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Application for Group LONG TERM DISABILITY Income Insurance

for Members of The American Postal Workers Union

SECTION C – STATEMENT OF HEALTH

To the best of your knowledge and belief: (Please initial any changes)

Yes

1.) Are you now taking any prescribed medication or receiving or contemplating any medical attention or surgical treatment?

2.) During the past five years have you ever been medically diagnosed by a physician as having or been treated for: heart or

circulatory trouble, elevated blood pressure, chest pain or pressure, gynecological or genitourinary disorders, ulcers,

cancer, diabetes, mental or nervous disorder or psychotherapeutic treatment, epilepsy, respiratory disorder, kidney or

liver disorder, (including hepatitis), enlarged lymph nodes or immunodeficiency disorder, thyroid disorder, blood

Yes

disorder, albumin, blood or sugar in urine, back trouble/disorder, arthritis, or unexplained weight loss?

3.) During the past five years has any person to be insured ever been counseled, treated or hospitalized for the use of

Yes

alcohol or drugs?

4.) Are you now pregnant?

Yes

5.) Are you now disabled, or applied or applying for, or receiving any disability or Workers’ Compensation benefits or

on waiver of premium for life or health insurance?

Yes

6.) Except for the residents of Minnesota and Connecticut, have you been convicted of a crime or served time in prison

Yes

because of a conviction or have an arrest pending?

For residents of Minnesota and Connecticut only, have you been convicted of a crime or served time in prison

because of a conviction or been convicted for any reason during the past 15 years?

Yes

7. If you have answered “Yes” to any of the questions above please give complete details below.

Illness or Condition-Date of Onset-Duration-Treatment-

Name and address of Physicians or other Medical Care

Operations-Degree of Recovery and Date:

Practitioners and Hospitals where confined or treated:

NOTE: (If you need to add more information, please attach a separate sheet if necessary, then sign and date it).

I understand that New York Life Insurance Company has the right to require additional information and, if necessary, an examination by a physician. I ask

New York Life to rely on all such statements made on this form, and any supplements to it, while considering this request. I also understand that the coverage

afforded will be in consideration of the answers and statements set forth above.

AUTHORIZATION: I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, laboratory, insur-

ance company, MIB, Inc. (“MIB”), or other organization, institution or person, that has any records or knowledge of me or my health to release information,

including prescription drug records, maintained by physicians, pharmacy benefit managers, and other sources of information to New York Life Insurance

Company, its reinsurers, its subsidiaries or the plan administrator about the physical and mental health of any persons proposed for insurance, including

significant history, findings, diagnosis and treatment, but excluding psychotherapy notes.

A photocopy of this AUTHORIZATION and request form shall be as valid as the original. In all circumstances, my authorized agent or representative, or I

may request a copy of this AUTHORIZATION. This AUTHORIZATION may be used for a period of 24 months from the date signed, unless sooner revoked as

stated in the IMPORTANT NOTICE.

By signing and dating this application, the member requests the insurance indicated; and the member and any person proposed for insurance consent

to authorize the disclosure of information to and from the providers noted in the IMPORTANT NOTICE, including making a brief report of my protected health

information to MIB, Inc.; and attest to having read the IMPORTANT NOTICE and Fraud Notices enclosed, including how my information is exchanged with

MIB, and that to the best of my knowledge and belief, the answers provided to the questions are true and complete.

I also hereby authorize the necessary salary deductions for the premium once approved for coverage, to pay for insurance for the APWU Group Long

Term Disability Income Plan underwritten by New York Life Insurance Company.

Date

Member Signature X

(Sign in ink)

G-29315-2

GPA-DI-EZ-2

Page 2 of 2 3/13

NOTE: If you have made corrections or strikeouts on this application, the Member MUST initial them.

Application For Group Long Term Disability Income Insurance For Members Of The American Postal Workers Union (Apwu) - New York Life Insurance Company Page 2

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