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The Guardian Life Insurance Company of America Customer Service Office

3900 Burgess Place, Bethlehem, PA 18017

Eligibility Considerations related to applying for the Accelerated Death Benefit for Long Term Care Services Rider

DO NOT SUBMIT THIS DOCUMENT WHEN APPLYING FOR THIS RIDER

The underwriting of the Accelerated Death Benefit for Long-Term Care (LTC) Rider differs greatly from traditional life insurance underwriting. Underwriting decisions are based on morbidity risks versus mortality risks. Some factors that are unique to long term care underwriting include functional impairment, cognitive impairment, degenerative conditions, mobility problems, and frailty. Please note that the information provided in this document is meant to be a guide in determining eligibility for the rider. It is not an all inclusive document and final determination of eligibility will be determined during the underwriting process.

Screening Tips: In order prevent declinations in coverage for your clients and to expedite the underwriting of your cases, please follow these guidelines to “pre-qualify” your clients before submitting the case to underwriting. We have included in this packet, listings of uninsurable medical conditions, uninsurable medications, and situations that will cause declination of the LTC Rider.

This document is not intended to be used to apply for the LTC rider; it should be used to determine whether or not a client is a good candidate for this rider.

Situations where LTC Rider will not be approved by underwriting:

• The base policy has a substandard rating or flat extra. • The rider is being issued as a replacement of an existing long term care product. • The inability to perform activities of daily living (ADL’s). These activities include:

Bathing, Continence (control of bladder or bowel), Dressing, Eating, Toileting, Transferring out of bed of chair.

• Applicants who are currently using a wheelchair, walker, multi-pronged cane, hospital bed, oxygen, dialysis machine, motorized cart, or stair lift.

• Applicants who currently reside in a nursing home, assisted care facility, custodial facility, or attend adult day care.

• Applicants who are receiving Medicaid. • Applicants currently receiving disability payments. • Applicants who have been declined long term care coverage previously. • Applicants who have surgery or an investigative work up pending. Or individuals who

have recently had surgery from which they have not been released from the doctors care and are not yet fully recovered.

13-LTC PRE QUAL WORKSHEET

Long Term Care Rider Uninsurable Medications: This table lists medications that if taken regularly within the past 5 years would most likely result in the LTC rider being declined. Please note that this list is NOT ALL INCLUSIVE. Medications that are not listed may also result in the rider being declined as part of the underwriting process.

Antabuse (disulfuram) Eldepryl (Selegiline) Methadone Remicade (infliximab) Arava (leflunomide) Enbrel (entanercept) Methotrexate Reminyl (galantamine) Aricept (donepezil) Ergoloid Morphine Requip (ropinirole) Artane (trihexyphenidyl) Exelon (rivastigmine) MS Contin ReVia (naltrexone) Avonex (interferon) Fentanyl Namenda (memantine Risperdal (risperidone) Baclofen Geodon (ziprasidone) Navane (thiothixene) Seroquel (quetiapine) Betaseron (interferon) Hydergine Oxycontin (oxycodone) Sinimet (levadopa) Campral (acamprosate) Interferon Parlodel (bromocriptine) Stezaline (trifluoperazine) Cogentin (benztropine) Insulin Permax (pergolide) Symmetral (amantadine) Cognex (tacrine) L-Dopa Prolixin (fluphenazine) Thorazine

(chlorpromazine) Comtan (entacapone) Larodopa Razadyne (galantamine) Trilafon (perphenazine) Copaxone ((glatiramer) Levodopa Rebif (interferon) Vivitrol (naltrexone) Depade (naltrexone) Lithium

Conditions where LTC Rider will not be approved: Please note that this list is NOT ALL INCLUSIVE. Conditions that are not listed may also result in the rider being declined as part of the underwriting process.

AIDS/HIV Cirrhosis (liver) Leukemia (within 10 years) Paralysis AIDS-related Complex (ARC)

Congestive heart failure Lymphoma Paraplegia/ Quadriplegia

Alcoholism (within 10 years)

COPD/emphysema Memory Loss Parkinson’s

ALS Cystic fibrosis Mental Retardation Polyarteritis Nodosa Alzheimer’s disease / dementia

Depression (severe or hospitalized within 10 years)

Mixed Connective Tissue Disease

Polycystic Kidney Disease

Amputations (multiple limbs or due to disease)

Diabetes (Insulin dependent)

Mobility impairment with ADL limitations

Post polio syndrome

Aneurysm (not repaired) Drug abuse (within 10 years)

Multiple Myeloma Pulmonary Hypertension

Arteritis (severe) Esophageal Varices Multiple Sclerosis Rheumatoid Arthritis Assistive devices (walker, cane, wheelchair)

Heart attack, heart or carotid artery surgery (within 6 months)

Muscular Dystrophy Schizophrenia

Ataxia/Gait impairments Hepatitis (chronic) Myasthenia Gravis Scleroderma / Crest syndrome

Atrophy (brain) Huntington’s disease Narcotic drug or prescription pain meds – regular use

Stroke

Balance disorders Hydrocephalus Neurogenic bladder Systemic Lupus Bowel Incontinence Implantable defibrillator Organic Brain Syndrome Transient Ischemic Attack

(TIA) (within 6 months or multiple)

Cardiomyopathy kidney disease (dialysis) Oxygen use Transplant (internal organs)

Pancreatitis (chronic) Wegener’s granulomatosis

13-LTC PRE QUAL WORKSHEET

Life Application L-AP-2011

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (Guardian) THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC. (GIAC) Customer Service Office 3900 Burgess Place Bethlehem, PA 18017

INSTRUCTIONS FOR COMPLETING THE LIFE INSURANCE APPLICATION

(For Producer Use Only)

All questions must be answered completely. Use blue or black ink. Any changes to these answers must be initialed by the Owner. In addition, the Proposed Insured must initial any change to answers pertaining to his/her personal information or any answer pertaining to insurability. An agent has no authority to waive, change or limit any question on the application.

1. This application is for insureds age 14 years 6 months and older. This application is for fully underwritten cases, that are not Pension Trust cases. If changing an inforce policy, exercising a Guaranteed Insurability Option, or converting term coverage, please use the appropriate Change Request or Conversion application.

2. The basic forms needed for a complete application are: The Part 1 application, the Authorization, the Notice of Information Practices (must be left with Proposed Insured), the appropriate Part 2 supplement (Non-Medical or Medical), and the Agent’s Certification.

3. You may also need any or all of the following forms depending on the particulars of the case in question:

• Replacement form(s). Generally, you will need to obtain the appropriate state replacement form if the answer to the replacement question in the application is Yes. Note that, in some states, the replacement form is required if the owner has any existing individual life or annuity contracts, even if no replacement is occurring. Please refer to the summary documents for Replacements that can be found in the Life Resource Center of Guardian Online.

• Guard-O-Matic forms if requesting GOM mode.

• Conditional Receipt if accepting cash with application. There are specific conditions that appear on the Receipt form under which the receipt cannot be used. Please do NOT complete and provide the Receipt if the case does not qualify for accepting cash with the application. In addition to the conditions on the Receipt form, please note that we do not allow cash with application for variable life policies, survivorship type policies, or any policy where the face amount is over $5,000,000. If using the Receipt, please complete the form and leave with owner. Please ensure the question regarding the Prepayment of Premium in the application is answered and that the client understands the terms and conditions of the temporary coverage provided.

• Consent for HIV testing, if required by state. Important: when a consent form is required, it must be signed prior to testing. So if your client is sent for a medical examination prior to completing the Part 1 application, the HIV form must be signed before the HIV test. In this situation, signing the consent form at time of application is too late.

• Underwriting supplements (aviation, avocation, alcohol/drug, military, foreign residence/travel). The application form has instructions as to when one of these forms would be needed. In addition, an Underwriter can always request a supplement.

• If this is an application for Variable Life, we require the Variable Life Supplement, the Patriot Act Notice, and appropriate PAS forms. Please see iPipeline for guidance.

• Other miscellaneous disclosure forms, depending on the product and state. All of the above forms are not contained in this application package, but are available on the iPipeline system.

LTC RIDER NEW BUSINESS SUBMISSION INSTRUCTION PAGE

This document provides instructions on what is needed in order to submit a case that contains our Long Term Care (LTC) rider. This information is in addition to the normal new business submission requirements that would normally apply to a whole life submission.

• PREQUALIFICATION WORKSHEET FORM (13-LTC PRE QUAL WORKSHEET) – This worksheet was developed as a tool for an agent to review information with their client to determine if a client is a viable candidate for applying for the LTC rider. This worksheet should only be used as a guide for the types of conditions and situations where an LTC rider would not be approved for issue. DO NOT complete this form and submit it with other New Business documentation. It should ONLY be used as a guide to determine if a client should apply for the rider.

The following documents must be completed and submitted in order to apply for the LTC rider:

• APPLICATION SUPPLEMENT FORM (ICC13-LTC APP SUPP) – This form is used to apply for the rider. It is where you select the benefit levels and optional features that are provided under the rider. It also includes a number of additional health questions that relate specifically to the underwriting considerations of the rider that are not contained in the base application.

• LTC AGENT CERTIFICATION FORM (13-LTC APP SUPP AC) –This is a separate agent certification that must be completed by the agent and submitted with the other paperwork. This is required by law since there are LTC related replacement questions that the agent is required to respond to. This agent certification is required in addition to the certification submitted for the base application.

• LTC PERSONAL WORKSHEET FORM (ICC13-LTC PERSONAL WORKSHEET) – This is a suitability type of form that is required to be completed and should be used in determining whether the LTC rider is a suitable rider for the applicant.

• TERMINAL ILLNESS DISCLOSURE FORM (ICC13-TIR DISC) – Since a terminal illness rider is also included whenever an LTC rider is attached to a policy, a signed disclosure is required for this rider.

• THIRD PARTY OWNERSHIP FORM (13-TPOD) – Whenever the insured is not the owner of the policy that contains the LTC Rider, Guardian requires completion of a disclosure which mentions the possible the tax implications of such an ownership structure. This form is required if the application shows an owner that is different than the insured.

In addition to the above forms that may need to be submitted as part of the new business application process, there are a number of other forms that need to be provided to the client at the time the application is taken. If the LTC rider is added to a case that has already been submitted, these forms must be given to the client prior to any request to add this rider to a case.

• OUTLINE OF COVERAGE FORM (ICC13-LTCR OC) – This is a legally required disclosure that must be given to the client at the time of applying for the LTC rider.

• POTENTIAL RATE INCREASE DISCLOSURE FORM (ICC13-LTC RATE DISCLOSURE) – Since the LTC rider premium is not guaranteed and may change in the future, we are required to provide this disclosure to all clients applying for the LTC Rider.

• THINGS YOU SHOULD KNOW BEFORE YOU BUY LONG TERM CARE INSURANCE FORM (ICC13-LTC NOTICE)

• LTC SHOPPERS GUIDE FORM (PUB. 5857) – This guide is developed by the NAIC and is required to be left with the client at the time of application. The guide can be ordered on GOL by clicking the Order Materials and Forms link and then click on Order Marketing Materials

• MEDICARE SUPPLEMENT FORM – You may be asked by a client for a copy of the Medicare Supplement Guide… If this happens you may order copies via GOL by clicking the Order Materials and Forms link and then click on Order Marketing Materials.

COMPACT STATES

ICC13 LTC APP SUPP Page 1

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (In this application, “the Company” is the insurer named above.)

Customer Service Office 3900 Burgess Place Bethlehem, PA 18017

APPLICATION SUPPLEMENT ACCELERATION OF DEATH BENEFIT FOR LONG TERM CARE SERVICES (LTC) RIDER

DISCLOSURE: Payment of a Monthly LTC Benefit may be taxable. The owner should consult a competent tax advisor to determine the current tax consequences before requesting any accelerated payments.

Please print (any changes must be initialed by the Owner and/or proposed insured)

SECTION A Proposed Insured/Owner Information

1. First Name MI Last Name

2. Social Security # 3. Sex Male Female

4. Date of Birth (mm/dd/yyyy)

5. Owner name (First, MI, Last) or name of trust, business entity or charity (Complete only if the proposed insured is NOT to be theowner)?

SECTION B LTC Rider Information By applying for the LTC rider, an Accelerated Benefit Rider for Terminal Illness will also be part of the policy if the LTC rider becomes part of the policy being applied for.

1. Basic LTC Pool – This is the amount of the policy face amount that can be accelerated under the LTC Rider. The maximumBasic LTC Pool is the lesser of (a) 90% of the basic policy face amount being applied for or (b) the basic policy face amount less$25,000. However, in no event can the Basic LTC Pool applicable to an insured life exceed $2,500,000.

I elect the maximum Basic LTC Pool as described above.

I elect a Basic LTC Pool of: $

2. Additional LTC Pool Yes No

3. Rider Value Option B – Enhanced Reduced Paid-up Benefit (Nonforfeiture Benefit) Yes No

NOTE: By electing the Optional Reduced Paid-up Benefit (Nonforfeiture Benefit) the Premiums for the LTC Rider will be higher than if the option is not elected.

SECTION C Protection From Unintended Lapse The Owner/Proposed Insured understands that the owner has the right to designate at least one person other than himself/herself to receive notice of lapse or termination of this LTC rider for non-payment of premium. Such notice will be provided to the designated person until 30 days after the premium is due and unpaid.

I elect NOT to designate a person to receive such notice

I elect to designate the following person(s) to receive notice prior to cancellation of the policy for nonpayment of premium

PERSON 1

First Name MI Last Name

Primary Residence (Do not use P.O. Box)

City State Zip

PERSON 2

First Name MI Last Name

Primary Residence (Do not use P.O. Box)

City State Zip


SECTION D Replacement Information Yes No

1. Is the Proposed Insured covered by Medicaid?

2. Are there any long-term care policies, certificates or riders in force (including health care service contracts and/or health maintenance organization contracts) during the last 12 months on the Proposed Insured’s life? Provide details below

3. Are there other life insurance policies in force that provide similar long term care coverage on the Proposed Insured’s life? Provide details below

4. Do you intend to replace any long-term care, medical or health coverage on the Proposed Insured’s life with the coverage being applied for in this supplement?

5. Has the proposed insured ever been denied coverage for a long-term care rider or policy?

*For any “No” answer, please provide date of lapse in the Remarks section. SECTION E Medical Information (for any “yes” responses, please provide details in the remarks section F) 1. Does the proposed insured currently need or receive help with any of the following: Eating, Bathing, dressing, toileting,

transferring from bed to chair? Yes No

2. Does the proposed insured currently use or has the proposed insured used in the past 12 months, a wheelchair, walker, multi-pronged cane, hospital bed, oxygen, dialysis machine, motorized cart or stair lift? Yes No

3. Does the proposed insured currently need help, assistance or supervision in performing any of the following everyday activities: taking medication, doing housework, laundry, shopping or meal preparation? Yes No

4. Has the proposed insured ever been diagnosed as having or treated by a member of the medical profession for: a. Alzheimer’s disease or dementia, Mild Cognitive Impairment, or organic brain syndrome? Yes No b. Multiple Sclerosis, Muscular Dystrophy, Parkinson’s Disease or ALS (Lou Gehrig’s Disease)? Yes No

5. Within the last 5 years, has the proposed insured been treated, examined, or received consultation or counseling by a member of the medical profession for: a. Amnesia, confusion, aphasia, memory loss or forgetfulness? Yes No b. Dizziness, fainting, weakness or chronic fatigue? Yes No c. Tremors or numbness? Yes No d. Any fractures or falls? Yes No e. A condition which causes limited motion? Yes No f. Incontinence problems? Yes No g. Ataxia, balance, or gait impairment? Yes No

6. During the last 12 months, has the proposed insured received any type of disability benefit, Worker’s Compensation or Social Security Disability? Yes No

7. Has the proposed insured’s parent or sibling ever been diagnosed as having or been treated by a member of the medical profession for Alzheimers, Huntington’s disease or schizophrenia? Yes No

8. Within the past 24 months has the proposed insured received home health care services, physical or other rehabilitative therapy? Yes No

9. Does the proposed insured currently reside in, been advised to enter, or plan to enter a nursing home, assisted care living facility, custodial facility, or is the proposed insured attending an adult day care center? Yes No

Name of Company Type (e.g. individual

or group)

Year Issued Total Amount Currently in force?

Yes No *

Being Replaced? Yes No


List all medication prescribed and/or taken by the Proposed Insured in the last 24 months THAT ARE NOT CURRENTLY BEING TAKEN and provide the appropriate details as requested below.

SECTION F Remarks Section

SECTION G Amendments or Corrections (For Home Office Or Customer Service Office Use Only)

Medication Dose and frequency Physician who prescribed

Reason for taking Date Started Date Stopped


Representations of the Proposed Insured and Owner

NOTICE: If the policy is to be owned by someone other than the Proposed Insured, I (Proposed Insured) provide consent to the proposed owner to own the policy on which this rider is attached and understand that any LTC benefits paid under the rider being applied for with this application supplement will be payable to the owner and not to me (Proposed Insured). CAUTION: If answers on this Application Supplement are not correctly recorded and complete and true to the best of the knowledge and belief of those who made them, the Company may have the right to deny benefits or rescind the LTC rider. The best time to clear up any questions is now, before a claim arises. If for any reason you feel the statements made in these applications are incorrect, contact us at the Customer Service Office shown at the top of this form.

Acknowledgement I agree that I am applying for the LTC Rider to be included on the life insurance policy that I am applying for and that this application supplement will form part of the basis for coverage under the policy and will be attached to and become a part of any policy issued. I further agree that I have read this application and all of the statements that are part of this supplement are correctly recorded, and are complete and true to the best of the knowledge and belief of those persons who made them. Any misrepresentation or omission, if found to be material, may adversely affect acceptance of the risk, claims payment or may cause the Company to seek rescission of any policy that is issued based on this application. I also understand that the agent cannot determine eligibility or alter the terms of the proposed rider. The company may require as part of this applications process an attending physician statement, medical records, an underwriting assessment, a medical exam, a Department of Motor Vehicle report or other questionnaire, test or a prescription drug or medication report. I further acknowledge that I have received the Outline of Coverage for the rider being applied for. I have also received the Things You Should Know Before You Purchase Long Term Insurance form, the Potential Rate Increase Disclosure and the Shopper’s Guide to Life Insurance (if required by law in the state in which this rider is delivered).

Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Signed by Owner at: on City and State mm/dd/yyyy

X X Signature of Proposed Insured Signature of Applicant/Owner if Other than Proposed Insured

X Date of Signature for Proposed Insured (mm/dd/yy) Signature of Additional Owner X Witness (for applications taken by mail – should not be beneficiary)

L-AP-2011

Customer Service Office THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA 3900 Burgess Place THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC. Bethlehem, PA 18017 (Please check appropriate company. In this application, “the

Company” is the insurer checked above.)

APPLICATION FOR LIFE INSURANCE Part 1

Please print (any changes must be initialed by the Owner and/or proposed insured) (Page 1 of 8) SECTION A Proposed Insured Information 1. First Name MI Last Name

2. Previous Name (if changed in the last 5 years)

3. Social Security # 4. Sex Male Female

5. Date of Birth (mm/dd/yyyy) 6. Place of Birth

7. Are you a U.S. citizen? Yes No (If no, please complete Foreign Travel and Residence Questionnaire)

8. Marital Status: Married Single Divorced Separated Widowed

9. Driver’s License Number Driver’s License State (if none, provide a government photo ID number, issuer and expiration date in Remarks section)

10. Primary Residence (Do not use P.O. Box)

City State Zip

11. How long at this address? (If less than 2 years at current address, please provide prior address in Remarks section)

12. Home phone 13. E-mail address

14. Telephone Interview – if more information is needed, a representative may call you. Show the most convenient place and range of times for such a call weekdays between the hours of 9:00 a.m. and 9:00 p.m.

Home Business Other – Phone Times SECTION B Employment Information

1. Name of Employer

2. Street Address

City State Zip

3. Business Phone 4. Business Web Site

5. Occupation 6. Job Title

7. Nature of Business

8. How many years employed? (If less than 2 years please furnish information on previous employer

in Remarks section, including name and address of previous employer, occupation, nature of business and job title.)

*IMNB0011000010201*

L-AP-2011

(Page 2 of 8) SECTION C Owner Information

(Complete only if the proposed insured is NOT to be the policyowner)

1. Owner: Individual Trust Business Entity Charity

2. Owner name (First, MI, Last) or name of trust, business entity or charity:

3. Social Security No./Tax ID No. 4. Relationship to proposed insured

5. Full Address (Do not use P.O. Box)

6. Telephone Number 7. Owner’s E-Mail Address

If Owner is an individual, please answer Questions 8 and 9

8. Date of Birth (mm/dd/yyyy) 9. Driver’s License No. and State (if none, provide a government photo ID number, issuer and expiration date in Remarks section)

10. If the Owner is an individual, is he/she a U.S. citizen? If Owner is a Trust, Business Entity, or Charity, is such entity established or organized under the laws of a state of the U.S.? Yes No (if no, provide details in Remarks)

11. Complete if Policy is Trust Owned (also, complete either Trust Certification form or provide copy of trust agreement):

Date of Trust

Complete Names of Authorized Trustees

SECTION D Change of Ownership

1. Is there an intention that any group of investors will obtain any right, title, or interest in any policy issued on the life of the proposed insured as a result of this application? Yes No

2. Will you (the owner/applicant) borrow money to pay the premiums for this policy or have someone else pay these premiums in return for an assignment of policy values back to them? Yes No (If Yes to either of these questions, please complete Statement of Owner Intent form)

SECTION E Beneficiary Information If you indicate shares, please ensure that the % for all the beneficiaries in each type (primary, contingent, tertiary) total 100%. Please use whole numbers only. If you do not indicate shares, all Primary Beneficiaries who survive the Insured shall share equally. If no Primary Beneficiary survives the Insured, benefits will be paid in equal shares to the Contingent Beneficiaries, etc., who survive the Insured.

Name (First, MI, Last) Date of Birth Soc. Sec. No. Relationship to Insured

Share (enter %) Beneficiary Type (see key)

P S T

P S T

P S T

P S T

P S T

P S T

Key: P = Primary Beneficiary; S = Secondary Beneficiary; T = Tertiary Beneficiary

SECTION F Purpose of Insurance Please describe the purpose of the proposed insurance (check one or more of the following, or describe in “Other”):

Buy-Sell Deferred Compensation Charitable Planning Family Income Mortgage Key Person Split Dollar Estate Planning Retirement Other Executive Bonus Collateral for Debt Wealth Accumulation Education

L-AP-2011

(Page 3 of 8) SECTION G Proposed Insurance

1. Plan of Insurance 2. Base Policy Face Amount $

3. Riders Whole Life (Note: Option Q and R riders are elected in the Dividends Section)

Waiver of Premium (WP) Accelerated Benefit Rider (EABR) (please complete required disclosure form) Scheduled/Unscheduled Paid-Up Additions (PUA) Rider Unscheduled Only Paid-Up Additions (PUA) Rider

If a Scheduled PUA Payment is desired, indicate annual amount $

If an Initial PUA Payment is to be made, indicate amount (not including first Scheduled payment) $

If Waiver of Specified Amount benefit is requested, indicate annual Specified Amount $ Guaranteed Purchase Option (GIO) select one: Regular GIO Limited GIO L10 GIO (for L10 plan only)

Indicate GIO Option Amount: $

Accidental Death Benefit (ADB) Indicate ADB Face Amount: $

10 Year Annually Renewable Term Term Amount: $ Select Security Rider Exchange of Insureds DuoGuard (List names & amounts for Designated Lives. Complete a separate application for each Designated Life.)

Term Waiver of Premium Waiver Plus (for Level Term only) Initial Period Waiver of Premium (For LifeSpan only) Extended Conversion Rider Whole Life Purchase Option Option Amount $

Accidental Death Benefit (ADB) ADB Face Amount: $

Universal Life and Variable Life Riders Additional Sum Insured (Do NOT include this amount in Base Face Amount shown above) $ Secondary Guarantee Coverage Rider Alternate Net Cash Surrender Value Benefit Accelerated Benefit Rider (EABR) (please complete required disclosure form) Waiver of Monthly Deductions Disability Benefit Rider (Waiver of Specified Amount) Indicate Monthly Specified Amount: $ Guaranteed Insurability Option (GIO/WLPO) Option Amount $

Accidental Death Benefit (ADB) ADB Face Amount: $ Select Security Rider Exchange of Insureds

Riders for Survivorship Products (EstateGuard WL, SUL, etc.) Survivorship Waiver of Premium (Death Waiver) (available on one or both of the base policy insureds) (1st Insured) (2nd Insured)

Policy Split Option * Four Year Term Rider for SUL (on both insureds) Term Amount: $ Single Life Term/RTR 85 (available on one or both of the base policy insureds) (1st Insured) $ (2nd Insured) $ Second to Die DuoGuard (List names & amounts for Designated Lives. Complete a separate application for each Designated Life.)

First To Die DuoGuard (available on one or both of the base policy insureds) (1st Insured) $ (2nd Insured) $

* Note the Policy Split Option rider will automatically be included for EstateGuard SUL and SUL-SG products, if the policy is eligible for such rider. The rider is not automatically included on EstateGuard WL policies and should be elected, if desired.

Other Riders Other $ Other $

L-AP-2011

(Page 4 of 8) SECTION H Premiums 1. Mode

Annual Semiannual Quarterly Monthly (list bill only – this may not be available for all products) Guard-O-Matic (complete the appropriate Request Form) New Service Add to my existing service Existing Policy Number Other 2. Who is to pay premiums? 3. Send premium notices to:

Residence Business Owner’s address Other List Bill

New – Billing Name Common billing date Existing account #

4. Automatic Premium Loan (if available) Yes No (if left blank, default will be Yes)

5. Complete for VUL/UL policies: Initial Premium $ Planned Premium (at the mode indicated above) $

6. Prepayment of Premium

No money is being submitted with this application. Money is being submitted with this application, in the amount of $ . By signing this application, agent is

attesting that the above amount of money was collected, that the Conditional Temporary Coverage Agreement and Receipt was provided to the client and that the conditions for providing such Receipt were met. By signing this application, applicant is attesting that the 3 medical questions asked in the Conditional Temporary Coverage Agreement and Receipt form were all answered “NO”, and that the applicant has received the Receipt form and agrees to its terms.

SECTION I Dividends (for participating policies only)

If you apply for a participating life insurance policy, and do not elect a dividend option, the following default options will apply: for Whole Life policies, Option D; for Term policies, Option C, for Universal Life policies, any dividend paid will be used to increase the unloaned policy account value. Note that for Term and Universal Life policies, we do not expect to ever pay a dividend. For any participating product, dividends are never guaranteed.

A- Paid in cash B- Reduce premiums C- Left at interest (Complete W-9 form if elected) D- Paid-Up Additional Insurance F- Term Insurance face amount not in excess of cash value/Balance to purchase paid-up additional insurance G-Term Insurance face amount not in excess of cash value/Balance to reduce premium L- Term insurance face amount not in excess of 2X face amount of basic policy/Balance to purchase paid-up additional insurance P- Term Insurance face amount not in excess of 2X face amount of basic policy/Balance to reduce premium

Q- One Year Term Insurance not to exceed Target Face Amount* of $

R- One Year Term Insurance with Increasing Target Face Amount* Initial Target $ Level Increases % Compound Increases % S- Premium Offset – (available only if a PUA rider is requested. Premiums to be offset at the end of the first policy year by use of PUA rider additions and future dividends) with Target Face Amount* not to exceed $

U- Loan Repayment/Balance to Paid-up Additions

Other * Do not include the base policy face amount in the Target Face Amount.

SECTION J Additional Information for VUL/UL Policies

1. Death Benefit Option (Note, not all options may be available with all policies)

Option 1 Option 2 Option 3 Other

2. Section 7702 Test (Note, the choice of 7702 Test may not apply to all policies) Section 7702 of the Internal Revenue Code defines Life Insurance and specifies the rules under which the growth of life insurance policy cash values is excludible from gross income. If the plan being applied for provides a choice of test under 7702 to qualify the policy as life insurance, please check one of the tests shown below. Once a test is elected, it cannot be changed. If there is a choice of Test and none is elected, the Guideline Premium Test will be used. Guideline Premium Test Cash Value Accumulation Test

L-AP-2011

(Page 5 of 8) SECTION K Financial Information 1. Is the applied for policy in accordance with your insurance objectives and your anticipated financial needs? Yes No

2. Do you believe you have the financial ability to continue making premium payments on this policy? Yes No

3. Have you ever filed for personal or business bankruptcy? Yes No (If yes, give full details and date of discharge in

Remarks section.)

4. Personal Finances (If this policy is business owned, please also complete the Business Finances section below.)

Proposed Insured Owner (if other than insured)

Total Assets $ $

Total Liabilities $ $

Net Worth $ $

Earned Income (Prior Year) $ $

Unearned Income (if over $10,000) $ $

Business Finances (Complete only if policy is business owned)

5. Type of Business (Check One): Limited Liability Co. Sole Proprietor Partnership S Corp C Corp Other

6. Total Assets $ 7. Total Liabilities $ 8. Net Worth $ 9. Net Profit After Taxes for past Two Years: Last Year $ Previous Year $

10. How long has the business been established?

11. What is the nature of the business?

12. What percentage of the business is owned by the proposed insured?

13. Is there business insurance applied for or in force on other key members of this firm? Yes No If “yes”, please provide details: SECTION H Proposed Insurance= SECTION L Insurance History

1. Please list below all existing life insurance policies in force on the proposed insured. If none, check here

Name of Company Type (e.g. individual or group)

Year Issued Total Amount Who Owns the Policy? Has WP Rider?

Has ADBRider?

2. Has the proposed insured ever had life, disability, accident or medical insurance declined, postponed, modified, rated, cancelled or withdrawn a pending application, or had a renewal or reinstatement refused? Yes No (if yes, provide full details in Remarks)

3. Are any other life, disability or accident insurance products currently being applied for on the life of the insured, or is there any plan to do so in the near future? Yes No (If “Yes”, in the Remarks section, please include amount and company applied with, and whether this other insurance will be in addition to or in lieu of insurance with Guardian/GIAC.)

L-AP-2011

(Page 6 of 8) SECTION M Replacement

1. As a result of the proposed purchase of life insurance, have you (the Owner) done any of the following, or are you considering doing any of the following to any existing life insurance policy or annuity contract that you own: (a) Lapse, partial lapse, surrender, forfeit, assignment to an insurer, or termination of existing insurance? Yes No (b) Taking loans, withdrawals, or any other use of funds from your existing insurance (including a stoppage or reduction in premium payments) to pay the premiums on the new life insurance policy? Yes No

IMPORTANT: If “Yes” to either of these questions, please complete the appropriate state replacement form(s). In addition, you must fully complete the information below for all policies for which you answered yes.

Policy Number Issuing Company Name of Insured

SECTION N Personal History of the Proposed Insured (These questions apply to the Proposed Insured. If “Yes” to Question 1, 3, 4 or 5, provide details in Remarks section.)

Yes No 1. Do you intend to change your occupation?………………………………………………………………………………….

2. Do you intend to reside outside of the U.S.? (If Yes, complete Foreign Travel and Residence Questionnaire)………………

3. Do you intend to travel outside of the U.S.?...............................................................................................................

4. Have you ever had your driver’s license suspended or revoked, or been convicted of DUI or DWI, or within the past five years, have you been charged with and/or convicted of any motor vehicle moving violations? (If yes, details must include date of violation, description of violation and penalty.) …………………………………………………..……

5. Within the last 10 years, have you been convicted of, or pled guilty or no contest to, a felony, or is such a charge pending against you?………….....................................................................................................................................

6. Within the last 3 years have you flown as a licensed pilot, student pilot, or crew member in any type of aircraft, or do you intend to do so in the future? (If yes, complete Aviation Supplement.) ……………………………………

7. Within the past 3 years, have you participated in, or do you intend to participate in, any of the following activities: mountain climbing, rock climbing, scuba diving, hang gliding, parachuting, skydiving; or motor vehicle racing?.......... (If yes, complete Avocation Supplement.)

8. Are you, or do you intend to become, a member of the armed forces, including the Reserves, or are you on alert? (If yes, please complete Military Status Questionnaire) ………………………………………………………...............

9. Have you ever used tobacco or any other nicotine product such as cigarettes, cigars, pipe, chewing tobacco, snuff, nicotine gum, nicotine patch, or electronic nicotine delivery device? If yes, please complete chart below…..…

Product Type(s) Date Last Used Frequency of Use

L-AP-2011

(Page 7 of 8) SECTION O Alternate/Additional Life Policy Owner: If the “Alternate Policy” box is checked below, you are indicating that you are applying for either the policy applied for in Section G or the policy indicated below. You do not intend to have both policies issued. If the “Additional Policy” box is checked, you are indicating that you are applying for both the policy shown in Section G and the policy indicated below. The total amount of insurance you are applying for is the sum of both policies.

Please indicate: Alternate Policy Additional Policy

Plan of Insurance: Face Amount:

Details (Riders, Benefits, Dividend Option, etc.): SECTION P Illustration

This section does not need to be completed if (a) the policy applied for is variable life insurance; (b) a signed illustration is not required by law for the policy applied for; or (c) the applicant has signed an illustration that matches the policy as applied for. Note that for most of our life insurance products, the applicant should be receiving and signing a sales illustration. Agent’s Certification (Check One)

No illustration was used in the sale of this life insurance policy. An illustration was used in the sale of life insurance, but the illustration used does not match the policy applied for herein. A computer screen illustration was used in the sale that which complied with state requirements for which no hard copy was

furnished to the applicant. My signature on this application certifies that I will provide the applicant with an illustration conforming to the policy as issued, no later than the time the policy is delivered. Applicant’s Certification

My signature on this application is my acknowledgement that (a) I have not received a sales illustration that conforms to the life insurance policy I have applied for, and (b) I understand that a sales illustration conforming to the policy as issued will be provided by the Company no later than at the time the policy is delivered.

SECTION Q Remarks Section

SECTION R Amendments or Corrections (For Home Office Or Customer Service Office Use Only)

L-AP-2011

Representations of the Proposed Insured and Owner

(Page 8 of 8) Those parties who sign below, agree that: 1. This application, (Part 1, Part 2, the Authorization, any amendments to the application, and any required supplements or

questionnaires) will form the basis for, and will be attached to and become a part of, any policy issued. That all of the statements that are part of the application are correctly recorded, and are complete and true to the best of the knowledge and belief of those persons who made them. Any misrepresentation or omission, if found to be material, may adversely affect acceptance of the risk, claims payment or may cause the Company to seek rescission of any policy that is issued based on this application.

2. No agent, broker or medical examiner has any right to accept risks, make or change contracts, or to waive or modify any of the Company's rights or requirements. No information acquired by any Representative of the Company shall bind the Company unless it shall have been set out in writing in this application.

3. For any policy that will be issued, the policy date is the date from which premiums are calculated and become due. The effective date is the date the policy is delivered and accepted by the owner, and the first premium is paid. Except as provided in the Conditional Temporary Coverage and Receipt (if an advance payment has been made and such Receipt has been issued and its terms complied with) coverage does not begin until the effective date assuming the first premium is paid during the lifetime of, and prior to any change in the health, of the Proposed Insured.

4. Changes or corrections made by the Company and noted in the “Amendments or Corrections” section are ratified by the Owner upon acceptance of a policy containing this application with the noted changes or corrections. Amendments as to plan, amount, classification, age at issue, or benefits, will be made only with the Owner's written consent.

5. By paying premiums on a basis more frequently than annually, the total premium payable during one year’s time will be greater than if the premium were paid annually. That is, the cost of paying annualized periodic premiums will be more than the cost of paying one annual premium.

6. Unless the policy applied for is a Level Term policy, a variable life policy, or GIAC’s Universal Life Secondary Guarantee products, a sales illustration is required. If no illustration was given at the time of application, the producer has explained why in Section P of this application. The owner understands that an illustration will be provided no later than at time of policy delivery.

7. Check here if backdating to save age is being requested. Note that a request to backdate to save age can only be honored if permitted by state law. If not backdating to save age, but a specific policy date is being requested, please enter date here:

Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may also be subject to civil penalties. Signed by Owner at: on City and State mm/dd/yyyy X X Signature of Proposed Insured (or Parent/Guardian if Insured under age 18) Signature of Applicant/Owner if Other than Proposed Insured

X Date of Signature for Proposed Insured (mm/dd/yy) Signature of Additional Owner X Witness (for applications taken by mail – should not be beneficiary)

Check here if this application was sent to the Proposed Insured for signature by mail. If so, the signature of the agent does not attest to the signature of the Proposed Insured.

Check here if this application was taken in the presence of the Proposed Insured. I certify that I have taken this application in the presence of the Proposed Insured, and that I have truly and accurately recorded on this application the information supplied by the Proposed Insured.

X Signature of Licensed Agent License Number(s) Agent’s Name State(s) where licensed

SUPP ID INFO

The Guardian Life Insurance Company of America The Guardian Insurance and Annuity Company, Inc. Administrative Office: 3900 Burgess Place Bethlehem, PA 18017

SUPPLEMENTAL IDENTIFICATION INFORMATION FOR OWNER, BENEFICIARY AND INSURED Please read these instructions carefully. Due to regulatory requirements, we request the following supplemental identification information for the beneficiary, owner and/or insured. The information we are requesting depends on which application type was used, as follows: If you completed the Regular Life Insurance Application (form L-AP-2011, or state variation thereof), please provide

the address and phone number for each named beneficiary. Please ensure that you completed all other requested information on the application itself.

If you completed the Juvenile Life Insurance Application (form JUV-AP-2006, or state variation thereof), please provide the address, phone number, Social Security Number and Date of Birth for each named beneficiary, as well as the phone number for the proposed insured.

If you completed the Simplified Issue/Guaranteed Issue Life Insurance Application (form L-AP-SIGI-2008, or state variation thereof), please provide the address, phone number and Social Security Number for each named beneficiary. Also, if the policy is to be owned by an individual other than the proposed insured, please provide this individual’s date of birth.

If you completed the Pension Trust Life Insurance Application (form PT-AP-2011, or state variation thereof), please provide the address, phone number and Social Security Number for each named beneficiary. However, if the Trust is to be the beneficiary of the policy, you do not need this form.

If you completed the Life Insurance Change Request Form (form L-AP-CHG-2005, or state variation thereof), and you are requesting a conversion or an exchange or you are exercising a GIO rider, please provide the address, phone number, Social Security Number and Date of Birth of each named beneficiary and also the Owner. If the Change form was completed for any other reason, you do not need this form.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ADDITIONAL INFORMATION FOR BENEFICIARIES (Please complete appropriate sections as described above) BENEFICIARY NAME ADDRESS PHONE NUMBER SSN DATE OF BIRTH

SUPP ID INFO

ADDITIONAL INFORMATION FOR OWNER (Please complete appropriate sections as described on page 1) OWNER NAME ADDRESS PHONE NUMBER SSN DATE OF BIRTH

ADDITIONAL INFORMATION FOR INSURED Please indicate phone number for Proposed Insured if Juvenile Application was completed

ICC13-LTC Personal Worksheet

The Guardian Life Insurance Company of America Customer Service Office 3900 Burgess Place, Bethlehem, PA 18017

Long Term Care Insurance Personal Worksheet

People buy long-term care insurance for many reasons. Some don't want to use their own assets to pay for long-term care. Some buy insurance to make sure they can choose the type of care they get. Others don't want their family to have to pay for care or don't want to go on Medicaid. But long term care insurance may be expensive, and may not be right for everyone.

By state law, the insurance company may be required to fill out part of the information on this worksheet and ask you to fill out the rest to help you and the company decide if you should buy this rider.

Premium Information

Rider Form Numbers ICC13-LTCR

The premium rates that apply to this rider are attached in Appendix A. Be sure to review those rates. The premiums differ based on the age and the underwriting class that is assigned to the insured as part of the underwriting process.

Type of Policy : GUARANTEED RENEWABLE

The Company's Right to Increase Premiums

The company has a right to increase premiums on this rider form in the future, provided it raises rates for all riders in the same class.

Rate Increase History

The company has sold long-term care insurance since May 2013 and has sold this rider since May 2013. The company has never raised its rates for any long-term care policy it has sold in this state or any other state.

*IMNB5213000640103*


Questions Related to Your Income

How will you pay each year’s premium?

From my Income

From my Savings/Investments

My Family will Pay

Have you considered whether you could afford to keep this rider if the premiums went up, for example by 20%? Yes No

What is your annual income? (check one)

Under $30,000 $30,001-$50,000 $50,001-$75,000 $75,001-100,000 Over $100,001

How do you expect your income to change over the next 10 years? (check one)

No change Increase Decrease

If you will be paying premiums with money received only from your own income, a rule of thumb is that you may not be able to afford this policy if the premiums will be more than 7% of your income.

Elimination period is 90 days and the cost of the rider does not vary by the number of days.

How are you planning to pay for your care during the elimination period? (check one)

From my Income From my Savings/Investments My Family will Pay

Questions Related to Your Savings and Investments

Not counting your home, about how much are all of your assets (your savings and Investments) worth? (check one) Under $20,000 $20,000-$30,000 $30,001-$50,000 Over $50,000

How do you expect your assets to change over the next ten years? (check one)

Stay about the same Increase Decrease

If you are buying this rider to protect your assets and your assets are less than $30,000, you may wish to consider other options for financing your long term care.

*IMNB5213000640103*


Disclosure Statement

(Check one)

The answers to the questions above describe my financial situation.

Or

I choose not to complete this information.

I acknowledge that the carrier and/or its agent (below) has reviewed this form with me including the premium, premium rate increase history and potential for premium increases in the future. I understand the above disclosures. I understand that the rates for this policy may increase in the future. (This box must be checked).

Signature of Applicant Date

I explained to the applicant the importance of completing this information.

Signature of Agent Date

Agent’s Printed Name

In order for us to process your application, please return this signed statement to The Guardian Life Insurance Company of America, along with your application.

My agent has advised me that this policy does not seem to be suitable for me. However, I still want the company to consider my application.

Signature of Applicant Date

The company may contact you to verify your answers.

L-AP-NONMED-2004 L-AP-2004

Customer Service Office THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA3900 Burgess Place THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC.Bethlehem, PA 18017 BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA

(Please check appropriate company. In this receipt, “the Company”is the insurer checked above.)

APPLICATION FOR LIFE INSURANCEPart 2 – Health and Personal History of Proposed Insured

Complete this section ONLY if no Medical or Paramedical Exam is required (Page 1 of 2)

PROPOSED INSURED INFORMATIONPlease print:

1a. First Name MI Last Name

b. Date of Birth (mm/dd/yyyy)

c. Name and Address of your personal physician. If none, so state.

d. Date and reason last consulted

e. What treatment or medication was given or recommended?

f. Height: ft. in. Weight: lbs.

g. Weight change past year: Gain Loss lbs.Reason for change:

(If you answer "Yes" to questions 2-14, provide details in item #15 on the next page.)

Yes No2. Have you ever had or been treated for cancer or tumor? ........................................................................................

3. In the last ten years, have you had, been treated for or received a consultation or counseling for:

i. high blood pressure, chest pain or disorder of the heart or circulatory system? .............................................

ii. diabetes or disorder of the glands, bone, blood or skin? ................................................................................

iii. complications of pregnancy, infertility, or any disorder of the breasts, reproductive or genitalorgans, prostate, kidneys, or urinary systems? ..............................................................................................

iv. hernia, hepatitis, or disorder of the liver, gall bladder, stomach, pancreas, spleen, intestinesor rectum? ......................................................................................................................................................

v. arthritis, rheumatism, or disorder of the joints, limbs or muscles? ..................................................................

vi. disorder or condition of the back, neck or spine? ...........................................................................................

vii. allergy, asthma, sinusitis, emphysema, disorder of the lungs or respiratory system, orsleep apnea? ..................................................................................................................................................

viii. epilepsy, stroke, dizziness, headache, or disorder of the brain, or spinal cord? .............................................

ix. disorder of the eyes, ears, nose or throat? .....................................................................................................

x. anxiety, depression, nervousness, stress, mental or nervous disorder, or other emotionaldisorder? ........................................................................................................................................................

xi. Chronic Fatigue Syndrome, Fibromyalgia, Epstein Barr virus or Lyme Disease? ...........................................

4. Do you have any loss of hearing or sight, an amputation of any kind, or any physical deformity,impairment or handicap? .........................................................................................................................................

5. Within the past ten years, have you been diagnosed by or received treatment from a member ofthe medical profession for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex(ARC), or any deficiency of the immune system such as Human Immunodeficiency Virus? ...................................

6. i. Are you currently taking prescribed medication?.............................................................................................

ii. Are you currently taking non-prescription medication? ...................................................................................

*IMNB0000000060201*

L-AP-NONMED-2004 L-AP-2004

Yes No7. i. Have you ever used stimulants, hallucinogens, narcotics or any other controlled substance? .......................

ii. Have you ever had or been advised to have counseling or treatment for alcohol or drug use? .....................(If yes to either question, complete the Alcohol and Drug Usage Supplement.)

8. Are you now pregnant? ...........................................................................................................................................If yes, expected delivery date:

9. Within the past five years, have you had a sickness or injury for which you have made a benefitsclaim or for which you will make a benefits claim? ..................................................................................................

10. Within the past five years, have you had a physical exam or check-up of any kind? ..............................................

11. Within the past five years, have you been advised to have surgery or any diagnostic tests thatwere not performed, except for HIV tests? ..............................................................................................................

12. Within the past 12 months, have you had symptoms of any condition listed, except thoseconditions listed in question 5, for which you have not sought medical attention or advice? .............................

13. Other than as previously stated on this application, in the last five years have you received medicaladvice from physicians, medical or mental health professionals, counselors, psychotherapists, or otherpractitioners, or have you been a patient in a hospital, clinic, sanatorium, or other medical facility? ....................

14. Do you have a family history of: diabetes, cancer, high blood pressure, heart disease, mentalillness or suicide? ....................................................................................................................................................

Age ifLiving Cause of Death

Age atDeath

FATHER

MOTHER

BROTHERS and SISTERS

No. Living

No. Dead

15. DETAILS OF "YES" ANSWERS. IDENTIFY QUESTION & NUMBER. CIRCLE APPLICABLE ITEMS:Give diagnosis or symptoms, tests performed, dates, types and amounts of medication, length of disability, degreeof recovery, and names and addresses of all physicians, medical or mental health professionals, counselors, psychotherapists,practitioners or hospitals. Additional paper may be attached if necessary to explain details.

I understand and agree that the statements and answers in this Part 2 application are written as made by me; to the best of myknowledge and belief are full, complete and true; and that they shall be a part of the contract of insurance, if issued.

Any person who knowingly, and with intent to defraud any insurance company or other person, files an application forinsurance or statement of claim containing any materially false information or conceals, for the purpose of misleading,information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may also besubject to civil penalties.

Signed at , this day of , .City and State Day Month Year

Witness Signature of Proposed Insured

C-AUTH-2013 *IMNB0013000040201*

Life Customer Service Office Disability Customer Service Office 3900 Burgess Place 700 South Street Bethlehem, PA 18017 Pittsfield, MA 01201

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC.

BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA (Please check appropriate company(ies). Any insurer checked above is herein referred to as the “Company.”)

Authorization to Obtain and Release Information Name of Proposed Insured Date of Birth Address of Proposed Insured

This Authorization Is Designed To Comply With The HIPAA Privacy Rule This Authorization applies to the Proposed Insured named above. It can only be signed by the Proposed Insured, or the parent or legal guardian of the Proposed Insured in the case of a minor under the age of 18.

Investigative consumer report. I authorize the Company or its legal representatives to obtain or have prepared an investigative consumer report as described in the notice given to me.

Medical Records and other information. I authorize any physician, medical or mental health professional, practitioner, hospital, clinic, other health facility, pharmacy, pharmacy benefit manager, consumer reporting agency, the Social Security Administration, MIB, Inc., insurance or reinsurance company, or employer or other organization, institution or person that has any records or knowledge of the Proposed Insured or his/her health to release any and all medical and non-medical information in its possession about the Proposed Insured, to the Company or its legal representatives. Medical information means all information in the possession of or derived from providers of health care regarding the medical history, pharmaceutical history, mental or physical condition, or treatment of the Proposed Insured. I understand that the information released could contain reference to or results of HIV Antibody (AIDS) testing, and may relate to the symptoms, evaluation, diagnosis, examination, treatment or prognosis of any mental or physical condition, including psychiatric, and psychological conditions, and drug or alcohol abuse.

I agree that this authorization shall be valid for two years from the date shown below and that a copy of the authorization shall be as valid as the original. I agree that if I sign this authorization electronically, that it will be equally as effective and valid as if I signed the form through traditional means. I understand, however, that I am under no obligation to sign this document electronically.

I know that I may revoke this authorization in writing, at any time, by sending a written request for revocation to the Guardian Corporate Secretary at 7 Hanover Square, New York, NY 10004-2616, or the Berkshire Corporate Secretary at 700 South Street, Pittsfield, MA 01201. I understand that a revocation is not effective to the extent that the Company and/or any of the entities listed above has already relied on this authorization, or to the extent that the Company has a legal right to contest a claim under an insurance policy or to contest the policy itself.

I understand that the Company or its legal representatives will use the information obtained by this authorization to determine eligibility for insurance or eligibility for benefits under an existing policy. I further understand that if I refuse to sign this authorization, the Company may not be able to process my application, or pay a claim in the case of coverage which is already in force. The Company or its legal representatives will not release any information obtained to any person or organization except to reinsurance companies, MIB, Inc., Innovative Underwriters Services (a subsidiary of The Guardian Life Insurance Company of America), or other persons or organizations performing business or legal services in connection with an application, claim, or as may be lawfully permitted or required, or as I may further authorize. I understand that any information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal regulations governing privacy (such as the HIPAA Privacy Rule).

I authorize the Company or its legal representatives to make a brief report of my personal health information to the MIB, Inc.

I acknowledge that I have been given a copy of this authorization and also acknowledge receipt of the Notice of Insurance Information Practices, which includes the Fair Credit Reporting Act Pre-Notice, the Medical Information Bureau Pre-Notice, and Medical Records.

Signed at this day of , . City and State Day Month Year Signature of Proposed Insured or Parent/Legal Guardian Witness Signature

AGENT’S CERTIFICATION (Please Print) This Agent’s Certification is to be used with the application for life insurance on the life of (Proposed Insured) for the application dated . Proposed Insured’s Date of Birth: . 1. Is the sale of this product being made in conjunction with a specific corporate marketing initiative? Please check one of

the following (select the most appropriate):

No Marketing Initiative CPA Referral Business Resource Center DI to Life Program Take Advantage/Rapid App Other

2. a. Is there a current individual Disability Income or Long-Term Care application pending with Berkshire? Yes No

b. Has an individual Disability Income or Long-Term Care application been submitted to Berkshire within the past 6 months? Yes No

For a yes answer to either question, please provide the policy number and other details in the “Remarks” section. 3. How long have you known the Proposed Insured? Years; the Proposed Owner? Years

4. If Proposed Insured is not gainfully employed, indicate amount of insurance on premium payor’s life and relationship to

Proposed Insured.

5. If beneficiary is estate, explain in Remarks why, and who will ultimately receive the proceeds of the policy?

6. Do you have knowledge of any existing life insurance policy or annuity contract in force on the Proposed Insured? Yes No

7. Do you have knowledge or reason to believe that replacement of an existing life insurance policy or annuity may be

involved by reason of this transaction? Yes No

8. Will the sale of this policy involve the use of Premium Financing? Yes No (If yes, please provide the name of the lending institution and other details in the Remarks section.)

9. a. Did every person signing this application communicate in English well enough to understand and answer each question in English? Yes No (If no, please answer questions 9b, 9c, and 9d)

b. Who acted as interpreter?

c. If English was not used as the primary language, which language and/or dialect(s) was the sales interview conducted in?

d. For the purpose of completing any Personal Information Telephone Interview, the proposed insured can converse comfortably in:

10. Was a preliminary inquiry previously submitted to Underwriting in connection with this application? Yes No If yes, please indicate application (policy) number:

11. Is the premium for this policy to be paid by a person or entity other than the policyowner? Yes No If yes, please provide a letter of authorization (with all required signatures) and also indicate payor’s Tax ID number.

12. Was this application signed and dated in a state other than the state in which the policyowner lives or works? Yes No (if yes, please provide details in Remarks)

L-AP-AC-2004

*IMNB0008000120302*

13. Complete if Medical Examination necessary. Medical Requirements being submitted: Chest X-ray EKG Stress EKG Full Blood Saliva Urine Paramedical Exam Medical Exam Other

14. Remarks (and additional instructions):

15. Commissions

Producer’s Name

Producer’s Code

Servicing Agent (Check 1)

Producer’s Social Security Number

Percentage

% % % % % %

Unless this application was taken by mail as indicated in the Representations section, I certify that I have taken this application in the presence of the Proposed Insured (and Owner, if Other than the Proposed Insured, for Variable Life) and that I have truly and accurately recorded on this application the information supplied by the Proposed Insured.

For all applications: The answers to all questions on this application are full, complete and true to the best of my knowledge and belief. I represent that, to the best of my knowledge and belief, the insurance being applied for is suitable for the Owner’s insurance needs and financial objectives. I know nothing unfavorable about this risk which is not fully set forth in these papers. The writing agent or broker is duly appointed and licensed in the state in which this application was signed and for the product(s) proposed.

Signed at: on City and State mm/dd/yyyy

Type or print Agent’s/Dealer’s name Signature of Soliciting Agent

Signature of Approved Registered Principal (For Variable Life Only) Signature of General Agent

LTC RIDER AGENT’S CERTIFICATION

(Please Print)

This Agent’s Certification is to be used with the application Supplement of the Accelerated Benefit for Long Term Care rider form on the life of (Proposed Insured).

1. Do you have knowledge or reason to believe that replacement of an existing long-term care policy or rider within the last 12months may be involved by reason of this transaction? Yes No

a. If yes, which company?b. If that policy/rider lapsed, indicate date of lapse?

2. Do you have any knowledge or reason to believe that the proposed insured or owner is covered by Medicaid? Yes No

3. List any health or long-term care insurance policies that you have sold the proposed insured/owner that are currently in force:

Name of Company Type (e.g. individual or group) Year Issued Total Amount Being Replaced? Yes No

4. List any health or long-term care insurance policies that you have sold the proposed insured/owner in the past 5 years that areno longer in force:

Name of Company Type (e.g. individual or group) Year Issued Total Amount Lapse Date

The answers to all questions on this application are full, complete and true to the best of my knowledge and belief. The writing agent or broker is duly appointed and licensed in the state in which this application was signed and for the product(s) proposed.

Signed at: on City and State mm/dd/yyyy

Type or print Agent’s/Dealer’s name Signature of Soliciting Agent

Signature of General Agent Agent Writing Code

13-LTC APP SUPP AC

ICC13-TIR Disc


ACCELERATED DEATH BENEFIT FOR TERMINAL ILLNESS RIDER SUMMARY AND DISCLOSURE STATEMENT

This Disclosure Statement provides a brief summary of the important features of an Accelerated Death Benefit for Terminal Illness rider; it does not alter any of the rider’s provisions. The actual provisions of the rider set forth its full details and conditions.

EFFECTS OF AN ACCELERATED BENEFIT PAYMENT ON A LIFE INSURANCE POLICY WHEN AN ACCELERATED BENEFIT IS PAID, A LIEN IS CREATED AGAINST THE POLICY EQUAL TO THE AMOUNT OF THE ACCELERATED BENEFIT WE PAY, PLUS LIEN CARRYING CHARGES TO THE NEXT POLICY ANNIVERSARY. ANY LIEN CREATED WILL BEAR CARRYING CHARGES WHICH ARE PAYABLE IN ADVANCE ON THE DATE THE LIEN WAS CREATED AND ON EACH SUBSEQUENT POLICY ANNIVERSARY. THE INTEREST RATE VARIES DEPENDING ON THE AMOUNT OF THE OUTSTANDING LIEN. IF THE OUTSTANDING LIEN IS LESS THAN OR EQUAL TO THE CASH VALUE OF THE POLICY PLUS THE CASH VALUE OF ANY ADDITIONS DISCOUNTED TO THE DATE THE LIEN CARRYING CHARGES ARE DETERMINED, THE LIEN CARRYING CHARGE RATE IS EQUAL TO THE LESSER OF THE FIXED LOAN INTEREST RATE THEN IN EFFECT UNDER THE POLICY OR AN ADJUSTABLE LOAN INTEREST RATE AS ALLOWED BY LAW. THE RATE FOR ANY AMOUNT OF AN OUTSTANDING LIEN WHICH EXCEEDS THE CASH VALUE OF THE POLICY PLUS THE CASH VALUE OF ADDITIONS DISCOUNTED TO THE DATE THE LIEN CARRYING CHARGES ARE DETERMINED IS EQUAL TO AN ADJUSTABLE LOAN INTEREST RATE AS ALLOWED BY LAW. THE ADJUSTABLE LOAN INTEREST RATE IS BASED ON THE MOODY’S CORPORATE BOND YIELD AVERAGE PUBLISHED BY MOODY’S INVESTORS SERVICE, INC., OR ANY SUCCESSOR THERETO, AS OF THE CALENDAR MONTH ENDING TWO MONTHS BEFORE THE FIRST DAY OF THE MONTH OF THE POLICY ANNIVERSARY.

THE CASH SURRENDER VALUE, LOAN VALUE, AND DEATH PROCEEDS PAYABLE WILL BE REDUCED BY ANY LIEN OUTSTANDING DUE TO THE PAYMENT OF AN ACCELERATED BENEFIT. HOWEVER, THE POLICY’S FACE AMOUNT AND CASH VALUE ARE NOT AFFECTED BY ANY OUTSTANDING LIEN. IN ADDITION, ANY DIVIDEND PAYABLE WILL BE AFFECTED BY ANY OUTSTANDING LIEN AND LIEN CARRYING CHARGES DURING THE POLICY YEAR. WHILE A LIEN IS OUTSTANDING, THE POLICY WILL REMAIN IN FORCE AND THE FULL POLICY PREMIUM WILL STILL BE DUE (UNLESS THE POLICY IS PAID-UP OR PREMIUMS ARE THEN BEING WAIVED UNDER A WAIVER OF PREMIUM RIDER). HOWEVER, IF THE TOTAL LOAN PLUS OUTSTANDING LIEN, INCLUDING LIEN CARRYING CHARGES, EXCEEDS THE POLICY’S FACE AMOUNT PLUS THE FACE AMOUNT OF ANY ADDITIONS, THEN THE POLICY AND ANY OTHER RIDERS WILL END.

UPON RECEIPT OF A REQUEST FOR AN ACCELERATED BENEFIT PAYMENT, GUARDIAN WILL NOTIFY THE OWNER AND ANY IRREVOCABLE BENEFICIARY OF THE EFFECT THAT SUCH PAYMENT WILL HAVE ON POLICY BENEFITS AND VALUES.

TAX CONSEQUENCES ALTHOUGH THE PAYMENTS MADE UNDER THIS RIDER ARE INTENDED TO QUALIFY FOR FAVORABLE TAX TREATMENT UNDER SECTION 101(g) OF THE FEDERAL INTERNAL REVENUE CODE, PAYMENTS UNDER THIS RIDER MAY BE TAXABLE. THE OWNER SHOULD CONSULT A COMPETENT TAX ADVISOR TO DETERMINE THE CURRENT TAX CONSEQUENCES BEFORE REQUESTING ANY ACCELERATED PROCEEDS.

GOVERNMENT ENTITLEMENTS YOUR ELIGIBILITY FOR PUBLIC ASSISTANCE PROGRAMS, SUCH AS MEDICAL ASSISTANCE (MEDICAID), AID TO FAMILIES WITH DEPENDENT CHILDREN, AND SUPPLEMENTAL SECURITY INCOME (“SSI”) MAY BE AFFECTED BY HAVING AN ACCELERATED DEATH BENEFIT RIDER AS PART OF YOUR LIFE INSURANCE POLICY OR BY RECEIVING AN ACCELERATED BENEFIT PAYMENT.

Exercising the option to receive an accelerated benefit payment and receiving such payment before applying for these programs, or while other government benefits are being received, may affect initial or continued eligibility. The appropriate social services agency (for example, the Medicaid Unit of the local Department of Public Welfare and Social Security Administration Office) should be consulted for more information concerning how receipt of an accelerated benefit payment will affect the eligibility of the recipient and/or the recipient’s spouse or dependents.

ICC13-TIR Disc

LIMITS OF AN ACCELERATED DEATH BENEFIT FOR TERMINAL ILLNESS RIDER THE ACCELERATED DEATH BENEFIT FOR TERMINAL ILLNESS RIDER IS NOT HEALTH, NURSING HOME, OR LONG TERM CARE INSURANCE, AND IT IS NOT INTENDED OR DESIGNED TO ELIMINATE YOUR NEED FOR SUCH COVERAGE. There are no restrictions or limits on the use of an accelerated benefit payment. An accelerated benefit payment may not be enough to cover your medical, nursing home or other bills. OTHER OPTIONS Even though it is attached to a policy, an Accelerated Death Benefit for Terminal Illness Rider does not have to be exercised. An Accelerated Death Benefit for Terminal Illness Rider provides you with an additional means of accessing cash under a life insurance policy. Alternatively, you may elect to receive a loan (if available under your policy) or surrender your policy. DEFINITIONS Terminally Ill or Terminal Illness: This means that the insured has been certified by a physician as having an illness or physical condition which can reasonably be expected to result in death within 12 months. Net Amount at Risk: Net Amount at Risk on a given date means the face amount of the base policy plus any additions, less the cash value of the base policy and any additions, as of the date to which premiums have been paid. Total Lien Limit: The Total Lien Limit is the policy’s Cash Value as of the date to which premiums have been paid plus 80% of the Net Amount at Risk. The percentage will be locked in, at the insurance attained age, when the first accelerated benefit payment is made. THE ACCELERATED BENEFIT PAYMENT An accelerated benefit payment may be made to the owner of a life insurance policy if the owner provides proof acceptable to Guardian that the insured is terminally ill as defined above. This proof includes but is not limited to a physician’s certification regarding the insured’s medical condition. Guardian must receive at its customer service office the owner’s written request for an accelerated benefit payment and the physician’s certification and claim form regarding the insured’s medical condition. The accelerated benefit payment will be paid to the owner in a lump sum. LIMITATIONS OR CONDITIONS ON ELIGIBILITY OF BENEFITS Accelerated Benefit payments are limited by the Total Lien Limit. The owner may take a maximum of 4 liens per policy year. The policy must be in force other than as extended term insurance on the date the accelerated benefit is requested. If the policy is in force as paid-up insurance on the date the first accelerated benefit is requested, the amount of paid-up insurance must be at least $100,000. ADMINISTRATIVE FEE A one-time Administrative Fee of $250 will be charged the first time that an Accelerated Benefit is paid under this rider. This charge is associated with administrative costs for processing an Accelerated Benefit payment to the owner. COST There is no additional premium charged to add an Accelerated Death Benefit for Terminal Illness Rider to a life insurance policy. TERMINATION This Accelerated Death Benefit for Terminal Illness Rider will terminate the date the policy terminates or, if earlier on: The date of the insured’s death; Upon receipt of proper written request for cancellation or to continue policy as Extended Term Insurance; Upon election of a Policy Value Option providing for reduced paid-up insurance, if the amount of reduced paid-up

insurance is less than $100,000 and no accelerated benefit has ever been paid under this rider; or The date the loan plus total lien, including lien carrying charges, exceeds the policy face amount plus the face amount of

any additions.

ACKNOWLEDGEMENT I hereby acknowledge that I have received and read this disclosure Statement. ____________________________________ ___________________ Signature of Proposed Insured Date ______________________________________________ ___________________ Signature of Proposed Owner (if other than Proposed Insured) Date ______________________________________________ ___________________ ___________________ Signature of Agent Agent Code Date ______________________________________________ ___________________ Agent Date

Life Insurance Buyer’s Guide

This guide can show you how to save money when you shop for life insurance. It helps you to:

n Decide how much life insurance you should buy,

n Decide what kind of life insurance policy you need, and

n Compare the relative cost of similar life insurance policies.

This guide has been prepared by the Illinois Department of Insurance, in part using materials developed bythe National Association of Insurance Commissioners.

Reprinted by Guardian, June, 2009 Pub 2187D

The National Association of Insurance Commissioners is an association of state insurance regulatoryofficials. This association helps the various State Insurance Departments to coordinate insurance laws forthe benefit of all consumers. You are urged to use this Guide in making a life insurance purchase.

THIS GUIDE DOES NOT ENDORSE ANY COMPANY OR POLICY.

BUYING LIFE INSURANCEWhen you buy life insurance, you want a policywhich fits your needs without costing too much.Your first step is to decide how much you need,how much you can afford to pay and the kind ofpolicy you want. Then, find out what variouscompanies charge for that kind of policy. You canfind important differences in the cost of lifeinsurance by using the life insurance cost indexeswhich are described in this guide. A good lifeinsurance agent or company will be able andwilling to help you with each of these shoppingsteps.

If you are going to make a good choice when youbuy life insurance, you need to understand whichkinds are available. If one kind does not seem to fityour needs, ask about the other kinds which aredescribed in this guide. If you feel that you needmore information than is given here, you may want

to check with a life insurance agent or company orbooks on life insurance in your public library. Lifeinsurance can be bought either on an individualbasis or on a group basis. Group insurance maybe inexpensive when compared to individualinsurance. It is important to remember thatinsurance purchased on this basis is usually terminsurance, and hence will not develop cash values,and is dependent on your continued membershipin the group or employment. Also, the amount ofinsurance that is available for purchase is usuallylimited.

CHOOSING THE AMOUNTOne way to decide how much life insurance youneed is to figure how much cash and income yourdependents would need if you were to die. Lifeinsurance can provide cash for last expenses, andincome for your family’s future living expenses.

For assistance you may reach Guardianat 1-800-441-6455or www.GuardianLife.com


Your insurance should come as close as you canafford to make up the difference between (1) whatyour dependents would have if you were to dienow, and (2) what they would actually need atsome time in the future when needs change.

CHOOSING THE RIGHT KINDAll life insurance policies agree to pay an amountof money if you die. But all policies are not thesame. There are three basic kinds of lifeinsurance.

1. Term insurance

2. Whole life insurance

3. Endowment insurance

The kind of life insurance you purchase isdependent on the need you are trying to satisfy.Some needs are temporary, i.e., do not existthroughout your life, while other needs arepermanent. As an example, the need to financeyour children’s education is a temporary need. Theneed to meet mortgage payments is also atemporary need since it exists only while themortgage exists. On the other hand, the financialneeds of your family after your death is apermanent need.

Remember, no matter how fancy the policy title orsales presentation might appear, all life insurancepolicies contain one or more of the three basickinds. If you are confused about a policy thatsounds complicated, ask the agent if it combinesmore than one kind of life insurance. The followingis a brief description of the three basic kinds:

TERM INSURANCETerm insurance is death protection for a “term” of

one or more years. Death benefits will be paid onlyif you die within that term of years. Term insurancegenerally provides the largest immediate deathprotection for your premium dollar.

Some term insurance policies are “renewable” forone or more additional terms even if your healthhas changed. Each time you renew the policy for anew term, premiums will be higher. You shouldcheck the premiums at older ages and the lengthof time the policy can be continued.

Some term insurance policies are also“convertible.” This means that before the end ofthe conversion period, you may trade the termpolicy for a whole life or endowment insurancepolicy even if you are not in good health. Premiumsfor the new policy will be higher than you havebeen paying for the term insurance.

WHOLE LIFE INSURANCEWhole life insurance gives death protection for aslong as you live. The most common type is called“straight life” or “ordinary life” insurance, for whichyou pay the same premiums for as long as youlive. These premiums can be several times higherthan you would pay initially for the same amount ofterm insurance. But they are smaller than thepremiums you would eventually pay if you were tokeep renewing a term insurance policy until yourlater years.

Some whole life policies let you pay premiums fora shorter period, such as 20 years, or until age 65.Premiums for these policies are higher than forordinary life insurance since the premiumpayments are squeezed into a shorter period.

For assistance you may reach Guardianat 1-800-441-6455 or www.GuardianL ife.com


Although you pay higher premiums, to begin with,for whole life insurance than for term insurance,whole life insurance policies develop “cash values”which you may have if you stop paying premiums.You can generally either take the cash, or use it tobuy some continuing insurance protection.Technically speaking, these values are called“nonforfeiture benefits.” This refers to benefits youdo not lose (or “forfeit”) when you stop payingpremiums. The amount of these benefits dependson the kind of policy you have, its size, and howlong you have owned it.

A policy with cash values may also be used ascollateral for a loan. If you borrow from the lifeinsurance company, the rate of interest is shown inyour policy. Any money which you owe on a policyloan would be deducted from the benefits if youwere to die, or from the cash value if you were tostop paying premiums.

ENDOWMENT INSURANCEAn endowment insurance policy pays a sum orincome to you - the policyholder - if you live to acertain age. If you were to die before then, thedeath benefit would be paid to your beneficiary.Premiums and cash values for endowmentinsurance are higher than for the same amount ofwhole life insurance. Thus endowment insurancegives you the least amount of death protection foryour premium dollar.

FINDING A LOW COST POLICYAfter you have decided which kind of life insurancefits your needs, look for a good buy.

YOUR CHANCES OF FINDING A GOOD BUYARE BETTER IF YOU USE TWO TYPES OFINDEX NUMBERS THAT HAVE BEENDEVELOPED TO AID IN SHOPPING FOR LIFEINSURANCE. One is called the “Surrender CostIndex” and the other is the “Net Payment CostIndex.” It will be worth your time to try tounderstand how these indexes are used, but in anyevent, use them ONLY for comparing the relativecosts of similar policies. LOOK FOR POLICIESWITH LOW COST INDEX NUMBERS.

WHAT IS COST?“Cost” is the difference between what you pay andwhat you get back. If you pay a premium for lifeinsurance and get nothing back, your cost for thedeath protection is the premium. If you pay apremium and get something back later on, such asa cash value, your cost is smaller than thepremium.

The cost of some policies can also be reduced bydividends; these are called “participating” policies.Companies may tell you what their currentdividends are, but the size of future dividends isunknown today and cannot be guaranteed.Dividends actually paid are set each year by thecompany.

Some policies do not pay dividends. These arecalled “guaranteed cost” or “non-participating”policies. Every feature of a guaranteed cost policyis fixed so that you know in advance what yourfuture cost will be.

The premiums and cash values of a participatingpolicy are guaranteed, but the dividends are not.

Premiums for participating policies are typically



higher than for guaranteed cost policies, but thecost to you may be higher or lower, depending onthe dividends actually paid.

WHAT ARE COST INDEXES?

In order to compare the cost of policies, you needto look at:

1. Premiums

2. Cash values

3. Dividends

Cost Indexes use one or more of these factors togive you a convenient way to compare relativecosts of similar policies. When you compare costs,an adjustment must be made to take into accountthat money is paid and received at different times.It is not enough to just add up the premiums youwill pay and to subtract the cash values anddividends you expect to get back. These indexestake care of the arithmetic for you. Instead ofhaving to add, subtract, multiply and divide manynumbers yourself, you just compare the indexnumbers, which you can get from life insuranceagents and companies:

1. Life Insurance Surrender Cost Index. Thisindex is useful if you consider the level of thecash values to be of primary importance toyou. It helps you compare costs if at somefuture point in time, such as 10 or 20 years,you were to surrender the policy and take itscash value.

2. Life Insurance Net Payment Cost Index. Thisindex is useful if your main concern is thebenefits that are to be paid at your death andif the level of cash values is of secondaryimportance to you. It helps you compare costs

at some future point in time, such as 10 or 20years, if you continue paying premiums on yourpolicy and do not take its cash value.

There is another number called the EquivalentLevel Annual Dividend. It shows the part dividendsplay in determining the cost index of a participatingpolicy. Adding a policy’s Equivalent Level AnnualDividend to its cost index allows you to comparetotal costs of similar policies before deductingdividends. However, if you make any costcomparisons of a participating policy with anon-participating policy, remember that the totalcost of the participating policy will be reduced bydividends, but the cost of the non-participatingpolicy will not change.

HOW DO I USE COST INDEXES?The most important thing to remember when usingcost indexes is that a policy with a small indexnumber is generally a better buy than acomparable policy with a larger index number. Thefollowing rules are also important:

1. Cost comparisons should only be madebetween similar plans of life insurance.Similar plans are those which provideessentially the same basic benefits andrequire premium payments for approximatelythe same period of time. The closer policiesare to being identical, the more reliable thecost comparison will be.

2. Compare index numbers only for the kind ofpolicy, for your age and for the amount youintend to buy. Since no one company offersthe lowest cost for all types of insurance at allages and for all amounts of insurance, it isimportant that you get the indexes for theactual policy, age and amount which you



you intend to buy. Just because a “Shopper’sGuide” tells you that one company’s policy is agood buy for a particular age and amount, youshould not assume that all of that company’spolicies are equally good buys.

3. Small differences in index numbers could beoffset by other policy features, or differencesin the quality of service you may expect fromthe company or its agent. Therefore, whenyou find small differences in cost indexes, yourchoice should be based on something otherthan cost.

4. In any event, you will need other informationon which to base your purchase decision.BE SURE YOU CAN AFFORD THEPREMIUMS, AND THAT YOU UNDERSTANDITS CASH VALUES, DIVIDENDS AND DEATHBENEFITS. You should also make ajudgement on how well the life insurancecompany or agent will provide service in thefuture, to you as a policyholder.

5. These life insurance cost indexes apply to newpolicies and should not be used to determinewhether you should drop a policy you havealready owned for awhile, in favor of a newone. If such a replacement is suggested, youshould ask for information from the companywhich issued the old policy before you takeaction.

6. An important fact to note is the difference inpremium payments paid during one year’stime based on an annual premium versus theannualized periodic premium. For example, ifyou choose to pay premiums on a monthlybasis, the annualized periodic premium wouldbe twelve (12) times the monthly premium.There may be a significant difference between

the annualized periodic premium and theannual premium and it should be consideredwhen deciding on a payment schedule.

IMPORTANT THINGS TOREMEMBER - A SUMMARYThe first decision you must make when buying alife insurance policy is choosing a policy whosebenefits and premiums most closely meet yourneeds and ability to pay. Next, find a policy whichis also a relatively good buy. If you compareSurrender Cost Indexes and Net Payment CostIndexes of similar competing policies, yourchances of finding a relatively good buy will bebetter than if you do not shop. REMEMBER, LOOKFOR POLICIES WITH LOWER COST INDEXNUMBERS. A good life insurance agent can helpyou choose the amount of life insurance and kindof policy you want and will give you cost indexes sothat you can make cost comparisons of similarpolicies.

DON’T BUY LIFE INSURANCE UNLESSYOU INTEND TO STICK WITH IT. A policywhich is a good buy when held for 20 years can bevery costly if you quit during the early years of thepolicy. If you surrender such a policy during thefirst few years, you may get little or nothing backand much of your premium may have been usedfor company expenses.

Read your new policy carefully, and ask the agentor company for an explanation of anything you donot understand. Whatever you decide now, it isimportant to review your life insurance programevery few years to keep up with changes in yourincome and responsibilities.


The Guardian Life Insurance Company of America

A Mutual Company Established 1860 Customer Service Office

3900 Burgess Place, Bethlehem, PA 18017 1-800-441-6455

ACCELERATED DEATH BENEFIT FOR LONG TERM CARE SERVICES RIDER

OUTLINE OF COVERAGE

Rider Form Number ICC13-LTCR

Caution: The issuance of this long term care insurance rider is based upon your responses to the questions on your application. A copy of your application for the policy and the rider will be attached to the policy. If your answers are incorrect or untrue, the company has the right to deny benefits or rescind your policy. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers are incorrect, contact the company at the address stated above.

NOTICE TO BUYER: This policy may not cover all of the costs associated with long-term care incurred by the Owner during the period of coverage. The Owner is advised to review carefully all policy limitations.

1. The Accelerated Death Benefit for Long Term Care Services rider is attached to an individual life insurance policy.

2. PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage provides a very brief description of the important features of the policy. You should compare this outline of coverage to outlines of coverage for other policies and riders available to you. This is not an insurance contract, but only a summary of coverage. Only the rider and individual life policy to which it is attached contains governing contractual provisions. This means that the policy and rider set forth in detail the rights and obligations of both you and the insurance company. Therefore, if you purchase this coverage, or any other coverage, it is important that you READ YOUR POLICY CAREFULLY!

3. FEDERAL TAX CONSEQUENCES. The rider is intended to be a federally tax-qualified long-term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as amended.

4. TERMS UNDER WHICH THE POLICY MAY BE CONTINUED IN FORCE OR DISCONTINUED. (a) Renewability: THE RIDER IS GUARANTEED RENEWABLE. This means that you have the right, subject to

the terms and conditions of the rider, to continue the rider as long as you pay your premiums on time. The Guardian cannot change any of the terms of your rider on its own, except that, in the future, IT MAY INCREASE THE PREMIUM YOU PAY.

(b) Waiver of Premium: The premium credit for the full premium of the rider will be applied while monthly benefits under the rider are being received. Additionally, a premium credit will be applied towards the premium for the policy to which the rider is attached. You may still need to pay a portion of the policy premium in order to keep the policy in force while you are receiving monthly benefit payments under the rider.

Rider Termination - The rider will terminate on the earliest of the following dates: • the date of the insured's death; • the date you exercise an Accelerated Death Benefit Rider for Terminal Illness that may be also

attached to the policy; • the date the accumulated monthly benefit payments equals the Total LTC Pool; • upon receipt of the Owner’s proper written request for cancellation at our Customer Service Office.

The rider may also provide a reduced or no benefit on the date the policy to which the rider is attached: • goes on Policy Value Option; or • is surrendered for its cash value.

ICC13-LTC OC Page 1

5. TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS. The Current LTC Rider Premium is guaranteed for the first year. Thereafter, it may be changed by the company on a class basis. However, the Current LTC Rider Premium will never exceed the Maximum LTC Rider Premium. In Addition, there may also be an LTC Dividend Charge applicable to your rider. If so, the Current LTC Dividend Charge Percentage may change on a class basis. However, it will never exceed the Maximum LTC Dividend Charge Percentage. See Section 13 for more information on the premiums associated with the rider.

6. TERMS UNDER WHICH THE RIDER MAY BE RETURNED AND PREMIUM REFUNDED. (a) You have the right to examine the rider and return it for cancellation to our Customer Service Office or

to any agent or agency within 30 days after receiving it. A written cancellation notice must be delivered or mailed to cancel the rider. Any notice given by mail is effective on being postmarked, properly addressed and postage prepaid. If the rider is cancelled during this period, the company will refund all premiums paid for the rider and the rider will be treated as if it had never been issued. The policy has its own separate free look period.

(b) The rider does not contain a provision providing for a refund or partial refund of the rider premium upon the death of the insured or upon surrender of the rider or policy.

7. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide available from the company. Neither The Guardian nor its agents represent Medicare, the federal government or any state government.

8. LONG-TERM CARE COVERAGE. Policies and riders of this category are designed to provide coverage for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services, provided in a setting other than an acute care unit of a hospital, such as in a nursing home, in the community or in the home.

9. BENEFITS PROVIDED BY THE RIDER. If the insured meets the eligibility requirements of the rider, we will provide monthly benefit payments to the Owner subject to the rider’s limitations and exclusions. Payments under the rider are accelerations of the death benefit provided under the policy to which the rider is attached. As a result, payment of the monthly benefit under the rider will reduce the death benefit available under the policy and will also proportionally reduce the policy’s cash value. The maximum monthly benefit is the lesser of:

(a) 2% of the Basic LTC Pool; or (b) 60 times the per diem amount declared by the Internal Revenue Code for a given calendar year.

Covered services under the rider are those received by the insured when he or she is Chronically Ill and receiving Qualified Long Term Care Services, as described in Section 8, by a Health Care Provider under a Plan of Care for: • Adult Day Care - which is a state licensed or certified program at an Adult Day Care Center for a specified

number of individuals providing social or health-related or both types of services during the day in a community group setting for the purpose of supporting frail, impaired elderly or other disabled adults who can benefit from care in a group setting outside the home. If license or certification requirements do not exist under state law, an Adult Day Care Center is a facility that provides Adult Day Care to 6 or more individuals who do not require 24 hour institutional care, but are not capable of full-time, independent living.

• Assisted Living Care - which is personal custodial monitoring and assistance with Activities of Daily Living provided in a residential setting at an Assisted Living Facility.

• Skilled Nursing Care, Intermediate Care or Custodial Care in a Long Term Care Facility - which is personal assistance and care, medically necessary care provided by a registered professional nurse or under the supervision of a Health Care Provider, as long as the insured is confined as an inpatient in any Long Term Care Facility licensed by the state.

• Home Health Care - which is personal assistance and care provided by a Home Health Care Provider in a private home or by a center that provides Adult Day Care. Home Health Care services include medical and nonmedical services, provided to ill, disabled or infirm persons in their residences.

ICC13-LTC OC Page 2

Elimination Period - The rider has a 90 day elimination period. This is the period of time that the insured must be receiving Qualified Long Term Care Services before monthly benefit payments under the rider will begin. The Elimination Period begins on the first day the insured receives Qualified Long Term Care Services. Each day Qualified Long Term Care Services are received by the insured will count towards satisfying the Elimination Period and are not required to be continuous. If Qualified Long Term Care Services are received 3 or more days in a given week, we will count all 7 days of that week in satisfying the Elimination Period. While the days where Qualified Long Term Care Services are received need not be continuous, the Elimination Period must be satisfied within 24 months of first receiving Qualified Long Term Care Services. The Elimination Period only needs to be satisfied once.

Eligibility for Payment of Benefits The rider will provide a monthly LTC benefit, when: • we receive a certification signed by a Physician that the insured meets the definition of Chronically Ill; • the insured is receiving Qualified Long Term Care Services (as described in Section 8) under a Plan of Care

prescribed by a Physician; • the rider is in force; • the Elimination Period has been satisfied; and • the claim request has been approved by the Guardian in accordance with the claims provisions of the rider.

A person is determined to be Chronically Ill under the rider if he or she has been certified within the prior 12 months by a Physician that he or she: • is unable to perform without Substantial Assistance from another person at least 2 Activities of Daily Living for

a period of at least 90 days due to loss of functional capacity; or • requires Substantial Supervision from another individual to protect the insured from threats to health and

safety due to Severe Cognitive Impairment.

Activities of daily living are bathing, continence, dressing, eating, toileting and transferring.

Severe Cognitive Impairment is the loss or deterioration in intellectual capacity that is (a) comparable to (and includes) Alzheimer's disease and similar forms of irreversible dementia, and (b) measured by clinical evidence and standardized tests that reliably measure impairment in the individual's (i) short-term or long-term memory, (ii) orientation as to people, places, or time, and (iii) deductive or abstract reasoning.

10. LIMITATIONS, EXCEPTIONS AND EXCLUSIONS. In addition to the benefit maximums stated above, there are certain exclusions and limitations to receiving benefits under the rider. This section includes those exclusions.

Pre-existing conditions. Benefits will not be paid for any claims made within 6 months after the issue date of the rider if the claim is due to a pre-existing condition. For this purpose, a preexisting condition means a condition for which the insured received medical advice or treatment or was recommended to receive treatment from a Health Care Provider within 6 months prior to the issue date of the rider. Exclusions and Limitations; The rider does not cover care or treatment: • From a Facility that primarily treats drug addicts or alcoholics, provides domiciliary, residency or

retirement care or is owned or operated by an Immediate Family Member. • From a Home Health Care Provider that is the Owner, insured, any Immediate Family Member even if

that individual is licensed to provide such services, or anyone under suspension from Medicare or Medicaid.

• When the Qualified Long Term Services are received outside of the United States unless the initial Physician’s Plan of Care and all renewal Plan of Care updates are provided by a Physician licensed in the United States.

An Immediate Family Member includes the Owner or insured’s spouse (including civil union partner or domestic partner), parents, grandparents as well as siblings, children, stepchildren, grandchildren and their spouses. In addition, an Immediate Family Member includes the listed members of the Owner and insured’s spouse.

ICC13-LTC OC Page 3

In addition, the Owner will not be eligible to receive monthly benefit payments if the insured’s Chronic Illness are due to or is directly caused by: • an attempted suicide or intentionally self-inflicted injuries; • alcoholism or drug addiction; • committing or attempting to commit a felony riot or insurrection; or • war or act of war (whether declared or undeclared).

THE RIDER MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR LONG-TERM CARE NEEDS.

11. RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costs of long-term care services will likely increase over time, you should consider whether and how the benefits of this plan may be adjusted. THE RIDER DOES NOT INCLUDE INFLATION PROTECTION COVERAGE. The Basic LTC Pool will not increase over time. However, if the optional Additional LTC Pool is elected, the benefit amount will increase by the amount of LTC dividend additions. While this means that it will increase the number of monthly payments you could receive under the rider, it will not increase the maximum amount of the monthly benefit payment that you would be eligible to receive. A charge against any dividends received under the policy will be applied if you elect to have those dividends used to purchase LTC Dividend Additions. As a result, while you will be purchasing dividend additions that can then be accelerated under the terms of the rider, the amount of paid-up additional life insurance coverage will be less than if you applied your dividends to purchase additional paid-up coverage that would not be eligible for acceleration under the rider. You also have the option of electing a nonforfeiture benefit (Enhanced Rider Value Option) under the rider. If elected, the premium for the rider and the percentage deducted from your dividend if you elected the LTC dividend option will both be higher. If you elect the Enhanced Rider Value Option, subject to the terms and conditions of the rider you will have a reduced benefit under the rider if you decide to surrender your policy. If you exercise any rights under your policy that impact the death benefit or cash value, like reducing your face amount, taking a policy loan or surrendering LTC dividend additions, you may be reducing the amount that can be accelerated under the rider. If you take a policy loan, we will use a portion of any benefit payment under the rider to repay a portion of that policy loan. This will reduce the actual benefit payment amount that you will receive.

12. ALZHEIMER'S DISEASE AND OTHER ORGANIC BRAIN DISORDERS. Subject to the conditions listed in Sections 9 and 10 above the rider provides coverage for insureds clinically diagnosed as having Alzheimer's disease or related degenerative and dementing illnesses. In order to receive benefits under the rider for the above conditions, we may require an evaluation to show that the condition includes a loss or deterioration in intellectual capacity that is measured by clinical evidence and standardized tests that reliably measure impairment in the insured's short-term or long-term memory, orientation as to people, places, or time, and deductive or abstract reasoning.

13. PREMIUM. The premium for the rider will be shown in the Rider Specifications section of your rider. Both the current premium that you will be paying for the rider and the guaranteed maximum premium that could be charged for the rider will be shown in the Rider Specifications section. The rate used to determine the dollar amount of the premiums for the rider vary by the insured’s issue age, sex, underwriting class and rider benefit amount. See Appendix A for these rates.

14. ADDITIONAL FEATURES. To determine whether we issue the rider to you, we will depend on certain medical information about the insured that you would provide as part of the application process. This is generally known as medical underwriting.

15. CONTACT THE STATE AGENCYLISTED IN YOUR SHOPPER’S GUIDE TO LONG TERM CAARE INSURANCE IF YOU HAVE GENERAL QUESTIONS REGARDING LONG TERM CARE INSURANCE. CONTACT THE INSURANCE COMPANY IF YOU HAVE SPECIFIC QUESTIONS REGARDING YOUR LONG-TERM CARE INSURANCE RIDER.

ICC13-LTC OC Page 4

Premium per 1000 of Basic LTC Pool

Issue Age Pref+ NT Pref NT

Non-Smoker Standard Pref+ NT Pref NT


Non-Smoker Standard

18 0.29 0.29 0.29 0.36 0.38 0.38 0.38 0.48 0.32 0.32 0.32 0.4019 0.30 0.30 0.30 0.38 0.40 0.40 0.40 0.50 0.34 0.34 0.34 0.4220 0.31 0.31 0.31 0.39 0.42 0.42 0.42 0.52 0.35 0.35 0.35 0.4421 0.32 0.32 0.32 0.40 0.44 0.44 0.44 0.54 0.36 0.36 0.36 0.4522 0.33 0.33 0.33 0.42 0.46 0.46 0.46 0.56 0.38 0.38 0.38 0.4723 0.35 0.35 0.35 0.43 0.47 0.47 0.47 0.59 0.39 0.39 0.39 0.4924 0.36 0.36 0.36 0.45 0.49 0.49 0.49 0.61 0.41 0.41 0.41 0.5125 0.37 0.37 0.37 0.46 0.51 0.51 0.51 0.63 0.42 0.42 0.42 0.5226 0.39 0.39 0.39 0.48 0.53 0.53 0.53 0.66 0.44 0.44 0.44 0.5427 0.40 0.40 0.40 0.50 0.55 0.55 0.55 0.69 0.45 0.45 0.45 0.5728 0.42 0.42 0.42 0.52 0.58 0.58 0.58 0.72 0.48 0.48 0.48 0.5929 0.43 0.43 0.43 0.54 0.60 0.60 0.60 0.75 0.49 0.49 0.49 0.6130 0.45 0.45 0.45 0.56 0.62 0.62 0.62 0.78 0.51 0.51 0.51 0.6431 0.47 0.47 0.47 0.59 0.65 0.65 0.65 0.82 0.53 0.53 0.53 0.6732 0.49 0.49 0.49 0.62 0.69 0.69 0.69 0.86 0.56 0.56 0.56 0.7033 0.52 0.52 0.52 0.64 0.72 0.72 0.72 0.91 0.59 0.59 0.59 0.7334 0.54 0.54 0.54 0.67 0.76 0.76 0.76 0.95 0.62 0.62 0.62 0.7735 0.56 0.56 0.56 0.70 0.79 0.79 0.79 0.99 0.64 0.64 0.64 0.8036 0.59 0.59 0.59 0.74 0.83 0.83 0.83 1.04 0.67 0.67 0.67 0.8537 0.62 0.62 0.62 0.77 0.87 0.87 0.87 1.09 0.71 0.71 0.71 0.8838 0.64 0.64 0.64 0.81 0.91 0.91 0.91 1.14 0.73 0.73 0.73 0.9339 0.67 0.67 0.67 0.84 0.95 0.95 0.95 1.19 0.77 0.77 0.77 0.9640 0.70 0.70 0.70 0.88 0.99 0.99 0.99 1.24 0.80 0.80 0.80 1.0141 0.73 0.73 0.73 0.92 1.05 1.05 1.05 1.31 0.84 0.84 0.84 1.0642 0.76 0.76 0.76 0.96 1.10 1.10 1.10 1.38 0.88 0.88 0.88 1.1143 0.80 0.80 0.80 1.00 1.16 1.16 1.16 1.45 0.93 0.93 0.93 1.1644 0.83 0.83 0.83 1.04 1.21 1.21 1.21 1.52 0.96 0.96 0.96 1.2145 0.86 0.86 0.86 1.08 1.27 1.27 1.27 1.59 1.00 1.00 1.00 1.2646 0.91 0.91 0.91 1.14 1.36 1.36 1.36 1.70 1.07 1.07 1.07 1.3447 0.96 0.96 0.96 1.20 1.45 1.45 1.45 1.81 1.13 1.13 1.13 1.4148 1.01 1.01 1.01 1.27 1.54 1.54 1.54 1.93 1.20 1.20 1.20 1.5049 1.06 1.06 1.06 1.33 1.63 1.63 1.63 2.04 1.26 1.26 1.26 1.5850 1.11 1.11 1.11 1.39 1.72 1.72 1.72 2.15 1.32 1.32 1.32 1.6651 1.17 1.17 1.17 1.47 1.87 1.87 1.87 2.33 1.42 1.42 1.42 1.7752 1.24 1.24 1.24 1.55 2.02 2.02 2.02 2.52 1.51 1.51 1.51 1.8953 1.30 1.30 1.30 1.63 2.16 2.16 2.16 2.70 1.60 1.60 1.60 2.0054 1.37 1.37 1.37 1.71 2.31 2.31 2.31 2.89 1.70 1.70 1.70 2.1255 1.43 1.43 1.43 1.79 2.46 2.46 2.46 3.07 1.79 1.79 1.79 2.2456 1.55 1.55 1.55 1.94 2.71 2.71 2.71 3.39 1.96 1.96 1.96 2.4557 1.67 1.67 1.67 2.09 2.96 2.96 2.96 3.70 2.12 2.12 2.12 2.6558 1.78 1.78 1.78 2.23 3.22 3.22 3.22 4.02 2.28 2.28 2.28 2.8659 1.90 1.90 1.90 2.38 3.47 3.47 3.47 4.33 2.45 2.45 2.45 3.0660 2.02 2.02 2.02 2.53 3.72 3.72 3.72 4.65 2.62 2.62 2.62 3.2761 2.27 2.27 2.27 2.84 4.25 4.25 4.25 5.31 2.96 2.96 2.96 3.7062 2.52 2.52 2.52 3.15 4.78 4.78 4.78 5.97 3.31 3.31 3.31 4.1463 2.77 2.77 2.77 3.47 5.31 5.31 5.31 6.64 3.66 3.66 3.66 4.5864 3.02 3.02 3.02 3.78 5.84 5.84 5.84 7.30 4.01 4.01 4.01 5.0165 3.27 3.27 3.27 4.09 6.37 6.37 6.37 7.96 4.36 4.36 4.36 5.4466 4.07 4.07 4.07 5.09 7.85 7.85 7.85 9.82 5.39 5.39 5.39 6.7567 4.88 4.88 4.88 6.10 9.34 9.34 9.34 11.67 6.44 6.44 6.44 8.0568 5.68 5.68 5.68 7.10 10.82 10.82 10.82 13.53 7.48 7.48 7.48 9.3569 6.49 6.49 6.49 8.11 12.31 12.31 12.31 15.38 8.53 8.53 8.53 10.6570 7.29 7.29 7.29 9.11 13.79 13.79 13.79 17.24 9.57 9.57 9.57 11.96

Additional LTC Pool Dividend Charge

Pref+ NT Pref NTNon-

Smoker Standard Pref+ NT Pref NTNon-


Smoker Standard

0.6% 0.6% 0.6% 0.8% 1.7% 1.7% 1.7% 2.1% 1.0% 1.0% 1.0% 1.3%

Current LTC Rider Rates - Non-forfeiture Option A

Male Female Unisex

Male Female Unisex

hlcrkat

Text Box

Appendix A





Non-Smoker Standard

18 0.58 0.58 0.58 0.72 0.76 0.76 0.76 0.96 0.64 0.64 0.64 0.8019 0.60 0.60 0.60 0.76 0.80 0.80 0.80 1.00 0.68 0.68 0.68 0.8420 0.62 0.62 0.62 0.78 0.84 0.84 0.84 1.04 0.70 0.70 0.70 0.8821 0.64 0.64 0.64 0.80 0.88 0.88 0.88 1.08 0.72 0.72 0.72 0.9022 0.66 0.66 0.66 0.84 0.92 0.92 0.92 1.12 0.76 0.76 0.76 0.9423 0.70 0.70 0.70 0.86 0.94 0.94 0.94 1.18 0.78 0.78 0.78 0.9824 0.72 0.72 0.72 0.90 0.98 0.98 0.98 1.22 0.82 0.82 0.82 1.0225 0.74 0.74 0.74 0.92 1.02 1.02 1.02 1.26 0.84 0.84 0.84 1.0426 0.78 0.78 0.78 0.96 1.06 1.06 1.06 1.32 0.88 0.88 0.88 1.0827 0.80 0.80 0.80 1.00 1.10 1.10 1.10 1.38 0.90 0.90 0.90 1.1428 0.84 0.84 0.84 1.04 1.16 1.16 1.16 1.44 0.96 0.96 0.96 1.1829 0.86 0.86 0.86 1.08 1.20 1.20 1.20 1.50 0.98 0.98 0.98 1.2230 0.90 0.90 0.90 1.12 1.24 1.24 1.24 1.56 1.02 1.02 1.02 1.2831 0.94 0.94 0.94 1.18 1.30 1.30 1.30 1.64 1.06 1.06 1.06 1.3432 0.98 0.98 0.98 1.24 1.38 1.38 1.38 1.72 1.12 1.12 1.12 1.4033 1.04 1.04 1.04 1.28 1.44 1.44 1.44 1.82 1.18 1.18 1.18 1.4634 1.08 1.08 1.08 1.34 1.52 1.52 1.52 1.90 1.24 1.24 1.24 1.5435 1.12 1.12 1.12 1.40 1.58 1.58 1.58 1.98 1.28 1.28 1.28 1.6036 1.18 1.18 1.18 1.48 1.66 1.66 1.66 2.08 1.34 1.34 1.34 1.7037 1.24 1.24 1.24 1.54 1.74 1.74 1.74 2.18 1.42 1.42 1.42 1.7638 1.28 1.28 1.28 1.62 1.82 1.82 1.82 2.28 1.46 1.46 1.46 1.8639 1.34 1.34 1.34 1.68 1.90 1.90 1.90 2.38 1.54 1.54 1.54 1.9240 1.40 1.40 1.40 1.76 1.98 1.98 1.98 2.48 1.60 1.60 1.60 2.0241 1.46 1.46 1.46 1.84 2.10 2.10 2.10 2.62 1.68 1.68 1.68 2.1242 1.52 1.52 1.52 1.92 2.20 2.20 2.20 2.76 1.76 1.76 1.76 2.2243 1.60 1.60 1.60 2.00 2.32 2.32 2.32 2.90 1.86 1.86 1.86 2.3244 1.66 1.66 1.66 2.08 2.42 2.42 2.42 3.04 1.92 1.92 1.92 2.4245 1.72 1.72 1.72 2.16 2.54 2.54 2.54 3.18 2.00 2.00 2.00 2.5246 1.82 1.82 1.82 2.28 2.72 2.72 2.72 3.40 2.14 2.14 2.14 2.6847 1.92 1.92 1.92 2.40 2.90 2.90 2.90 3.62 2.26 2.26 2.26 2.8248 2.02 2.02 2.02 2.54 3.08 3.08 3.08 3.86 2.40 2.40 2.40 3.0049 2.12 2.12 2.12 2.66 3.26 3.26 3.26 4.08 2.52 2.52 2.52 3.1650 2.22 2.22 2.22 2.78 3.44 3.44 3.44 4.30 2.64 2.64 2.64 3.3251 2.34 2.34 2.34 2.94 3.74 3.74 3.74 4.66 2.84 2.84 2.84 3.5452 2.48 2.48 2.48 3.10 4.04 4.04 4.04 5.04 3.02 3.02 3.02 3.7853 2.60 2.60 2.60 3.26 4.32 4.32 4.32 5.40 3.20 3.20 3.20 4.0054 2.74 2.74 2.74 3.42 4.62 4.62 4.62 5.78 3.40 3.40 3.40 4.2455 2.86 2.86 2.86 3.58 4.92 4.92 4.92 6.14 3.58 3.58 3.58 4.4856 3.10 3.10 3.10 3.88 5.42 5.42 5.42 6.78 3.92 3.92 3.92 4.9057 3.34 3.34 3.34 4.18 5.92 5.92 5.92 7.40 4.24 4.24 4.24 5.3058 3.56 3.56 3.56 4.46 6.44 6.44 6.44 8.04 4.56 4.56 4.56 5.7259 3.80 3.80 3.80 4.76 6.94 6.94 6.94 8.66 4.90 4.90 4.90 6.1260 4.04 4.04 4.04 5.06 7.44 7.44 7.44 9.30 5.24 5.24 5.24 6.5461 4.54 4.54 4.54 5.68 8.50 8.50 8.50 10.62 5.92 5.92 5.92 7.4062 5.04 5.04 5.04 6.30 9.56 9.56 9.56 11.94 6.62 6.62 6.62 8.2863 5.54 5.54 5.54 6.94 10.62 10.62 10.62 13.28 7.32 7.32 7.32 9.1664 6.04 6.04 6.04 7.56 11.68 11.68 11.68 14.60 8.02 8.02 8.02 10.0265 6.54 6.54 6.54 8.18 12.74 12.74 12.74 15.92 8.72 8.72 8.72 10.8866 8.14 8.14 8.14 10.18 15.70 15.70 15.70 19.64 10.78 10.78 10.78 13.5067 9.76 9.76 9.76 12.20 18.68 18.68 18.68 23.34 12.88 12.88 12.88 16.1068 11.36 11.36 11.36 14.20 21.64 21.64 21.64 27.06 14.96 14.96 14.96 18.7069 12.98 12.98 12.98 16.22 24.62 24.62 24.62 30.76 17.06 17.06 17.06 21.3070 14.58 14.58 14.58 18.22 27.58 27.58 27.58 34.48 19.14 19.14 19.14 23.92





Smoker Standard

1.2% 1.2% 1.2% 1.6% 3.4% 3.4% 3.4% 4.2% 2.0% 2.0% 2.0% 2.5%

Unisex

Guaranteed LTC Rider Rates - Non-forfeiture Option A

Male Female

UnisexMale Female





Non-Smoker Standard

18 0.46 0.46 0.46 0.59 0.62 0.62 0.62 0.77 0.52 0.52 0.52 0.6519 0.48 0.48 0.48 0.61 0.65 0.65 0.65 0.81 0.54 0.54 0.54 0.6820 0.50 0.50 0.50 0.63 0.68 0.68 0.68 0.84 0.56 0.56 0.56 0.7021 0.52 0.52 0.52 0.65 0.71 0.71 0.71 0.87 0.59 0.59 0.59 0.7322 0.54 0.54 0.54 0.67 0.74 0.74 0.74 0.91 0.61 0.61 0.61 0.7523 0.56 0.56 0.56 0.70 0.76 0.76 0.76 0.94 0.63 0.63 0.63 0.7824 0.58 0.58 0.58 0.72 0.79 0.79 0.79 0.98 0.65 0.65 0.65 0.8125 0.60 0.60 0.60 0.74 0.82 0.82 0.82 1.01 0.68 0.68 0.68 0.8326 0.62 0.62 0.62 0.77 0.86 0.86 0.86 1.06 0.70 0.70 0.70 0.8727 0.65 0.65 0.65 0.80 0.89 0.89 0.89 1.11 0.73 0.73 0.73 0.9128 0.67 0.67 0.67 0.84 0.93 0.93 0.93 1.16 0.76 0.76 0.76 0.9529 0.70 0.70 0.70 0.87 0.96 0.96 0.96 1.21 0.79 0.79 0.79 0.9930 0.72 0.72 0.72 0.90 1.00 1.00 1.00 1.26 0.82 0.82 0.82 1.0331 0.76 0.76 0.76 0.95 1.05 1.05 1.05 1.33 0.86 0.86 0.86 1.0832 0.79 0.79 0.79 0.99 1.11 1.11 1.11 1.39 0.90 0.90 0.90 1.1333 0.83 0.83 0.83 1.04 1.16 1.16 1.16 1.46 0.95 0.95 0.95 1.1934 0.86 0.86 0.86 1.08 1.22 1.22 1.22 1.52 0.99 0.99 0.99 1.2335 0.90 0.90 0.90 1.13 1.27 1.27 1.27 1.59 1.03 1.03 1.03 1.2936 0.95 0.95 0.95 1.19 1.33 1.33 1.33 1.67 1.08 1.08 1.08 1.3637 0.99 0.99 0.99 1.25 1.40 1.40 1.40 1.75 1.13 1.13 1.13 1.4338 1.04 1.04 1.04 1.30 1.46 1.46 1.46 1.84 1.19 1.19 1.19 1.4939 1.08 1.08 1.08 1.36 1.53 1.53 1.53 1.92 1.24 1.24 1.24 1.5640 1.13 1.13 1.13 1.42 1.59 1.59 1.59 2.00 1.29 1.29 1.29 1.6241 1.18 1.18 1.18 1.48 1.68 1.68 1.68 2.11 1.36 1.36 1.36 1.7042 1.23 1.23 1.23 1.55 1.77 1.77 1.77 2.22 1.42 1.42 1.42 1.7843 1.28 1.28 1.28 1.61 1.86 1.86 1.86 2.34 1.48 1.48 1.48 1.8744 1.33 1.33 1.33 1.68 1.95 1.95 1.95 2.45 1.55 1.55 1.55 1.9545 1.38 1.38 1.38 1.74 2.04 2.04 2.04 2.56 1.61 1.61 1.61 2.0346 1.46 1.46 1.46 1.84 2.19 2.19 2.19 2.74 1.72 1.72 1.72 2.1647 1.54 1.54 1.54 1.94 2.33 2.33 2.33 2.92 1.82 1.82 1.82 2.2848 1.63 1.63 1.63 2.04 2.48 2.48 2.48 3.10 1.93 1.93 1.93 2.4149 1.71 1.71 1.71 2.14 2.62 2.62 2.62 3.28 2.03 2.03 2.03 2.5450 1.79 1.79 1.79 2.24 2.77 2.77 2.77 3.46 2.13 2.13 2.13 2.6751 1.89 1.89 1.89 2.37 3.01 3.01 3.01 3.76 2.28 2.28 2.28 2.8652 1.99 1.99 1.99 2.50 3.25 3.25 3.25 4.05 2.43 2.43 2.43 3.0453 2.10 2.10 2.10 2.62 3.48 3.48 3.48 4.35 2.58 2.58 2.58 3.2354 2.20 2.20 2.20 2.75 3.72 3.72 3.72 4.64 2.73 2.73 2.73 3.4155 2.30 2.30 2.30 2.88 3.96 3.96 3.96 4.94 2.88 2.88 2.88 3.6056 2.49 2.49 2.49 3.12 4.37 4.37 4.37 5.45 3.15 3.15 3.15 3.9457 2.68 2.68 2.68 3.36 4.77 4.77 4.77 5.96 3.41 3.41 3.41 4.2758 2.87 2.87 2.87 3.59 5.18 5.18 5.18 6.47 3.68 3.68 3.68 4.6059 3.06 3.06 3.06 3.83 5.58 5.58 5.58 6.98 3.94 3.94 3.94 4.9360 3.25 3.25 3.25 4.07 5.99 5.99 5.99 7.49 4.21 4.21 4.21 5.2761 3.65 3.65 3.65 4.57 6.84 6.84 6.84 8.56 4.77 4.77 4.77 5.9762 4.05 4.05 4.05 5.07 7.70 7.70 7.70 9.62 5.33 5.33 5.33 6.6663 4.46 4.46 4.46 5.58 8.55 8.55 8.55 10.69 5.89 5.89 5.89 7.3764 4.86 4.86 4.86 6.08 9.41 9.41 9.41 11.75 6.45 6.45 6.45 8.0665 5.26 5.26 5.26 6.58 10.26 10.26 10.26 12.82 7.01 7.01 7.01 8.7666 6.56 6.56 6.56 8.20 12.65 12.65 12.65 15.81 8.69 8.69 8.69 10.8667 7.85 7.85 7.85 9.82 15.04 15.04 15.04 18.80 10.37 10.37 10.37 12.9668 9.15 9.15 9.15 11.43 17.42 17.42 17.42 21.78 12.04 12.04 12.04 15.0569 10.44 10.44 10.44 13.05 19.81 19.81 19.81 24.77 13.72 13.72 13.72 17.1570 11.74 11.74 11.74 14.67 22.20 22.20 22.20 27.76 15.40 15.40 15.40 19.25





Smoker Standard

1.0% 1.0% 1.0% 1.3% 2.7% 2.7% 2.7% 3.4% 1.6% 1.6% 1.6% 2.0%

Current LTC Rider Rates - Non-forfeiture Option B

Male Female Unisex

Male Female Unisex





Non-Smoker Standard

18 0.92 0.92 0.92 1.18 1.24 1.24 1.24 1.54 1.04 1.04 1.04 1.3019 0.96 0.96 0.96 1.22 1.30 1.30 1.30 1.62 1.08 1.08 1.08 1.3620 1.00 1.00 1.00 1.26 1.36 1.36 1.36 1.68 1.12 1.12 1.12 1.4021 1.04 1.04 1.04 1.30 1.42 1.42 1.42 1.74 1.18 1.18 1.18 1.4622 1.08 1.08 1.08 1.34 1.48 1.48 1.48 1.82 1.22 1.22 1.22 1.5023 1.12 1.12 1.12 1.40 1.52 1.52 1.52 1.88 1.26 1.26 1.26 1.5624 1.16 1.16 1.16 1.44 1.58 1.58 1.58 1.96 1.30 1.30 1.30 1.6225 1.20 1.20 1.20 1.48 1.64 1.64 1.64 2.02 1.36 1.36 1.36 1.6626 1.24 1.24 1.24 1.54 1.72 1.72 1.72 2.12 1.40 1.40 1.40 1.7427 1.30 1.30 1.30 1.60 1.78 1.78 1.78 2.22 1.46 1.46 1.46 1.8228 1.34 1.34 1.34 1.68 1.86 1.86 1.86 2.32 1.52 1.52 1.52 1.9029 1.40 1.40 1.40 1.74 1.92 1.92 1.92 2.42 1.58 1.58 1.58 1.9830 1.44 1.44 1.44 1.80 2.00 2.00 2.00 2.52 1.64 1.64 1.64 2.0631 1.52 1.52 1.52 1.90 2.10 2.10 2.10 2.66 1.72 1.72 1.72 2.1632 1.58 1.58 1.58 1.98 2.22 2.22 2.22 2.78 1.80 1.80 1.80 2.2633 1.66 1.66 1.66 2.08 2.32 2.32 2.32 2.92 1.90 1.90 1.90 2.3834 1.72 1.72 1.72 2.16 2.44 2.44 2.44 3.04 1.98 1.98 1.98 2.4635 1.80 1.80 1.80 2.26 2.54 2.54 2.54 3.18 2.06 2.06 2.06 2.5836 1.90 1.90 1.90 2.38 2.66 2.66 2.66 3.34 2.16 2.16 2.16 2.7237 1.98 1.98 1.98 2.50 2.80 2.80 2.80 3.50 2.26 2.26 2.26 2.8638 2.08 2.08 2.08 2.60 2.92 2.92 2.92 3.68 2.38 2.38 2.38 2.9839 2.16 2.16 2.16 2.72 3.06 3.06 3.06 3.84 2.48 2.48 2.48 3.1240 2.26 2.26 2.26 2.84 3.18 3.18 3.18 4.00 2.58 2.58 2.58 3.2441 2.36 2.36 2.36 2.96 3.36 3.36 3.36 4.22 2.72 2.72 2.72 3.4042 2.46 2.46 2.46 3.10 3.54 3.54 3.54 4.44 2.84 2.84 2.84 3.5643 2.56 2.56 2.56 3.22 3.72 3.72 3.72 4.68 2.96 2.96 2.96 3.7444 2.66 2.66 2.66 3.36 3.90 3.90 3.90 4.90 3.10 3.10 3.10 3.9045 2.76 2.76 2.76 3.48 4.08 4.08 4.08 5.12 3.22 3.22 3.22 4.0646 2.92 2.92 2.92 3.68 4.38 4.38 4.38 5.48 3.44 3.44 3.44 4.3247 3.08 3.08 3.08 3.88 4.66 4.66 4.66 5.84 3.64 3.64 3.64 4.5648 3.26 3.26 3.26 4.08 4.96 4.96 4.96 6.20 3.86 3.86 3.86 4.8249 3.42 3.42 3.42 4.28 5.24 5.24 5.24 6.56 4.06 4.06 4.06 5.0850 3.58 3.58 3.58 4.48 5.54 5.54 5.54 6.92 4.26 4.26 4.26 5.3451 3.78 3.78 3.78 4.74 6.02 6.02 6.02 7.52 4.56 4.56 4.56 5.7252 3.98 3.98 3.98 5.00 6.50 6.50 6.50 8.10 4.86 4.86 4.86 6.0853 4.20 4.20 4.20 5.24 6.96 6.96 6.96 8.70 5.16 5.16 5.16 6.4654 4.40 4.40 4.40 5.50 7.44 7.44 7.44 9.28 5.46 5.46 5.46 6.8255 4.60 4.60 4.60 5.76 7.92 7.92 7.92 9.88 5.76 5.76 5.76 7.2056 4.98 4.98 4.98 6.24 8.74 8.74 8.74 10.90 6.30 6.30 6.30 7.8857 5.36 5.36 5.36 6.72 9.54 9.54 9.54 11.92 6.82 6.82 6.82 8.5458 5.74 5.74 5.74 7.18 10.36 10.36 10.36 12.94 7.36 7.36 7.36 9.2059 6.12 6.12 6.12 7.66 11.16 11.16 11.16 13.96 7.88 7.88 7.88 9.8660 6.50 6.50 6.50 8.14 11.98 11.98 11.98 14.98 8.42 8.42 8.42 10.5461 7.30 7.30 7.30 9.14 13.68 13.68 13.68 17.12 9.54 9.54 9.54 11.9462 8.10 8.10 8.10 10.14 15.40 15.40 15.40 19.24 10.66 10.66 10.66 13.3263 8.92 8.92 8.92 11.16 17.10 17.10 17.10 21.38 11.78 11.78 11.78 14.7464 9.72 9.72 9.72 12.16 18.82 18.82 18.82 23.50 12.90 12.90 12.90 16.1265 10.52 10.52 10.52 13.16 20.52 20.52 20.52 25.64 14.02 14.02 14.02 17.5266 13.12 13.12 13.12 16.40 25.30 25.30 25.30 31.62 17.38 17.38 17.38 21.7267 15.70 15.70 15.70 19.64 30.08 30.08 30.08 37.60 20.74 20.74 20.74 25.9268 18.30 18.30 18.30 22.86 34.84 34.84 34.84 43.56 24.08 24.08 24.08 30.1069 20.88 20.88 20.88 26.10 39.62 39.62 39.62 49.54 27.44 27.44 27.44 34.3070 23.48 23.48 23.48 29.34 44.40 44.40 44.40 55.52 30.80 30.80 30.80 38.50





Smoker Standard

2.0% 2.0% 2.0% 2.6% 5.4% 5.4% 5.4% 6.8% 3.2% 3.2% 3.2% 4.1%

Unisex

Guaranteed LTC Rider Rates - Non-forfeiture Option B

Male Female Unisex

Male Female


Things You Should Know Before You Buy Long-Term Care Insurance

Long-Term Care Insurance

• A long-term care insurance policy may pay most of the costs for your care in anursing home. Many policies also pay for care at home or other communitysettings. Since policies can vary in coverage, you should read this policy andmake sure you understand what it covers before you buy it.

• You should not buy this insurance policy unless you can afford to pay thepremiums every year. Remember that the company can increase premiumsin the future.

• The personal worksheet includes questions designed to help you and thecompany determine whether this policy is suitable for your needs

Medicare • Medicare does not pay for most long-term care.

Medicaid • Medicaid will generally pay for long-term care if you have very little incomeand few assets. You probably should not buy this policy if you are noweligible for Medicaid.

• Many people become eligible for Medicaid after they have used up their ownfinancial resources by paying for long-term care services.

• When Medicaid pays your spouse’s nursing home bills, you are allowed tokeep your house and furniture, a living allowance, and some of your jointassets.

• Your choice of long-term care services may be limited if you are receivingMedicaid. To learn more about Medicaid, contact your local or state Medicaidagency.

Shopper’s Guide

• Make sure the insurance company or agent gives you a copy of a book calledthe National Association of Insurance Commissioners’ “A Shopper’s Guide toLong-Term Care Insurance.” Read it carefully. If you have decided to apply forlong-term care insurance, you have the right to return the policy within 30days and get back any premium you have paid if you are dissatisfied for anyreason or choose not to purchase the policy.

Counseling • Free counseling and additional information about long-term care insuranceare available through your state’s insurance counseling program. For moreinformation about the senior health insurance counseling program in yourstate, contact the state agency listed in the Directories in the abovementioned Shopper’s Guide To Long-Term Care Insurance.

Facilities • Some long-term care insurance contracts provide for benefit payments incertain facilities only if they are licensed or certified, such as in assisted livingcenters. However, not all states regulate these facilities in the same way.Also, many people move into a different state from where they purchasedtheir long-term care insurance policy. Read the policy carefully to determinewhat types of facilities qualify for benefit payments, and to determine thatpayment for a covered service will be made if you move to a state that has adifferent licensing scheme for facilities than the one in which you purchasedthe policy.

ICC13-LTC Notice

The Guardian Life Insurance Company of America Customer Service Office

3900 Burgess Place, Bethlehem, PA 18017

Long Term Care Insurance Potential Rate Increase Disclosure Form

The following information is provided with regard to potential rate increases for the Accelerated Death Benefit for Long Term Care Services (LTC) Rider. This disclosure is required by state law and does not apply to the premiums for the life insurance policy to which the LTC rider is attached.

Rates The current and maximum Rates for the LTC Rider Premium and the current and maximum Rates for the LTC Dividend Charge Percentage applicable to the LTC Rider will be shown on the Specification section of the LTC Rider. The Maximum LTC Rider Premium and Maximum LTC Dividend Charge Percentage cannot change.

The current Rates will remain in effect unless The Guardian Life Insurance Company of America (“Guardian”) has provided written notification of a Rate adjustment and the effective date of the change. The Guardian may change the Rates for the LTC Rider Premium, the LTC Dividend Charge Percentage or both.

Rate Schedule Adjustments Any adjustments to the rates will be effective on the policy anniversary following the effective date of the change identified in Guardian’s notification. Potential Rate Revisions Guardian reserves the right to increase the current LTC Rider Premium and/or the LTC Dividend Charge in the future, but in no event will the rates ever exceed the maximum rates shown in the Specification section of LTC rider. No change in either the Current LTC Rider Premium or Current LTC Dividend Charge Percentage will occur because of a deterioration in the insured's health. The Current LTC Rider Premium and Current LTC Dividend Charge Percentage are redetermined only prospectively. We will not recoup any prior losses by means of a change in either the Current LTC Rider Premium or the Current LTC Dividend Charge Percentage.

Some of the options available if there is a Rate increase include:

1. Pay the increased LTC rider premium and continue the LTC Rider coverage in force as is; 2. Choose to lower your Basic LTC Pool to a level such that the LTC Rider Premium will not

increase. 3. Choose to discontinue purchasing LTC Dividend Additions; or 4. Choose to terminate your LTC rider.

ICC13-LTC Rate Disclosure

C-NIIP-2003

Life Customer Service Office Disability Customer Service Office 3900 Burgess Place 700 South Street Bethlehem, PA 18017 Pittsfield, MA 01201


BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA (Please check appropriate company(ies). Any insurer checked above

is herein referred to as the “Company.”)

Insurance Information Practices The notification below must be completed and given to the Proposed Insured before the application is completed

Notice to

Proposed Insured

Thank you for your interest in insurance with our Company. This notice is given to you at the time you apply for life or disability insurance to tell you about the kinds of information we may obtain in connection with your application. Only qualified members of our Company’s staff or its legal representatives will have access to your medical file to evaluate your eligibility for insurance or to service your claim for benefits under a policy. Your authorization will govern our request for information and any later disclosure of that information. We will treat all personal information about you as confidential. You have a right of access and correction with respect to this information. If you wish a more detailed explanation of our Information Practices, please send your written request to the Privacy Office of the Guardian Corporate Family at 7 Hanover Square, New York, NY 10004-2616.

Fair Credit Reporting Act Pre-Notice When we begin to process your application, we may ask for a consumer report from a consumer reporting agency. All or part of that report may be an investigative consumer report. Such a report will include information about your character, general reputation, personal characteristics or mode of living, except as may be related directly or indirectly to your sexual orientation. It will be obtained through personal interviews with people who know you. You may ask to be interviewed in connection with this report. We may request later consumer reports, other than an investigative consumer report, at a future update, renewal or extension of the insurance for which you have applied. At your request, we will tell you if we have asked for a consumer report or an investigative consumer report in the initial processing of your application. If we have, we will tell you the name and address of the consumer reporting agency to which we have made our request for a report. You can obtain a copy of this report by contacting this consumer reporting agency. At your written request, we will give you more detailed information about the nature and scope of this kind of investigation.

Medical Information Bureau Pre-Notice The Medical Information Bureau is a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another Bureau Member company for life or disability insurance, or if a claim for benefits is submitted to such company, the Bureau, upon request, will supply such company with the information in its files. Our Company, its legal representatives, or its reinsurers may make a brief report of objective findings about you to the Bureau. If you so request of the Bureau, it will arrange to disclose the information it may have in your file. If you question the accuracy of the information in the Bureau's file, you may contact the Bureau and seek to correct the information according to procedures set forth in the Federal Fair Credit Reporting Act. The Bureau's address is 50 Braintree Hill, Suite 400, Braintree, MA 02184-8734, and its telephone number is 866-692-6901 (TTY 866-346-3642 for the hearing impaired). Information for consumers about MIB may be obtained on its website at www.mib.com.

Medical Records We may request information from health care providers or others who have records of your medical history, mental or physical condition, or treatment. Only qualified members of our Company’s staff or its legal representatives will have access to your medical file to evaluate your eligibility for insurance or to service your claim for benefits under a policy. Your authorization will govern our request for information and any later disclosure of that information.

Personal Information Telephone Interview We may phone you to verify or supplement information you have given us on your application. The call will be made from our underwriting office or from a consumer reporting agency acting for us.

LTC SHOPPERS GUIDE FORM (PUB. 5857) – This is a 78 page guide developed by the NAIC that is required to be left with an applicant for the LTC Rider. This guide can be ordered on GOL by clicking the Order Materials and Forms link and then click on Order Marketing Materials. You may also click the following link to go directly to this guide. http://fulfillment.cfgweb.com/showpdf-sku.cfg?sku=pub5857&clientcode=glic

http://fulfillment.cfgweb.com/showpdf-sku.cfg?sku=pub5857&clientcode=glic

L-AP-CR-2011

Customer Service Office THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA 3900 Burgess Place THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC. Bethlehem, PA 18017 (Please check appropriate company. In this receipt, “the Company” is the insurer checked above.)

CONDITIONAL TEMPORARY COVERAGE AGREEMENT AND RECEIPT

Received from the amount of $ for the application for insurance on the life of (Proposed Insured) dated .

Provided that the above payment is equal to at least 1/12 of the annual premium for the insurance applied for in Section G of the application referred to above, we will provide conditional temporary life insurance coverage. We will pay a death benefit to the beneficiary named in the application if the proposed insured dies while coverage under this Agreement is in effect and subject to the terms and conditions stated herein. For Universal Life policies, the “annual premium” is the Target Premium for the insurance applied for.

IMPORTANT NOTE TO APPLICANT: This receipt is to be given for advance payment on first premium. All premium checks must be made payable to the company, as checked above. Do not make check payable to the agent/dealer or leave payee blank. Cash payments and money orders cannot be accepted.

IMPORTANT NOTE TO AGENT: This receipt may only be used if all of the following are true: (a) The Insured answers “no” to all 3 medical questions asked below; (b) The insured is not younger than 30 days old, and not older than 64 years, 6 months old; (c) Payment is made concurrent with the signing of the application and such payment is at least equal to one-twelfth of the annual premium for the amount of all insurance applied for on the application referred to above. Note: depending on the contractual provisions of the policy(ies) being applied for, the minimum payment referred to above may not be sufficient to put the policy(ies) in force. (d) The application is not taken by mail.

1) Has the Proposed Insured, within the last 12 months, been treated for or had any known heart attack, stroke or cancer? Yes No 2) Has the Proposed Insured, within the last 12 months, had an electrocardiogram because of chest pain or any Yes No

other physical problem? 3) Within the past 10 years, has the Proposed Insured been diagnosed by or received treatment from a member of Yes No

the medical profession for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or any deficiency of the immune system, such as Human Immunodeficiency Virus (HIV)?

IF ANY OF THESE QUESTIONS IS ANSWERED “YES” OR LEFT BLANK, THIS CONDITIONAL RECEIPT SHALL BE VOID.

Limitation on Coverage: The amount of life insurance available under this receipt cannot exceed the face amount of the insurance applied for in the application referred to above, including the amount of any Accidental Death Benefit rider, any Renewable Term Rider and any Paid-up Additions Rider (but only for any Initial PUA payment that is paid in full on the date the application is signed). Special Provision Relating to Additional and Alternate policies: If the application referred to above indicates that Alternate or Additional coverage has been requested, then the following provisions apply. If an Alternate policy has been requested, the temporary coverage under this Agreement will be deemed to relate to the coverage applied for in Section G of the application, and not the Alternate policy requested. If an Additional policy has been requested, coverage is available under this Agreement for both policies, provided the initial premium amount collected is equal to at least the sum of 1/12 of the annual premium for each of these policies. Otherwise, coverage will be provided only for the policy applied for in Section G of the application.

If the amount of coverage described above, combined with the amount of coverage under any other Conditional Temporary Coverage Agreement in effect on the proposed insured listed above, exceeds $1,000,000, the maximum total amount of coverage payable under all such Agreements shall be $1,000,000. In no event will we pay more than $1,000,000 in Conditional Temporary Coverage on a single insured, regardless of the amount of premium collected under all applications on that insured.

*IMNB0011000090201*

L-AP-CR-2011

Conditions:

The temporary insurance shall be effective on the later of:

(a) the date of the Part I application;

(b) the date of whatever Part II application, including any medical examination, that is initially required by the Company’s published underwriting rules; and

(c) the date of any lab work that is initially required by the Company’s published underwriting rules.

Coverage is not effective if the Part I or any Part II , including any medical examination, and/or initial lab work, required by our published underwriting rules, is not completed. Coverage ends 60 days after it is effective, or if earlier on the date the insurance applied for in the application is issued.

The Proposed Insured must be insurable as a standard or better risk under our underwriting rules, for the amount, plan and benefits applied for, without restriction or modification. Information required by the Company to determine insurability must be received at its Customer Service Office within 60 days of the date of this receipt.

If the Proposed Insured should die within 60 days of the effective date of this receipt and:

• After the required Parts I and II have been received at the Home Office; and

• After the last of any required medical examinations, including any required lab work, have been completed;

Then the Company shall not deny liability because of failure to submit any additional evidence of insurability it may have required. Instead, it shall determine insurability as of the effective date described above.

For the temporary insurance to be payable, there must be no material misrepresentation on this form or on the application referred to above. Also, the insured’s death must not have been the result of suicide. If the Proposed Insured dies within 60 days of the effective date of this receipt, but the temporary coverage is not payable because any of the above conditions were not met, we will refund the initial premium that was paid with the application. This receipt will be void if any check or draft given in exchange for the receipt is dishonored when first presented for payment. Special rules for 1035 exchanges: If the applied for coverage is intended to be part of an exchange under Section 1035 of the Internal Revenue Code, and if the Proposed Insured is determined to be, within 60 days of the effective date of the receipt, a standard or better risk under our underwriting rules, then coverage will not end 60 days after the receipt and the premium will not be refunded. Instead, the temporary coverage will continue until: (a) the policy is issued, or (b) the existing carrier indicates that our request for the proceeds under the existing insurance can not or will not be processed.

Dated at , on City and State month day year Signature of Agent/ Dealer

I have read the terms of this receipt and have had them explained to me by the agent/dealer. I understand that the insurance applied for shall not be effective unless and until the conditions of this receipt have been complied with exactly. If these conditions are not met, the Company shall have no liability under this receipt except to return the payment made. Signature of Proposed Insured Signature of Owner, if other than Proposed Insured

*IMNB1502000180101* 110-4 7/06 IL

Customer Service Office 3900 Burgess Place Bethlehem, PA 18017 1-800-441-6455

NOTICE REGARDING REPLACEMENT OF LIFE INSURANCE OR ANNUITY

REPLACING YOUR LIFE INSURANCE POLICY OR ANNUITY? THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC. BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA

(Please check appropriate company) Are you thinking about buying a new life insurance policy or annuity and discontinuing or changing an existing one? If you are, your decision could be a good one – or a mistake. You will not know for sure unless you make a careful comparison of your existing benefits and the proposed benefits. Make sure you understand the facts. You should ask the insurance producer or company that sold you your existing policy to give you information about it. Hear both sides before you decide. This way you can be sure you are making a decision that is in your best interest. REMEMBER, you have twenty (20) days following receipt to examine the contents of any individual life insurance policy or annuity. If you are not satisfied with it for any reason, you have the right to return it to the insurer at its home or branch office, or to the agent through whom it was purchased, for a full refund of premium. We are required by law to notify your existing company that you may be replacing their policy. List below identification information for policies which are involved in the replacement transaction. Applicant’s Signature Agent’s Signature Date

Contract Number Contract Number

Contract Number Contract Number

(Original-Applicant; 1st Copy-Home Office; 2nd Copy-Agency)

110-8 1 /88 IL *IMNB1501000180101*

Customer Service Office3900 Burgess PlaceBethlehem, PA 180171-800-441-6455

DISCLOSURE NOTICE

NOTICE REGARDING REPLACEMENT OF LIFE INSURANCE OR ANNUITY

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICATHE GUARDIAN INSURANCE & ANNUITY COMPANY, INC.BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA

(Please check appropriate company)

To:Existing Insurer

Address

,

Attn: Policy Replacement Administration

You are herewith given notice that we are in receipt of application(s) for life insurance or annuity(ies) for an individual presently insured with your company.

Identification

Name of Insured

Address

,

Contract Number

Contract Number

Contract Number

Contract Number

Contract Number

Contract Number

Contract Number

Contract Number

This notice is given pursuant to 50 Ill. Adm. Code 917.70 (c)

(Agent’s Signature) (Date)

(Original – Applicant; 1st Copy – Home Office; 2nd Copy – Agency)

List Policy Numbers

The Guardian Life Insurance Company of America (“Guardian”) The Guardian Insurance & Annuity Company, Inc. (“GIAC”) Berkshire Life Insurance Company of America (“Berkshire”) Please check the appropriate company(ies). Any insurer Selected above is herein referred to as the “Company”

REQUEST FOR GUARD-O-MATIC ARRANGEMENT (page 1 of 2)

In this Request for G-O-M Arrangement form, the “Company” is the insurer checked above See next page for VUL instructions.

AGENCY USE ONLY New Application Bank Change Agency Code:

IMPORTANT: A voided blank check or photocopy (starter checks are not acceptable) is required for checking accounts or a deposit slip for a savings account. See next page for general Guard-O-Matic information.

Guardian and/or GIAC and/or Berkshire is requested and authorized to debit your financial institution or to initiate electronic funds transfer on or about the 1st (Guardian life policies only) or 15th of each month to pay premiums due and/or on the 1st

business day of each month to pay the policy loan on the policy(ies) identified below (on or about the 15th of each month to pay the policy loan on Guardian policy(ies) administered by Berkshire). I understand that: 1. Completion of this form shall not constitute a premium payment and/or loan payment. Authorization for premium

payments is not effective until the initial premium(s) has been received and paid at the home office or you have requested initial premiums be paid under this Arrangement. Multiple months’ premiums may be required to bring the policy to a current due date. If dividends are currently being used to purchase paid-up additional insurance, and dividends for term insurance policies and annuities will be left with us to accumulate at interest.

2. The Guard-O-Matic Premium Arrangement or Loan Payment Arrangement may be terminated by the Policyowner or by the Company upon written notice. If the Bank Depositor is other than the policyowner, the Company will terminate the arrangement upon written request of such Bank Depositor. The policyowner or depositor may cancel this authorization by giving our home office 30 days’ written notice

3. If the Loan Payment Arrangement is cancelled, any outstanding loans will remain unpaid. 4. Any withdrawal returned due to insufficient funds may be deposited for collection a second time. We may terminate the

Guard-O-Matic plan immediately by written notice in the event any withdrawal or electronic fund transfer is dishonored.

PLEASE PRINT Type of account: Checking Savings Begin deductions effective (Month) (Year) Financial Institution:

Street Address: ___________________________________________ City: __________________________ State: _____ Zip: _________ Account Number:

Transit/ABA Number:

Guard-O-Matic Premium Arrangement.

Name of Account Holder: ___________________________________

Draft Date Election Guardian life policies only

Insured Name Last 4 digits of SS#

For Home Office Use Only – Control No:

Guard-O-Matic Loan Payment Arrangement. Life Policy Numbers Amount to be Deducted Life Policy Number Amount to be Deducted

As a convenience to me, I authorize you to pay and charge to my account checks, electronic funds transfer debits or other account debits made upon my account by and payable to the order of Guardian/GIAC/Berkshire indicated above. I agree that your treatment of each check or debit, and your rights with respect to it, will be the same as if it were signed or initialed personally by me. I further agree that if any check or debit is dishonored for any reason you will not be under any liability even though dishonor results in the forfeiture of insurance. I further agree that this authorization is to remain in effect until you receive written notice from me of its revocation unless you end it earlier.

Date Signature of Bank Account Owner

Signature of Policy Owner, if other than Bank Account Owner

Page 1 of 2

R223 (Rev. 7/12)

Complete if applying for Universal or Variable Universal Life Insurance: Your policy is designed to have flexible premiums. When using the Guard-O-Matic check drafting feature, we require that a minimum premium be drawn from your account to keep the policy in force. You will be notified by a lapse notice if it is necessary to increase this amount to keep the policy from lapsing.

Please check the box below if you wish to request this option: Please deduct $_ keep the policy from lapsing.

monthly from my account. I understand that this amount may need to be increased to

If you have any questions about your policy or about the amounts to be drafted to pay premiums, please contact your agent.

"Please be advised that you will not automatically receive a confirmation statement for premium payments paid through the pre-authorized checking plan. Confirmation statements will be mailed only upon request. For details on the automatic monthly payments, please refer to your annual benefits statement, policy contract, or product prospectus. You will receive a confirmation if you have purchased a Park Avenue Variable Whole Life Insurance policy or a Park Avenue Variable Universal Life (97) Policy. Please contact our customer service department at 1-800-441-6455 for more information."

GUARD-O-MATIC General Information

You have elected to pay your insurance premiums and/or your policy loan by monthly deductions payable through your financial institution. To enjoy the benefits of this convenient method of payment, we suggest you review the following: Each month, deduct the amount(s) from your account balance. You may wish to attach a reminder to your account until

this practice becomes automatic. The monthly deduction to your account for any policy premiums will be made on or about the 1st day of each month (Guardian life policies only) or 15th day of each month. The monthly deduction to your account for any policy loan payments will be made on the 1st business day of each month. (on or about the 15th of each month to pay the policy loan on Guardian policy(ies) administered by Berkshire).

A canceled check or other notification of a charge to the account will be provided by your financial institution with its periodic statement. Compare your records when the statement is received.

Please provide us with 30 days’ advance notification of any change in your banking arrangements. If advance notification cannot be provided, sufficient funds should be left in the old account to honor charges until our records are changed.

Please inform us of any change in name or address. When this service is no longer in effect, premiums will be due according to the most frequent payment mode we offer.

INDEMNIFICATION AGREEMENT

TO: The Bank named on the previous page. In consideration of your compliance with the request and authorization of the depositor named above, THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA AND THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC. AND BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA (COLLECTIVELY, “GUARDIAN”) AGREE THAT:

1. They will indemnify and hold you harmless from any liability, including costs, legal expenses and attorney fees, to any person having an

account with you or to any beneficiary or other claimant under a policy covered by the Guard-O-Matic Arrangement arising out of the payment by you of any check or debit drawn by Guardian, its own order on the account of such depositor, or arising out of the dishonor by you, whether with or without cause, of any such check or debit drawn by Guardian, provided there are sufficient funds in such account to pay the same upon presentation, whether or not such claim or liability asserted against you be based upon the forfeiture, or alleged forfeiture, of a policy the premium on which is sought to be collected by Guardian by any such check or debit.

2. They will refund to you any amount erroneously paid by you to Guardian on any such check or debit if claim for the amount of such erroneous payment is made by you within fifteen months from the date of the check or debit on which such erroneous payment was made.


BERKSHIRE LIFE INSURANCE COMPANY OF AMERICA Authorized in a resolution approved by the Board of Directors of The Guardian Life Insurance Company of America on April 27, 1960, and by the Board of Directors of The Guardian Insurance & Annuity Company, Inc. on November 17, 1988 and by the Board of Directors of the Berkshire Life Insurance Company of America on July 19, 2002.

Page 2 of 2

R223 (Rev. 7/12)

Please check one:

p The Guardian Life Insurance Company of America

p The Guardian Insurance & Annuity Co., Inc.

1035 EXCHANGE AGREEMENT

This Agreement is entered into by and between ____________________________________ (hereinafter “Owner”) and theCompany indicated above (hereinafter “Guardian”).

1. Owner is the owner of the following policies or contracts:

Current Policy Number Current Insurer

______________________________ __________________________________________________________

______________________________ __________________________________________________________

______________________________ __________________________________________________________

______________________________ __________________________________________________________

______________________________ __________________________________________________________

(collectively hereinafter “Current Policy”).

The Owner represents and warrants that the Current Policy, as listed above: is in force; is unencumbered by any policyloan; and is not assigned as collateral for a loan. The Owner also represents and warrants that no person, trust, firm,corporation or any other entity, other than the Owner, has an interest in the policy and that no proceedings of either alegal or equitable nature have been instituted or are pending against the Owner.

2. a. The Owner of the Current Policy desires to exchange the Current Policy for a new policy issued by Guardian. Thenew policy has been applied for by the Owner.

b. Upon the execution of this Agreement, the Owner will either (1) transfer absolute ownership of the Current Policyto Guardian on forms acceptable to the Current Insurer, simultaneously naming Guardian beneficiary of theCurrent Policy; or (2) absolutely assign the Current Policy to Guardian on forms acceptable to the Current Insurer.Guardian will file the appropriate form, as submitted by the Owner to Guardian, with the Current Insurer at suchtime in its underwriting process as Guardian finds it is prepared to offer a new policy to the Owner.

3. Guardian will issue a new policy in accordance with the Owner’s application if all requirements prescribed by Guardianfor this transaction have been met. Guardian shall be free to accept or reject the Owner’s application for the new policyon the basis of underwriting requirements established and revised from time to time by Guardian. Insurance under thenew policy will be subject entirely to the provisions of the new policy and will not be affected by any provisions of theCurrent Policy or this Agreement. Upon Guardian’s rejection of the Owner’s application for a new policy, the CurrentPolicy shall be returned to the Owner, this Agreement shall become null and void and Guardian will have no furtherobligations hereunder.

4. The owner will be responsible for payment of premiums for the Current Policy until such time as the Current Policy hasbeen surrendered by Guardian in accordance with the terms of this Agreement. If any premium due on the CurrentPolicy is not paid, Guardian will have the option to treat this Agreement as null and void, and Guardian will be releasedfrom all obligations hereunder and will return the Current Policy to the Owner. Guardian assumes no responsibility forkeeping the Current Policy in force prior to the time it is surrendered to the Current Insurer.

5. The Current Policy will be surrendered by Guardian after it is determined by Guardian that it will issue a new policy tothe Owner. However, no new policy will be issued or delivered to the owner until the Current Policy is surrendered andall cash surrender funds are received by Guardian. All funds received by Guardian upon surrender of the CurrentPolicy shall be applied against the new policy as instructed by the Owner in the application for the new policy, allsubject to any limitations set by Guardian.

The Guardian Life InsuranceCompany of AmericaAdministrative Office:3900 Burgess PlaceBethlehem, PA 18017

®

011247 (10/03)

6. In the event the insured under the Current Policy dies before the new policy is issued and before the Current Policyhas been surrendered, Guardian will pay the net proceeds received, if any, by Guardian from the Current Policy to theperson or persons or entity named as beneficiary of the Current Policy immediately prior to the time when Guardianbecame owner and beneficiary or absolute assignee of the Current Policy. Guardian shall then be released from anyand all obligations arising out of this Agreement.

7. If the new policy is not accepted by the Owner during the contractual period specified in the new policy, the Ownershall have no right to the return of the Current Policy. Upon such failure by the Owner to accept the new policy,Guardian will pay to the Owner the cash surrender value of the Current Policy received by Guardian. Upon payment ofthe cash surrender value to the Owner, Guardian shall be released from any and all obligations arising out of thisAgreement.

8. The Owner agrees to execute any additional forms required by the Current Insurer to make this exchange.

9. a. While the Owner may anticipate that this exchange will result in tax free exchange treatment under Section 1035 ofthe Internal Revenue Code of 1986, the Owner understands that this Agreement neither constitutes tax advicefrom Guardian nor guarantees tax free treatment under Section 1035 of the Internal Revenue Code of 1986.

b. Guardian is not responsible for the accuracy of any tax information provided by the Current Insurer regarding theCurrent Policy.

c. Guardian, by virtue of acceptance of this agreement and application for new policy, takes no position on the statusof the new policy as a Modified Endowment Contract under Section 7702A of the Internal Revenue Code of 1986,as amended.

10. This agreement shall take effect on the later of the date it is signed by the Owner or filed with Guardian.

011247 (10/03)

Accepted By Guardian:

Date

Date

Owner

Witness

Officer

The Guardian Life InsuranceCompany of AmericaAdministrative Office:3900 Burgess PlaceBethlehem, PA 18017

Please check one:

o The Guardian Life Insurance Company of America

o The Guardian Insurance & Annuity Co., Inc.

ABSOLUTE ASSIGNMENT AND SURRENDER FORM (1035 EXCHANGE)

Policy No. (hereinafter “original Contract”), issued by

(hereinafter “original company”) on the life of(hereinafter “Insured”).

Taxpayer Social Security/Tax ID #

ASSIGNMENT OF POLICY

I hereby absolutely assign and transfer to Guardian (hereinafter “the new company”) all of mybenefits, title, options, interest, privileges and rights in the original contract.In making this assignment, I understand that the new company will surrender the original contractto the original company and the funds received by the new company will be applied to a newcontract issued by the new company pursuant to a separate agreement with me.I understand that the original company and the new company assume no liability or responsibilityand make no representations as to the validity or effectiveness of the exchange under IRC section1035 or otherwise. The new company has and assumes no responsibility for any income taxliability which may arise from this transaction. I understand that I may incur tax liability if any partof the cash value of the original contract is paid to me in cash or has been paid to me, at any time,as a loan or cash withdrawal.

WITNESS POLICYOWNER

DATE

CASH SURRENDER

In consideration of and in exchange for the cash value of the above referenced original contract,the undersigned hereby surrenders original contract for cancellation subject to its terms and thefollowing condition: Upon payment of the cash value of the policy, the original company is releasedfrom any further liability. The undersigned represents that no person or organization, except theundersigned, has any interest in the policy being surrendered.

For: GUARDIAN By:(NEW COMPANY) (SIGNATURE AND TITLE OF OFFICER)

(DATE)Forward proceeds to: The Guardian Life Insurance Company of America

ATTN:1035 Exchange Unit - 3 West3900 Burgess PlaceBethlehem, PA 18017

Received and duplicate filed at the Home Office of

in By:

(NEW COMPANY)

(CITY) (STATE) (TITLE)

011548 (Rev 10/03)

o The policy is enclosed; or o The policy has been lost, mislaid or destroyed and the newcompany agrees to return the policy if it is recovered.

Make Checks payable to: The Guardian Life Insurance Company of America

®

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