Life App Email Initiated

DocuSign Envelope ID: F32F4D21-B168-4E01-88D6-6AEC60525B37
RightBridge report prepared by: Steve Bernstein | johnny feliciano | 10/19/2020 | Page 1
CASE NAME DATE
johnny feliciano 10/19/2020

Case Information
Information Value Information Value Information Value
Print Revision 1 Loans $3,500,000 Policy Owner/Insured Relationship The owner is the insured
First Name johnny Income Replacement $0 Length of Insurance Needed Intermediate: 11 - 20 years
Last Name feliciano Final Expenses $0 Premium Flexibility Preference Prefers guarantees over flexibility
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Age 58 Education $0 Features vs Fees Preference Favors lower premium over features
Gender Male Monthly Income Available for Premium $300.00 Life Insurance Objective Basic Needs
Marital Status Married Investable Assets $100,000 Financial Objectives/Needs Addressing Housing\Mortgage Costs
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Employment Status Employed Total Assets $600,000
Income $120,000 Total Debts $0
Household Income $150,000 Current Life Insurance Holdings $0
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Tax Bracket 22% Mutual Fund Experience More than 10 years
State Of Issue NY Annuity Experience No Experience
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Financial Dependents 0 Equity Experience More than 10 years
Risk Tolerance Conservative Life Insurance Experience Less than 1 Year
Validation Face Amount $300,000 Funding Sources Current Income
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Validation Estimated Annual Premium $2,014.00 Accepts Non-guaranteed Policy
Elements No
Covered Lives Single Life (Insured's life

only)
Purchase Type New policy
The RightBRIDGE® Life Insurance Wizard® presents “bridges” that are suggestions, not recommendations or solicitations. Using RightBRIDGE® is not a substitute for due diligence. CapitalRock does not offer investment or financial advice and the RightBRIDGE® application
is intended to be an analytic tool and is not a replacement for a product prospectus. The information in this tool and report is not guaranteed as accurate or complete. Refer to each product prospectus (when applicable) for specific product information. CapitalRock, LLC is
not responsible for any losses or damages resulting from use of the information in this tool or report for any purpose. ©Copyright 2020 CapitalRock
Notes
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State Farm - Term 20

Information Value Information Value
Term/Perm Term Pay Until 20 years
Policy Type Term Premium Type Level Premium
Lives Type Single Or Joint Convertible To

Perm Yes
Min Age 18
A.M. Best A++
Max Age 65
Standard &
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Poor's AA
Min Face Amount $100,000
Max Face Amount $99,999,999 NOTICE: The strategies represented are not actual products for sale. Graphs displaying rates,
premium, death benefit and cash value are for educational purposes only and are designed to
demonstrate a relationship between premiums paid and future values.
TERM LIFE
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Product Provides coverage for a limited time period (term), if premiums are paid.
Description
Provides a death benefit, but typically no cash value.
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Initially, less expensive form of life insurance.
May be renewable or convertible.
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Reasons to consider State Farm - Term 20

Area Status Area Status
Age Financial Experience
Annual Income Affordability
Funding Resources Liquid Net Worth
Financial Objectives/Intended Use of Policy Risk Tolerance
Existing Assets Tax Status
Financial Time Horizon Non-Guaranteed Policy Elements
features .
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It was indicated that the proposed policy owner Favors lower premium over
This product aligns with the proposed policy owner's preference regarding the amount of features available and
Financial Time Horizon: The proposed policy owner has indicated the needed
length of insurance is Intermediate: 11 - 20 years .
This term policy aligns with the coverage length needed as indicated by the proposed policy owner.
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associated premium.
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Financial Experience: The proposed policy owner meets the minimum required Financial Time Horizon: The proposed policy owner has debt obligations for 0
financial experience for this product. years .
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The proposed policy owner has indicated that they have More than 10 years working with mutual funds, No This term product provides coverage for 20 years and covers the length of the debt obligations indicated.
Experience working with annuities, More than 10 years working with equities, and Less than 1 Year working with
life insurance.
Financial Objectives/Intended Use of Policy: This product may be a primary

option for 1 of the need(s) identified for the proposed policy owner.
The needs of Addressing Housing\Mortgage Costs may be supported by this product type.
ssFunding Resources: The source of funding is Current Income .
This source of funds may be appropriate for this purchase.
Affordability: The proposed policy premium is within the proposed policy owner's Affordability: The proposed policy owner's debt to income ratio (including the
available amount for monthly premiums. proposed premium for this policy) is 1.68% .
The proposed policy's annual premium was entered as $2,014.00 , which is $167.83 monthly. This value is It is suggested that the proposed policy owner's debt and liabilities to income ratio does not exceed 66% .
within the $300.00 that the proposed policy owner indicated is available for monthly premiums.
Affordability: The proposed policy owner's monthly income available for It was indicated that the proposed policy owner Prefers guarantees over
premium represents 3% of their monthly income. flexibility when considering a life insurance policy.
In general, it is suggested that the proposed policy owner's policy payment does not exceed 10% of their Flexibility vs guarantees may not be an important factor when considering a term product.
monthly income.
additional insurance need of $3,500,000 of life insurance.

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Based on the insured's situation, it was calculated that they may have an It was indicated that the proposed policy owner's risk tolerance is Conservative .
Risk tolerance may not be an important factor when considering a term product.
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This policy is being validated at a face amount of $300,000 .
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The proposed policy owner indicated that the insured does not have any existing The proposed policy owner indicated that they have no debts/liabilities.
life insurance policies.
Policy suggestions are based on the proposed policy owner having no debts or liabilities.
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Based on the information gathered, the policy suggestion assumes that the insured does not currently own any
life insurance.
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Summary
Thank you for completing the Life Insurance Wizard Report.
Complete the life application
Review, complete, and sign the Life Insurance Wizard Report Disclosure and Attestation
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Guarantees based on the claims-paying ability of the issuing State Farm Life & Accident Assurance Company.
Neither State Farm nor its agents provide tax or legal advice.
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State Farm Life and Accident Assurance Company (Licensed in NY and WI)
Bloomington, IL
Not FDIC insured No Bank Guarantee

May Lose Value
Life Insurance Wizard Report Disclosure and Attestation

New York Regulation 194 Disclosure:
The role of the insurance producer is to solicit applications, collect premiums, countersign, and deliver policies, reinstate and transfer insurance, assist customers, and cooperate
with State Farm Life and Accident Assurance Company representatives in reporting and handling claims.
The agent assigned to your policy will receive compensation from State Farm® based on the sales of insurance products. Compensation may vary depending on a number of
factors, including quality, production, product mix, and growth targets.
You may obtain more information about your agent's compensation, upon request, for the insurance products you purchase.
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Signature(s) on following page(s)
Doc type 53
Page 1 of 3
1010750 2001 156303 201 08-13-2020
New York Regulation 187 Agent Documentation:

New York Regulation 187 requires all recommendations be in the customers’ best interest. Appropriate agent documentation explaining the recommendation is required as part of
the suitability review.
Answer each question below. Include specific considerations that influenced the recommendation, final product and amount selected. These may include: affordability, duration of
coverage, product features, and a desire for living benefits.
1. Explain why the product applied for was selected. Include in the response the factors that may have influenced the recommendation.
primary concern is for mtgee protection for spouse
2. If the product is indicated as yellow or red on the Life Insurance Wizard, please include why the product being applied for is preferred over other products.
Not Applicable
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3. Explain how the amount of insurance was determined. This may include insurance to cover a specific need or if a needs analysis was completed. If the amount differs from the
needs analysis, please include why the amount applied for is different.
approx. 350 left on mtge
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Page 2 of 3
1010750 2001 156303 201 08-13-2020
New York Regulation 187 Customer Attestation:

The Life Insurance Wizard Report is not a contract of life insurance nor is it a guarantee that any life insurance product and/or coverage amount specified in the report will be issued.
Any application for life insurance submitted is still subject to underwriting requirements.
By signing below, I acknowledge I have received a copy of the Life Insurance Wizard Report. The information I provided on the Life Insurance Wizard report and application is
complete and accurate to the best of my knowledge.
I further acknowledge that neither State Farm nor its representatives offer legal or tax advice.
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#$S01 10/20/2020
#$D01
Applicant/owner signature Date (mm/dd/yyyy)
Joint applicant/owner signature Pr Date (mm/dd/yyyy)
New York Regulation 187 Agent Attestation:

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I affirm that I have reviewed the Life Insurance Wizard report with the applicant and informed them of the various features and potential consequences, both favorable and
unfavorable, of the life insurance product(s) recommended and applied for.
#$SAgent
Agent signature
#$Dagent
Date (mm/dd/yyyy)
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Page 3 of 3
1010750 2001 156303 201 08-13-2020
Doc
Type: 25
APPENDIX 11
DEPARTMENT OF FINANCIAL SERVICES OF THE STATE OF NEW YORK
DEFINITION OF REPLACEMENT
IN ORDER TO DETERMINE WHETHER YOU ARE REPLACING OR OTHERWISE CHANGING THE STATUS OF
EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS, AND IN ORDER TO RECEIVE THE VALUABLE
INFORMATION NECESSARY TO MAKE A CAREFUL COMPARISON IF YOU ARE CONTEMPLATING REPLACEMENT,
THE AGENT OR BROKER IS REQUIRED TO ASK YOU THE FOLLOWING QUESTIONS AND EXPLAIN ANY ITEMS
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THAT YOU DO NOT UNDERSTAND.
AS PART OF YOUR PURCHASE OF A NEW LIFE INSURANCE POLICY OR A NEW ANNUITY CONTRACT, HAS
EXISTING COVERAGE BEEN, OR IS IT LIKELY TO BE:
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(1) LAPSED, SURRENDERED, PARTIALLY SURRENDERED, FORFEITED, ASSIGNED TO THE INSURER
REPLACING THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT, OR OTHERWISE TERMINATED?
YES NO
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(2) CHANGED OR MODIFIED INTO PAID-UP INSURANCE; CONTINUED AS EXTENDED TERM INSURANCE OR
UNDER ANOTHER FORM OF NONFORFEITURE BENEFIT; OR OTHERWISE REDUCED IN VALUE BY THE
USE OF NONFORFEITURE BENEFITS, DIVIDEND ACCUMULATIONS, DIVIDEND CASH VALUES OR OTHER
CASH VALUES?
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YES NO
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(3) CHANGED OR MODIFIED SO AS TO EFFECT A REDUCTION EITHER IN THE AMOUNT OF THE EXISTING
LIFE INSURANCE OR ANNUITY BENEFIT OR IN THE PERIOD OF TIME THE EXISTING LIFE INSURANCE OR
ANNUITY BENEFIT WILL CONTINUE IN FORCE?
YES NO
(4) REISSUED WITH A REDUCTION IN AMOUNT SUCH THAT ANY CASH VALUES ARE RELEASED, INCLUDING
ALL TRANSACTIONS WHEREIN AN AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS
TO BE RELEASED ON ONE OR MORE OF THE EXISTING POLICIES?
YES NO
(5) ASSIGNED AS COLLATERAL FOR A LOAN OR MADE SUBJECT TO BORROWING OR WITHDRAWAL OF ANY
PORTION OF THE LOAN VALUE, INCLUDING ALL TRANSACTIONS WHEREIN ANY AMOUNT OF DIVIDEND
ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE BORROWED OR WITHDRAWN ON ONE OR MORE
EXISTING POLICIES?
YES NO
(6) CONTINUED WITH A STOPPAGE OF PREMIUM PAYMENTS OR REDUCTION IN THE AMOUNT OF PREMIUM
PAID?
YES NO
1007068 Page 1 of 2 2002 148109 202 03-20-2019

IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, A REPLACEMENT AS DEFINED BY NEW
YORK INSURANCE REGULATION 60 HAS OCCURRED OR IS LIKELY TO OCCUR AND YOUR AGENT OR BROKER IS
REQUIRED TO PROVIDE YOU WITH THE IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE
INSURANCE POLICIES OR ANNUITY CONTRACTS. YOU WILL ALSO RECEIVE A COMPLETED DISCLOSURE
STATEMENT NO LATER THAN THE TIME YOUR NEW POLICY OR NEW CONTRACT IS DELIVERED.
Date: Signature of Applicant: #$S01 - for office use only
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#$D01 - for office use only
10/20/2020
Date:
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Signature of Applicant:
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TO THE BEST OF MY KNOWLEDGE, A REPLACEMENT IS INVOLVED IN THIS TRANSACTION: YES NO
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Date: #$Dagent - for office use only
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Signature of Agent or Broker: #$Sagent - for office use only
1007068 Page 2 of 2 2002 148109 202 03-20-2019

State Farm Life and Accident

Assurance Company
1 State Farm Plaza, Bloomington, IL 61710-0001
Summary Adjustment of Premium

understanding of this document by signing below.
POLICIES
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This document describes how term insurance premiums can be adjusted after a specified time. Please confirm your
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Return of Premium Term-20 Select Term-10
Return of Premium Term-30 Select Term-20
Select Term-30
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I understand that the premiums for the Basic Plan applied for may be adjusted after the Initial Premium Guarantee period. Any adjusted
premium may not exceed the maximum premium for the Basic Plan. The policy shows the maximum premiums for the Basic Plan. Any
adjustment will be made on a policy anniversary and will apply for the entire policy year. If the adjusted premium is less than the
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maximum premium for the Basic Plan, such premium will be guaranteed for that policy year. It is not expected that dividends will be
paid on this policy.
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RIDERS (Insured or Additional Insured)
Select Term-10
Select Term-20
Select Term-30
I understand that the premiums for the rider applied for may be adjusted after ten, twenty, or thirty years depending upon the rider
selected. Any adjusted premium may not exceed the maximum premium for this rider. The policy shows the maximum premiums for
this rider. Any adjustment will be made on a policy anniversary and will apply for the entire policy year. If the adjusted premium for the
rider is less than the maximum premium, such premium will be guaranteed for that policy year. It is not expected that dividends will be
paid on this rider.
JOHNNY FELICIANO
Print Applicant name
#$S01 10/20/2020
#$D01
Applicant signature Date (mm/dd/yyyy)

sb 32-2031
Agent /Licensed Insurance Producer name Code
Doc type 25
1004708.1 NY 2003 150293 203 08-13-2020


Assurance Company
Application Individual Life Insurance

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1 Select Application Type
New policy
Change to an existing policy/added benefits
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Term conversion with increase in amount
Universal Life increase
Select Term re-entry
Indicate the existing policy number(s)
2 Personal Information - Proposed Insured 1 og

FELICIANO
Last name
JOHNNY
First name re Middle name
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63 CORTLANDT ST
Address
STATEN ISLAND NY 10302-2014
City State ZIP Code
Sex: Male Female Married
Marital status
Citizenship: United States (including territories such as Puerto Rico and Guam) Canada Other
58 01/12/1962 NY 5 / 10 205
Age Date of birth (MM/DD/YYYY) State of birth Height (feet/inches) Weight (lbs)
782721349 NY 067-46-4660
Driver's license number (If none, please explain in Explanations, Section 17.) State SSN/ITIN
Service Worker nyc board of ed
Occupation Employer
Annual household income: 0 - $25,000 $25,001 - $50,000 $50,001 - $100,000 $100,001 or more
Do you work in one of the following industries: amusement, construction, diving, explosives, gas/oil, liquor, logging, mining,
sports, military? Yes No If yes, please describe your exact duties:
Doc type 01.01

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1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
3 Personal Information - Proposed Insured 2/Additional Insured/Payor
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Last name First name Middle name
Address
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City State ZIP Code
Sex: Male Female
Marital status
If married, is Proposed Insured 2 married to Proposed Insured 1? (not applicable if Payor) Yes No
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Age Date of birth (MM/DD/YYYY) State of birth Height (feet/inches) Weight (lbs)
Driver's license number (If none, please explain in Explanations, Section 17.) State SSN/ITIN
Occupation
sports, military? Yes No If yes, please describe your exact duties:

Employer
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Do you work in one of the following industries: amusement, construction, diving, explosives, gas/oil, liquor, logging, mining,
4 Add Applicant/Owner Information

Complete this section if the Owner is not the Proposed Insured 1 named in Section 2.
APPLICANT/OWNER 1 Individual Organization Is the organization your employer? Yes No
Last name First name Middle name
Address
City State ZIP Code
Page 2 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
SSN/ITIN/TIN Date of birth (MM/DD/YYYY) Relationship to Proposed Insured 1
Home Phone Work Phone Cell Phone Organization type
APPLICANT/OWNER 2 (Joint Owner)
Last name First name Middle initial
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Address
City State ZIP Code
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SSN/ITIN/TIN Date of birth (MM/DD/YYYY) Relationship to Proposed Insured 1
Home Phone Work Phone Cell Phone
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SUCCESSOR OWNER
Complete this section unless Applicant/Owner is a trust or corporation. A Successor Owner is recommended for juvenile applications.
Last name First name
re Middle initial
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Address
City State ZIP Code
SSN/ITIN/TIN Date of birth (MM/DD/YYYY)
Home Phone Work Phone Cell Phone
5 Proposed Insured Under Age 14½

Applicant must complete Life Insurance Applied for on a Minor (form 1006642) if the Proposed Insured is under age 14 ½.
a. Do you want Proposed Insured 1 to become Owner of policy at, and after, age 21? Yes No
b. Please indicate total amount of life insurance on: Parent/Guardian 1 $ Select if none
Parent/Guardian 2 $ Select if none
6 Select Coverages and Policy Provisions

Complete appropriate section based on product selection.
Term Life and Whole Life
Universal Life/Joint Universal Life/Survivorship Universal Life
Page 3 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
a. Term Life and Whole Life

i. Policy and Amount
Basic Policy Type:
Select Term-10 Return of Premium Term-20 10 Pay Whole Life
Select Term-20 Return of Premium Term-30 15 Pay Whole Life
Select Term-30 Whole Life 20 Pay Whole Life
Single Premium Whole Life
$ 300,000
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Amount applied for
ii. Riders/Benefits
Waiver of Premium (Proposed Insured 1 only): Yes No
Guaranteed Insurability Option: $
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Children's Term Rider: units
CTR unit = $1,000, minimum is 5 units, maximum is 20 units
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Payor (Please complete information for Proposed Insured 2)
Proposed Insured 1 Proposed Insured 2
Select Term-10 $ $
Select Term-20
Select Term-30
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$
$
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iii. Premium Amount and Mode of Premium Payment
Amount of premium submitted with application: $ 0.00
Mode of premium payment: Special Monthly
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iv. Dividend Options
Dividends are not guaranteed. Please select a dividend option from the list provided. If the selected option is unavailable, the
policy provisions will determine the option.
• Whole Life default dividend option is Paid-up Additions
• Term Life default dividend option is Dividend Accumulation
Accumulation Cash Paid-up Additions (not available on Term Life) Reduce Premium
v. Accumulations To Avoid Lapse
Accumulations to Avoid Lapse is a policy provision, available for some policy types, that a policyowner may elect. If, at the end of
the Policy's grace period, a due premium has not been paid, any available dividend credit will be automatically applied to pay the
unpaid premium. If the amount of such credit is not sufficient to pay the entire premium, the credit available will be applied to keep
the Policy in force on a pro rata basis.
Do you want available dividend accumulations used to pay unpaid premiums at the end of the grace period? Yes No
vi. Automatic Premium Loan (APL)
Automatic Premium Loan (APL) is a policy provision, available for some policy types, that a policyowner may
elect. If any premium remains unpaid at the end of the Policy’s grace period, a loan against the cash value is
automatically made to pay the unpaid premium. Do you want the APL provision to apply, if available? Yes No
7 Designate Your Beneficiaries
Page 4 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
(1) Indicate beneficiary type(s) below and provide appropriate details.

(2) Provide additional information for these beneficiary types in Explanations, Section 17:
• Individual - Indicate if Per Stirpes is desired.
• Beneficiary Class/Trust - Indicate class type(s) and beneficiary allocation(s).
• Children of Insured, Children of Spouse and/or Children of this Marriage: Name, Address, City, State of residence,
ZIP Code, Date of birth, SSN/ITIN, Preferred phone number and if Per Stirpes is desired.
• Living Trust (Inter vivos trust): Title of trust, Name of trustee, Trust category (Formal or Informal) and Date of trust
year.
• Trust Under Will: Date of will and Name of trustee.
• UTMA/UGMA (minor beneficiary):
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• Minor beneficiary information - Name of minor beneficiary, Minor beneficiary relationship to Proposed Insured, SSN/
ITIN and Preferred phone number.
• Custodian information - Name of custodian, Address, City, State of residence, ZIP Code, Date of birth, SSN/ITIN,
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Preferred phone number and age at which trust terminates (maximum age is 21).
(3) Assign each beneficiary a percentage of the policy proceeds. The total allocation for any group must add up to 100%.
(4) Providing information may help State Farm® locate the beneficiary in the future.
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(5) If you are requesting a Change of Existing Policy or an addition in coverage, this designation will replace previous
designations for this insured.
(6) If additional beneficiary fields are needed, please include in Explanations, Section 17.
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a. Proposed Insured 1
Primary Beneficiary(ies)
If there will be multiple primary beneficiaries, allocate equally to all primary beneficiaries: Yes No
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(If “Yes” is selected, do not enter any beneficiary allocation below. If “No” enter the desired allocations below.)
Individual
Name (First name, Middle initial, SSN/ITIN Address, City, State of residence, Relationship to insured* Date of birth Beneficiary
Last name) ZIP Code (MM/DD/YYYY) Allocation %
maria, c, feliciano Spouse 100
* If relationship is friend, relative or other, please provide this person’s insurable interest in Explanations, Section 17.
Organization (enter Beneficiary Allocation): %
Name of organization:
Address, City, State,
ZIP Code:
Preferred phone number: TIN:
Page 5 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
Estate (enter Beneficiary Allocation): %

Beneficiary Class/Trust
Successor Beneficiary(ies)
If there will be multiple successor beneficiaries, allocate equally to all successor beneficiaries: Yes No
Individual
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Name (First name, Middle initial, SSN/ITIN Address, City, State of residence, Relationship to insured Date of birth Beneficiary
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ZIP Code:
b. Proposed Insured 2
Primary Beneficiary(ies)
If there will be multiple primary beneficiaries, allocate equally to all primary beneficiaries: Yes No
Page 6 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
Individual
Name (First name, Middle initial, SSN/ITIN Address, City, State of residence, Relationship to insured* Date of birth Beneficiary
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* If relationship is friend, relative or other, please provide this person’s insurable interest in Explanations, Section 17.
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ZIP Code:
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Successor Beneficiary(ies)
If there will be multiple successor beneficiaries, allocate equally to all successor beneficiaries: Yes No
Individual
Name (First name, Middle initial, SSN/ITIN Address, City, State of residence, Relationship to insured Date of birth Beneficiary
Page 7 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019

ZIP Code:
8 Children's Term Rider

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Do you have any children (including stepchildren or legally adopted children) under 18 years old? Yes No
List children under age 18, if any. For relationship to Proposed Insured (PI), please indicate Child, Stepchild or Legally
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Adopted Child. Social Security Number should be provided when available.
Name (First name, Middle initial, Sex Relationship to Relationship to PI 2 Date of birth Amount of life insurance
Last name) PI 1 (Joint Universal Life only) (MM/DD/YYYY) on child*
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Male
$
Female
Social Security Number / Individual Taxpayer Identification Number:
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Male
$
Female
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Male
$
Female
Male
$
Female
*Excludes the amount being applied for.
If additional space is needed for children’s names, please include in Explanations, Section 17.
9 Children's Term Rider/Juvenile Medical Information

a. In the last 10 years, has Proposed Insured 1, or any children named in Children's Term Rider Section 8, been diagnosed, treated
or given advice by a licensed member of the medical profession for any of the following? (select all that apply):
Anemia Cancer Impairment of sight, Leukemia
Asthma Diabetes hearing or speech Mental Disorder
Birth Defect Heart Murmur Kidney Disease Seizure
None of the above
If any are selected, please provide a detailed explanation in the space provided in Explanations, Section 17.
b. Has Proposed Insured 1, or any children named in Children's Term Rider Section 8, ever been diagnosed as Yes No
having or been treated by a licensed member of the medical profession for Acquired Immune Deficiency
Syndrome (AIDS)?
If yes, please provide a detailed explanation in the space provided in Explanations, Section 17.
Page 8 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
c. In the last three (3) years, has Proposed Insured 1, or any children named in Children's Term Rider Section 8, Yes No
seen a licensed member of the medical profession for any reason not previously explained (excluding routine
physical examinations with normal findings)?
If yes, please provide a detailed explanation in the space provided in Explanations, Section 17.
10 Other - Life Insurance or Annuities

In Force Coverage
These questions should be completed by Proposed Insured(s).
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a. What is the total amount of life insurance in force from all companies?
Proposed Insured 1 $ 0 - 250,000 Proposed Insured 2 $
Other Transactions
These questions should be completed by the Applicant/Owner when Proposed Insured(s) is age 50 or over, and face amount of
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policy is $500,000 or greater.
b. Have you entered into, or are you considering plans to enter into, any agreement to sell, transfer, or assign Yes No
any ownership or rights to this policy or its benefits?
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c. Have you received or is there a plan in place to receive any type of inducement, fee, or compensation as an Yes No
incentive to purchase the policy you are applying for?
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Sections 11 through 15 are required for all applications when Proposed Insured is age 16 or older. Provide a detailed
explanation for all "Yes" answers in Explanations, Section 17.
11 Additional Insurance Information
a. Have you ever had an application for life insurance declined or postponed?
If yes, date life insurance was declined or postponed; (if more than one, enter the
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PROPOSED
INSURED 1
Yes No
PROPOSED
INSURED 2
Yes No
/ /
most recent and indicate reason(s) for decline or postpone in Explanations, Section MM YYYY MM YYYY
17.)
b. In the last three (3) years, have you claimed or received any disability benefits Yes No Yes No
because of injury or sickness? (If yes, please provide a detailed explanation in the
space provided in Explanations, Section 17.)
12 Medical Information
PROPOSED PROPOSED
INSURED 1 INSURED 2
a. Have you ever been diagnosed as having or been treated by a licensed member of Yes No Yes No
the medical profession for Acquired Immune Deficiency Syndrome (AIDS)?
(If yes, please provide a detailed explanation in the space provided in Explanations,
Section 17.)
b. In the last three (3) years, have you been treated, diagnosed, or advised by a Yes No Yes No
licensed member of the medical profession as follows? (If yes, select all that apply
and provide a detailed explanation in the space provided in Explanations, Section 17.)
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1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
• Hospitalized or surgically treated for chest pain or any disorder of the heart?
• Hospitalized or surgically treated for stroke or mini-stroke (transient ischemic
attack/TIA)?
• Diagnosed with, or are you currently being treated for, cancer or tumor or mass
(excluding basal cell and squamous cell cancer of the skin)?
• Diagnosed with any kidney disorder that requires current dialysis treatment?
• Advised to have further evaluation or testing (except for Human Immunodeficiency
Virus) to determine a diagnosis; or had surgery recommended that has not been
performed?
13 Criminal Charges and Convictions

In PROPOSED
INSURED 1
PROPOSED
INSURED 2
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a. In the last three (3) years, have you been involved in any of the following? (If yes, Yes No Yes No
select all that apply and indicate dates and the nature of the charge(s) in
Explanations, Section 17.)
• Convicted of or pleaded guilty to any felony?
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• Have criminal charges pending at this time?
• Placed on parole or probation?
• Incarcerated or facing incarceration as the result of a guilty plea or conviction?
b. In the last three (3) years, have you been convicted of or pleaded guilty to
driving under the influence of alcohol or drugs? (If yes, indicate dates of DUIs in
Explanations, Section 17.) re Yes No Yes No
14 Lifestyle and Travel Information
Travel Information
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PROPOSED
INSURED 1
PROPOSED
INSURED 2
a. Are you currently residing or traveling in any country outside of the United States or Yes No Yes No
Canada? If yes, provide the following:
Location you are currently at
When do you plan on returning to the United States or Canada? / /
MM YYYY MM YYYY
b. In the next six (6) months, do you plan to leave or travel from the United States or Yes No Yes No
Canada? If yes, provide the following:
Destination you are traveling to

Date leaving or beginning travel / /
MM YYYY MM YYYY
Page 10 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
Length of time out of the United States or Canada

If more than 2 months, indicate purpose of travel
• Business
• Vacation
• Other (please explain below)
PROPOSED PROPOSED
Lifestyle Information INSURED 1 INSURED 2
In
c. In the last three (3) years, have you engaged in any of the following? Yes No Yes No
(If yes, select all that apply, and add additional details on the corresponding Aviation,
Mountain/rock climbing, Vehicle racing and/or SCUBA Questionnaire.)
• Aviation (other than as a passenger or commercial airline crew)
• Sky diving (more than 1 time)
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• BASE jumping
• Hang gliding
• Mountain/rock climbing
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• SCUBA diving to depths greater than 100 feet OR any specialty diving
(including caves, ice, wrecks, etc.)
• Vehicle racing
15 Tobacco Use
re PROPOSED PROPOSED
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INSURED 1 INSURED 2
a. Have you ever used tobacco or other nicotine products in any form (including e- Yes No Yes No
cigarettes or vaping)?
If yes, please provide month/year last used: / /
MM YYYY MM YYYY
Provide the tobacco/nicotine products used in the last three (3) years, along with the date and year last used for each product, in
Explanations, Section 17
16 Additional Medical Information (If no medical exam is required)

This section is required for all:
• New business applications when Proposed Insured is age 16 or older and no medical exam is required.
• Change of plan applications when the Proposed Insured is age 16 or older.
Provide a detailed explanation for all “Yes” answers in Explanations, Section 17.
PROPOSED PROPOSED
INSURED 1 INSURED 2
a. In the last 10 years, have you been diagnosed, treated, or been given advice by a Yes No Yes No
licensed member of the medical profession for any of the conditions listed below?
(If yes, select all that apply.)
• Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder (ADHD)
• Asthma
• Blood Disorder
Page 11 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
• Cancer or Tumor or Mass

• Chronic Obstructive Pulmonary Disease (COPD)/Emphysema
• Diabetes
• Heart Disease or Disorder
• High Blood Pressure
• Intestinal Disorder
• Liver Disorder
• Mental/Nervous Disorder
• Organ Transplant (other than cornea transplant)
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• Sleep Apnea
b. In the last five (5) years, have you for any reason not previously explained:
• Seen a doctor or any licensed member of the medical profession, or been treated Yes No Yes No
at a hospital or other medical facility (excluding seasonal illnesses such as colds,
flu, bronchitis and allergies such as hay fever)?
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• Had medication prescribed other than medications for cold, flu, seasonal allergies Yes No Yes No
or birth control?
c. Have you, in the last three (3) years, used marijuana in any form? Yes No Yes No
d. In the last 10 years, have you:
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• Used cocaine, heroin, methamphetamine, or any other controlled substance or Yes No Yes No
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narcotic not prescribed by a member of the medical profession?
• Had medical treatment or counseling for use of alcohol or prescribed or non- Yes No Yes No
prescribed drugs?
• Been advised by a licensed member of the medical profession to discontinue use of Yes No Yes No
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alcohol or prescribed or non-prescribed drugs?
17 Explanations
If you need more space, please attach additional pages, which will become part of this application. Please note that these must be
signed and dated by the Proposed Insured(s) and/or Applicant, and witnessed by Agent.
I have agreed to complete the life insurance application and supporting forms using
electronic documents.
JOHNNY FELICIANO - Tobacco Use; In the last three (3) years, have you used tobacco or
other nicotine products in any form? no
JOHNNY FELICIANO has agreed to receive documents and communications electronically.
JOHNNY FELICIANO Primary Beneficiary Name: maria, c, feliciano
; Per Stirpes:No
Page 12 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
18 Agreements
Coverage will be effective as of the Policy Date if the following conditions are met: the first premium is paid when this policy is
delivered; the Proposed Insureds are living on the delivery date; and the information given to the Company at the time the
application was completed is true and complete to the best of the Proposed Insureds’ and Applicant’s knowledge and belief.
For changes in Basic Amount for a Universal Life Policy or Joint Universal Life, the change will be effective on the Deduction Date
on or next following acceptance of the change by the Company if on such Deduction Date the following conditions are met: there is
enough Cash Surrender Value to make the required monthly deduction; the Proposed Insureds are all living; and the information
given to the Company at the time the application was completed is true and complete to the best of the Proposed Insureds’ and
In
Applicant’s knowledge and belief.
However, if a Binding Receipt has been given and is in effect, its terms apply.
All Proposed Insureds and the Applicant state that the information in this Application and any medical history is true and complete
to the best of their knowledge and belief and may be verified by a telephone interview. Neither the agent nor a medical examiner
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may pass on insurability. It is agreed that the Company can investigate the truth and completeness of such information while this
policy is contestable.
Any policy issued on this Application will be owned by Proposed Insured 1 or the Applicant, if other than Proposed Insured 1. This
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Application will be attached to and made a part of the Policy.
IMPORTANT INFORMATION ABOUT PROCEDURES WHEN APPLYING FOR A NEW LIFE INSURANCE POLICY: To help the
government fight the funding of terrorism and money laundering activities, State Farm will obtain, verify, and record information
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that identifies each Proposed Insured(s) and Applicant(s) identified on the application. What this means for you. We will ask for
your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s
license or other identifying documents.
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Page 13 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
Taxpayer Identification Number (TIN) Certification – Substitute W-9

I certify under penalties of perjury that:
(1) The TIN shown above is correct, and
(2) I am a U.S. citizen or other U.S. person (defined below), and
(3) Backup Withholding:
I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service (IRS) that
I am subject to backup withholding as a result of failure to report all interest or dividends, or the IRS has notified me that I
am no longer subject to backup withholding or I am exempt from backup withholding.
In
I am subject to backup withholding.
(4) I am exempt from reporting under the Foreign Account Tax Compliance Act (FATCA) with respect to the account(s) for which
this form has been requested because I hold or otherwise maintain the account(s) in the United States.
Definition of U.S. person. For federal tax purposes, you are considered a U.S. person if you are:
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• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United
States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
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For instructions on how to complete the form, visit the IRS website at www.irs.gov or contact your local IRS office. The
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Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding.
#$S01 - for office use only

Proposed Insured 1 signature (Signature not required if Proposed Insured is under age 14½)
#$D01
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- for office use only
10/20/2020
Date (MM/DD/YYYY)
#$S02 - for office use only #$D02 - for office use only
Proposed Insured 2 signature Date (MM/DD/YYYY)
#$Sowner - for office use only #$Downer - for office use only
Applicant 1 signature/Applicant 2 signature Date (MM/DD/YYYY)
Applicant 1 signature is not required unless Applicant is other than Proposed Insured 1. If a firm or corporation is to be the policyowner,
please provide company name and signature of an authorized officer. Applicant 2 signature is not required unless Joint Owner
selected.
#$Sagent - for office use only #$Dagent - for office use only
Agent/Licensed Insurance Producer signature Date (MM/DD/YYYY)
At Brooklyn NY
City State
Page 14 of 14
1004522 NY.2 AS-0193-9863 1006686 2002 145659 202 09-26-2019
General Instructions for Substitute W-9

Section references are to the Internal Form W-9 to request your TIN, you must • In the case of a grantor trust with a U.S.
Revenue Code unless otherwise noted. use the requester’s form if it is grantor or other U.S. owner, generally,
substantially similar to this Form W-9. the U.S. grantor or other U.S. owner of
Future developments. The IRS has the grantor trust and not the trust, and
created a page on IRS.gov for information Definition of a U.S. person. For federal
• In the case of a U.S. trust (other than a
about Form W-9 at www.irs.gov/w9. tax purposes, you are considered a U.S.
grantor trust), the U.S. trust (other than
Information about any future person if you are:
a grantor trust) and not the beneficiaries
developments affecting Form W-9 (such • An individual who is a U.S. citizen or
of the trust.
as legislation enacted after we release it) U.S. resident alien,
will be posted on that page. • A partnership, corporation, company, or Foreign person. If you are a foreign
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association created or organized in the person or the U.S. branch of a foreign
Purpose of Form United States or under the laws of the bank that has elected to be treated as a
A person who is required to file an United States, U.S. person, do not use Form W-9.
information return with the IRS must • An estate (other than a foreign estate), Instead, use the appropriate Form W-8
obtain your correct taxpayer identification or (see Publication 515, Withholding of Tax
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number (TIN) to report, for example, • A domestic trust (as defined in on Nonresident Aliens and Foreign
income paid to you, payments made to Regulations section 301.7701-7). Entities).
you in settlement of payment card and Special rules for partnerships. Nonresident alien who becomes a
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third party network transactions, real Partnerships that conduct a trade or resident alien. Generally, only a
estate transactions, mortgage interest business in the United States are nonresident alien individual may use the
you paid, acquisition or abandonment of generally required to pay a withholding terms of a tax treaty to reduce or
secured property, cancellation of debt, or
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tax under section 1446 on any foreign eliminate U.S. tax on certain types of
contributions you made to an IRA. partners’ share of effectively connected income. However, most tax treaties
Use Form W-9 only if you are a U.S. taxable income from such business. contain a provision known as a “saving
Further, in certain cases where a Form clause.” Exceptions specified in the
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person (including a resident alien), to
provide your correct TIN to the person W-9 has not been received, the rules saving clause may permit an exemption
requesting it (the requester) and, when under section 1446 require a partnership from tax to continue for certain types of
applicable, to: to presume that a partner is a foreign income even after the payee has
(1) Certify that the TIN you are giving is person, and pay the section 1446 otherwise become a U.S. resident alien
correct (or you are waiting for a withholding tax. Therefore, if you are a for tax purposes.
number to be issued), U.S. person that is a partner in a
If you are a U.S. resident alien who is
(2) Certify that you are not subject to partnership conducting a trade or
relying on an exception contained in the
backup withholding, or business in the United States, provide
saving clause of a tax treaty to claim an
(3) Claim exemption from backup Form W-9 to the partnership to establish
exemption from U.S. tax on certain types
withholding if you are a U.S.exempt your U.S. status and avoid section 1446
of income, you must attach a statement
payee. If applicable, you are also withholding on your share of partnership
to Form W-9 that specifies the following
certifying that as a U.S. person, your income.
five items:
allocable share of any partnership In the cases below, the following person (1) The treaty country. Generally, this
income from a U.S. trade or business must give Form W-9 to the partnership for must be the same treaty under which
is not subject to the withholding tax on purposes of establishing its U.S. status you claimed exemption from tax as a
foreign partners’ share of effectively and avoiding withholding on its allocable nonresident alien.
connected income, and share of net income from the partnership (2) The treaty article addressing the
(4) Certify that you are exempt from conducting a trade or business in the income.
FATCA reporting based on the United States: (3) The article number (or location) in the
account(s) being held or maintained in • In the case of a disregarded entity with tax treaty that contains the saving
the United States. a U.S. owner, the U.S. owner of the clause and its exceptions.
Note. If you are a U.S. person and a disregarded entity, not the entity, (4) The type and amount of income that
requester gives you a form other than qualifies for the exemption from tax.
Page 1 of 2
1006666 2000 147301 200 06-25-2014
(5) Sufficient facts to justify the exemption Payments you receive will be subject furnish your correct TIN to a requester,
from tax under the terms of the treaty to backup withholding if: you are subject to a penalty of $50 for
article. (1) You do not furnish your TIN to the each such failure unless your failure is
requester, due to reasonable cause and not to willful
Example. Article 20 of the U.S.-China neglect.
(2) You do not certify your TIN when
income tax treaty allows an exemption
required (*See Note 1), Civil penalty for false information with
from tax for scholarship income received
(3) The IRS tells the requester that you respect to withholding. If you make a
by a Chinese student temporarily present
furnished an incorrect TIN, false statement with no reasonable basis
in the United States. Under U.S. law, this
(4) The IRS tells you that you are subject that results in no backup withholding, you
student will become a resident alien for
to backup withholding because you are subject to a $500 penalty.
tax purposes if his or her stay in the
did not report all your interest and
United States exceeds 5 calendar years. Criminal penalty for falsifying
dividends on your tax return (for
However, paragraph 2 of the first Protocol information. Willfully falsifying
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reportable interest and dividends
to the U.S.-China treaty (dated April 30, certifications or affirmations may subject
only), or
1984) allows the provisions of Article 20 you to criminal penalties including fines
(5) You do not certify to the requester that
to continue to apply even after the and/or imprisonment.
you are not subject to backup
Chinese student becomes a resident
withholding under 4 above (for Misuse of TINs. If the requester
alien of the United States. A Chinese
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reportable interest and dividend discloses or uses TINs in violation of
student who qualifies for this exception
accounts opened after 1983 only). federal law, the requester may be subject
(under paragraph 2 of the first protocol)
and is relying on this exception to claim Certain payees and payments are exempt to civil and criminal penalties.
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an exemption from tax on his or her from backup withholding. (*See Note 1). *Note 1. For more information, see full
scholarship or fellowship income would instructions for Form W-9 and separate
Also see Special rules for partnerships on
attach to Form W-9 a statement that Instructions for the Requester of Form
page 1.
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includes the information described above W-9 at www.irs.gov.
to support that exemption. If you are a What is FATCA reporting?
nonresident alien or a foreign entity, give The Foreign Account Tax Compliance Act
the requester the appropriate completed (FATCA) requires a participating foreign
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Form W-8. financial institution to report all United
States account holders that are specified
What is backup withholding?
United States persons. Certain payees
Persons making certain payments to you
are exempt from FATCA reporting. (*See
must under certain conditions withhold
Note 1)
and pay to the IRS a percentage of such
payments. This is called “backup Updating Your Information
withholding.” Payments that may be
subject to backup withholding include You must provide updated information to
interest, tax-exempt interest, dividends, any person to whom you claimed to be an
broker and barter exchange transactions, exempt payee if you are no longer an
rents, royalties, nonemployee pay, exempt payee and anticipate receiving
payments made in settlement of payment reportable payments in the future from
card and third party network transactions, this person. For example, you may need
and certain payments from fishing boat to provide updated information if you are
operators. Real estate transactions are a C corporation that elects to be an S
not subject to backup withholding. corporation, or if you no longer are tax
exempt. In addition, you must furnish a
You will not be subject to backup new Form W-9 if the name or TIN
withholding on payments you receive if changes for the account, for example, if
you give the requester your correct TIN, the grantor of a grantor trust dies.
make the proper certifications, and report
all your taxable interest and dividends on Penalties
your tax return. Failure to furnish TIN. If you fail to
Page 2 of 2
1006666 2000 147301 200 06-25-2014
Notice and Consent for Body Fluids

(Blood, Urine, Oral Specimen) Testing State Farm Life and Accident Assurance Company
Which Includes AIDS Virus (HIV) 1 State Farm Plaza, Bloomington, IL 61710-0001
Antibody Testing - New York

To determine your insurability, State Farm Life and Accident formerly known as the Medical Information Bureau, and you
Assurance Company (State Farm) is requesting that you provide choose to decline that request, State Farm may report to the
a sample of your body fluids (blood, urine, oral specimen) for MIB, Inc. a generic code which specifies only that a blood test
testing and analysis. In order to adequately perform all testing has been ordered and not received. Regardless of the number of
procedures, it may be necessary for you to provide additional tests requested, if the final test result for HIV antibodies is other
In
samples of several body fluids. State Farm will contact you if than normal, State Farm may report to the MIB, Inc. a generic
further follow-up testing is needed. All tests will be performed by code which signifies only a non-specific blood, oral fluid (saliva),
a licensed laboratory. Tests will be performed to determine the or urine test abnormality. The MIB, Inc. is an insurance exchange
presence of antibodies to the Human Immunodeficiency Virus formed to prevent insurance fraud. If your HIV antibody test is
(HIV), also known as the AIDS virus. The HIV antibody test is normal, no report will be made about it to the MIB, Inc. Other test
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actually a series of tests done by a medically accepted results may be reported to the MIB, Inc. in a more specific
procedure. The test is extremely reliable. Other tests which may manner. The organizations described in this paragraph may
be performed include determinations of blood cholesterol and maintain the test results in a file or databank. There will be no
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related lipids, cotinine, cocaine, screening for liver or kidney other disclosure of test results or even that the tests have been
disorders, diabetes, immune disorders, and other physical done except as may be required or permitted by law or as
conditions. authorized by you.
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All test results will be treated confidentially. They will be reported If your HIV antibody test result is normal, no routine notification
by the laboratory to State Farm. When necessary for business will be sent to you. If the final HIV antibody test result is other
reasons in connection with insurance you have or have applied than normal, State Farm will contact you. State Farm may also
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for with State Farm, State Farm may disclose test results to contact you if there are other abnormal test results which, in
others such as its affiliates, reinsurers, employees, or State Farm's opinion, are significant. State Farm will send an
contractors. If an oral specimen is tested for HIV antibodies, abnormal final HIV antibody test result to you or to the person
State Farm may request a sample of your blood for further you designate here.
testing. If State Farm is a member of the MIB, Inc.,
Release an abnormal final HIV antibody test result to my physician or other person (give name and address)
A positive HIV antibody test result does not mean that you HIV antibody test result means that no antibodies to the HIV
have AIDS, but that you are at significantly increased risk of virus were found. Because of varying incubation periods,
developing AIDS or AIDS-related conditions. Federal absence of HIV antibodies does not necessarily mean that
authorities say that persons who are HIV antibody positive you have not been infected with the virus.
should be considered infected with the AIDS virus and
A positive HIV antibody test result or other significant
capable of infecting others. If your test result is positive, you
abnormalities will adversely affect your application for
may wish to consider further independent testing. A negative
Doc type
07.04
Page 1 of 2
1006741 2000 147270 200 05-25-2016
insurance. This means that your application may be For additional information about AIDS, the meaning of the
declined, that an increased premium may be charged, or that HIV-related test results, and the availability and location of
other policy changes may be necessary. HIV counseling services, you may call the Department of
Health statewide toll free number which is 1-800-541-AIDS.
I have read and I understand this Notice and Consent for Body Fluids (Blood, Urine, Oral Specimen) Testing Which Includes AIDS
Virus (HIV) Antibody Testing. I voluntarily consent to the withdrawal of body fluids from me, the testing of those fluids, and the
disclosure of the test results as described above.
I understand that I have the right to request and receive a copy of this authorization. A copy of this form will be as valid as the original.
This authorization is valid for six months.
JOHNNY FELICIANO
Print Proposed Insured Name In 01/12/1962
Date of Birth (MM/DD/YYYY)
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10/20/2020 NEW YORK
Proposed Insured or Parent/Guardian Signature Date (MM/DD/YYYY) State of Residence
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Page 2 of 2
1006741 2000 147270 200 05-25-2016

Assurance Company
Notices
Notices State Farm, or its reinsurers may also release information
In
INFORMATION PRACTICES from its file to other insurance companies to whom you may
apply for life or health insurance, or to whom a claim for
The application requests personal information about the persons benefits may be submitted. Information for consumers about
proposed for coverage. We may collect personal information MIB may be obtained on its website at www.mib.com.
from persons other than the individual or individuals applying for
PRE-NOTICE OF INVESTIGATIVE CONSUMER
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coverage. Such personal information as well as other personal or
privileged information subsequently collected may, in certain REPORT NEW YORK
circumstances, be disclosed to third parties without your Under the New York and federal Fair Credit Reporting Act,
this is to inform you that State Farm may request an
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authorization as permitted by law. If you would like additional
information about the collection and disclosure of personal investigative consumer report as part of our procedure for
information, please contact your State Farm® agent. You may processing your application for life insurance. In preparing
also act upon your right to see and correct any personal this report, interviews with your neighbors, friends or other
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information in your State Farm files by writing your State Farm acquaintances may be conducted. This inquiry includes
agent to request this access. questions as to your character, general reputation, personal
MIB NOTICE characteristics and mode of living (except as it relates to your
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sexual orientation). You can make a written request within a
Information regarding your insurability will be treated as reasonable period of time to be informed whether or not an
confidential. State Farm, or its reinsurers may, however, make a investigative consumer report was requested, and if such
brief report of your personal health information to MIB, Inc., a report was requested, the name and address of the
not-for-profit membership organization of insurance companies, consumer reporting agency to whom the request was made,
which operates an information exchange on behalf of its the nature and scope of the investigation. You may also ask
members. If you apply to another MIB member company for life to be interviewed during the preparation of the report. You
or health insurance coverage, or a claim for benefits is submitted also have the right to receive a copy of the report.
to such a company, MIB, upon request, will supply such
company with the information about you in its file.
Upon receipt of a request from you, MIB will arrange disclosure
of any information in your file. Please contact MIB at
866-692-6901. If you question the accuracy of the information in
MIB’s file, you may contact MIB and seek a correction in
accordance with the procedures set forth in the federal Fair
Credit Reporting Act. The address of MIB’s information office is
50 Braintree Hill Park, Suite 400, Braintree, Massachusetts
02184-8734.
1006547.1 [LIFE - NY] 2001 146302 201 11-20-2017


Assurance Company
IMPORTANT NOTICE
PRELIMINARY STATEMENT OF POLICY COST - New York
JOHNNY FELICIANO
Name of Proposed Insured
In 58
Age
Sex: M F
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sb
Name of Agent/Licensed Insurance Producer
1301 Coney Island Ave
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Address of Agent/Licensed Insurance Producer
Brooklyn NY 11230-3520
City State ZIP Code
If no Agent involved, Direct Inquiries to:

New Albany Operations Center re
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P.O. Box 3040
Newark, OH 43058-3040
Select Term - 20
Insurance Plan
$ 300,000.00 $ 227.67 10/19/2020

Initial Amount of Insurance Initial Annual Premium Date Prepared
BEFORE YOU BUY ANY LIFE INSURANCE, you should:

• Decide how much life insurance you need.
• Figure out how much you can afford to pay in premiums. You should not buy a policy unless you can afford the
premiums and stick with it. A policy that is a good buy when held for 20 years can be very costly if you quit during
the early years of the policy. If you surrender such a policy during the first few years, you may get little or nothing
back and much of your premium may have been used for company expenses.
• Find out what type of policy best fits your individual and family needs.
• Note that the cost of protection varies depending on when and how the policy stops, that is, by death of the
insured or by surrender of the policy.
• Compare costs of similar insurance policies using the index numbers shown below. COMPARISON SHOPPING
SAVES MONEY!
• Try to determine how well the insurance company and agent will provide service to you in the future.
• READ THE BUYER’S GUIDE. It will help you to make a good purchase decision.
1006900.1 2001 147678 201 06-09-2017

Important Notice — Preliminary Statement of Policy Cost — New York, page 2 of 2
DIVIDENDS
Although this policy is participating, no dividends are anticipated.
GUARANTEED CASH SURRENDER VALUE
10th Year 20th Year
Guaranteed Cash Surrender Value for the plan
being applied for is: 0.00 0.00
POLICY LOAN INTEREST RATE
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• A POLICY LOAN PROVISION IS ONLY AVAILABLE IF THE PLAN SELECTED IS A RETURN OF PREMIUM 20
OR RETURN OF PREMIUM 30.
• The loan interest rate is an adjustable rate.
• The loan interest rate is determined each calendar quarter and takes effect the first day of January, April, July
and October. Such rate applies to any new and existing loan under the Policy.
Current loan interest rate is: 5.0 %

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• The loan interest is payable on the policy anniversary date following the loan date.
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COST INDEXES
When comparing the cost of two or more policies:
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• LOOK FOR POLICIES WITH LOW INDEX NUMBERS. Generally, they will cost less than policies with higher
index numbers.
• COMPARE POLICIES OF SIMILAR PLANS AND FACE AMOUNT ONLY.
Net Payment Cost Index (Cost of protection if

insured dies at end of): 8.72
10th Year
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8.72
20th Year
Surrender Cost Index (Cost of protection if the

policy is surrendered at end of): 8.72 8.72
Equivalent level annual dividend: 0.00 0.00
• REMEMBER TO COMPARE THE COST INDEXES ABOVE WITH THOSE THAT WILL APPEAR IN YOUR
POLICY SUMMARY. REQUEST AN EXPLANATION OF DIFFERENCES.
By the time the policy is delivered, you will be given a complete Policy Summary, including cost data which will be
based on benefits, premiums, and dividends of the Policy as issued. The figures shown in this Preliminary
Statement of Policy Cost are based on the assumption that a proposed Policy is issued as applied for.
Adjustments will be necessary if the policy is actually issued on some other basis. You may return any life policy
delivered in New York within 30 days of delivery and obtain a full refund of all premium paid.
1006900.1 2001 147678 201 06-09-2017

Life Insurance Buyer's Guide
This guide can help you when you shop for life insurance. It discusses how to:
• Find a Policy That Meets Your Needs and Fits Your Budget
• Decide How Much Insurance You Need
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• Make Informed Decisions When You Buy a Policy.
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Prepared by the National Association of Insurance Commissioners
The National Association of Insurance Commissioners is an association of state insurance regulatory officials. This
association helps the various insurance departments to coordinate insurance laws for the benefit of all consumers.
THIS GUIDE DOES NOT ENDORSE ANY COMPANY OR POLICY
Reprinted by State Farm Life Insurance Company (Not in MA, NY, or WI)
State Farm Life and Accident Assurance Company (NY and WI)
Home Office: Bloomington, IL 61710
1997 NAIC
Page 1 of 7
1006128 2001 151836 200 12-12-2016
Important Things to Consider

1. Review your own insurance needs and circumstances. Choose the kind of policy that has benefits that most closely fit
your needs. Ask an agent or company to help you.
2. Be sure that you can handle premium payments. Can you afford the initial premium? If the premium increases later and
you still need insurance, can you still afford it?
3. Don’t sign an insurance application until you review it carefully to be sure all the answers are complete and accurate.
4. Don’t buy life insurance unless you intend to stick with your plan. It may be very costly if you quit during the early years
of the policy.
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5. Don’t drop one policy and buy another without a thorough study of the new policy and the one you have now. Replacing
your insurance may be costly.
6. Read your policy carefully. Ask your agent or company about anything that is not clear to you.
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7. Review your life insurance program with your agent or company every few years to keep up with changes in your
income and your needs.
BUYING LIFE INSURANCE
When you buy life insurance, you want a policy which fits your needs.
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First decide how much you need - and for how long - and what you can afford to pay. Keep in mind the
major reason you buy life insurance is to cover the financial effects of unexpected or untimely death. Life
insurance can also be one of many ways you plan or the future.
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Next, learn what kinds of policies will meet your needs and pick the one that best suits you.
Then, choose the combination of policy premium and benefits that emphasizes protection in case of early
death, or benefits in case of long life, or a combination of both.
It makes good sense to ask a life insurance agent or company to help you. An agent can help you review your insurance
needs and give you information about the available policies. If one kind of policy doesn’t seem to fit your needs, ask about
others.
This guide provides only basic information. You can get more facts from a life insurance agent or company or from your
public library.
WHAT ABOUT THE POLICY YOU NOW HAVE?
If you are thinking about dropping a life insurance policy, here are some things you should consider:
• If you decide to replace your policy, don’t cancel your old policy until you have received the new one.
You then have a minimum period to review your new policy and decide if it is what you wanted.
• It may be costly to replace a policy. Much of what you paid in the early years of the policy you have now,
paid for the company’s cost of selling and issuing the policy. You may pay this type of cost again if you buy
a new policy.
• Ask your tax advisor if dropping your policy could affect your income taxes.
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1006128 2001 151836 200 12-12-2016
• If you are older or your health has changed, premiums for the new policy will often be higher. You will not
be able to buy a new policy if you are not insurable.
• You may have valuable rights and benefits in the policy you now have that are not in the new one.
• If the policy you have now no longer meets your needs, you may not have to replace it. You might be able
to change your policy or add to it to get the coverage or benefits you now want.
• At least in the beginning, a policy may pay no benefits for some causes of death covered in the policy you
have now.
In all cases, if you are thinking of buying a new policy, check with the agent or company that issued you the one you have
now. When you bought your old policy, you may have seen an illustration of the benefits of your policy. Before replacing
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your policy, ask your agent or company for an updated illustration. Check to see how the policy has performed and what you
might expect in the future, based on the amounts the company is paying now.
How Much Do You Need?
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Here are some questions to ask yourself:
• How much of the family income do I provide? If I were to die early, how would my survivors, especially my
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children, get by? Does anyone else depend on me financially, such as a parent, grandparent, brother or
sister?
• Do I have children for whom I’d like to set aside money to finish their educations in the event of my death?
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• How will my family pay final expenses and repay debts after my death?
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• Do I have any family members or organizations to whom I would like to leave money?
• Will there be estate taxes to pay after my death?
• How will inflation affect future needs?
As you figure out what you have to meet these needs, count the life insurance you have now, including anygroup insurance
where you work or veteran’s insurance. Don’t forget Social Security and pension plan survivor’s benefits. Add other assets
you have: savings, investments, real estate and personal property. Which assets would your family sell or cash in to pay
expenses after your death?
What is the Right Kind of Life Insurance?
All policies are not the same. Some give coverage for your lifetime and others cover you for a specific number of years.
Some build up cash values and others do not. Some policies combine different kinds of insurance, and others let you
change from one kind of insurance to another. Some policies may offer other benefits while you are still living. Your choice
should be based on your needs and what you can afford.
There are two basic types of life insurance: term insurance and cash value insurance. Term insurance generally has
lower premiums in the early years, but does not build up cash values that you can use in the future. You may combine cash
value life insurance with term insurance for the period of your greatest need for life insurance to replace income.
Term Insurance covers you for a term of one or more years. It pays a death benefit only if you die in that term. Term
insurance generally offers the largest insurance protection for your premium dollar. It generally does not build up cash value.
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1006128 2001 151836 200 12-12-2016
You can renew most term insurance policies for one or more terms even if your health has changed. Each time you renew
the policy for a new term, premiums may be higher. Ask what the premiums will be if you continue to renew the policy. Also
ask if you will lose the right to renew the policy at some age. For a higher premium, some companies will give you the right
to keep the policy in force for a guaranteed period at the same price each year. At the end of that time you may need to
pass a physical examination to continue coverage, and premiums may increase.
You may be able to trade many term insurance policies for a cash value policy during a conversion period--even if you are
not in good health. Premiums for the new policy will be higher than you have been paying for the term insurance.
Cash Value Life Insurance is a type of insurance where the premiums charged are higher at the beginning than they would
be for the same amount of term insurance. The part of the premium that is not used for the cost of insurance is invested by
the company and builds up a cash value that may be used in a variety of ways. You may borrow against a policy’s cash
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value by taking a policy loan. If you don’t pay back the loan and the interest on it, the amount you owe will be subtracted
from the benefits when you die, or from the cash value if you stop paying premiums and take out the remaining cash value.
You can also use your cash value to keep insurance protection for a limited time or to buy a reduced amount without having
to pay more premiums. You also can use the cash value to increase your income in retirement or to help pay for needs such
as a child’s tuition without canceling the policy. However, to build up this cash value, you must pay higher premiums in the
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earlier years of the policy. Cash value life insurance may be one of several types; whole life, universal life and variable life
are all types of cash value insurance.
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Whole Life Insurance covers you for as long as you live if your premiums are paid. You generally pay the same amount in
premiums for as long as you live. When you first take out the policy, premiums can be several times higher than you would
pay initially for the same amount of term insurance. But they are smaller than the premiums you would eventually pay if you
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were to keep renewing a term policy until your later years.
Some whole life policies let you pay premiums for a shorter period such as 20 years, or until age 65. Premiums for these
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policies are higher since the premium payments are made during a shorter period.
Universal Life Insurance is a kind of flexible policy that lets you vary your premium payments. You can also adjust the face
amount of your coverage. Increases may require proof that you qualify for the new death benefit. The premiums you pay
(less expense charges) go into a policy account that earns interest. Charges are deducted from the account. If your yearly
premium payment plus the interest your account earns is less than the charges, your account value will become lower. If it
keeps dropping, eventually your coverage will end. To prevent that, you may need to start making premium payments, or
increase your premium payments, or lower your death benefits. Even if there is enough in your account to pay the
premiums, continuing to pay premiums yourself means that you build up more cash value.
Variable Life Insurance is a kind of insurance where the death benefits and cash values depend on the investment
performance of one or more separate accounts, which may be invested in mutual funds or other investments allowed under
the policy. Be sure to get the prospectus from the company when buying this kind of policy and STUDY IT CAREFULLY.
You will have higher death benefits and cash value if the underlying investments do well. Your benefits and cash value will
be lower or may disappear if the investments you chose didn’t do as well as you expected. You may pay an extra premium
for a guaranteed death benefit.
Life Insurance Illustrations
You may be thinking of buying a policy where cash value, death benefits, dividends or premiums may vary based on events
or situations the company does not guarantee (such as interest rates). If so, you may get an illustration from the agent or
company that helps explain how the policy works. The illustration will show how the benefits that are not guaranteed will
change as interest rates and other factors change.
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1006128 2001 151836 200 12-12-2016
The illustration will show you what the company guarantees. It will also show you what could happen in the future.
Remember that nobody knows what will happen in the future. You should be ready to adjust your financial plans if the
cash value doesn’t increase as quickly as shown in the illustration. You will be asked to sign a statement that says you
understand that some of the numbers in the illustration are not guaranteed.
Finding a Good Value in Life Insurance
After you have decided which kind of life insurance is best for you, compare similar policies from different companies to find
which one is likely to give you the best value for your money. A simple comparison of the premiums is not enough. There are
other things to consider. For example:
• Do premiums or benefits vary from year to year?
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• How much do the benefits build up in the policy?
• What part of the premiums or benefits is not guaranteed?
• What is the effect of interest on money paid and received at different times on the policy?
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Remember that no one company offers the lowest cost at all ages for all kinds and amounts of insurance. You should also
consider other factors:
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• How quickly does the cash value grow? Some policies have low cash values in the early years that build
quickly later on. Other policies have a more level cash value build-up. A year-by-year display of values
and benefits can be very helpful. (The agent or company will give you a policy summary or an illustration
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that will show benefits and premiums for selected years.)
• Are there special policy features that particularly suit your needs?
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• How are nonguaranteed values calculated? For example, interest rates are important in determining
policy returns. In some companies increases reflect the average interest earnings on all of that
company’s policies regardless of when issued. In others, the return for policies issued in a recent year,
or group of years, reflects the interest earnings on that group of policies; in this case, amounts paid
are likely to change more rapidly when interest rates change.
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1006128 2001 151836 200 12-12-2016
ADDENDUM TO LIFE INSURANCE BUYER'S GUIDE
After you have decided which kind of life insurance fits your needs, look for a good buy. Your chances of finding a good
buy are better if you use two types of index numbers that have been developed to aid in shopping for life insurance. One
is called the "Surrender Cost Index" and the other is the "Net Payment Cost Index". It will be worth your time to try to
understand how these indexes are used, but in any event, use them only for comparing the relative costs of similar
policies. LOOK FOR POLICIES WITH LOW COST INDEX NUMBERS.
What is Cost?
"Cost" is the difference between what you pay and what you get back. If you pay a premium for life insurance and get
nothing back, your cost for the death protection is the premium. If you pay a premium and get something back later on,
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such as a cash value, your cost is smaller than the premium.
The cost of some policies can also be reduced by dividends; these are called "participating" policies. Companies may tell
you what their current dividends are, but the size of future dividends is unknown today and cannot be guaranteed.
Dividends actually paid are set each year by the company.
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Some policies do not pay dividends. These are called "guaranteed cost" or "nonparticipating" policies. Every feature of a
guaranteed cost policy is fixed so that you know in advance what your future cost will be.
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The premiums and cash values of a participating policy are guaranteed, but the dividends are not. Premiums for
participating policies are typically higher than for guaranteed cost policies, but the cost to you may be higher or lower,
depending on the dividends actually paid. What are Cost Indexes?
In order to compare the cost of policies, you need to look at:
1. Premiums re
2. Cash Values
3. Dividends
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Cost Indexes use one or more of these factors to give you a convenient way to compare relative costs of similar policies.
When you compare costs, an adjustment must be made to take into account that money is paid and received at different
times. It is no enough to just add up the premiums you will pay and to subtract the cash values and dividends you expect
to get back. These indexes take care of the arithmetic for you. Instead of having to add, subtract and multiple and divide
many numbers yourself, you just compare the index numbers which you can get from life insurance agents and
companies.
1. Life Insurance Surrender Cost Index. This index is useful if you consider the level of the cash values to be of primary
importance to you. It helps you compare costs if at some future point in time, such as 10 or 20 years, you were to
surrender the policy and take its cash value.
2. Life Insurance Net Payment Cost Index. This index is useful if your main concern is the benefits that are to be paid at
your death and if the level of cash values is of secondary importance to you. It helps you compare costs at some future
point in time, such as 10 or 20 years, if you continue paying premiums on your policy and do not take its cash value.
There is another number called the Equivalent Level Annual Dividend. It shows the part dividends play in determining the
cost index of a participating policy. Adding a policy's Equivalent Level annual Dividend to its cost index allows you to
compare total costs of similar policies before deducting dividends. However, if you make any cost comparisons of a
participating policy with a non-participating policy, remember that the total cost of the participating policy will be reduced
by dividends, but the cost of the non-participating policy will not change.
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1006128 2001 151836 200 12-12-2016
How Do I Use Cost Indexes?
The most important thing to remember when using cost indexes is that a policy with a small index number is generally a
better buy than a comparable policy with a larger index number. The following rules are also important:
(1) Cost comparisons should only be made between similar plans of life insurance. Similar plans are those which provide
essentially the same basic benefits and require premium payments for approximately the same period of time. The closer
policies are to being identical, the more reliable the cost comparison will be.
(2) Compare index numbers only for the kind of policy, for your age and for the amount you intend to buy. Since no one
company offers the lowest cost for all types of insurance at all ages and for all amounts of insurance, it is important that
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you get the indexes for the actual policy, age and amount which you intend to buy. Just because a Shopper's Guide tells
you that one company's policy is a good buy for a particular age and amount, you should not assume that all of that
company's policies are equally good buys.
(3) Small differences in index numbers could be offset by other policy features, or differences in the quality of service you
may expect from the company or its agent. Therefore, when you find small differences in cost indexes, your choice should
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be based on something other than cost.
(4) In any event, you will need other information on which to base your purchase decision. Be sure you can afford the
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premiums, and that you understand its cash values, dividends and death benefits. You should also make a judgment on
how well the life insurance company or agent will provide service in the future, to you as a policyholder.
(5) These life insurance cost indexes apply to new policies and should not be used to determine whether you should drop
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a policy you have already owned for a while, in favor of a new one. If such a replacement is suggested, you should ask for
information from the company which issued the old policy before you take action.
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Page 7 of 7
1006128 2001 151836 200 12-12-2016
Acknowledgment and Authorization

State Farm Life and Accident Assurance Company
Acknowledgment Information obtained using this Authorization may later be

redisclosed and may not be protected under the Health Insurance
By signing this document, I acknowledge that I have received the
Portability and Accountability Act of 1996. However, other applicable
Notices and the Acknowledgment and Authorization wording with
state laws and protections will still apply. I authorize State Farm to
my application for life insurance coverage.
obtain an investigative consumer report on me (and any others
Authorization proposed for insurance).
I authorize any source having medical or non-medical information I understand that:
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about me or my children (if coverage applied for) to give State Farm • I may revoke this Authorization by providing a written request to
Life and Accident Assurance Company (State Farm®), its State Farm, except when State Farm has taken action based on
contractors, reinsurers, or its representatives all information this Authorization;
available within the last 10 years including but not limited to all or • Revoking this Authorization will cause my application to be
any of the following: declined;
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• Health history; • I may refuse to sign this Authorization, but doing so will cause my
• Prescription history; application to be declined; and
• Diagnosis, treatment or prognosis with respect to any physical or • My medical sources cannot condition treatment, payment,
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mental condition; enrollment or eligibility for benefits on whether I sign this
• Employment history; Authorization.
• Consumer reports; and This Authorization is valid for two (2) years from the date of
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• Other insurance coverage. signature for the purpose of obtaining information. Information
Medical sources include but are not limited to any doctor, hospital, obtained may later be used for insurance research purposes. This
clinic, U.S. Veterans Affairs (VA) hospital, mental health facility, and two-year limit complies with the time limit, if any, permitted by
any other medically related facility. Non-medical sources include but applicable law in the state where the policy is issued for delivery.
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are not limited to insurance companies, consumer reporting Non-medical information may be shared with State Farm Mutual
agencies, and MIB, Inc. Automobile Insurance Company and its affiliates or non-affiliated
I authorize State Farm Life and Accident Assurance Company or its third parties as permitted or required by law. No MIB information will
reinsurers to make a brief report of my personal health information be released to another consumer reporting agency.
to MIB, Inc. A copy of this Authorization is as valid as the original. I understand I
I understand that State Farm will use any information they obtain to and/or my authorized representative have the right to receive a copy
determine my eligibility for insurance. of this Authorization.
Doc type
JOHNNY FELICIANO 01/12/1962
Print Proposed Insured 1 name Date of birth (MM/DD/YYYY) 07.03
10/20/2020
Proposed Insured 1 signature (Parent or Guardian signature if juvenile application) Date (MM/DD/YYYY)
Print Proposed Insured 2 name Date of birth (MM/DD/YYYY)
Proposed Insured 2 signature Date (MM/DD/YYYY)
1006542.1 [Life - NY] 2001 146072 201 10-25-2017
Acknowledgment and Authorization

(Proposed Insured Copy) State Farm Life and Accident Assurance Company
Acknowledgment Information obtained using this Authorization may later be

By signing this document, I acknowledge that I have received redisclosed and may not be protected under the Health
the Notices and the Acknowledgment and Authorization Insurance Portability and Accountability Act of 1996. However,
wording with my application for life insurance coverage. other applicable state laws and protections will still apply. I
authorize State Farm to obtain an investigative consumer report
Authorization
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on me (and any others proposed for insurance).
I authorize any source having medical or non-medical I understand that:
information about me or my children (if coverage applied for) to
• I may revoke this Authorization by providing a written request
give State Farm Life and Accident Assurance Company (State
to State Farm, except when State Farm has taken action
Farm®), its contractors, reinsurers, or its representatives all
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based on this Authorization;
information available within the last 10 years including but not
limited to all or any of the following: • Revoking this Authorization will cause my application to be
declined;
• Health history;
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• I may refuse to sign this Authorization, but doing so will
• Prescription history;
cause my application to be declined; and
• Diagnosis, treatment or prognosis with respect to any
• My medical sources cannot condition treatment, payment,
physical or mental condition;
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enrollment or eligibility for benefits on whether I sign this
• Employment history; Authorization.
• Consumer reports; and This Authorization is valid for two (2) years from the date of
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• Other insurance coverage. signature for the purpose of obtaining information. Information
Medical sources include but are not limited to any doctor, obtained may later be used for insurance research purposes.
hospital, clinic, U.S. Veterans Affairs (VA) hospital, mental This two-year limit complies with the time limit, if any, permitted
health facility, and any other medically related facility. Non- by applicable law in the state where the policy is issued for
medical sources include but are not limited to insurance delivery. Non-medical information may be shared with State
companies, consumer reporting agencies, and MIB, Inc. Farm Mutual Automobile Insurance Company and its affiliates
or non-affiliated third parties as permitted or required by law. No
I authorize State Farm Life and Accident Assurance Company
MIB information will be released to another consumer reporting
or its reinsurers to make a brief report of my personal health
agency.
information to MIB, Inc.
A copy of this Authorization is as valid as the original. I
I understand that State Farm will use any information they
understand I and/or my authorized representative have the right
obtain to determine my eligibility for insurance.
to receive a copy of this Authorization.
1007435.1 [Life - NY] 2000 156002 200 10-31-2019

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DocuSign Envelope ID: F32F4D21-B168-4E01-88D6-6AEC60525B37

CASE NAME DATE

johnny feliciano 10/19/2020

Income $120,000 Total Debts $0

Household Income $150,000 Current Life Insurance Holdings $0

State Of Issue NY Annuity Experience No Experience

Risk Tolerance Conservative Life Insurance Experience Less than 1 Year

Validation Face Amount $300,000 Funding Sources Current Income

Covered Lives Single Life (Insured's life

Purchase Type New policy

State Farm - Term 20

Policy Type Term Premium Type Level Premium

Lives Type Single Or Joint Convertible To

Reasons to consider State Farm - Term 20

Financial Objectives/Intended Use of Policy: This product may be a primary

This source of funds may be appropriate for this purchase.

additional insurance need of $3,500,000 of life insurance.

Not FDIC insured No Bank Guarantee

Life Insurance Wizard Report Disclosure and Attestation

New York Regulation 187 Agent Documentation:

New York Regulation 187 Customer Attestation:

Applicant/owner signature Date (mm/dd/yyyy)

Joint applicant/owner signature Pr Date (mm/dd/yyyy)

New York Regulation 187 Agent Attestation:

1007068 Page 1 of 2 2002 148109 202 03-20-2019

Date: Signature of Applicant: #$S01 - for office use only

1007068 Page 2 of 2 2002 148109 202 03-20-2019

State Farm Life and Accident

Summary Adjustment of Premium

Applicant signature Date (mm/dd/yyyy)

1004708.1 NY 2003 150293 203 08-13-2020

State Farm Life and Accident

Application Individual Life Insurance

Indicate the existing policy number(s)

2 Personal Information - Proposed Insured 1 og

Doc type 01.01

3 Personal Information - Proposed Insured 2/Additional Insured/Payor

sports, military? Yes No If yes, please describe your exact duties:

4 Add Applicant/Owner Information

Last name First name Middle name

City State ZIP Code

SSN/ITIN/TIN Date of birth (MM/DD/YYYY) Relationship to Proposed Insured 1

Home Phone Work Phone Cell Phone Organization type

APPLICANT/OWNER 2 (Joint Owner)

Last name First name Middle initial

City State ZIP Code

Home Phone Work Phone Cell Phone

Last name First name

City State ZIP Code

SSN/ITIN/TIN Date of birth (MM/DD/YYYY)

Home Phone Work Phone Cell Phone

5 Proposed Insured Under Age 14½

6 Select Coverages and Policy Provisions

a. Term Life and Whole Life

(1) Indicate beneficiary type(s) below and provide appropriate details.

Estate (enter Beneficiary Allocation): %

Organization (enter Beneficiary Allocation): %

8 Children's Term Rider

9 Children's Term Rider/Juvenile Medical Information

10 Other - Life Insurance or Annuities