The following is a brief summary of the rules that apply to Employer Owned Life Insurance policies, such as policies purchased in key person, entity Buy-Sell, deferred compensation and endorsement split-dollar arrangements. This summary is not meant to be comprehensive or to cover every situation and should not be construed as tax or legal advice. As explained below, if the "Notice and Consent" are received and certain Specified Exceptions are met, the death benefit of a life insurance policy owned by and payable to an employer on the life of an employee will, generally, remain income tax-free.

IF THESE RULES ARE NOT SATISFIED, THE DEATH BENEFIT WILL GENERALLY BE TAXABLE.

The "Notice and Consent" requirements are satisfied if before the policy is issued or before there is a material increase or other material change to a grandfathered policy:

1. The employee is notified in writing that the employer intends to insure the employee's life,
2. The employee is notified in writing of the maximum face amount for which the employee could be insured at the time the policy was issued,
3. The employee provides written consent to being insured under the policy and that such coverage may continue after the insured terminates employment, and
4. The employee is informed in writing that the employer will be a beneficiary of any insurance proceeds payable on the death of the employee.

The policy must be issued before the earlier of (1) the expiration of the one-year period beginning on the date the consent was executed, or (2) termination of the employee's employment.

It is not necessary to provide further notice or renew an employee's consent with regard to an existing policy unless, for example, the total face amount of the employer owned life insurance policy with regard to the employee exceeds the amount of which the employee was notified and to which the employee consented.

An inadvertent failure to satisfy the notice and consent requirements can generally be remedied if the failure is discovered and corrected no later than the due date of the tax return for the taxable year that the policy was issued. However, failure to obtain such consent cannot be corrected after the insured employee has died.

In general, if the notice and consent requirements are satisfied, policy death proceeds may be received income tax free (subject to existing Transfer for Value and Alternative Minimum Tax rules) if any of the following exceptions are met:

1. Recent Employees: The insured was an employee at any time during the 12-month period before death. (In other words, if the employee is no longer employed by the employer at the time of death, the death proceeds will keep their income tax-free status if death occurs within the 12 months following the date of the employee's employment termination.)
2. Directors and Highly Compensated Employees: If at the time of the policy was issued, the insured was:
   • a director,
   • a highly compensated employee under the rules for qualified retirement plans:
     • generally, owner of more than 5% of outstanding or voting stock of the employer (or more than 5% of capital or profits interest if employer is not a corporation) in the current or preceding year; or
     • an employee receiving compensation in excess of the applicable threshold; or
   • a highly compensated individual under the rules for self-insured medical reimbursement plans, (generally defined as one of the five highest paid officers, or among the highest paid 35% of all employees, or a more than 10% owner by value of employer stock).
3. Death Benefits Paid to Heirs:
   • to a family member of the insured,
   • to an individual who is the designated beneficiary of the insured (other than the employer),
   • to a trust established for the benefit of any such family member or designated beneficiary, or
   • to the estate of the insured.
4. Buy-Sell Situations: To the extent that death proceeds are used to purchase an equity (or partnership capital or profits) interest in the employer from any party described in 3 (a) - (d) above.

To qualify for this exception, proceeds paid to heirs or used in Buy-Sell situations must be so paid or used by the due date, including extensions, of the tax return for the year when death benefits under the policy are received by the employer.

This is to notify you that:

1. The Policy Owner or its designee intends to insure your life under a life insurance policy issued by the carrier named below or one of its affiliated companies (the "Policy").
2. The maximum face amount for which you could be insured at the time the Policy is issued is listed below. Any underwritten increase will require additional consent.
3. The Policy Owner or its designee will be the beneficiary of any life insurance proceeds payable at your death under the Policy, subject to the terms, if any, of any separate legal agreement (e.g., a Buy-Sell or split-dollar agreement).

I consent to being insured under the Policy in accordance with information in the above Notice to me and that this coverage may continue after my employment terminates.

The Undersigned Policy Owner hereby acknowledges that:

1. If we fail to adhere to these rules for Employer Owned life insurance, as described above, the death benefit will generally be subject to Federal income tax except to the extent of premiums paid. In addition to the notice and consent requirement, the insured must fit within one of the "Specified Exceptions" as described in Section II above. (The rules are found in IRC Section 101(j).)
2. We understand that we should consult with and rely on the advice of our own tax counsel.
3. Neither the insurance carrier nor any affiliate of the carrier is in the position to guarantee tax results.

Records and Information obtained from the Proposed Insured or other parties may be disclosed to and between the insurance companies or the insurance agencies listed below, and their affiliates, Vanbridge, brokers, contractors, employees, representatives and agents working for or through for purposes of the Proposed Insured applying for or evaluating insurance coverage.

I understand that any Insurer or Agency named afore, its reinsurers, and insurance support organizations, and those persons authorized to represent them may need to collect such information for proposed insurance coverage. The Insurers and Agencies named afore and their reinsurers will use the information in order to determine whether I am insurable or to assist in the application and underwriting process. The insurance producer may also use this information to help update and improve my insurance program.

Any medical facility, health plan, health care professional, laboratory, other medical entity, insurance support organization, brokers, financial institution, consumer reporting agency and my employer, to give the information described above to the Insurers and Agencies listed afore.

21st Services

Accordia

Allianz Life

American General Life Insurance Co.

American National Insurance Co.

Americo Financial Life & Annuity

Ameritas

APPS Paramedical

Ashar Group, LLC

AXA Equitable Life Insurance Co.

Axcelus Financial

Axonic

Banner Life

Better Health Advisors

Brighthouse Financial

Cincinnati Life

Columbus Life

Companion Life Insurance Company

Corebridge Financial

Crown Global Insurance Group, LLC

Equitable

EMSI

EPIC

EPIC Vanbridge

ExamOne

Exceptional Risk Advisors

Express Imaging Services

Fidelity & Guaranty Life Insurance Co.

Fidelity Life Association

General Re Life Corp

Global Atlantic

Great-West Life & Annuity Insurance Co.

Guardian Life

Hanleigh Insurance

HCC/Tokio Marine

IDU, Inc.

JetStream Pro Offer (Risk Righter, LLC)

John Hancock Life Insurance Co. (U.S.A.)

The Leaders Group, Inc.

Legal & General America

Liberty Mutual

Life of South West

Lincoln Financial Companies

Lincoln Life & Annuity Co. of New York

Lincoln National Life Insurance Co.

Lloyd's of London

Lombard International

Massachusetts Mutual

MediPro Direct

Met Life

Minnesota Life

Mutual of Omaha

National Life of Vermont

National Western

Nationwide Life and Annuity Co. of America

New York Life Insurance and Annuity Co.

New York Life Insurance Co.

NYLIFE Insurance Co. of Arizona

North American Co.

OneAmerica

Pacific Life and Annuity Co.

Pan-American Assurance Company

Penn Mutual Life

Petersen International UW

Portamedics

Principal National Life Insurance Company

Principal Life Insurance Company

ProScan Partners

Protective Life Insurance Co.

Pruco Life Insurance Co.

Prudential Life Insurance Companies

Quest Diagnostics/Exam One

RGA Reinsurance Company

Savings Bank Life Insurance Company of MA

Securian Financial

Security Life of Denver

Security Mutual Life

Sterling Resources

Sun Life Financial

Symetra Life Insurance Company

TDC Life

The Standard

Transamerica Life Insurance and Annuity Co.

Union Central

United of Omaha

Unum

US Life Insurance Co.

Vanbridge, an EPIC company

Western Reserve Life

William Penn of New York

Zurich American Life Insurance Co.

The purpose of this Authorization is to assist in the evaluation and placement of my application for insurance. I hereby authorize the release of any and all records and information regarding me, the proposed insured, pursuant to this Authorization. This includes, without limitation, any and all records and protected health information regarding diagnosis, testing, treatment, and prognosis of my physical or mental condition, with the exclusion of psychotherapy notes.

Such records and information to be released may include, but are not limited to, facts about my: (1) mental and physical health; (2) alcohol/drug abuse treatment, (3) pharmacy prescriptions, (4) HIV testing and treatment, except where prohibited by law, (5) reproductive healthcare services, (6) sexually transmitted diseases, (7) Sickle Cell testing and treatment, (8) laboratory test results, (9) other insurance coverage, (10) hazardous activities, (11) character, (12) general reputation, (13) mode of living, (14) finances, (15) occupation, and (16) other personal traits.

Obtain and use non-health and non-medical information, including but not limited to financial information, credit reports, consumer reports, driving record, criminal record, character, general reputation, personal characteristics or behavioral and lifestyle factors and information about avocations and aviation activity; use all of this information to evaluate an application for insurance, a claim for insurance benefits, or both; use any information relating to communicable diseases and other risk factors relating to me or to my spouse or life partner to evaluate an application for insurance on either me or my spouse or life partner.

I understand that any Insurer or Agency named afore, its reinsurers, and insurance support organizations, pharmacy benefit managers and those persons authorized to represent them may need to collect such information for proposed insurance coverage.

I hereby authorize any medical practitioner, including my primary care physician.

I (we) authorize Vanbridge to release and disclose the information described:

1. to its affiliates, insurers, reinsurers, persons or organization providing services relating to insurance underwriting, MIB and as otherwise required by law.
2. to release and disclose the information to other duly licensed life insurers if I (we) have applied or apply to the other insurers for insurance.
3. to the Life Insurance Representative(s) representing me to duly licensed specific life insurers for the purpose of applying for life insurance if my (our) application is declined or if unable to offer coverage at an acceptable rate.
4. to the Life Insurance Representative(s) and its staff, affiliated companies and/or entities, insurance companies and their re-insurers representing me on my (our) application for insurance if it is necessary to provide an explanation of the reasons for a decision to impose special underwriting requirements, whenever my application cannot be approved as submitted, or in connection with a claim for benefits.

I understand that my information will be kept confidential, and will not be disclosed to other persons or organizations without this written permission for the purposes referenced herein, except to the extent that it is necessary for (1) the Insurers and Agencies named afore and their reinsurers and other entities required to conduct business; (2) other insurers to which I have applied or may apply; (3) reinsurers; or (4) other persons whom perform business, professional or insurance services for them. They may also disclose this information as allowed by law. I understand that the Agencies and Insurers listed afore may use secured internet-based systems to store/access some or all of the confidential and personal medical information.

I understand I do not have to sign this authorization in order to obtain benefits (treatment, payment or enrollment). I (we) understand that any information about me (us) that is disclosed pursuant to this authorization may be subject to re-disclosure and no longer covered by certain federal rules governing privacy and confidentiality of health information. The information contained in these medical and financial records will be held in confidence and may be used only for the purpose of the procurement, or underwriting for the possible procurement or the evaluation of life, health, long term care, or other insurance products.

During the evaluation of my (our) insurance application, I (we) understand that I (we) have the right to revoke the authorizations in the previous sections (above) by writing to Vanbridge, 225 NE Mizner Blvd, Suite 675, Boca Raton, FL 33432. If this authorization is revoked, this would result in the file being closed and no coverage provided. Agreement is valid for 24 months.