enrollment/ change/waiver Group Insurance Form Ameritas Life Insurance Corp. P.O. Box 81889 / Lincoln, NE 68501-1889 / 800-659-2223 / Fax: 402-467-7338 Ameritas� Policy and Div.# 010- __________ _

Cert.# ______________ _

COBRA: If individual Qualifying Event is a continuee:

Date of Event

Name and Address of Employer (Policyholder) _____________________________ _

1 to enroll □ Dental □ Eye Care □ To terminate all coverages Employee Information Marital Status D Single D Married D Civil Union* D Domestic Partner* *As defined by state law or your Group.

Social Security number __________ Dept. number _________ _

Employee's last name, first name, Ml---------------------------------

Date of birth______ D Male D Female Full time date of hire _____ _ D Rehire: Rehire date _____ _

Occupation ________________ Hours worked each week __ Are your earnings paid: D Hourly or D Salaried

Street address City __________ State ZIP ____ _

E-mail address (limit of 60 characters) _______________________________ _Are you covered under another dental insurance plan? ................. Employee: D Yes D No Dependents: D Yes D No Are you covered under another eye care insurance plan? ................ Employee: D Yes D No Dependents: D Yes D No

Dependent Coverage Information List all eligible dependents to be added or deleted. (Employee must be enrolled to cover dependents) Dental Eye Care College

Print full legal name (last, first. Ml) add drop add drop Relationship Sex Date of birth Social Security no. student?

1 □ □ □ □ □

2 □ □ □ □ □

3 □ □ □ □ □

4 □ □ □ □ □

5 □ □ □ □ □

Please Sign (employee/policyholder) The certificate provides dental and eye care benefits only. Review your certificate carefully. As an employee, I hereby apply for, or waive (if indicated), group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. THE FOLLOWING APPLIES ONLY TO SECTION 125 FLEXIBLE BENEFITS PLANS: I am signing up for coverage until the next enrollment period except in the case of a life event. This information was explained in the plan's solicitation materials which I have read and understand. I represent that the information I have provided is complete and accurate to the best of my knowledge. The policyholder certifies the date of employment, job title, hours worked and salary information are correct according to the Policyholder's records.

X X Employee Signature (do not print) Date Policyholder Signature (do not print) Date

In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete, or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. (State-specific statements on back.)

Employee late entrant date ________ _

Dependent late entrant date _______ _ I Effective Date I

Class

IDep. Code

2 to change □ Name Change New Name ______________ _ Old Name _____________ _

□ Add Dependent CoverageD If due to marriage, what is the date of marriage? ____ _ D If due to birth/adoption, what is the date of event? ______ _

D If due to loss of coverage, date and reason: ___________________________ _

D If other, the date of event and please explain: ___________________________ _

D Drop Dependent Coverage Number of dependents still covered: __ Effective date of drop: ___________ _ D Due to divorce D Due to death D Due to annual election period D Exceeds maximum age to qualify as dependent

D Other (please explain)----------------------------------

3 to waive IF YOU DO NOT WANT COVERAGE, COMPLETE THE WAIVER SECTION. THE WAIVER MAY NOT BE ALLOWED FOR THIS PLAN, CHECK WITH YOUR EMPLOYER. I have been given an opportunity to apply for Group Insurance offered by my employer, and have decided not to accept the offer for: D myself (does not apply to TRUST policies) D spouse/domestic partner D child(ren) only D spouse/domestic partner and child(ren)

because-----------------------------------------

Name of insurance company and employer of dependent __________________________ _ Should I desire to apply for this group insurance in the future, I realize that a "late entrant" penalty may be applied.

GR 875 Rev. 06-12 Page 1 of 2 09-07-1701.ENR.9000578 USA

Policy and Div 010: Cert: Dental: OffEye Care: OffTo terminate all coverages: OffSocial Security number: Dept number: Date of birth: Full time date of hire: D Rehire Rehire date: Occupation: Hours worked each week: City: ZIP: Email address limit of 60 characters: Employee late entrant date: Dependent late entrant date: New Name: Old Name: D If due to marriage what is the date of marriage: D If due to birthadoption what is the date of event: D If due to loss of coverage date and reason: D If other the date of event and please explain: Effective date of drop: D Other please explain: Name of insurance company and employer of dependent: Text122: Date123_af_date: Text124: Check Box125: OffCheck Box126: OffCheck Box127: OffCheck Box128: OffText129: Check Box130: OffCheck Box131: OffCheck Box132: OffCheck Box133: OffCheck Box134: OffText135: Text136: Check Box137: OffCheck Box138: OffCheck Box139: OffCheck Box140: OffCheck Box141: OffCheck Box142: OffCheck Box143: OffCheck Box144: OffCheck Box145: OffCheck Box146: OffCheck Box147: OffCheck Box148: OffCheck Box149: OffCheck Box150: OffCheck Box151: OffCheck Box152: OffCheck Box153: OffCheck Box154: OffCheck Box155: OffCheck Box156: OffCheck Box157: OffCheck Box158: OffCheck Box159: OffCheck Box160: OffCheck Box161: OffCheck Box162: OffCheck Box163: OffCheck Box164: OffCheck Box165: OffCheck Box166: OffCheck Box167: OffCheck Box168: OffCheck Box169: OffText170: Text171: Text172: Text173: Text174: Text175: Text176: Text177: Text178: Text179: Text180: Text181: Text182: Text183: Text184: Text185: Text186: Text187: Text188: Text189: Text191: Text192: Text193: Text194: Text195: Date198_af_date: Date200_af_date: Text202: Text203: Text204: Check Box205: OffCheck Box206: OffCheck Box207: OffCheck Box208: OffCheck Box209: OffCheck Box210: OffCheck Box211: OffCheck Box212: OffCheck Box213: OffCheck Box214: OffNumber of dependents still covered: Check Box215: OffCheck Box216: OffCheck Box217: OffCheck Box218: OffCheck Box219: OffText220: Check Box221: Off