AmAm

Final Expense (Ages 50 to 85): Voice Signature Script

I. Record the following with the proposed insured for each application:

Mr/Mrs. _ as a final step to completing the application process, I need you to please verify the following:

• Please state your full name and today’s date.
• Do you understand that you have applied for a Whole Life Final Expense Insurance policy through American-Amicable Life Insurance Company of Texas (hereafter referred to as American-Amicable)?
• Do you understand that this Whole Life Insurance policy is separate from any other insurance policy that you may have been presented?
• Do you acknowledge that the application for insurance with American-Amicable was completed over the telephone and that you were not in the presence of the licensed insurance agent who sold you this policy?
• Do you agree that answers and statements you have provided while completing your application are true, complete and correctly recorded to the best of your knowledge and belief?
• Do you acknowledge that you have received and read all of the following items or they have been read to you:
  • Copy of your application
  • Conditional Receipt (If applicable)
  • Copy of the Fair Credit Reporting Act Notice and MIB Pre-Notice
  • Terminal Illness Accelerated Benefit Rider Disclosure Statement
  • Accelerated Benefit Rider – Confined Care Disclosure Statement (only on Immediate Death Benefit Plan)
• Do you understand that a copy of your completed application will be provided as part of your policy contract, if issued?
• Do you acknowledge that you have provided your bank account information and authorized the drafting of insurance premiums from said account?
• Do you authorize American-Amicable to obtain and disclose protected health information including prescription history for the purpose of determining eligibility for insurance from any pharmacy, any pharmacy benefit manager, the MIB, Inc. and do you authorize said entities to furnish such information to American-Amicable for the purpose of evaluating your application for insurance?
• Health information obtained will not be re-disclosed without your authorization unless permitted by law, in which case it may not be protected under Federal Privacy Rules. This authorization shall be valid for two years from this date and may be revoked by sending written notice to American-Amicable.
• Do you agree to American-Amicable accepting your signature electronically through voice recording and do you understand that by stating ‘yes’ you are signing the application electronically just as if you had signed a paper application?

Thank you very much for your application. It will now be submitted to the Home Office for consideration for
approval.

II. Record the following (in addition to the above) only if someone other than the proposed insured will be owner of the policy:

• Please state your name and your relationship to the individual applying for life insurance.
• Please verify the last 4 digits of your Social Security number.
• Is it your intent to be the owner of this policy?
• Is it your intent for this recording to represent your signature?

PRIVACY NOTIFICATION FOR THE INDUSTRIAL ALLIANCE GROUP – US OPERATIONS

If you have some form of disability that makes it difficult for you to use this document, you may access this information in an alternative format at: www.iaamerican-waco.com.

The Industrial Alliance Group-U.S. Operations is composed of Industrial Alliance Insurance and Financial Services Inc.’s U.S. Branch and Industrial Alliance Insurance and Financial Services Inc.’s U.S. subsidiaries, including but not limited to IA American Life Insurance Company, American-Amicable Life Insurance Company of Texas, Occidental Life Insurance Company of North Carolina, Pioneer American Insurance Company, Pioneer Security Life Insurance Company and Industrial Alliance Portfolio Management (U.S.) LLC (the “Company”). The Company is committed to protecting the Company’s clients’, employees’ and representatives’ (the “Individual/s”) privacy, and to ensuring the confidentiality of the personal information provided to it in the course of the Company’s business.

The Company’s Privacy Policy sets out the Company’s standards for collecting, using, disclosing and storing your personal information. The Company’s Privacy Policy also explains how the Company safeguards your personal information and the individual’s right to access that information. The Privacy Policy is located at: www.iaamerican-waco.com.

The purpose of this notice is to inform you at or before the time of collection of your personal information of the categories of personal information that will be collected from you and the purposes for which these categories of personal information will be used.

We will not use your personal information for any purpose other than those disclosed in this notice. In the event that in the future we determine it is necessary to use your personal information for a purpose that was not previously disclosed to you, we will directly notify you of this new use and obtain explicit consent from you to use your information for this new purpose.

We will be collecting the following categories of personal information about you: