Tele-App Order Form - ikclife.com

1 A148 1 Revised January 2018 Tele-App Order form PERSONAL DATA Proposed Insured Information Full Name (First, Middle, Last) Male Female Date of Birth / / State of Birth SSN or Tax ID Occupation Driver's License Number and State of Issue Street Address City State Zip Email Address Phone Number ( ) Home Cellular Office Other Insured Full Name (First, Middle, Last)

2 Male Female Date of Birth / / State of Birth SSN or Tax ID Occupation Driver's License Number and State of Issue Phone Number ( ) Home Cellular Office PLAN DATA Life Insurance Plan Name Specified/Face Amount $ Planned/Annual Premium $ DEFRA Compliance: Guideline Premium Test (GPT) Cash Value Accumulation Test (CVAT) UL Coverage Option A B C (if available) Non-Tobacco Tobacco Riders/Benefits Accidental Death $ UL Only.

3 Assured Insurability $ Additional Life Insurance $ Charitable Giving (Term) Disability Continuance of Insurance Children's Term units Disability Payment of Premium $ Living Benefits Enhanced Living Benefits $ Waiver of Premium (Non-UL) Other Insured (complete information below) Accelerated Death Benefit for Terminal Illness Monthly Benefit $ Accelerated Death Benefit for Chronic Illness Additional Term Coverage (IUL only)

4 $ Other BILLING INFORMATION Premium * Mode Ann SA Qtly Mo PAC GA CB Single Other REPLACEMENT Will any existing life, health, or annuity contract be replaced, financed by loans, or a 1035 Exchange?

5 If so, provide the name of the company. EXISTING INSURANCE Total existing Kansas City Life Insurance Company contracts in force: $ BENEFICIARY INFORMATION Primary Beneficiary (First and Last Name) Relationship to Insured SSN or Tax ID # Date of Birth Contingent Beneficiary (First and Last Name) Relationship to Insured SSN or Tax ID # Date of Birth A148 2 Revised January 2018 OWNER (if other than the proposed Insured)

6 Primary Owner (First, Middle, Last) Relationship to Insured Date of Birth / / State of Birth SSN or Tax ID Street Address City State Zip Successor Owner (First, Middle, Last) Relationship to Insured Date of Birth / / State of Birth SSN or Tax ID Street Address City State Zip AGREEMENT 1) The statements and answers recorded in all parts of the Tele-App Order form are true and complete, to the best of my knowledge and belief. 2) I(We) have received the Notice of Information Practices, which explains my(our) rights under the Fair Credit Reporting Act.

7 3) I(We) have paid $ * to the agent in exchange for the Conditional Receipt and I(we) acknowledge that I(we) fully understand and accept its terms. *All premium checks must be made payable to Kansas City Life Insurance Company. Do not make the check payable to the agent or leave the payee blank. AUTOMATED TECHNOLOGY CONSENT Kansas City Life and its service partners, including ExamOne World Wide, use technology that includes automated telephone dialing systems and prerecorded messages ( Automated Technology ) to improve the application process.

8 I understand that I am not required to provide consent to use this Automated Technology as a condition of completing the application process or purchasing insurance or other products from Kansas City Life. Unless specified below, I consent to the parties indicated above contacting me at any of the phone numbers I have provided, including cell phones, using Automated Technology. I do not consent to the parties indicated above contacting me using Automated Technology. TAXPAYER IDENTIFICATION NUMBER CERTIFICATION Under penalties of perjury, I certify that: 1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me).

9 And 2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3) I am a citizen or other person (defined below); and 4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

10 Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN.