Symetra Life Insurance Co

TERM LIFE and AD&D Policy#: INSURANCE ENROLLMENT FORM Underwritten by: For Symetra Life Insurance New Hires Co 777 108th Ave NE, Ste Diocese of Stockton 1200 Bellevue, WA 98004- 5135 Phone 1-800-426- 7784 | Fax 1-866-348- 0056 |

Applicant Name: Social Security #: - - Date of Hire: / / Date of Birth: / / Hours Worked per Week: Annual Earnings: $

 I elect the following coverage (please circle one cost option): Monthly Monthly Term Life Employee Cost Employee Cost – AD&D

(see rate sheet) ($.027 per $1,000 increment) $ 10,000 $ 25,000 $ 50,000 $ 75,000 $100,000 $125,000 $ 150,000 $ 175,000

Non-Medical Maximum is: Spouse Non-Medical Maximum is: $175,000 $25,000

No te: Any Life amounts over the non-medical maximum are subject to medical evidence of insurability. The cost of your coverage may vary slightly due to rounding differences. Spouse Life Coverage: Child Life Coverage: $ 10 , 0 0 0 Spouse Life Premium: Child Life Premium: $2.94 _ Up to 100% of employee amount Child(ren) Dates of Birth Not to exceed $175,000.

Spouse AD&D Premium:______Child(ren) AD&D Premium:___.030______($.028 per $1,000 increment)

TOTAL MONTHLY PREMIUM (Employee, Spouse, Child(ren): $ Total PER PAY PERIOD Premium: $

Spouse Information (complete only if spouse coverage is selected) Name: Social Security #: - - Date of Birth: / / Primary Beneficiar(ies) Name: Name:

Relationship: Benefit %: Relationship: Benefit %:

Contingent Beneficiary(ies)

Name: Name:

Relationship: Benefit %: Relationship: Benefit %:

I understand that any coverage I am requesting is subject to all the terms of the policy including any exclusions, any provisions requiring the submission of Evidence of Insurability and approval by Symetra, and any provisions specifying a Delayed Effective Date in the event that I am absent from work or an eligible dependent is totally disabled on the date coverage would otherwise begin. I also understand that if I submit Evidence of Insurability for additional coverage, the Effective Date for the additional coverage will be the first of the month coincident with or next following the date Symetra approves my submission.

I certify that all statements are true to the best of my knowledge and belief and I understand a copy of this form will be made available at my request. I authorize my employer to make the necessary deductions from my salary or wages to pay the premium when my insurance becomes effective.

Employee Signature: Date: / /