SURROGACY INFORMATION PACKET

Dear Future Parents,

Thank you for requesting information regarding our services at 3 Sisters Surrogacy. With offices in Houston, Dallas, and Phoenix, we offer family building services to clients all over the United States, as well as internationally.

We work closely with fertility programs, donor agencies, prospective surrogates, as well as intended parents to create an atmosphere that provides professionalism, support, and a unique experience for all involved in the path to parenthood.

Our company stands apart from other surrogacy agencies in that we are owned and operated by ART industry professionals. With over fifteen years in ART and Third-Party Reproduction experience, CEO Mary Fusillo, RN, BSN, MS, is well-versed in matching families with just the right egg donor or gestational carrier. In addition, Mary holds degrees in Nursing, Journalism/Public Relations and Public Health Administration – a unique educational and professional experience that streamlines the entire process, from initial complementary consultation through delivery.

Scientific Liaison, Sunday Crider, Ph.D., HCLD/ELD (ABB) is an Embryologist by training. Having served as a Laboratory Director for two fertility programs, as well as a Donor Sperm Bank, in the last 10 years, Sunday’s extensive scientific knowledge and medical background allows her to effectively counsel families on the nuances of surrogate selection and to make the complex world of IVF and Third Party Parenting manageable for both Intended Parents and Gestational Carriers.

We strongly believe that it is in the client’s best interest (both IP and Surrogate) to use affiliated services, such as Trust Accounts and Attorneys, that are independent of our firm. This protects both parties financially and legally.

3 Sisters Surrogacy – we are not prior surrogates, intended parents, pharmaceutical reps, lawyers, or escrow agents. We are infertility professionals, with knowledge, experience, and desire for positive outcomes.

We would be happy to consult with you to provide more information on our services. And for added convenience, we have one central number that you can call if you have any questions or to schedule an appointment with one of our client case managers: 877-976-9483

Sincerely,

Mary Fusillo, CEO Sunday Crider, Scientific Liaison

[email protected] www.3sisterssurrogacy.com 1-877-976-9483 972-499-2469 (fax)

Why Choose 3 Sisters Surrogacy?

• We offer a concierge-type service to our clients, assisting with not only surrogate matching, but also with travel booking, coordination of medical appointments, and financial matters. • We only choose the most exceptional surrogates, focusing on those that offer the gift because of their altruistic nature. • Our CEO, Mary Fusillo, has over 30 years of Third Party Parenting experience and donor recruitment, and the Chief Scientific Liaison, Sunday Crider, is a reproductive scientist that has worked almost 20 years as PhD IVF Embryologist and Laboratory Director. The combination of this experience is unique to the industry, resulting in the highest standard of service. • Surrogate Health Insurance is available through an independent broker. • All funds are held and managed with an independent escrow company, ensuring the protection of the deposits and proper distribution of monies. • All potential surrogates are pre-screened with a medical review of charts and social work assessment BEFORE being added to the database. • Our close working relationship with a number of referral clinics and R.E.’s around the country makes facilitation of off-site monitoring simple. • All inclusive fees, which include insurance, legal representation of GC during contract phase, social work evaluation, and psychological testing and evaluation of the surrogate. • Several program levels to fit all budgets. • Complimentary consultations with a member of our staff are always available. • Surrogate deposits are partially refundable if surrogate does not pass initial screening with physician and clinic and FULLY refundable if donor does not pass testing through omission of medical or psychological history. At any time the deposit may be rolled over onto a new surrogate for no additional fees. • Member of ASRM, PCRS, ESHRE, RESOLVE , AIA, AAB, ABB • Close relationship with The Donor Solution, should egg donation be needed. Offering discounts for using both companies. • Offices in Dallas, Houston, and Phoenix, serving families all over the world.

[email protected] www.3sisterssurrogacy.com 1-877-976-9483 972-499-2469 (fax) FERTILITY AND REPRODUCTIVE FINANCING NEED AN AFFORDABLE PAYMENT PLAN?

Submit an inquiry in less than a minute and receive an instant response without affecting your credit!*

LOANS UP TO TERMS UP TO NO PREPAYMENT AVAILABLE $100,000** 84 MONTHS** PENALTIES ON ANY DEVICE

ANYONE CAN SUBMIT AN INQUIRY – IF YOU DO NOT QUALIFY FOR A LOAN, ASK A FAMILY MEMBER OR FRIEND TO SUBMIT. Finance anything– procedure, medication, aftercare, anesthesia, Go to PatientFinancing.com and click on and more. 1 “Click here to submit a loan inquiry” *Only for inquiries submitted through the Standard Credit Program.

**The annual percentage rate for this loan is fixed and will not vary. Enter the provider # for your healthcare **Loan terms vary from 24-84 months based on approved credit, loan amount, and 2 the program you qualify for. For example, an 84-month term is only available on the provider Exceptional Credit Program for loan amounts greater than $25,000. Individuals requesting more than $35,000 must submit to the Exceptional Credit Program. The annual percentage rate for this loan is fixed and will not vary. All loans are fixed-rate. Enter your information and wait for your 3 loan decision

Select a loan offer*** and verify personal 4 information

5 Receive funds via direct deposit

***Loan offers are given by independent lenders based on approved credit. Not everyone will qualify. Prosper Healthcare Lending is not itself a lender. We do not make loans or loan decisions. We help you inquire about loans by sharing your information with independent lenders that may be interested in lending you the money you need for the treatments you are considering.

Information on this brochure is accurate as of 4/27/2015. Please contact Prosper HealthCare Lending for current rates and terms.

VISIT PATIENTFINANCING.COM CALL 800.625.7412 x2 EMAIL [email protected] Intended Parent Timeline Checklist This is intended to be a guide, and the order in which these items are completed may vary depending on your unique case.

 Complete and sign the Initial Intended Parent Application, Questionnaire, Background and Child Abuse forms, Exhibit A, and Agency Agreement and return to 3 Sisters Surrogacy along with pictures by fax or email.  We will review and begin the process of finding a gestational carrier for you. As we get to know you, we will select portfolios that may be a good match and send them to you. Depending on your requirements, this process may take a couple of weeks to a couple of months.  Schedule a psychological consult and physical exam for both partners, including FDA-required blood testing and urine/cervical cultures as required by your treating physician.

 Select a potential gestational surrogate. We will set up a Skype and, if possible, an in-person meeting. This will allow you to get to know the candidate. If you choose to move forward with her, a nonrefundable agency fee installment of $2000 is necessary to hold your surrogate for screening at your clinic.  Once the installment is received, we will begin creating the match portfolio - this includes the compilation of paperwork to send to the attorneys and physicians and takes up to a week. We will then arrange for the gestational surrogate's medical screening appointment with your IVF physician to review her medical history, have relevant medical testing performed, and confirm that she is an acceptable candidate to become pregnant. This cost (travel and screening) will be billed directly to the intended parent.  The potential gestational surrogate will be scheduled for psychological screening.  Once we have received confirmation from the clinic that the surrogate is medically cleared for surrogacy, contract negotiations between the surrogate and the Intended Parents will begin.  Each party will retain an attorney (we can provide referrals). Once the contract is signed, the intended parents pay 2nd installment for agency fee.

 The attorney(s) will send a Confirmation Letter, stating that the surrogacy contract has been executed.

 We will put you in contact with an escrow company specializing in surrogate compensation disbursement. They will go over the process of setting up escrow and the fees involved. Escrow account setup and management typically runs between $750 - $1000. For most funds, you will deposit the amount of the base compensation into this account, with the requirement that you must maintain a minimal balance. These funds will be managed and distributed by the escrow company.

 Life insurance is typically a requirement for surrogacy if the Gestational Carrier does not have an existing policy or is underinsured. We will assist in putting a life insurance policy in place. These policies typically run around $400.

[email protected] www.3sisterssurrogacy.com 1-877-976-9483 972-499-2469 (fax)  If your surrogate is to travel to your clinic, it may be necessary to obtain credit card travel authorization required or cash/check deposit of estimated travel expenses if not already deposited into the escrow account.

 Once the contract is signed, you and your gestational surrogate will be receiving a cycle calendar from your clinic. Your final installment for the agency fee is due 7 days prior to Embryo Transfer. Delay in receipt of the final installment may result in a delay of embryo transfer.  3 Sisters Surrogacy will be frequently checking in with all parties to help coordinate any necessary travel or appointments.  The FET will occur in approximately 4 weeks after started the FET Calendar. A pregnancy test is generally performed approximately ten days after the embryo transfer with a confirmatory ultrasound about two weeks after the positive test.  At about 16 weeks of pregnancy, your attorney will draw up a pre-birth order for both parties to sign. This document will establish you as the legal parent(s) of the child before it is born. Be sure to keep a copy of this document on hand to take to the hospital at delivery.

 Should you so desire, doula services can be arranged for the birth. A doula is a great resource for first time parents, and can make the birth experience very special by assisting during the delivery and easing the transition of the baby to his/her parents.  During the birth, the gestational carriers are usually very open to having at least on of the parents present to witness the birth of their child. Be sure to take lots of pictures! The hospital will generally set up a separate room so that you can "room-in" with your baby. Your names will be on the birth certificate and you will be able to take your baby home in about a day, providing there are no complications.

[email protected] www.3sisterssurrogacy.com 1-877-976-9483 972-499-2469 (fax)

Gestational Surrogate (First name, last initial)

Date Completed 2018 CONTRACT WORKSHEET The purpose of this document is to outline your wishes regarding the surrogacy process and contract. It entails some of the more common contract items, including financial requests. The amounts listed are industry averages, but you do have the opportunity to set your own fees. This form will be reviewed by the Intended Parents as well as attorneys for both parties to draft the Gestational Agreement. Please complete, initial each column accepting the given amount (or other amount), and sign. This document will be shared with potential intended parents and submitted to the attorneys to begin the contract process.

1. How many embryos are you willing to transfer? ______

2. Would you be comfortable with carrying:  Singleton only  Singleton or Twins  Twins or Triplets 3. How many attempts are you willing to try with your matched Intended Parents: ______

4. Regarding a possible physician-advised and Intended Parent’s wishes for termination/selective reduction of the surrogate pregnancy, would you be comfortable with (you can select more than one):  Termination for Down’s Syndrome  Termination for other genetic disorder  Termination for Severe Medical or Developmental abnormalities  Termination for Minor abnormalities (Cleft left, palate; club foot, etc)  Selective Reduction to reduce the number of fetuses (in a twin or greater pregnancy)  Any Instance  I would not be comfortable with termination for any reason unless my life is at risk

5. With the exception of above would you allow the Intended Parents to make the medical decisions regarding their baby during pregnancy? This may include testing, chorionic villus sampling, amniocentesis, etc. This would not include decisions when the surrogate’s health is in danger.  Yes No

6. What kind of contact would you like to have with the Intended Parents during the pregnancy?  Daily Weekly Monthly  Calls Email Text Skype

7. In the event of a life-threatening illness or injury during the pregnancy, would you consider having your life sustained on life support until the baby can be delivered?  Yes No

8. Do you have any plans on traveling/vacation in the next 12 months?  Yes No Where?______

9. Do you currently work?  Yes No (if no, will not be entitled to lost wages)

Full time?  Part time?  PRN? 

10. If no, do you plan on getting a job in the next 12 months?  Yes No

11. Do you have disability insurance?  Yes No

12. Do you have life insurance?  Yes No

13. Who is your current health insurance carrier?______ Individual Group

MONETARY REQUESTS for GESTATIONAL SURROGACY

Please review each line item below. Input your request and initial. These amounts will be used in the drafting of the Gestational Agreement (although the intended parents may counter offer). These amounts are about average for TEXAS. If you have any questions regarding any particular item, don’t hesitate to email your case manager.

Item Description Suggested Your request Amount and/or initials Base Compensation – *1st Time Surrogate $28,000 with no insurance or insurance with exclusion Paid monthly at confirmation of pregnancy by fetal st heartbeat. If baby is born on or after 32 weeks after *1 Time Surrogate $30,000 embryo transfer, all payments for base compensation with insurance/no surrogacy exclusion will be made, even if child is stillborn. If baby is born prior to 32 weeks, and does not survive to discharge, compensation will cease as of delivery date.

ǂBase Comp Add-ons *Experienced Surrogate $5000 and up *International IPs add $2500 *Special circumstance (Communicable add $2000 disease, etc) ǂMultiples Fee A contingency for carrying twins or more $5000 per additional fetus Paid monthly starting at 16 weeks of pregnancy, with any balance due within 14 days of delivery. If babies are born on or after 30 weeks after embryo transfer, all payments for base compensation will be made, even if child(ren) is stillborn. If babies are born prior to 30 weeks, and does not survive to discharge, compensation will cease as of delivery date.

Med Start Non-injectable meds for cycle (excluding $500 birth control; includes estrace and similar) This fee will start on the first business day of the month -OR- after signing Gestational Agreement with Intended Injectable (Lupron, etc) for cycle $500 Parents.

Embryo Transfer Per attempt $750

To reimburse for lost wages, miscellaneous expense while on physician-ordered bedrest for embryo transfer. Travel expenses may still apply.

ǂCancelled Cycle Per cancellation $750

To be paid if the embryo transfer cycle is cancelled at no fault of the surrogate. If the cycle is cancelled, the $500 paid at med start applies to the cancelled cycle fee. Remaining comp is $250 of a total of $750.

ǂInvasive Procedure Hysteroscopy $750

Amniocentesis (each needle insertion) $750 Chorionic Villus Sampling $750 Dilation and Curettage (D&C) $1000 Selective Reduction (each needle $1000 insertion) Surgical procedure related to ectopic $1000 pregnancy, each tube Any other procedure requiring anesthesia $1000 Any other invasive procedure not $750 requiring anesthesia. (Each event - Blood transfusion, uterine clot removal by physician, endometrial receptivity assay or other endometrial biopsy, cerclage, etc. Does not include routine bloodwork, ultrasounds )

ǂTermination of pregnancy Vacuum aspiration; Dilation and $2500 Evacuation; labor induction for the As recommended by the physician or requested by IPs purpose of termination (due to fetal death)

ǂMiscarriage Medically-induced miscarriage (by $1000 medication) after confirmation of pregnancy (heartbeat at ultrasound) ǂC-Section Medically advised, unscheduled, planned, $3000 or repeat

ǂHysterectomy Partial or total hysterectomy as a result of $4000 pregnancy (up to 3 months post- termination or delivery) ǂLoss of ovaries or fallopian tubes Loss of any ovary(ies) or fallopian tube(s) $1000 as a result of pregnancy, and up to 3 If loss is due to ectopic pregnancy, the “Surgical months post-termination or delivery. procedure related to ectopic pregnancy” fee will apply.

Monthly Allowance To start once contract is signed until 2 $200 months after delivery (or terminated contract) This allowance will start on the first business day of the covers expenses such as mileage less than month after signing Gestational Agreement with 50 miles, tolls, postage, housekeeping, Intended Parents. vitamins, childcare for doctor visits, notary fees, meals during in-town travel Maternity Clothes Singleton $500 Multiples $750 Payable on the 1st of the month following 14th week after embryo transfer. Travel Expenses Mileage (over 50 mile round trip) $0.50/mile Airfare Actual Uber/Taxi/Rental Car Actual Receipts must be provided to 3SS Hotel Actual Meals $50/day Companion Meals $25/day Companion airfare for transfer only Actual ǂLost Wages If physician-ordered restricted work or Based on actual bed rest after surrogate becomes net wages after Must provide documentation, including letter from pregnant, or for appointments, or post- mandatory physician and dates. Paycheck stubs (3) must be delivery. (if applicable and if not using deductions not provided. Calculated at $__.__ max gross hourly wage; sick or vacation time). This includes up to covered by max ___hours per week. 4 weeks post-vaginal and up to 6 weeks disability. post c-section with physician’s note.

ǂPartner’s Lost Wages (if applicable) If applicable, and if not using sick or Based on actual vacation time. net wages after mandatory deductions not covered by disability. Actual hourly rate up to

40hours or 5 days. ǂBedrest For physician-ordered bedrest, either $200/wk home or hospital. To include weekly meal Cap at $5000 Surrogate must provide receipts to 3SS to be eligible for delivery, childcare (in addition to those reimbursement. To reimburse for expenses incurred for normally incurred) as needed, weekly activities she cannot perform. Must provide letter from physician stating necessity. housekeeping during period of bedrest.

ǂChildcare Childcare beyond that normally incurred Actual rate for the care of children. Would include care for children when surrogate is traveling to screening and transfer, doctor visits, etc. Must provide receipt. ǂHousekeeping If placed on physician-ordered restricted Actual up to activity or bedrest $100/wk.

ǂBreast Milk If requested by IPs $250 per week

Life Insurance $250K – $1M policy Actual expense $350-800 Health Insurance/Medical If GC has pre-existing insurance with no $0 exclusions through an employer OR is paying for an individual plan herself.

If GC does not have pre-existing with no Actual premium exclusions – IPs to purchase. Copayment, Coinsurance, and Deductibles Actual premium Medical Screening (bloodwork, IP will pay hysteroscopy, saline ultrasound, actual for etc)/Embryo Transfer Cost pregnancy- related expenses ǂPsychological Support from licensed Counseling services for pregnancy-related Actual rate Mental Health Professional counseling if needed during pregnancy, or post-delivery, miscarriage, or termination. If covered by insurance, IP will pay copayment/co- insurance for visits during pregnancy or up to 1 month post-birth, miscarriage, or termination.

Attorney Fees Gestational Surrogate 3SS will provide an attorney for contract review and cover that cost. Intended Parent(s) IP will have independent representation and will pay actual

ǂ - indicates “contingency” items – will only be paid if event occurs Any additional requests:

GESTATIONAL SURROGATE: I understand that this is not a contract, but a worksheet to assist in the determination of contractual items. Actual amounts that are written into the contract may be different. 3 Sisters Surrogacy does not employee attorneys, nor do they offer legal advice.

Gestational Surrogate Signature

Date

3 Sisters Surrogacy Fee Exhibit A Thank you for choosing 3 Sisters Surrogacy for your family building! Our team at 3 Sisters Surrogacy is committed to providing the very best experience for both you and your gestational carrier. And, we are proud to be offering one of the most cost- effective, straight-forward agency fees in the country. Our fees include candidate recruitment, screening and interview, facilitation of the match process, including Skype and/or in-person meetings, assistance with scheduling travel and physician visits, support for both the parents and surrogate through the matching and clinical process leading up to confirmation of pregnancy. **Ask us about our discount when using egg donors from The Donor Solution!**

BASIC Program $6,500 The BASIC program is for couples with a known gestational carrier or doing an “independent” journey. This package includes case management until pregnancy confirmation. Payment is due in full with application. Criminal Background Check Included Medical Records Review Included Social Work Visit Included Insurance Review Included Psychological Screening of Surrogate Candidate with PhD Included Psychologist Psychological Testing Included Cycle Management until Pregnancy Confirmation: Included Coordination of appointments Coordination of travel Coordination of legal contracts Coordination of escrow establishment Updates to all parties On-call Case Manager Attorney Fees for Gestational Surrogate Included TRAVEL ESCROW – if matched with an out-of-town gestational $2500 carrier. Remaining balance can be refunded or applied to subsequent installments. CLASSIC Program $12,950 The CLASSIC program is for couples being matched with a gestational carrier represented and screened by 3 Sisters Surrogacy. This package includes case management until pregnancy confirmation. Payment is in 3 installments: $2000 once matched (1st installment), $6450 when gestational agreement is executed (2nd installment), and $4500 due 7 days before embryo transfer (3rd installment). Travel escrow funds (if needed) due with 1st installment. BASIC PROGRAM items listed above Included Matching with a 3 Sisters Surrogacy Gestational Carrier Included Gift from Agency for Surrogate at Birth Included TRAVEL ESCROW – if matched with an out-of-town gestational $2500 carrier. Remaining balance can be refunded or applied to subsequent installments.

PREMIER Program – our most popular! $15,950 The PREMIER program is for couples that request pregnancy management as part of their experience. This package includes case management until delivery. Payment is in 4 installments: $2000 once matched (1st installment), $6450 when gestational agreement is executed (2nd installment), $4500 due 7 days before embryo transfer (3rd installment), $3000 due at confirmation of pregnancy (4th installment). Travel escrow funds (if needed) due with 1st installment. CLASSIC PROGRAM ITEMS listed above Included Pregnancy Management: Included On-Call Case Manager Weekly calls/reports Coordination of birth documentation with attorneys and hospital Designing a birth plan BUMP BOX Subscription for GC Surrogate gift at birth TRAVEL ESCROW – if matched with an out-of-town gestational $2500 carrier. Remaining balance can be refunded or applied to subsequent installments.

CONCIERGE Program $19,950 The CONCIERGE program is for couples that want the entire no-hassle surrogacy and pregnancy experience! This package includes case management through birth, plus coordination of many pre- and post-natal services. Payment is in 4 installments: $2000 once matched (1st installment), $6450 when gestational agreement is executed (2nd installment), $4500 due 7 days before embryo transfer (3rd installment), $7000 due at confirmation of pregnancy (4th installment). Travel escrow funds (if needed) due with 1st installment. STANDARD PLUS Items listed above Included Nursery design Included Coordination of Birth Photographer Nursery Registry Coordination of Doula Coordination of Lactation Consultant Coordination of nanny services Baby shower planning Gift planning for gestational surrogate throughout pregnancy TRAVEL ESCROW – if matched with an out-of-town gestational $2500 carrier. Remaining balance can be refunded or applied to subsequent installments.

Special Services International Fee $1500 International case management fee required for those living outside the US. Due with 2nd Installment. In-person Case Manager for Transfer/Medical Appointments/Birth $1000/day plus We will send one of our case managers to be with the surrogate during actual travel, procedures, appointments, and even birth! Due 1 week prior to travel lodging, and meal date. expenses. Consultation Services $200/hr in 15 min For those couples wanting to manage their independent surrogacy, we increments offer consultation by the hour to guide you along the way. California Escrow Management $500 Due to California law, all escrow accounts managed by California companies must first be approved by 3SS. This fee covers the agency side of the process and will be in addition to the escrow company’s fee. Due with 2nd Installment.

I (we) understand the above costs, what all is included, and payment schedule for the 3 Sisters Surrogacy Agency Fee. I (we) understand that the deposit for the Agency Fee is nonrefundable, but that we are able to utilize it for a different carrier if (1) the gestational surrogacy candidate does not pass screening, or (2) the candidate is unable to proceed or declines to continue prior to contract phase. I (we) acknowledge that all fees must be paid prior to embryo transfer or the procedure may be postponed. I (we) have read and understand the payment structure as outlined in the Agency Agreement.

Parent Signature Date Parent Signature Date

Parent Name (printed) Parent Name (printed)

3 Sisters Surrogacy INTENDED PARENT APPLICATION FOR SURROGACY 4265 San Felipe Road, Suite 1100 Houston, Texas 77027

Thank you for completing the Intended Parent Application. This information will help us to select the best gestational surrogate candidate profiles for your review. In addition to the application, we will also need the following:

1. Completed Background Check and Child Abuse Check forms, signed Exhibit A 2. Photographs of you (to be shared with the candidate prior to interview) 3. Signed Agency Agreement and 1st Installment of Agency Fee billed at Surrogate Selection INTENDED PARENT INFORMATION IP1 Last Name IP1 First Name Birthdate

IP2 Last Name IP2 First Name Birthdate

Address City State/Country Zip Phone 1 Phone 2 Phone 3/Fax Email 1 Email 2

INTENDED PARENT 1 INTENDED PARENT 2

Occupation Occupation Place of Birth Place of Birth Religion Religion Race Race

Nationality Nationality Educational Educational Degree Degree Major Major College College Post Graduate Post Graduate

BACKGROUND INFORMATION

How long have you been married (if applicable)

How did you meet?

Do you have any children currently?

3 Sisters Surrogacy INTENDED PARENT APPLICATION FOR SURROGACY 4265 San Felipe Road, Suite 1100 Houston, Texas 77027

Do you have an infertility diagnosis? Please briefly explain.

Have you seen a physician regarding this Who? When? issue? Where are you in the infertility process? Just starting/testing, donor selection/frozen embryos, etc.

What IVF Clinic will you be using? Contact info?

Has a Medical Doctor confirmed that you are in need of an egg donor and/or surrogate?

Are you considering: EGG DONOR ☐ SPERM DONOR ☐ GESTATIONAL SURROGATE ☐ Are you willing to share identifying information with your gestational surrogate?

Would you like to use a particular doctor? Who?

Do you wish to attend your gestational surrogate’s prenatal appointments? How (and how often) would you like to keep in contact with your gestational surrogate during the pregnancy?

In the event of a multiple pregnancy, would you be requesting your surrogate to undergo selective reduction?

Would you require your surrogate to have an amniocentesis?

In the event of fetal abnormalities, would you request the surrogate to terminate the pregnancy?

Would you consider a gestational surrogate of a different ethnicity than you? If so, which ones would you be interested? (Most of our surrogates are Caucasian, Hispanic, or African American)

Do you plan on attending the birth of your child?

3 Sisters Surrogacy INTENDED PARENT APPLICATION FOR SURROGACY 4265 San Felipe Road, Suite 1100 Houston, Texas 77027

What sort of relationship (if any) would you like to have with your gestational carrier after delivery?

How do you feel about not having a genetic linkage to the baby (if using donor)?

How do your families feel about what you are doing?

What else would you like us to know about you? (Use additional paper if desired)

How were you referred to 3 Sisters Surrogacy?

SIGNATURE

Your signature below indicates that information contained in this Gestational Surrogacy Application is true and correct at the time of completion and will be updated by you should any events occur in your lives which render the information herein inaccurate prior to finalization of your surrogacy. Please include a current photograph of yourselves.

Intended Parent #1 Signature Date

Intended Parent #2 Signature Date

3 Sisters Surrogacy INTENDED PARENT PROFILE

Please help us and your future gestational surrogate get to know you!

IP1 First Name IP1 Age

IP2 First Name IP2 Age

Tell us a little about where you are from.

And where do you live now? How long have you been together/married?

What do you do for a living?

Do you have any hobbies?

3 Sisters Surrogacy INTENDED PARENT PROFILE

How would you describe your personalities?

Do you have any children currently?

Are you religious or spiritual? If so, what do you practice?

What is your reason for seeking the assistance of a gestational surrogate?

3 Sisters Surrogacy INTENDED PARENT PROFILE

What type of relationship do you desire to have during the pregnancy? What level of contact?

Will you be doing a fresh or frozen cycle? If frozen, how many embryos do you have? PGS tested?

How many embryos are you wanting to transfer? Do you want a singleton or twins?

How do you feel about termination/selective reduction?

How do you envision the delivery of the baby? By a doctor or midwife? Hospital, birthing center, home? Who present?

3 Sisters Surrogacy INTENDED PARENT PROFILE

What type of relationship do you desire to have after the pregnancy?

Any additional information you’d like the surrogate to know?

International intended parents face a vast and often unfamiliar U.S. healthcare system. Obtaining coverage for newborn medical expenses can be expensive and overwhelming. To simplify the process for intended parents from outside the U.S., Universal Family Insurance and ART Risk Financial and Insurance Solutions are proud to offer Newborn Coverage policy options specifically for children born in the U.S. through surrogacy. Intended parents can choose their coverage based on individual needs and comfort level. These insurance plans: • Eliminate any concern of legality Plan Highlights issues • Up to $1 Million in newborn • Remove the complexity and liability medical expense uncertainty of obtaining coverage insurance coverage for children • Singleton and twins coverage born in the United States available through surrogacy • Variety of premiums and self • Simplify things for intended retention amounts available parents, agencies, and attorneys • No limited network of providers—plans cover any For more information, hospital or doctor nationwide please contact our retail broker, • Includes The Newborn Resource, ART Risk Financial and Insurance Solutions: with skilled claims negotiation by www.artrisksolutions.com NES Assurance Tel. 661-257-6242 • S&P A+ (Strong) Rated Insurer

Note: “Newborn Insurance Coverage” is Contractual Liability Reimbursement Indemnity Insurance and should not be considered Basic Hospital or Basic Major Medical Health Insurance Coverage. Plan provides financial case management and self pay reimbursement insurance coverage. Lockton, State Licensed Producer. Insurance taxes and fees not included. The Newborn Resource financial case management plan is coordinated by ART Risk Financial and Insurance Solutions, a licensed retail health insurance broker.

Newborn Insurance

Terms and Conditions Between the Ages of 21 – 38. Surrogates greater in age may be eligible, previous pregnancies must be free from complications Underwriters would consider a Surrogate candidate with prior complications but with appropriate policy exclusion(s), terms and conditions to apply.

Network Providers: No Restrictions. May use any doctor or hospital within the United States.

NES Assurance, Financial Case Management Firm, in conjunction with Universal Claims Administrator: Family Insurance, LLC.

Coverage Period: 60 days from date of birth; or until Newborn leaves the US, whichever is sooner.

$125,000; $250,000; or $500,000 per child depending upon policy limit purchased, Maximum Policy Limit: unless otherwise agreed.

All covered medically necessary expenses for newborn and NICU care payable at the Hospital Expenses: 90th percentile of Usual, Customary and Reasonable (UCR) costs.

Should bills exceed 90th percentile of UCR, amounts not indemnified and will be Balance Billing: responsibility of the insured.

Out of Network Payment Not Applicable, NO NETWORK RESTRICTIONS Percentages: All covered medically necessary NICU and Nursery charges payable at the 90th Physician, Nurse, Specialist percentile of UCR.

Medically necessary emergency transport to a medical facility for emergency care or Emergency neonatal medical care to nearest suitable facility – limited to $5,000.00 in the Transportation: aggregate.

All medically necessary covered prescriptions will be 100% reimbursed based on Prescriptions: policy terms and conditions When to Purchase: Upon confirmation of pregnancy

Yes, however plan is medically underwritten and complications to date will be taken Purchase Mid-Pregnancy? into account, underwriters reserve the right to deny coverage.

Surrogacy contract and power of attorney/grant of authority should be executed in US; Contract to require IP to pay medical expenses of surrogate/newborn; Power of Additional Requirements: Attorney given by IP to TRG Management Systems authorizing TRG to control the escrow account on behalf of IP’s from which medical expense payments are made; Premium to be paid to TRG Management systems; All claims paid in the US.

25020 Ave Stanford Suite 140 * Valencia * CA 91355 *661-257-6242 FAX 661-257-0110