508(c)(v). I understand that I have the right to revoke this authorization at any time. The request for revocation must be in writing and sent to: Life and Disability Underwriting, Life and Health Segment, Principal Life Insurance Company and/or Principal National Life Insurance Company, Des Moines, IA 50392-1780. I understand that a revocation is not effective if the Company has relied on the protected health information disclosed to it or has a legal right to contest a claim under an insurance policy or to contest the policy itself. Statement required by §164.508(c)(2)(i). Such revocation shall not apply to any use or disclosure of my protected health information specifically allowed withoutauthorization by HIPAA and no action relating to this authorization shall be construed as creating any restriction on the uses that HIPAA allows without my authorization. I understand that if I refuse to sign this authorization to release my complete medical record, the Company may not be able to process my application for life and/or disability coverage, or if coverage has been issued, may not be able to make any such benefit payments. Statement required by §164.508(c)(2)(ii). Upon receipt of your signed authorization, a copy will be provided to you. Statement required by §164.508(c)(4). Any alteration of this form will not be accepted.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I further understand that My Providers cannot condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization.

Signature of Proposed Insured/Patient or Personal Representative Date

If you are the personal representative of the proposed insured/patient, describe the scope of your authority to act on this individual’s behalf (parent, legal guardian, power of attorney, etc.) on the line above. Statement required by §164.508(c)(1)(vi).

Life Underwriting

Tips for Ensuring Accurate Paramed Results

Having your clients follow some simple guidelines prior to their Paramed examination is key to ensuring accurate results. Not to mention, it may improve their underwriting rating, possibly save them money, increase their insurance coverage, AND you’ll be looked upon as a true insurance expert.

Following these tips will help your clients attain the most favorable and accurate exam results

• Fast for 4-8 hours prior to the exam and try to schedule the

exam for first thing in the morning, prior to eating • Limit salt and high-cholesterol foods 24 hours prior to the

exam • Refrain from drinking alcoholic beverages for at least 24

hours prior to the exam (can increase fat in blood and liver functions)

• Limit caffeine and nicotine 24 hours prior to the exam (can increase blood pressure, cholesterol)

• Smokers should not smoke 30 minutes prior to exam (tends to constrict artery walls and elevate blood pressure)

• Drink a glass of water one hour prior to the exam • Get a good night of sleep prior to the exam

Helpful reminders • Be prepared with a photo ID at the time of the exam • Provide names and dosages of current medications • Provide any history of problems associated with providing a

blood sample • Women should mention to the examiner if mensturating at

the time of exam (can caues blood in the urine specimen) • Have information cards available, including member

numbers, for any current health insurance • Have available names, addresses and phone numbers of any

doctors or clinics visited in the last five years • Tell the examiner if exercise is a regular activity • Tell the examiner if vitamins or aspirin are taken on a daily

basis

If your client has experienced one of the following impairments, follow these additional guidelines:

HYPERTENSION • Avoid stimulants (caffeine, alcohol, cigarettes) • Schedule a morning exam • Have the examiner take blood pressure after the client

has had a chance to relax — three attempts at 10 minute intervals

• Take usual medications DIABETES

• Schedule the exam for 2½ hours after a meal (no sweets or sugars after the meal), but if blood is being drawn, fast for 4-8 hours prior to the exam

• Empty bladder right after meal • Drink 1-2 glasses of water before the exam

URINARY SPECIMEN PROBLEMS (albumin, Red Blood Cells [RBCs], sugar, etc.)

• Empty bladder right after meal • Drink 2-3 glasses of water before the exam • Avoid sweets or foods with sugar content before the exam • Avoid strenuous exercise, such as running, for 24 hours prior

to the exam

CORONARY, EKG PROBLEMS

• Avoid stimulants (caffeine, alcohol, cigarettes)