APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company)

For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of

Liberty National Life Insurance Company or its reinsurers may also release information in its file to other insurance companies to whom you may apply for life or health insurance,

The United States Life Insurance Company in the City of New York, or its reinsurers, may also release information from its file to other insurance companies to whom you may apply

Hartford Life Insurance Company or Hartford Life and Accident Insurance Company or its reinsurer(s) may release information in their files to other life insurance companies to whom

Hartford Life Insurance Company, Hartford Life and Accident Insurance Company, or their reinsurers, may also release information from their files to other insurance companies to

Your gross disability payment will be the benefit amount before the company subtracts direct deductible sources of income and disability earnings such as Social Security disability

AG Select-a-Term Policy Form Number 09007N, Accidental Death Benefit Rider Form Number ADB 79-1E, Child Rider Form Number CI 79-1E, Waiver of Premium Rider Form Number WP 79-1E

General Life Insurance Company or The United States Life Insurance Company in the City of New York up to the 60th month of the term contract (prior to the fifth policy