Preliminary Aflac Application

Member Information

1. First Name*
2. Middle Initial*
3. Last*
4. Gender*

   1. Male
   2. Female
5. Date Of Birth*

   1. Year 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932
   2. Month January February March April May June July August September October November December
   3. Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
6. Date Of Hire*

   1. Year 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952
   2. Month January February March April May June July August September October November December
   3. Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Member Contact Information

1. Phone Number*
2. Street*
3. City*
4. State*
5. ZIP*
6. Email Address*

Spouse Information

1. Full Name*
2. Gender*

   1. Male
   2. Female
3. Date Of Birth*

   1. Year 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932
   2. Month January February March April May June July August September October November December
   3. Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Children Information

1. Name*
2. Gender*

   1. Male
   2. Female
3. Date Of Birth*

   1. Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
   2. Month January February March April May June July August September October November December
   3. Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

---

4. Name*
5. Gender*

   1. Male
   2. Female
6. Date Of Birth*

   1. Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
   2. Month January February March April May June July August September October November December
   3. Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

---

7. Name*
8. Gender*

   1. Male
   2. Female
9. Date Of Birth*

   1. Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
   2. Month January February March April May June July August September October November December
   3. Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

---

10. Name*
11. Gender*

    1. Male
    2. Female
12. Date Of Birth*

    1. Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
    2. Month January February March April May June July August September October November December
    3. Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Critical Illness

1. Critical Illness Coverage Level*

   1. Member & Spouse
   2. Member
   3. None

Member Questions

2. Face Amount*

   1. $50,000
   2. $40,000
   3. $30,000
   4. $20,000
   5. $10,000

Answering yes to any of the below does NOT disqualify you from coverage.

3. Have you used tobacco products in the last 12 months?*

   1. Yes
   2. No
4. Have you ever been treated for or diagnosed by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS) or “AIDS” Related Complex (ARC) or ever tested positive for antigens or antibodies to an “AIDS” virus?*

   1. Yes
   2. No
5. In the last 7 years have you been treated for or diagnosed with cancer or any malignancy, which includes carcinoma, sarcoma, Hodgkin’s Disease, leukemia, lymphoma, or malignant tumor? Cancer does not include basal cell or squamous cell carcinoma.*

   1. Yes
   2. No
6. Have you ever been treated for or diagnosed with a) a stroke, a heart attack, a heart condition, heart trouble, or any abnormality of the heart (including artery disease), diabetes, or any liver disorder; b) kidney (renal) failure or end stage kidney (renal) disease; c) organ transplant; d) emphysema or e) now taking 3 or more medications for high blood pressure?*

   1. Yes
   2. No

Spouse Questions

7. Face Amount*

   1. $50,000
   2. $40,000
   3. $30,000
   4. $20,000
   5. $10,000

Answering yes to any of the below does NOT disqualify you from coverage.

8. Have you used tobacco products in the last 12 months?*

   1. Yes
   2. No
9. Have you ever been treated for or diagnosed by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS) or “AIDS” Related Complex (ARC) or ever tested positive for antigens or antibodies to an “AIDS” virus?*

   1. Yes
   2. No
10. In the last 7 years have you been treated for or diagnosed with cancer or any malignancy, which includes carcinoma, sarcoma, Hodgkin’s Disease, leukemia, lymphoma, or malignant tumor? Cancer does not include basal cell or squamous cell carcinoma.*

    1. Yes
    2. No
11. Have you ever been treated for or diagnosed with a) a stroke, a heart attack, a heart condition, heart trouble, or any abnormality of the heart (including artery disease), diabetes, or any liver disorder; b) kidney (renal) failure or end stage kidney (renal) disease; c) organ transplant; d) emphysema or e) now taking 3 or more medications for high blood pressure?*

    1. Yes
    2. No

Accident

1. Accident & Injury Coverage Level*

   1. Family
   2. Member & Children
   3. Member & Spouse
   4. Member
   5. None