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EVAPP2016GNSECTION VII. IMPORTANT STATEMENTS TO BE READ BY APPLICANT You do not need more than one Medicare supplement policy. If you purchase this policy, you may want to evaluate your existing health coverage and decide if youneed multiple coverages. You may be eligible for benefits under Medicaid and may not need a Medicare Supplement InsurancePolicy. If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under yourMedicare Supplement Insurance Policy can be suspended, if requested, during your entitlement tobenefits under Medicaid for 24 months. You must request this suspension within 90 days of becomingeligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplementpolicy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted, if requested,within 90 days of losing Medicaid eligibility. If the Medicare supplement policy provided coverage foroutpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, thereinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantiallyequivalent to your coverage before the date of suspension. If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and youlater become covered by an employer or union-based group health plan, the benefits and premiums underyour Medicare supplement policy can be suspended, if requested, while you are covered under theemployer or union-based group health plan. If you suspend your Medicare supplement policy under thesecircumstances, and later lose your employer or union-based group health plan, your suspended Medicaresupplement policy (or, if that is no longer available a substantially equivalent policy) will be reinstituted, ifrequested, within 90 days of losing your employer or union based group health plan. If the Medicaresupplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare PartD while your policy was suspended, the reinstituted policy will not have outpatient prescription drugcoverage, but will otherwise be substantially equivalent to your coverage before the date of suspension. Counseling services may be available in your state to provide advice concerning your purchase of aMedicare Supplement Insurance policy and concerning medical assistance through the state Medicaidprogram, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-IncomeMedicare Beneficiary (SLMB).EVAPP2016GNEverest Reinsurance CompanyPage 6 of 7

EVAPP2016GNSECTION VIII. AUTHORIZATION AND CERTIFICATIONI hereby authorize any licensed physician, medical practitioner, hospital, clinic, laboratory, pharmacy, pharmacybenefit manager or other medical facility, insurance or reinsurance company, Medical Information Bureau (MIB),consumer reporting agency, Division of Motor Vehicles, the Veterans Administration or other medical ormedically-related facility, insurance company or Medicare, that has any records or knowledge of me or myhealth to give Everest Reinsurance Company, or its reinsurers, any such information. I understand that I amauthorizing Everest Reinsurance Company to receive my health information and prescription drug usage history.The released information received by Everest Reinsurance Company will remain protected by federal and/orstate regulations as long as it is maintained by the health plan. Any information that is disclosed pursuant to thisauthorization may be redisclosed as provided herein or as required or authorized by law and may then no longerbe covered by federal rules governing privacy and confidentiality of health information. I authorize EverestReinsurance Company or its reinsurers to make a brief report on my personal health to MIB. Medicalinformation will not be used to decline coverage if I am applying during an open enrollment or guaranteed issueperiod.I understand that the information requested is necessary for evaluation and underwriting of my application forthe Medicare Supplement Insurance Policy for which I have applied; to determine eligibility for insurance, riskrating or policy issue determinations; obtain reinsurance; administer claims and determine or fulfill responsibilityfor coverage and provision of benefits; and to conduct other legally permissible activities that relate to anycoverage I have, or have applied for, with Everest Reinsurance Company. I understand that telephoneinterviews may be a part of the application process and that any information obtained from such telephoneinterviews may be used to decline my application for coverage. I understand that failure to provide theauthorization to Everest Reinsurance Company will result in the rejection of the Medicare Supplement InsurancePolicy coverage. I understand that I may revoke this authorization at any time by notifying Everest ReinsuranceCompany in writing at their Medicare Supplement Administrative Office: P.O. Box 10878, Clearwater, Florida33757-8878. I understand that such revocation will not have any effect on actions Everest ReinsuranceCompany took prior to their receiving the revocation notice. I understand that this authorization will be valid fortwenty-four (24) months from the date signed if used in connection with an application for an insurance policy,reinstatement of an insurance policy, or change in policy benefits. A photocopy of this authorization will betreated in the same manner as the original. I understand that I or my authorized representative am entitled to acopy of this authorization.To the best of my knowledge and belief, all of the answers to the questions contained in this application are trueand complete and I understand and agree that: (a) the insurance shall not take effect until my Medicarecoverage is effective, the application has been accepted and approved by the Company, the first premium hasbeen paid, and the policy has been delivered to the applicant; and (b) oral statements between the agent andmyself are not binding on the Company unless accepted by the Company in writing. The undersigned applicantcertifies that the applicant has read, or had read to him, the completed application and that he realizes that anyfalse statements or misrepresentations therein material to the risk may result in loss of coverage under thepolicy to which this application is a part. I understand that any change in my health history prior to delivery ofthis policy may be used in the underwriting evaluation process.Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit orknowingly presents false information in an application for insurance is guilty of a crime and may besubject to fines and confinement in prison.I wish to apply for a Medicare supplement insurance policy. I acknowledge that I have received or been givenaccess to review or print: (a) an Outline of Coverage for the policy applied for, and (b) a ”Guide to HealthInsurance for People with Medicare.”MM/DD/YYYYSigned at:StateApplicant’s SignatureDateMM/DD/YYYYAgent Writing NumberAgent’s SignaturePolicy Mailing Preference (check one):EVAPP2016GNMail to AgentEverest Reinsurance CompanyDateMail to ApplicantPage 7 of 7

Phone: 1-844-301-0395Fax:1-816-701-2548Web: everestre.com/medicaresupplementMedicare SupplementPO Box 10879Clearwater, FL 33757-8879ELECTRONIC PAYMENT AUTHORIZATION FORMInsured Name:Insurance Policy Number:Sign and date this authorization belowAs a convenience to me, I hereby request and authorize you to pay and charge to my bank account checks drawn byand payable to the order of Everest Reinsurance Company provided there are sufficient collected funds in said accountto pay the same upon presentation. It will not be necessary for any officer or employee of Everest ReinsuranceCompany to sign such checks. I agree that your rights in respect to each such check shall be the same as if it were acheck drawn by you and signed personally by me. This authority is to remain in effect until revoked by me in writing,and until you actually receive such notice I agree that you shall be fully protected in honoring any such check. I furtheragree that if any such check be dishonored, whether with or without cause and whether intentionally or inadvertently,you shall be under no liability whatsoever even though such dishonor results in the forfeiture of insurance.Please indicate below when you would like your account drafted. Many of our customers have requested the option topay their premiums on the same day they receive Social Security or SSI payments. The options below allow you toselect the date that best fits your needs. You may select any option regardless of whether or not you receive SocialSecurity.Section 1 – Select one of the following date options.Initial Premium Payment:(choose one)Same as subsequent payment date selected below, on or afterthe requested Effective DateOn the Policy Issue DatePaid by enclosed checkSubsequent Premium Payments:(choose one)st2 Wednesday of the Monthrd3 Wednesday of the Month1 day of the Month3 day of the Monthndrdth4 Wednesday of the MonthNOTE: If one of the above dates falls on a weekend or holiday, deduction will be on prior business day.Other, please specify a day of the month from 1 to 28 (if this date falls on a weekend or holiday,deduction will be on next business day)Section 2 – Select one of the payment options.CheckingSavingsAttach voided checkBranch/Bank Name:Routing Number:Account Number:Section 3 – Complete name and address as shown on account.Accountholder Name:Address/City/State/Zip:Section 4 – Please sign and date.Signature:Date:ELECTRONIC PAYMENT FORM

EVEREST REINSURANCE COMPANYStatutory Office: 1209 Orange Street, Wilmington, DE 19801Administration: P.O. Box 10878Clearwater, Florida 33757-8878MEDICARE SUPPLEMENT HOUSEHOLD DISCOUNT FORMApplicant Name:Applicant Social Security Number:To qualify for the Household Discount, the applicant must meet one of the following criteria below. Pleaseselect the box which applies:I am currently married and residing with my spouse named below.I have been residing with the person named below who is at least age 40 or older.Spouse/Household Member NameFirst NameMILast NameRelationship toApplicantDate of BirthPhone Number1. Does this person currently reside at the same address of the applicant? . YesNoIf yes, can this be verified by postal and tax records? . YesNo2. Is this a permanent (not temporary) and full-time (not part-time) arrangement? . YesNo3. Is this person receiving disability benefits? . YesNoThe Household Discount will not be applied if questions #1 or #2 are answered “NO” or if question #3 isanswered “Yes.”Agent/Applicant Signature:By signing this form I certify that I qualify for the Household Discount by meeting the criteria listed above.Agent SignatureDateApplicant SignatureDateEVHHD2016HHD FORM

NOTICE TO APPLICANT REGARDING REPLACEMENTOF MEDICARE SUPPLEMENT INSURANCEOR MEDICARE ADVANTAGEEVEREST REINSURANCE COMPANYStatutory Office: 1209 Orange Street, Wilmington, Delaware 19801Medicare Supplement Administrative Office: P. O. Box 10879, Clearwater, Florida 33757-8879SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTUREAccording to your application, you intend to terminate existing Medicare supplement or Medicare Advantageinsurance and replace it with a policy to be issued by Everest Reinsurance Company. Your new policy willprovide thirty (30) days within which you may decide without cost whether you desire to keep the policy.You should review this new coverage carefully. Compare it with all accident and sickness coverage you nowhave. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wisedecision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You shouldevaluate the need for other accident and sickness coverage you have that may duplicate this policy.STATEMENT TO APPLICANT BY AGENT:I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicaresupplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantagecoverage because you intend to terminate your existing Medicare supplement coverage or leave your MedicareAdvantage plan. The replacement policy is being purchased for the following reason (check one):Additional benefits.No change in benefits, but lower premiums.Fewer benefits and lower premiums.Change in benefits. (Gaining additional benefit(s) but losing some existing benefit(s)).My plan has outpatient drug coverage and I am enrolling in Part D.Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment.Other (please specify)If, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully andcompletely answer all questions on the application concerning your medical and health history. Failure to includeall material medical information on an application may provide a basis for the company to deny any future claimsand to refund your premium as though your policy had never been in force. After the application has beencompleted and before you sign it, review it carefully to be certain that all information has been properly recorded.Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.Signature of Agent, Broker or Other RepresentativeName and Address of AgentThe above “Notice to Applicant” was delivered to me on:Applicant’s SignatureEVREPL2016GNDate

EVAPP2016GN Everest Reinsurance Company Page 1 of 7 APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE EVEREST REINSURANCE COMPANY P. O. Box 10878, Clearwater, Florida 33757-8878 Application is for (check one): New Business Reinstatement Conversion SECTION I. APPLICANT INFORMATION First Name MI Last Name Age Date of Birth (MM/DD/YYYY)