Document:

exv10w3

 

EXECUTION COPY 

AMENDMENT, WAIVER, CONSENT AND ASSUMPTION AGREEMENT

     This AMENDMENT, WAIVER, CONSENT AND ASSUMPTION AGREEMENT, dated as of July 21, 2007 (this
“Agreement”), is by and among Merck & Co., Inc., a New Jersey corporation
(“Merck”), FoxHollow Technologies, Inc., a Delaware corporation (“FoxHollow”), and
ev3 Inc., a Delaware corporation (“ev3”).

     A. Merck and FoxHollow are parties to that certain Amended and Restated Collaboration and
License Agreement dated as of September 26, 2006, pursuant to which Merck and FoxHollow have agreed
to perform certain collaboration activities related to the removal of atherosclerotic plaque from
patient arteries (the “Collaboration Agreement”), and that certain Stock Purchase Agreement
dated September 26, 2006 (the “Stock Purchase Agreement”), and that certain Registration
Rights Agreement dated September 26, 2006 (the “Registration Rights Agreement,” together
with the Collaboration Agreement and the Stock Purchase Agreement, the “Merck Agreements”),
relating to Merck’s ownership of FoxHollow common stock.

     B. ev3, Foreigner Merger Sub, Inc., a wholly owned subsidiary of ev3, and FoxHollow have
entered into an Agreement and Plan of Merger (the “Merger Agreement”), pursuant to which
ev3’s wholly owned subsidiary will merge with and into FoxHollow and FoxHollow will become a wholly
owned subsidiary of ev3 (the “Merger”). Capitalized terms used but not defined herein have
the meanings given to them in Annex A hereto.

     C. ev3 desires Merck to agree, and subject to the terms and conditions of this Agreement Merck
is willing to agree, to (i) waive certain of its rights to terminate the Collaboration Agreement,
(ii) consent to the Merger Agreement and the Merger, and (iii) enter into certain amendments to the
Merck Agreements.

     D. Merck desires that ev3 agree to cause FoxHollow to continue to perform its obligations
under the Collaboration Agreement and agree to assume certain of FoxHollow’s obligations under the
Collaboration Agreement and the Stock Purchase Agreement, which ev3 is willing to agree to subject
to the terms and conditions of this Agreement.

     Accordingly, and in consideration of the foregoing and for due and valuable consideration, the
receipt of which is hereby acknowledged, and intending to be legally bound, the parties hereto do
hereby agree as follows:

1. Waiver. Merck hereby expressly, irrevocably and unconditionally waives any and all
rights that Merck may have to terminate the Collaboration Agreement as a result of the Merger,
including any rights to terminate the Collaboration Agreement as a result of the Merger pursuant to
Sections 8.2.1(c)(iii) and 8.2.3 of the Collaboration Agreement, or pursuant to Section 5.6(c) of
the Stock Purchase Agreement.

2. Consent. Subject to the terms and conditions of this Agreement, Merck hereby (a)
acknowledges receipt of notice of the Merger and waives any notice periods that may be required
under the Merck Agreements in respect of the Merger Agreement and the Merger, including the notice
requirements of Section 8.2.3 in the Collaboration Agreement; (b) consents, even though such
consent may not be required, to any “assignment” of the Merck Agreements, including the
Collaboration Agreement and any license granted thereunder, as a result of the Change of
Control caused by the Merger; and (c) acknowledges and agrees that the surviving corporation in

 

 

the Merger will continue to enjoy the same rights and will remain subject to the same obligations that
FoxHollow enjoyed immediately prior to the Merger, except as amended, modified or waived as set
forth in this Agreement.

3. Merck Director. ev3 and FoxHollow agree that as of the Effective Date (as defined in
Section 11 below) an individual designated by Merck (the “Investor Director”), who shall initially
be Richard N. Kender will be appointed to ev3’s board of directors with a term ending in 2009, as
one of FoxHollow’s four (4) directors to be part of the ev3 board following the Merger pursuant to
Section 5.12(a) of the Merger Agreement. Merck shall have the right to designate a representative
to replace Richard N. Kender, provided that the individual designated to replace Mr. Kender shall
be reasonably acceptable to a majority of the independent members of ev3’s board of directors in
their sole reasonable discretion. The Investor Director will be accorded no less favorable
treatment than any other member of the ev3 board of directors, including without limitation,
expense reimbursement and indemnification, membership on committees (it being agreed that for such
purposes, the Investor Director shall be given the same consideration regarding membership as all
other members of the ev3 board of directors), except that the Investor Director may be excluded
from participation or deliberation by the Company’s Board of Director or committees thereof in
connection with issues involving: (i) interpretations of the Collaboration Agreement or any other
agreements between ev3 and Merck (as reasonably determined by ev3’s board of directors or relevant
committee thereof), (ii) matters of conflict or dispute between ev3 and Merck, or (iii) any other
matter between ev3 and a third party which is confidential and in the reasonable determination of
ev3’s board of directors, would be compromised by the presence of the Investor Director due to such
Investor Director’s affiliation with Merck. Merck agrees that such appointment of the Investor
Director to the ev3 board in accordance with this Section 3 will satisfy all of the obligations of
FoxHollow and/or ev3 pursuant to Section 5.1(a) of the Stock Purchase Agreement.

4. Collaboration Agreement Amendment and Guaranty. The parties hereto agree that effective
on and after the Effective Date: (a) Section 8.2.1(c) of the Collaboration Agreement shall be
amended by amending subsection (ii) to read as follows: “If at any time prior to November 9, 2009,
Dr. John Simpson ceases to be a director of ev3 for any reason other than his death, or
disability.”; (b) ev3 will guarantee to Merck that ev3 will procure the due and punctual
performance and observance by FoxHollow of its obligations under or in accordance with the
Collaboration Agreement, as amended pursuant to this section; and (c) ev3 hereby assumes, and is
bound by, the obligations of FoxHollow pursuant to Section 2.9 of the Collaboration Agreement, even
though FoxHollow is not a “Down-Stream Affiliate (as such term is defined in the Collaboration
Agreement). If Merck and FoxHollow agree to amend, modify or alter FoxHollow’s obligations under
the Collaboration Agreement after the Effective Date then, upon ev3’s consent to such amendment,
modification or alteration, ev3 will continue to guaranty the due and punctual performance by
FoxHollow of the Collaboration Agreement as so revised.

5. Stock Purchase Agreement Amendment and Assumption. The parties hereto agree that
effective on and after the Effective Date: (a) the Stock Purchase Agreement will be amended by
deleting Sections 5.2, 5.4, 5.9 and 5.10 in their entirety and amending the first clause of
subsection (b) of Section 5.6 to read as follows: “If at any time prior to ev3’s annual meeting in
2010 Dr. John Simpson ceases to be a director of ev3 for any reason other than his death, or
disability, then:”; and (b) subject to the foregoing amendment, ev3 will assume the obligations

2

 

of FoxHollow pursuant to Article V of the Stock Purchase Agreement, and Merck consents to ev3’s
assumption of such obligations.

6. Registration Rights Agreement. Pursuant to and in accordance with the Merger Agreement,
in exchange for Merck’s FoxHollow common stock Merck will receive shares of ev3 common stock
registered pursuant to a Registration Statement on Form S-4 (the “Registered Shares”).
Merck agrees that upon the issuance by ev3 of such Registered Shares all of the Registrable
Securities (as defined in the Registration Rights Agreement) will cease to be Registrable
Securities and the Registration Rights Agreement will terminate and be of no further force or
effect.

7. No Terminations. Merck represents and warrants that as of the date hereof: (a) the
Merck Agreements are in full force and effect; and (b) there are no current plans to terminate the
Merck Agreements.

8. Merger Agreement. Each of ev3 and FoxHollow agrees that it shall use its reasonable
best efforts to take, or cause to be taken, all actions and to do, or cause to be done, all things
necessary, proper or advisable under the Merger Agreement and Applicable Laws (as defined in the
Merger Agreement) to consummate the Merger and the other transactions contemplated by the Merger
Agreement on or before November 9, 2007.

9. Dispute Resolution. The parties agree that any dispute arising out of or relating to
this Agreement or the formation, breach, termination or validity thereof will be resolved pursuant
to the dispute resolutions procedures set forth in Section 9.7 of the Collaboration Agreement.

10. Governing Law. This Agreement will be governed by and construed in accordance with the
laws of the State of New York, without reference to its conflict of laws principals.

11. Notice. All notices which are required or permitted hereunder will be in writing and
sufficient if delivered personally, sent by facsimile (and promptly confirmed by personal delivery,
registered or certified mail or overnight courier), sent by nationally-recognized overnight courier
or sent by registered or certified mail, postage prepaid, return receipt requested, addressed as
follows:

If to ev3 (or to FoxHollow

after the Effective Date):

ev3 Inc.

9600 54th Avenue North, Suite 100

Plymouth, MN 55442-2111

Attention: Kevin M. Klemz

Fax: (763) 398-7200

With a copy to:

Oppenheimer Wolff & Donnelly LLP

Plaza VII, Suite 3300

45 South Seventh Street

Minneapolis, MN 55402-1609

3

 

Attention: Bruce A. Machmeier, Esq.

Fax: (612) 607-7100

If to FoxHollow prior to

the Effective Date:

FoxHollow Technologies, Inc.

740 Bay Road

Rewood City, CA 94063-2469

Attention: John Simpson

Fax: (650) 839-7920

With a copy to:

Wilson Sonsini Goodrich & Rosati

Professional Corporation

650 Page Mill Road

Palo Alto, California 94304

Facsimile: (650) 493-6811

Attention: Martin W. Korman, Esq.

                 Robert T. Ishii, Esq.

                 Philip Oettinger, Esq.

If to Merck:

Merck & Co., Inc.

One Merck Drive

P.O. Box 100, WS3A-65

Whitehouse Station, NJ 08889-0100

Attention: Office of Secretary

Facsimile No.: (908) 735-1246

With a copy to:

Merck & Co., Inc.

One Merck Drive

Attention: Chief Licensing Officer

P.O. Box 100, WS2A-30

Whitehouse Station, NJ 08889-0100

Facsimile No.: (908) 735-1214

or to such other address(es) as the party to whom notice is to be given may have furnished to the
other party in writing in accordance herewith. Any such notice will be deemed to have been given:
(a) when delivered if personally delivered or sent by facsimile on a business day (or if delivered
or sent on a non-business day, then on the next business day); (b) on the business day after
dispatch if sent by nationally-recognized overnight courier; or (c) on the fifth (5th)
business day following the date of mailing, if sent by mail.

4

 

12. Effective Date. Other than paragraph 8 hereof which shall be effective as of the date
hereto, this Agreement will be effective as of the effective time of the Merger (such date on which
the effective time of the Merger occurs, the “Effective Date” of this Agreement). This
Agreement will be of no force and effect and will be null and void if ev3 and FoxHollow do not
consummate the transactions contemplated by the Merger Agreement.

[Remainder of page intentionally left blank]

5

 

     IN WITNESS WHEREOF, the parties have duly executed this Agreement effective as of the
Effective Date.

	 	 	 	 	 	 	 
	MERCK & CO, INC.	 	EV3 INC.
	 
	 	 	 	 	 	 
	By:

	 	/s/ Judy C. Lewent
	 	By:
	 	/s/ Kevin M. Klemz
	 

	 	 
	 	 	 	 
	Name: Judy C. Lewent

Its: Executive Vice President &

Chief Financial Officer
	 	Name: Kevin M. Klemz

Its: Vice President, Secretary

and Chief Legal Officer
	 
	 	 	 	 	 	 
	 	 	 	 	FOXHOLLOW TECHNOLOGIES, INC.
	 
	 	 	 	 	 	 
	 

	 	 	 	By:
	 	/s/ John B. Simpson, M.D.
	 

	 	 	 	 	 	 
	 

	 	 	 	Name: John B. Simpson, M.D.

Its: Chief Executive Officer

6exv10w3

 

Exhibit
10.3

					
	
	 	Investors Heritage Life Insurance Company
P.O. Box 717 Frankfort KY 40602-0717

1-800-422-2011 Fax: 502-875-7084
investorsheritage@ihlic.com

Automatic YRT

Reinsurance Agreement

between

Trinity Life Insurance Company

Tulsa, Oklahoma

                         (hereinafter referred to as the “Ceding Company”)

and

Investors Heritage Life Insurance Company

Frankfort, Kentucky     (hereinafter referred to as “IHLIC”)

Effective February 1, 2007

Treaty #                                         

 

 

Table of Contents

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	Page
	ARTICLE 1 - PREAMBLE	 	 	1	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	1.1	 	 	Parties to the Agreement
	 	 	1	 
	 

	 	 	1.2	 	 	Compliance
	 	 	1	 
	 

	 	 	1.3	 	 	Construction
	 	 	1	 
	 

	 	 	1.4	 	 	Entire Agreement
	 	 	1	 
	 

	 	 	1.5	 	 	Severability
	 	 	1	 
	 

	 	 	1.6	 	 	Third Party Administrator
	 	 	1	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 2 - AUTOMATIC REINSURANCE	 	 	2	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	2.1	 	 	General Conditions
	 	 	2	 
	 

	 	 	2.2	 	 	New Business
	 	 	2	 
	 

	 	 	2.3	 	 	Retained Amounts
	 	 	2	 
	 

	 	 	2.4	 	 	Underwriting Standards
	 	 	3	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 3 - FACULTATIVE REINSURANCE	 	 	4	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 4 - COMMENCEMENT OF LIABILITY	 	 	5	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	4.1	 	 	Automatic Reinsurance
	 	 	5	 
	 

	 	 	4.2	 	 	Facultative Reinsurance
	 	 	5	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 5 - REINSURED RISK AMOUNT	 	 	6	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	5.1	 	 	Life
	 	 	6	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 6 - PREMIUM ACCOUNTING	 	 	7	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	6.1	 	 	Premiums
	 	 	7	 
	 

	 	 	6.2	 	 	Payment of Premiums
	 	 	7	 
	 

	 	 	6.3	 	 	Delayed Payment
	 	 	7	 
	 

	 	 	6.4	 	 	Failure to Pay Premiums
	 	 	7	 
	 

	 	 	6.5	 	 	Premium Rate Guarantee
	 	 	8	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 7 - REDUCTIONS, TERMINATIONS AND CHANGES	 	 	9	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	7.1	 	 	Reductions and Terminations
	 	 	9	 
	 

	 	 	7.2	 	 	Increases
	 	 	9	 
	 

	 	 	7.3	 	 	Risk Classification Changes
	 	 	10	 
	 

	 	 	7.4	 	 	Reinstatement
	 	 	10	 
	 

	 	 	7.5	 	 	Nonforfeiture Benefits
	 	 	10	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 8 - CONVERSIONS, EXCHANGES, AND REPLACEMENTS	 	 	11	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	8.1	 	 	Conversions
	 	 	11	 
	 

	 	 	8.2	 	 	Exchanges and Replacements
	 	 	11	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 9 - CLAIMS	 	 	13	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	9.1	 	 	Notice
	 	 	13	 
	 

	 	 	9.2	 	 	Proofs
	 	 	13	 
	 

	 	 	9.3	 	 	Amount and Payment of Reinsurance Benefits
	 	 	13	 
	 

	 	 	9.4	 	 	Contestable Claims
	 	 	13	 
	 

	 	 	9.5	 	 	Claim Expenses
	 	 	14	 

 

 

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	Page
	 

	 	 	9.6	 	 	Misrepresentation or Suicide
	 	 	14	 
	 

	 	 	9.7	 	 	Misstatement of Age or Sex
	 	 	14	 
	 

	 	 	9.8	 	 	Extra-Contractual Damages
	 	 	14	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 10 - RETENTION LIMIT CHANGES	 	 	16	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 11 - RECAPTURE	 	 	17	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 12 - GENERAL PROVISIONS	 	 	18	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	12.1	 	 	Currency
	 	 	18	 
	 

	 	 	12.2	 	 	Premium Tax
	 	 	18	 
	 

	 	 	12.3	 	 	Inspection of Records
	 	 	18	 
	 

	 	 	12.4	 	 	Forms, Manuals & Issue Rules
	 	 	18	 
	 

	 	 	12.5	 	 	Interest Rate
	 	 	18	 
	 

	 	 	12.6	 	 	Other
	 	 	18	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 13 - DAC TAX	 	 	19	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 14 - OFFSET	 	 	20	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 15 - INSOLVENCY	 	 	21	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	15.1	 	 	Insolvency of a Party to this Agreement
	 	 	21	 
	 

	 	 	15.2	 	 	Insolvency of the Ceding Company
	 	 	21	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 16 - ERRORS AND OMISSIONS	 	 	22	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 17 - DISPUTE RESOLUTION	 	 	23	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 18 - ARBITRATION	 	 	24	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 19 - CONFIDENTIALITY	 	 	26	 
	 
	 	 	 	 	 	 	 	 	 	 
	Article 20 - DURATION OF AGREEMENT	 	 	28	 
	 
	 	 	 	 	 	 	 	 	 	 
	ARTICLE 21 - EXECUTION	 	 	29	 

Exhibits

	 	 	 	 	 
	A

	 	—
	 	Retention Limits of the Ceding Company and First Excess Limits
	B

	 	—
	 	Plans Covered and Binding Limits
	C

	 	—
	 	Forms, Manuals and Issue Rules
	D

	 	—
	 	Reinsurance Premiums
	E

	 	—
	 	Self-Administered Reporting
	F

	 	—
	 	List of Risks Reinsured
	G

	 	—
	 	List of Amendments
	H

	 	—
	 	In Force Summary Form
	I

	 	—
	 	Application for Facultative Reinsurance Form

 

 

Article 1 — PREAMBLE

	1.1	 	Parties to the Agreement
	 
	 	 	This is a YRT agreement for indemnity reinsurance (the “Agreement”) solely between Trinity
Life Insurance Company, Tulsa, Oklahoma (“the Ceding Company”), and Investors Heritage Life
Insurance Company (“IHLIC”),of Frankfort, Kentucky, collectively referred to as the
“parties”.
	 
	 	 	The acceptance of risks under this Agreement will create no right or legal relationship
between IHLIC and the insured, owner or beneficiary of any insurance policy or other
contract of the Ceding Company.
	 
	 	 	The Agreement will be binding upon the Ceding Company and IHLIC and their respective
successors and assigns.
	 
	1.2	 	Compliance
	 
	 	 	This Agreement applies only to the issuance of insurance by the Ceding Company in a
jurisdiction in which it is properly licensed.
	 
	 	 	The Ceding Company represents that, to the best of its knowledge, it is in compliance with
all state and federal laws applicable to the business reinsured under this Agreement. In
the event the Ceding Company is found to be in non-compliance with any law material to this
Agreement, the Agreement will remain in effect and the Ceding Company will indemnify IHLIC
for any direct loss IHLIC suffers as a result of the non-compliance, and will seek to remedy
the non-compliance.
	 
	1.3	 	Construction
	 
	 	 	This Agreement will be construed in accordance with the laws of the state of Oklahoma.
	 
	1.4	 	Entire Agreement
	 
	 	 	This Agreement constitutes the entire agreement between the parties with respect to the
business reinsured hereunder. There are no understandings between the parties other than as
expressed in this Agreement. Any change or modification to this Agreement will be null and
void unless made by amendment to this Agreement and signed by both parties.
	 
	1.5	 	Severability
	 
	 	 	If any provision of this Agreement is determined to be invalid or unenforceable, such
determination will not impair or affect the validity or the enforceability of the remaining
provisions of this Agreement.
	 
	1.6	 	Third Party Administrator
	 
	 	 	It is understood that the Ceding Company has appointed IHLIC, as its
Third Party Administrator (hereinafter referred to as the
“Administrator”). In connection therewith, the Ceding Company has
authorized the Administrator to perform the duties of underwriting,
administration and claim adjudication with the Ceding Company’s
oversight
and a valid Third Party Administrative Services agreement by and between the Ceding Company
and the Administrator has been executed.

1

 

Article 2 — AUTOMATIC REINSURANCE

	2.1	 	General Conditions
	 
	 	 	The Ceding Company will automatically cede to IHLIC new business as defined in Section 2.2
on the life insurance policies, supplementary benefits, and riders listed in Exhibit B
issued on and after the effective date of this Agreement. The basis for the automatic
reinsurance is shown in Exhibit B.
	 
	 	 	IHLIC will automatically accept its share of the above-referenced policies up to the limits
shown in Exhibit B, provided that:

	 	(a)	 	the insured, at the time of the application, must be a permanent resident of
the United States, United States Protectorates or Canada;
	 
	 	(b)	 	the Ceding Company keeps its full retention, as specified in Exhibit A, or
otherwise holds its full retention on a life under previously issued inforce policies
and applies the same underwriting standards it would have applied if the new policy had
fallen completely within its regular retention;
	 
	 	(c)	 	the Administrator makes all underwriting determination and the Ceding Company,
through the Administrator, applies its normal underwriting guidelines in accordance
with Section 2.4 of this article and Section 12.4;
	 
	 	(d)	 	the total of new ultimate amount of reinsurance required including contractual
increases, and the amount already reinsured on that life under this Agreement and all
other agreements between IHLIC and the Ceding Company, does not exceed the Automatic
Binding Limits set out in Exhibit B;
	 
	 	(e)	 	the application is on a life that has not been submitted facultatively to IHLIC
or any other reinsurer unless the reason for any prior facultative submission was
solely for capacity that may now be accommodated within the terms of this Agreement,
and
	 
	 	(g)	 	IHLIC’s underwriting manual will be used.

	2.2	 	New Business
	 
	 	 	New business as defined in this article and Article 8.2 are those
policies on which (a) the Ceding Company, through the Administrator,
has obtained complete and current underwriting evidence on the full
amount issued, (b) the full normal commissions are paid by the Ceding
Company, through the Administrator, for the new plan, and (c) the
suicide and contestable provisions apply from the effective date of
the new plan.
	 
	2.3	 	Retained Amounts
	 
	 	 	The Ceding Company may not reinsure on any basis any portion of the amount it has retained
on the business covered under this Agreement without prior notification to IHLIC.

2

 

	2.4	 	Underwriting Standards
	 
	 	 	The parties hereby declare and agree that all policies and benefits covered under this
Agreement shall be issued in accordance with Munich American Reassurance Company’s Life
Underwriting Manual, unless the Ceding Company and IHLIC agree to use an alternative method.
The Ceding Company should discuss any proposed changes in underwriting standards,
requirements, or other criteria with IHLIC, and will be subject to the written approval of
IHLIC before being applied to policies and benefits to be covered by this agreement.

3

 

Article 3 — FACULTATIVE REINSURANCE

	3.1	 	The Ceding Company, through the Administrator, may submit any application on a plan or rider
identified in Exhibit B to IHLIC for its consideration on a facultative basis.
	 
	 	 	The Ceding Company, through the Administrator, will apply for reinsurance on a facultative
basis by sending to IHLIC an Application for Facultative Reinsurance, providing the
information outlined in Exhibit I. Accompanying this Application will be copies of all
underwriting evidence that is available for risk assessment including, but not limited to,
copies of the application for insurance, medical examiners’ reports, attending physicians’
statements, inspection reports, and any other information bearing on the insurability of the
risk. The Ceding Company, through the Administrator, also will notify IHLIC of any
outstanding underwriting requirements at the time of the facultative submission. Any
subsequent information received by the Ceding Company, through the Administrator, that is
pertinent to the risk assessment will be immediately transmitted to IHLIC.
	 
	 	 	After consideration of the Application for Facultative Reinsurance and related information,
IHLIC will promptly inform the Ceding Company, through the Administrator, of its
underwriting decision. IHLIC’s offer will expire at the end of 120 days, unless otherwise
specified by IHLIC.
	 
	 	 	If the underwriting decision is acceptable, the Ceding Company, through the Administrator,
will notify IHLIC in writing of its acceptance of the offer.
	 
	 	 	Unless the Ceding Company, through the Administrator, gives notification before the
expiration date, there shall not be any reinsurance on the risk and errors and omissions, as
stated in Article 16 will not apply.

4

 

Article 4 — COMMENCEMENT OF LIABILITY

	4.1	 	Automatic Reinsurance
	 
	 	 	For automatic reinsurance, IHLIC’s liability for amounts ceded hereunder will commence at
the same time as the Ceding Company’s liability.
	 
	4.2	 	Facultative Reinsurance
	 
	 	 	For facultative reinsurance, IHLIC’s liability will commence at the same time as the Ceding
Company’s liability, provided that IHLIC has made a facultative offer and that offer was
accepted, during the lifetime of the insured, in accordance with the terms of this
Agreement.

5

 

Article 5 — REINSURED RISK AMOUNT

	5.1	 	Life
	 
	 	 	The reinsured net amount at risk of the policy is defined as the policy face amount less the
cash value, account value, or terminal reserve, less the amount retained by the Ceding
Company, and for automatic policies, multiplied by IHLIC’s share as stated in Exhibit B.
For variable amount plans, the reinsured net amount at risk is calculated using the account
value in effect at the end of the monthly reinsurance billing period.
	 
	 	 	Any change in the net amount at risk due to changes in the policy’s cash value or account
value will be shared proportionately between the Ceding Company and IHLIC.

6

 

Article 6 — PREMIUM ACCOUNTING

	6.1	 	Premiums
	 
	 	 	Reinsurance premium rates for life insurance and other benefits reinsured under this
Agreement are shown in Exhibit D. The rates will be applied to the reinsured net amount at
risk.
	 
	 	 	The Ceding Company, through the Administrator, will pay IHLIC the percentages of the premium
rates shown in Exhibit D.
	 
	6.2	 	Payment of Premiums
	 
	 	 	Reinsurance premiums are payable monthly and in advance. The Ceding Company, through the
Administrator, will calculate the amount of reinsurance premium due and, within forty-five
(45) days after the end of the month, will send IHLIC a statement that contains the
information shown in Exhibit E, showing reinsurance premiums due for that period. If an
amount is due IHLIC, the Ceding Company, through the Administrator, will remit that amount
together with the statement. If an amount is due the Ceding Company, IHLIC will remit such
amount within twenty (20) days of receipt of the statement.
	 
	6.3	 	Delayed Payment
	 
	 	 	Premium balances that remain unpaid for more than thirty (30) days after the Remittance Date
will incur interest from the end of the reporting period. The Remittance Date is defined as
thirty (30) days after the end of the reporting period. Interest will be calculated using
the index specified in Article 12.5.
	 
	6.4	 	Failure to Pay Premiums
	 
	 	 	The payment of reinsurance premiums is a condition precedent to the liability of IHLIC for
reinsurance covered by this Agreement. In the event that reinsurance premiums are not paid
within thirty (30) days of the Remittance Date, IHLIC will have the right to terminate the
reinsurance under all policies having reinsurance premiums in arrears. If IHLIC elects to
exercise its right of termination, it will give the Ceding Company, through the
Administrator, thirty (30) days written notice of its intention. Such notice will be sent
by certified mail.
	 
	 	 	If all reinsurance premiums in arrears, including any that become in arrears during the
thirty (30) day notice period, are not paid before the expiration of the notice period,
IHLIC will be relieved of all liability under those policies as of the last date to which
premiums have been paid for each policy. Reinsurance on policies on which reinsurance
premiums subsequently fall due will automatically terminate as of the last date to which
premiums have been paid for each policy, unless reinsurance premiums on those policies are
paid on or before their Remittance Dates.
	 
	 	 	Terminated reinsurance may be reinstated, subject to approval by IHLIC, within thirty (30)
days of the date of termination, and upon payment of all reinsurance premiums in
arrears including any interest accrued thereon. IHLIC will have no liability for any claims
incurred between the date of termination and the date of the reinstatement of the
reinsurance. The right to terminate reinsurance will not prejudice IHLIC’s right to collect

7

 

	 	 	premiums for the period during which reinsurance was in force prior to the expiration of the
thirty (30) days notice.
	 
	 	 	The Ceding Company, through the Administrator, will not force termination under the
provisions of this Article solely to avoid the provisions regarding recapture in Article 11,
or to transfer the reinsured policies to another reinsurer.
	 
	6.5	 	Premium Rate Guarantee
	 
	 	 	IHLIC does not guarantee the premium rates for more than one (1) year; hence deficiency
reserves are not required.

8

 

Article 7 — REDUCTIONS, TERMINATIONS AND CHANGES

Whenever a change is made in the status, plan, amount or other material feature of a policy
reinsured under this Agreement, IHLIC will, upon receipt of notification of the change, provide
adjusted reinsurance coverage in accordance with the provisions of this Agreement. The Ceding
Company, through the Administrator, will notify IHLIC of any such change within thirty (30) days of
its effective date.

	7.1	 	Reductions and Terminations
	 
	 	 	In the event of the reduction, lapse, or termination of a policy or policies reinsured under
this Agreement or any other agreement, the Ceding Company, through the Administrator, will,
reduce or terminate reinsurance on that life. The reinsured amount on the life with all
reinsurers will be reduced, effective on the same date, by the amount required such that the
Ceding Company maintains its retention as defined under this Agreement.
	 
	 	 	The reinsurance reduction will apply first to the policy or policies being reduced and then,
on a chronological basis, to other reinsured policies on the life, beginning with the oldest
policy. If a fully retained policy on a life that is reinsured under this Agreement is
terminated or reduced, the Ceding Company, through the Administrator, will reduce the
existing reinsurance on that life by a corresponding amount, with the reinsurance on the
oldest policy being reduced first. If the amount of reduction exceeds the risk amount
reinsured, the reinsurance on the policy or policies will be terminated.
	 
	 	 	IHLIC will refund any unearned reinsurance premiums net of allowances. However, the
reinsured portion of any policy fee will be deemed earned for a policy year if the policy is
reinsured during any portion of that policy year.
	 
	7.2	 	Increases

	 	(a)	 	Noncontractual Increases
	 
	 	 	 	If the amount of insurance is increased as a result of a noncontractual change, the
increase will be underwritten by the Ceding Company, through the Administrator, in
accordance with its customary standards and procedures and will be considered new
reinsurance under this Agreement. IHLIC’s approval is required if the original
policy was reinsured on a facultative basis or if the new amount will cause the
reinsured amount on the life to exceed either the Automatic Binding Limits or the
Jumbo Limits shown in Exhibit B.
	 
	 	 	 	IHLIC will assume its share of the entire amount in excess of the Ceding Company’s
applicable retention and the first excess. Premiums for the additional reinsurance
will be at the new-issue rate from the point of increase.
	 
	 	(b)	 	Contractual Increases
	 
	 	 	 	For policies reinsured on an automatic basis, reinsurance of increases in amount
resulting from contractual policy provisions will be accepted only up to the
Automatic Binding Limits shown in Exhibit B.
	 
	 	 	 	For policies reinsured on a facultative basis, reinsurance will be limited to the
ultimate amount shown in IHLIC’s facultative offer. Reinsurance premiums for

9

 

	 	 	 	contractual increases will be on a point-in-scale basis from the original issue age
of the policy.

	7.3	 	Risk Classification Changes
	 
	 	 	If the policyholder requests a Table Rating reduction or removal of a
Flat Extra, such change will be underwritten according to the Ceding
Company’s, through the Administrator, normal underwriting practices.
Risk classification changes on facultative policies will be subject to
IHLIC’s approval.
	 
	7.4	 	Reinstatement
	 
	 	 	If a policy reinsured on an automatic basis is reinstated in
accordance with its terms and in accordance with Ceding Company rules
and procedures, IHLIC will, upon notification of reinstatement,
reinstate the reinsurance coverage. If a policy reinsured on a
facultative basis is reinstated, approval by IHLIC will be required
prior to the reinstatement of the reinsurance if the Ceding Company’s
regular reinstatement rules, through the Administrator, indicate that
more evidence than a Statement of Good Health is required.
	 
	 	 	Upon reinstatement of the reinsurance coverage, the Ceding Company,
through the Administrator, will pay the contractual reinsurance
premiums plus accrued interest for the period and at the interest rate
for which it receives premiums in arrears.
	 
	7.5	 	Nonforfeiture Benefits

	 	(a)	 	Extended Term
	 
	 	 	 	If the original policy lapses and extended term insurance is elected under the terms
of the policy, reinsurance will continue on the same basis as under the original
policy until the expiry of the extended term period.
	 
	 	(b)	 	Reduced Paid-up
	 
	 	 	 	If the original policy lapses and reduced paid-up insurance is elected under the
terms of the policy, the amount reinsured will be reduced.
	 
	 	 	 	Reinsurance will be reduced by the full amount of the reduction. The reinsurance
premiums will be calculated in the same manner as reinsurance premiums were
calculated on the original policy. If the amount of reduction exceeds the risk
amount reinsured, the reinsurance on the policy will be terminated.

10

 

Article 8 — CONVERSIONS, EXCHANGES, AND REPLACEMENTS

If a policy reinsured under this Agreement is converted, exchanged or replaced, the Ceding Company,
through the Administrator, will promptly notify IHLIC. Unless mutually agreed otherwise, policies
that are not reinsured with IHLIC and that exchange or convert to a plan covered under this
Agreement will not be reinsured hereunder.

	8.1	 	Conversions
	 
	 	 	IHLIC will continue to reinsure policies resulting from the contractual conversion of any policy
reinsured under this Agreement, in an amount not to exceed the original amount reinsured
hereunder. If the plan to which the original policy is converting is reinsured by IHLIC,
either under this Agreement or under a different Agreement, reinsurance premium rates for the
resulting converted policy will be those contained in the Agreement that covers the plan to
which the original policy is converting. However, if the new plan is not reinsured by IHLIC,
reinsurance premiums for a policy resulting from a contractual conversion will be agreed upon
between the parties. Reinsurance premiums and any allowances for conversions will be on a
point-in-scale basis from the original issue age of the policy.
	 
	 	 	If the conversion results in an increase in the risk amount, the increase will be
underwritten by the Ceding Company, through the Administrator, in accordance with its
customary standards and procedures. IHLIC will accept such increases, subject to the new
business provisions of this Agreement. Reinsurance premiums and any allowances for
increased risk amounts will be first-year premiums at the agreed-upon premium rate.
	 
	8.2	 	Exchanges and Replacements
	 
	 	 	A policy resulting from an internal exchange or replacement will be underwritten by the
Ceding Company, through the Administrator, in accordance with its underwriting guidelines,
standards and procedures for exchanges and replacements. If the Ceding Company’s guidelines
treat the policy as new business, then the reinsurance will also be considered new business.
For purposes of this Article, new business is defined as those policies on which:

	 	(a)	 	the Ceding Company, through the Administrator, has obtained complete and
current underwriting evidence on the full amount; and
	 
	 	(b)	 	the full normal commissions are paid by the Ceding Company, through the
Administrator, for the new plan; and
	 
	 	(c)	 	the Suicide and Contestable provisions apply from the effective date of the new
plan.

	 	 	In the event of an internal exchange, if the state in which a replacement policy is issued
requires waiver of the suicide and/or contestable provisions, then IHLIC will honor that
obligation and waive the suicide and/or contestable provisions.
	 
	 	 	IHLIC’s approval to exchange or replace the policy will be required if the original policy
was reinsured on a facultative basis.
	 
	 	 	If the Ceding Company’s guidelines do not treat the policy as new business, the exchange or
replacement will continue to be ceded to IHLIC. The rates will be based on

11

 

	 	 	the original
issue age, underwriting class and duration since the issuance of the original policy.

12

 

Article 9 — CLAIMS

Claims covered under this Agreement include only death claims, which are those due to the death of
the insured on a policy reinsured under this Agreement, and any additional benefits specified in
Exhibit B, which are provided by the underlying policy and are reinsured under this Agreement.

	9.1	 	Notice
	 
	 	 	The Ceding Company, through the Administrator, will notify IHLIC, as soon as reasonably
possible, after it receives a claim on a policy reinsured under this Agreement.
	 
	9.2	 	Proofs
	 
	 	 	The Ceding Company, through the Administrator, will promptly provide IHLIC with proper claim
proofs, including a copy of the proof of payment by the Ceding Company, a copy of the
claimant statement and a copy of the insured’s death certificate. In addition, for
contestable claims, the Ceding Company, through the Administrator, will send to IHLIC a copy
of all papers in connection with the claim, including investigation papers, the underwriting
file and underwriter’s notes.
	 
	9.3	 	Amount and Payment of Reinsurance Benefits
	 
	 	 	As soon as IHLIC receives proper claim notice and proof of the claim, IHLIC will promptly
examine the claim and pay the reinsurance benefits due the Ceding Company as appropriate.
The Ceding Company’s contractual liability for policies reinsured under this Agreement is
binding on IHLIC. However, for claims incurred during the contestable period if the total
amount of reinsurance ceded to all Reinsurers on the policy is greater than the amount
retained by the Ceding Company, or if the Ceding Company retained less than its usual
retention on the policy, the Ceding Company, through the Administrator, will consult with
IHLIC before conceding liability or making settlement to the claimant. The Ceding Company
will wait at least ten (10) business days for IHLIC’s recommendation.
	 
	 	 	The total reinsurance recoverable from all companies will not exceed the Ceding Company’s
total contractual liability on the policy, less the amount retained. The maximum
reinsurance death benefit payable to the Ceding Company under this Agreement is the risk
amount specifically reinsured with IHLIC. IHLIC will also pay its proportionate share of
the interest that the Ceding Company pays on the death proceeds until the date of
settlement.
	 
	 	 	Life benefit payments will be made in a single sum, regardless of the Ceding Company’s
settlement options.
	 
	9.4	 	Contestable Claims
	 
	 	 	The Ceding Company, through the Administrator, will promptly notify IHLIC of its intention
to contest, compromise, or litigate a claim involving a reinsured policy. The Ceding
Company will also promptly and fully disclose all information relating to the claim.
Once notified, IHLIC will have fifteen (15) business days to notify the Ceding Company,
through the Administrator, in writing of its decision to accept participation in the
contest, compromise, or litigation. If IHLIC has accepted participation, the Ceding
Company, through the Administrator, will promptly advise IHLIC of all significant
developments in

13

 

	 	 	the claim investigation, including notification of any legal proceedings
against it in response to denial of the claim.
	 
	 	 	If IHLIC does not accept participation, IHLIC will then fulfill its obligation by paying the
Ceding Company its full share of the reinsurance amount, and will not share in any
subsequent reduction or increase in liability.
	 
	 	 	If IHLIC accepts participation and the Ceding Company’s contest, compromise, or litigation
results in a reduction or increase in liability, IHLIC will share in any such reduction or
increase in proportion to its share of the risk on the contested policy.
	 
	9.5	 	Claim Expenses
	 
	 	 	IHLIC will pay its share of reasonable claim investigation and legal expenses connected with
the litigation or settlement of contractual liability claims unless IHLIC has discharged its
liability pursuant to Section 9.4 above. If IHLIC has so discharged its liability, IHLIC
will not participate in any expenses incurred thereafter.
	 
	 	 	IHLIC will not reimburse the Ceding Company, through the Administrator, for routine claim
and administration expenses, including but not limited to the Ceding Company’s home office
expenses, compensation of salaried officers and employees, and any legal expenses other than
third party expenses incurred by the Ceding Company, through the Administrator. Claim
investigation expenses do not include expenses incurred by the Ceding Company, through the
Administrator, as a result of a dispute or contest arising out of conflicting claims of
entitlement to policy proceeds or benefits.
	 
	 	 	Furthermore, IHLIC will not reimburse the Ceding Company, through the Administrator, for any
expenses, if said expense was not incurred by the Ceding Company, through the Administrator,
while investigating, defending or settling a claim.
	 
	9.6	 	Misrepresentation or Suicide
	 
	 	 	If the Ceding Company, through the Administrator, returns premium to the policyowner or
beneficiary as a result of misrepresentation or suicide of the insured, IHLIC will refund
its proportionate share of the premium refund to the Ceding Company in lieu of any other
form of reinsurance benefit payable under this Agreement.
	 
	9.7	 	Misstatement of Age or Sex
	 
	 	 	In the event of a change in the amount of the Ceding Company’s liability on a reinsured
policy due to a misstatement of age or sex, IHLIC’s liability will change proportionately.
The face amount of the reinsured policy will be adjusted from the inception of the policy,
and any difference will be settled without interest.
	 
	9.8	 	Extra-Contractual Damages
	 
	 	 	IHLIC will not participate in punitive or compensatory damages that are awarded against the
Ceding Company as a result of an act, omission, or course of conduct committed solely by the
Ceding Company, its agents, or representatives in connection with claims covered under this
Agreement. IHLIC will, however, pay its share of statutory penalties awarded against the
Ceding Company in connection with claims covered under this Agreement if IHLIC elected in
writing to join in the contest of the coverage in question.
The parties recognize that circumstances may arise in which equity would require IHLIC, to
the extent permitted by law, to share proportionately in punitive and compensatory damages.
Such circumstances are difficult to define in advance, but would generally be

14

 

	 	 	those
situations in which IHLIC was an active party and, in writing, recommended, consented to, or
ratified the act or course of conduct of the Ceding Company that ultimately resulted in the
assessment of the extra-contractual damages. In such situations, IHLIC and the Ceding
Company will share such damages so assessed, in equitable proportions.
	 
	 	 	For purposes of this Article, the following definitions will apply.
	 
	 	 	“Punitive Damages” are those damages awarded as a penalty, the amount of which is
neither governed nor fixed by statute.
	 
	 	 	“Compensatory Damages” are those amounts awarded to compensate for the actual
damages sustained, and are not awarded as a penalty, nor fixed in amount by statute.
	 
	 	 	“Statutory Penalties” are those amounts awarded as a penalty, but are fixed in
amount by statute.

15

 

Article 10 — RETENTION LIMIT CHANGES

	10.1	 	If the Ceding Company changes its maximum retention limits as shown in Exhibit A, it will
provide IHLIC with written notice of the intended changes thirty (30) days in advance of their
effective date.
	 
	 	 	A change to the Ceding Company’s maximum retention limits will not affect the reinsured
policies in force except as specifically provided elsewhere in this Agreement. Furthermore,
unless agreed between the parties, an increase in the Ceding Company’s retention schedule
will not effect an increase in the total risk amount that it may automatically cede to
IHLIC.

16

 

Article 11 — RECAPTURE

	11.1	 	Whenever the Ceding Company increases its maximum retention limits over the maximum retention
limits set forth in Exhibit A, the Ceding Company, through the Administrator, has the option
to recapture certain risk amounts. If the Ceding Company has maintained its maximum stated
retention (not a special retention limit) for the plan and the insured’s issue age, sex, and
mortality classification, it may apply its increased retention limits to reduce the amount of
reinsurance in force as follows.

	 	(a)	 	The Ceding Company, through the Administrator, must give IHLIC thirty (30) days
written notice prior to the commencement of recapture.
	 
	 	(b)	 	The reduction of reinsurance on affected policies will become effective on the
policy anniversary date immediately following the notice of election to recapture;
however, no reduction will be made until a policy has been in force for at least twenty
(20) years.
	 
	 	(c)	 	If any reinsured policy is recaptured, all reinsured policies eligible for
recapture under the provisions of this Article must be recaptured up to the Ceding
Company’s new maximum retention limits in a consistent manner and the Ceding Company
must increase its total amount of insurance on each reinsured life. The Ceding Company
may not revoke its election to recapture for policies becoming eligible at future
anniversaries.

	 	 	If portions of the reinsured policy have been ceded to more than one reinsurer, the Ceding
Company, through the Administrator, must allocate the reduction in reinsurance so that the
amount reinsured by each reinsurer after the reduction is proportionately the same as if the
new maximum dollar retention limits had been in effect at the time of issue.
	 
	 	 	The amount of reinsurance eligible for recapture is based on the current amount at risk as
of the date of recapture. For a policy issued as a result of exchange, conversion, or
re-entry, the recapture terms of the reinsurance agreement covering the original policy will
apply, and the duration period for the purpose of recapture will be measured from the
effective date of the reinsurance on the original policy.
	 
	 	 	If there is a reinsured waiver of premium claim in effect when recapture takes place, IHLIC
will continue to pay its share of the waiver claim until it terminates. IHLIC will not be
liable for any other benefits, including the basic life risk, that are eligible for
recapture. All such eligible benefits will be recaptured as if there were no waiver claim in
effect.
	 
	 	 	After the effective date of recapture, IHLIC will not be liable for any reinsured policies
or portions of such reinsured policies eligible for recapture that the Ceding Company has
overlooked.
	 
	 	 	No recapture will be permitted if the Ceding Company has either obtained or increased stop
loss reinsurance coverage as justification for the increase in retention limits.

17

 

Article 12 — GENERAL PROVISIONS

	12.1	 	Currency
	 
	 	 	All payments and reporting by both parties under this Agreement will be made in United
States dollars.
	 
	12.2	 	Premium Tax
	 
	 	 	IHLIC will not reimburse the Ceding Company for premium taxes.
	 
	12.3	 	Inspection of Records
	 
	 	 	IHLIC and the Ceding Company, or their duly authorized representatives, will have the right
to inspect original papers, records, and all documents relating to the business reinsured
under this Agreement including underwriting, claims processing, and administration. Such
access will be provided during regular business hours at the office of the inspected party.
	 
	12.4	 	Forms, Manuals & Issue Rules
	 
	 	 	The Ceding Company affirms that its retention schedule, underwriting guidelines, issue rules,
premium rates and policy forms applicable to the Reinsured Policies and in use as of the
effective date, have been supplied to IHLIC.
	 
	 	 	It is the Ceding Company’s responsibility to ensure that its practice and applicable forms
are in compliance with current Medical Information Bureau (MIB) guidelines.
	 
	12.5	 	Interest Rate
	 
	 	 	If, under the terms of this Agreement, interest is accrued on amounts due either party, such
interest will be calculated using the 180 day treasury rate as reported in the Wall Street
Journal on the date the payment becomes due, except as it pertains to Article 9, and
outlined elsewhere in this Agreement.
	 
	12.6	 	Other
	 
	 	 	IHLIC will not participate in gross annual premiums and policy fees
paid by the policyholder, expense charges, cash values, accumulation
fund amounts, dividends nor any benefits not expressly referred to
herein.

18

 

Article 13 — DAC TAX

	13.1	 	The parties to this Agreement agree to the following provisions pursuant to Section
1.848-2(g)(8) of the Income Tax Regulations effective December 29, 1992, under Section 848 of
the Internal Revenue Code of 1986, as amended:

	 	(a)	 	The term ‘party’ refers to either the Ceding Company or IHLIC, as appropriate.
	 
	 	(b)	 	The terms used in this Article are defined by reference to Regulation Section
1.848-2, effective December 29, 1992.
	 
	 	(c)	 	The party with the net positive consideration for this Agreement for each
taxable year will capitalize specified policy acquisition expenses with respect to this
Agreement without regard to the general deductions limitation of Section 848(c)(1).
	 
	 	(d)	 	Both parties agree to exchange information pertaining to the amount of net
consideration under this Agreement each year to ensure consistency, or as otherwise
required by the Internal Revenue Service.
	 
	 	(e)	 	The Ceding Company will submit a schedule to IHLIC by April 1 of each year with
its calculation of the net consideration for the preceding calendar year. This
schedule of calculations will be accompanied by a statement signed by an officer of the
Ceding Company stating that the Ceding Company will report such net consideration in
its tax return for the preceding calendar year. IHLIC may contest such calculation by
providing an alternative calculation to the Ceding Company in writing within thirty
(30) days of IHLIC’s receipt of the Ceding Company’s calculation. If IHLIC does not so
notify the Ceding Company within the required timeframe, IHLIC will report the net
consideration as determined by the Ceding Company in IHLIC’s tax return for the
previous calendar year.
	 
	 	(f)	 	If IHLIC contests the Ceding Company’s calculation of the net consideration,
the parties will act in good faith to reach an agreement as to the correct amount
within thirty (30) days of the date IHLIC submits its alternative calculation. If the
Ceding Company and IHLIC reach an agreement on an amount of net consideration, each
party will report the agreed upon amount in its tax return for the previous calendar
year.
	 
	 	(g)	 	Both the Ceding Company and IHLIC represent and warrant that they are subject
to United States taxation under either Subchapter L or Subpart F of Part III of
Subchapter N of the Internal Revenue Code of 1986, as amended.

19

 

Article 14 — OFFSET

	14.1	 	Any debts or credits, in favor of or against either IHLIC or the Ceding Company with respect
to this Agreement or any other reinsurance agreement between the parties, are deemed mutual
debts or credits and may be offset and only the balance will be allowed or paid.
	 
	 	 	The right of offset will not be affected or diminished because of the insolvency of either
party.

20

 

Article 15 — INSOLVENCY

	15.1	 	Insolvency of a Party to this Agreement
	 
	 	 	A party to this Agreement will be deemed insolvent when it:

	 	(a)	 	applies for or consents to the appointment of a receiver, rehabilitator,
conservator, liquidator or statutory successor of its properties or assets; or
	 
	 	(b)	 	is adjudicated as bankrupt or insolvent; or
	 
	 	(c)	 	files or consents to the filing of a petition in bankruptcy, seeks
reorganization to avoid insolvency or makes formal application for any bankruptcy,
dissolution, liquidation or similar law or statute; or
	 
	 	(d)	 	becomes the subject of an order to rehabilitate or an order to liquidate as
defined by the insurance code of the jurisdiction of the party’s domicile.

	15.2	 	Insolvency of the Ceding Company
	 
	 	 	In the event of the insolvency of the Ceding Company, all reinsurance payments due under
this Agreement will be payable directly to the liquidator, rehabilitator, receiver, or
statutory successor of the Ceding Company, without diminution because of the insolvency, for
those claims allowed against the Ceding Company by any court of competent jurisdiction or by
the liquidator, rehabilitator, receiver or statutory successor having authority to allow
such claims.
	 
	 	 	In the event of insolvency of the Ceding Company, the liquidator, rehabilitator, receiver,
or statutory successor will give written notice to IHLIC of all pending claims against the
Ceding Company on any policies reinsured within a reasonable time after such claim is filed
in the insolvency proceeding. While a claim is pending, IHLIC may investigate and
interpose, at its own expense, in the proceeding where the claim is adjudicated, any defense
or defenses that it may deem available to the Ceding Company or its liquidator,
rehabilitator, receiver, or statutory successor.
	 
	 	 	The expense incurred by IHLIC will be chargeable, subject to court approval, against the
Ceding Company as part of the expense of liquidation to the extent of a proportionate share
of the benefit that may accrue to the Ceding Company solely as a result of the defense
undertaken by IHLIC. Where two or more reinsurers are participating in the same claim and a
majority in interest elect to interpose a defense or defenses to any such claim, the expense
will be apportioned in accordance with the terms of this Agreement as though such expense
had been incurred by the Ceding Company.
	 
	 	 	IHLIC will be liable only for the amounts reinsured and will not be or become liable for any
amounts or reserves to be held by the Ceding Company on policies reinsured under this
Agreement.

21

 

Article 16 — ERRORS AND OMISSIONS

	16.1	 	This provision will apply to oversights, misunderstandings or clerical errors relating to the
administration of reinsurance covered by this Agreement. If through unintentional error,
oversight, omission, or misunderstanding (collectively referred to as “errors”), IHLIC or the
Ceding Company, through their Administrator, fails to comply with the terms of this Agreement
and if, upon discovery of the error by either party, the other is promptly notified, each
thereupon will be restored to the position it would have occupied if the error had not
occurred, including interest, except as provided for in Article 3.
	 
	 	 	If it is not possible to restore each party to the position it would have occupied but for
the error, the parties will endeavor in good faith to promptly resolve the situation in a
manner that is fair and reasonable, and most closely approximates the intent of the parties
as evidenced by this Agreement.
	 
	 	 	However, IHLIC will not provide reinsurance for policies that do not satisfy the parameters
of this Agreement, nor will IHLIC be responsible for negligent or deliberate acts or for
repetitive errors in administration by the Ceding Company, through their Administrator.
Upon discovery of such errors, the Ceding Company, through the Administrator, will endeavor
to correct such errors within ninety (90) days; otherwise, there will be no reinsurance on
the affected policies. If either party discovers that the Ceding Company, through the
Administrator, has failed to cede reinsurance as provided in this Agreement, or failed to
comply with its reporting requirements, IHLIC may require the Ceding Company, through their
Administrator, to audit its records for similar errors and to take the actions necessary to
avoid similar errors in the future. If IHLIC has received no evidence that the Ceding
Company, through the Administrator, has taken action to remedy such a situation, IHLIC’s
liability is limited to correctly reported policies only.

22

 

Article 17 — DISPUTE RESOLUTION

	17.1	 	In the event of a dispute arising out of or relating to this agreement, the parties agree to
the following process of dispute resolution. Within thirty (30) days after IHLIC or the
Ceding Company has first given the other party written notification of a specific dispute,
each party will appoint a designated company officer to attempt to resolve the dispute. The
officers will meet at a mutually agreeable location as soon as possible and as often as
necessary, in order to gather and furnish the other with all appropriate and relevant
information concerning the dispute. The officers will discuss the problem and will negotiate
in good faith without the necessity of any formal arbitration proceedings. During the
negotiation process, all reasonable requests made by one officer to the other for information
will be honored. The designated officers will decide the specific format for such
discussions.
	 
	 	 	If the officers cannot resolve the dispute within thirty (30) days of their first meeting,
the dispute will be submitted to formal arbitration, unless the parties agree in writing to
extend the negotiation period for an additional thirty (30) days.

23

 

Article 18 — ARBITRATION

	18.1	 	It is the intention of IHLIC and the Ceding Company that the customs and practices of the
life insurance and reinsurance industry will be given full effect in the operation and
interpretation of this Agreement. The parties agree to act in all matters with the highest
good faith. If IHLIC and the Ceding Company cannot mutually resolve a dispute that arises out
of or relates to this Agreement, and the dispute cannot be resolved through the dispute
resolution process described in Article 17, the dispute will be decided through arbitration.
	 
	 	 	To initiate arbitration, either the Ceding Company or IHLIC will notify the other party in
writing of its desire to arbitrate, stating the nature of its dispute and the remedy sought.
The party to which the notice is sent will acknowledge to the notification in writing
within fifteen (15) days of its receipt.
	 
	 	 	There will be three arbitrators who will be current or former officers of life insurance or
life reinsurance companies other than the parties to this Agreement, their affiliates or
subsidiaries. Each of the parties will appoint one of the arbitrators and these two
arbitrators will select the third. If either party refuses or neglects to appoint an
arbitrator within sixty (60) days of the initiation of the arbitration, the other party may
appoint the second arbitrator. If the two arbitrators do not agree on a third arbitrator
within sixty (60) days of the appointment of the second arbitrator, then each arbitrator
shall nominate three candidates [within ten (10) days thereafter], two of whom the other
shall decline, and the decision shall be made by drawing lots for the final selection.
	 
	 	 	Once chosen, the arbitrators are empowered to select the site of the arbitration and decide
all substantive and procedural issues by a majority of votes. As soon as possible, the
arbitrators will establish arbitration procedures as warranted by the facts and issues of
the particular case. The arbitrators will have the power to determine all procedural rules
of the arbitration including but not limited to inspection of documents, examination of
witnesses and any other matter relating to the conduct of the arbitration. The arbitrators
may consider any relevant evidence; they will weigh the evidence and consider any
objections. Each party may examine any witnesses who testify at the arbitration hearing.
	 
	 	 	The arbitrators will base their decision on the terms and conditions of this Agreement and
the customs and practices of the life insurance and reinsurance industries rather than on
strict interpretation of the law. The decision of the arbitrators will be made by majority
rule and will be submitted in writing. The decision will be final and binding on both
parties and there will be no appeal from the decision. Either party to the arbitration may
petition any court having jurisdiction over the parties to reduce the decision to judgment.
The arbitrators may not award any exemplary or punitive damages.

24

 

	 	 	Unless the arbitrators decide otherwise, each party will bear the expense of its own
arbitration activities, including its appointed arbitrator and any outside attorney and
witness fees. The parties will jointly and equally bear the expense of the third arbitrator
and other costs of the arbitration.
	 
	 	 	This Article will survive termination of this Agreement.

25

 

Article 19 — CONFIDENTIALITY

	19.1	 	Privacy
	 
	 	 	IHLIC agrees to treat Customer Information provided by the Ceding Company as confidential, as prescribed under Federal and
State laws and regulations related to privacy. Customer Information includes, but is not limited to, medical, financial,
and other personal information about proposed, current, and former policyowners, insureds, applicants, and beneficiaries
of policies issued by the Ceding Company. IHLIC may disclose such information to its retrocessionaires as necessary to
perform its internal risk-management functions and to comply with retrocessionaire requirements. IHLIC may also disclose
such information to its external auditors as necessary to comply with audit requirements. IHLIC will take reasonable
steps to assure such outside parties maintain the confidentiality of Customer Information.
	 
	 	 	IHLIC will furnish to the Ceding Company a copy of IHLIC’s privacy policy upon request.
	 
	19.2	 	Proprietary Information

	 	(a)	 	The Ceding Company and IHLIC acknowledge that compliance with the terms of this
agreement requires that they exchange Proprietary Information with each other.
	 
	 	(b)	 	Proprietary Information includes, but is not limited to, business plans, trade
secrets, experience studies, underwriting manuals, guidelines and decisions,
applications, policy forms, quote terms, actuarial data and assumptions, valuations,
financial condition, and the specific terms and conditions of this agreement.
	 
	 	(c)	 	Proprietary Information will not include information that:

	 	(i)	 	is or becomes available to the general public other than as a
result of disclosure by the party receiving the information (hereinafter the
“Recipient”);
	 
	 	(ii)	 	is developed independently by the Recipient;
	 
	 	(iii)	 	is acquired by the Recipient from a third party that is not
known by the Recipient to be bound to keep the information confidential; or
	 
	 	(iv)	 	was already within the possession of the Recipient, and not
subject to a confidentiality agreement, prior to being furnished by the other
party.

	19.3	 	IHLIC and the Ceding Company shall hold all Proprietary Information received from the other
party in confidence and will not disclose such information except to their own directors,
officers, employees, affiliates, and advisors (collectively the “Representatives”) who need to
know such information in connection with the proper execution of this agreement. IHLIC and
the Ceding Company shall inform all Representatives of the confidentiality of the Proprietary
Information and will direct such Representatives to treat the information accordingly.

	19.4.	 	IHLIC may disclose Proprietary Information to its retrocessionaires or MIB as necessary
to perform its internal risk-management functions and to comply with retrocessionaire
requirements. The Ceding Company or IHLIC may disclose Proprietary Information to its
external auditors as necessary to comply with audit requirements. The parties will take

26

 

	 	 	reasonable steps to assure such outside parties maintain the confidentiality of such
Proprietary Information.
	 
	19.5	 	Either party may disclose Proprietary Information when legally compelled to do so. In such
event, the party so compelled will provide the other party with prompt notice prior to
disclosure so that the other party may seek an appropriate remedy.
	 
	19.6	 	The provisions of this Article survive for two years beyond the termination of the last in
force policy reinsured under this Agreement.

27

 

Article 20 — DURATION OF AGREEMENT

	20.1	 	This Agreement is indefinite as to its duration. The Ceding Company or IHLIC may terminate
this Agreement with respect to the reinsurance of new business by giving thirty (30) days
written notice of termination to the other party, sent by certified mail. The first day of
the notice period is deemed to be the date the document is postmarked.
	 
	 	 	During the notification period, the Ceding Company, through the Administrator, will continue
to cede and IHLIC will continue to accept policies covered under the terms of this
Agreement. Reinsurance coverage on all reinsured policies will remain in force until the
termination or expiry of the policies or until the contractual termination of reinsurance
under the terms of this Agreement, whichever occurs first.

28

 

Article 21 — EXECUTION

	21.1	 	This Agreement is effective as of February 1, 2007, and applies to all eligible policies with
issue dates on or after such date and to eligible policies applied for on or after such date
that were backdated for up to six (6) months to save age. This Agreement has been made in
duplicate and is hereby executed by all parties.

	 	 	 	 	 	 	 	 	 	 	 
	Trinity Life Insurance Company	 	 	 	Investors Heritage Life Insurance Company	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	By:

	 	 	 	 	 	By:	 	 	 	 
	 

	 	 

(signature)
	 	 
	 	 	 	 

(signature)
	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 

(print or type name)
	 	 
	 	 	 	 

(print or type name)
	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Title:

	 	 	 	 	 	Title:	 	 	 	 
	 

	 	 

	 	 
	 	 	 	 

	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Date:

	 	 	 	 	 	Date:	 	 	 	 
	 

	 	 

	 	 
	 	 	 	 

	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Location:

	 	 	 	 	 	Location:	 	 	 	 
	 

	 	 

	 	 
	 	 	 	 

	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Attest:

	 	 	 	 	 	Attest:	 	 	 	 
	 

	 	 

(signature)
	 	 
	 	 	 	 

(signature)
	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	Title:

	 	 	 	 	 	Title:	 	 	 	 
	 

	 	 

	 	 
	 	 	 	 

	 	 

29

 

Exhibit A

RETENTION LIMITS OF THE CEDING COMPANY AND FIRST EXCESS REINSURANCE LIMITS

	A.1	 	Maximum Limits of Retention
	 
	 	 	IHLIC will retain 20% of first $25,000 and will additionally retain all amounts from $60,001
to $80,000.

 

 

Exhibit B

PLANS COVERED AND BINDING LIMITS

The business automatically reinsured under this Agreement is defined as follows. Reinsurance will
only be on the mortality risk portion of the Life Insurance Benefit.

	B.1	 	Plans, Riders and Benefits
	 
	 	 	Policies issued on plans with effective dates within the applicable period shown below may
qualify for automatic reinsurance under the terms of this Agreement.

	 	 	 	 	 	 	 
	 	 	 	 	Commencement	 	Termination
	Plan Identification	 	Form No.             	 	Date	 	Date
	 
	Modified Whole Life

	 	TLIC-1 (10/06)
	 	February 1, 2007	 	 
	 
	 	 	 	 	 	 
	Riders and Benefits:
	 	 	 	 	 	 
	 
	Accidental Death Benefit 

Rider*

	 	

TLIC-3
	 	*The ADB Rider is
not covered under
this agreement, but
will be reinsured
on a bulk basis
under a separate
agreement.	 	 

	B.2	 	Basis
	 
	 	 	IHLIC will retain 20% of first $25,000 and will additionally retain all amounts from $60,001
to $80,000. This amount will not exceed IHLIC’s share of the maximum Automatic Binding
Limits specified in Exhibit B.3.
	 
	B.3	 	Automatic Binding Limits

	 	(a)	 	Life

	 	 	 	 	 	 	 	 	 	 	 
	Issue	 	Standard	 	 	 	 
	Ages	 	(Non Rated)	 	Tables 1 - 8	 	Tables 8+
	0-80

	 	$	80,000	 	 	$	80,000	 	 	n/a

The maximum issue amount is $80,000.

The maximum autobind amount above includes the Ceding Company’s retention and the
first excess retention.

 

 

Exhibit C

FORMS, MANUALS AND ISSUE RULES

 

 

	APPLICATION FOR LIFE INSURANCE
7633 East 63rd Place, Suite 230
Tulsa, OK 74133 (918) 249-2438 000000
PRINT USING BLACK INK            COVERAGE INFORMATION

	(1) Name (First, Middle, Last) (2) Birth Date (3) State/Country of Birth
Month            Day            Year
(4) Street Address (5) Sex (6) Citizenship (Country)
  Male
  Female
(7) City, State, Zip (8) Home Phone (9) Other Phone
Section 1 ( ) ( )

	(10) Social Security Number (11) Employer Name & Address (12) Occupation & Duties
(13) E-mail Address (14) Driver’s License Number/State of Issue
—— OWNER (If different from Proposed Insured) and C0-OWNER ——
(1) Owner’s Full Name (If different from Proposed Insured) (2) Home Phone (3) Other Phone
( ) ( )

	(4) Mailing Address (5) Birth Date (6) E-mail Address
Month            Day            Year
(7) Relationship to Proposed Insured (8) Social Security Number or Tax ID Number
Section 2 (9) Co-Owner’s Full Name (10) Home Phone (11) Other Phone
( ) ( )

	(12) Mailing Address (13) Birth Date (14) E-mail Address
Month            Day            Year
(15) Relationship to Proposed Insured (16) Social Security Number or Tax ID Number
—— PREMIUM PAYOR (If different from Proposed Insured, Owner and Co-Owner) ——
(1) Premium Payor’s Full Name (2) Home Phone (3) Other Phone
( ) ( )
Section 3 (4) Mailing Address
BENEFICIARY INFORMATION

	(1a) Primary Beneficiary Name            SSN            Relationship to Proposed Insured Share % if not equal
(1b) Primary Beneficiary Name            SSN            Relationship to Proposed Insured            Share % if not equal
Section 4 (2a) Contingent Beneficiary Name            SSN            Relationship to Proposed Insured Share % if not equal

	(2b) Contingent Beneficiary Name            SSN            Relationship to Proposed Insured Share % if not equal
THE POLICY
(1) Plan of Insurance: (2) Face Amount/Units (3) Annual Premium (5) Cash with Application

	  Trinity Life Accumulator (TLA) $
(4) Benefits (If available) (6) Payment mode:

	  Accidental Death Benefit Rider on Primary Insured            Annual
Semi-Annual
  Waiver of Premium Rider on Primary Insured            Monthly PAT
Section 5 (complete PAT card)

	  Flexible Premium Deferred Annuity Rider
(8) Planned modal
premium
(7) Automatic Premium Loan Opt?   YES   NO Total Annual Premium $ $

	REMARKS/SPECIAL INSTRUCTIONS
TLICAPP (01-2007)

 

 

	GENERAL RISK INFORMATION
1. Has the proposed insured:

	(a) Had new insurance or reinstatement postponed or offered or issued not as applied for?    Yes    No
(b) Insurance or annuity this is to replace? (If “Yes”, show name of insurer and policy number(s) in space

	provided below   Yes    No

	(c) Any other application for life or health insurance pending?    Yes    No
(d) Flown as a Student, Private, Commercial or Military pilot in the past two years, or are any such

	flights planned in the future? (If “Yes”, complete the Avocation Questionnaire)    Yes    No
(e) Engaged in any form of racing, skydiving, underwater diving, or other hazardous activity in the

	past two years? (If “Yes”, complete the Avocation Questionnaire)    Yes    No

	(f) Belong to or intend joining any active military, navel or aeronautic organization?    Yes    No

	(g) Any intention of changing occupations or traveling or residing outside the U.S. or            Canada?    Yes    No

	(h) Used tobacco in any form in the past 12 months?    Yes    No
(i) Been charged with a driving while impaired (alcohol, drug, other) violation, had a drivers license revoked
or suspended, or within the last 24 months received 3 or more citations for moving traffic violations?    Yes    No

	Section 6 Number Date Details

	MEDICAL INFORMATION

	(1) Name and address of usual medical advisor(s)

	Date of last visit Reason for last visit

	What treatment was given or medication prescribed?
(2) Height Weight Weight change in past year? Cause if weight gain or loss

	ft in. lbs.    Gain   Loss   No Change

	(3) Within the past 10 years, has the Proposed Insured had, or been told he or she had, or received treatment or advice for:
(a) High blood pressure, stroke, chest pain, coronary artery disease or any other disease of the heart, blood vessels,

	cerebrovascular system, or cardiovascular system?    Yes    No

	(b) Cancer, tumor, leukemia, lymphatic cancer or any other growth or malignancy?    Yes    No

	(c) Diabetes, thyroid disorder, anemia or any blood or glandular disorder?    Yes    No
(d) Asthma, shortness of breath, sleep apnea, or any other nose, throat, lung, or respiratory disorder?    Yes    No
(e) Any disorder of the stomach, intestines, liver or pancreas, including hepatitis, ulcers or any other disorder of

	the digestive system?    Yes    No

	(f) Any injury or disease of the bones, muscles, joints, eyes or skin?    Yes    No

	(g) Epilepsy, seizures, brain disorder, or any other disease of the nervous system?    Yes    No

	Section 7 (h) Anxiety, depression, or an emotional, behavioral, mental or nervous disorder?    Yes    No

	(i) Any disease or disorder of the kidney, bladder, reproductive system?    Yes    No
(4) Within the past 10 years, has Proposed Insured used or experimented with intravenous drugs, cocaine,
barbiturates, hallucinogens, illegally obtained prescription drugs, or sought advice or treatment for alcohol or

	drug use?    Yes    No
(5) Within the past 10 years, has the Proposed Insured been diagnosed by a member of the medical profession as

	having or been tested positive for, or been treated by a member of the medical profession for any of the following:
Acquired Immune Deficiency Syndrome (AIDS), Aids Related Complex (ARC), Human Immunodeficiency

	Virus (HIV), or any other disease or disorder of the immune system?    Yes    No
(6) Other than stated above, within the past 5 years has the Proposed Insured consulted, received treatment or
advice from, or been prescribed medication by any member of the medical profession, or had any abnormal

	diagnostic test?    Yes    No
(7) Has the Proposed Insured’s parents and/or siblings had heart disease, kidney disease, diabetes, cancer,
stroke, or other hereditary disease? (If “Yes”, indicate family member, illness, age at onset of illness, and if

	applicable, age at death)    Yes    No

	Explanation of all “Yes” answers above. Use additional paper if necessary.
Number Illness Date & Duration Treatment & Results            Doctors & Hospitals

	TLICAPP (01-2007) 2

 

 

	OTHER INSURANCE / REPLACEMENT INFORMATION
(1) Does the Proposed Insured now have any life insurance or annuity (includes personal, business or group life)
(a) in force or applications pending in any company?  Yes  No
(b) which will be replaced, changed, or borrowed against because of this application?  Yes  No
Provide details to “Yes” answers below and submit appropriate replacement forms.
(2)Name of Company Date of Issue Life Amount Personal/Business Accidental Death Amount            To be replaced?
 Yes  No
 Yes  No
 Yes  No
 Yes  No
(If there is additional insurance beyond those listed, please provide in the space below)

	TAX CERTIFICATION
Under penalties of perjury, it is certified that (a) the Social Security number(s) or Tax ID number(s) shown in this application are correct taxpayer
identification numbers, and (b) the holders of said numbers are not subject to any backup withholding of U.S. Federal income tax for failure to report

	interest or dividends.

	ACKNOWLEDGEMENT
I, the Proposed Insured (and any Owner signing below), ACKNOWLEDGE that I have been given a copy of the “Notice of Information Practices”
required by Public Law 91-508 and other information practices statutes, and also a copy of the MIB Pre-Notice. I know that this application cannot

	be processed if I do not sign the authorization below.

	AGREEMENT

	I      , the Proposed Insured (and any Owner signing below) AGREE to the following:

	a. All statements and answers in this application are complete and true to the best of my knowledge and belief.
b. Insurance will start only as provided in the Conditional Receipt. If no Conditional Receipt is issued or if insurance under it has stopped and
not started again, no insurance will start by reason of the application until the policy is delivered and the first premium paid in full. No

	insurance will start if at that time the health of all proposed insureds is not as described in the application.

	c. No agent has authority to waive any answer or otherwise modify this application or to bind Trinity Life Insurance Company,

	hereafter called “Insurance Company”, in any way by making any promise or representation which is not set out in writing in this

	application.
d. $        has been deposited toward payment of the first premium on the applied for policy. The terms of the Conditional Receipt

	for that premium deposit are accepted.

	AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

	Each of the undersigned declares that:
a. I understand that the information obtained by use of this authorization will be used to determine eligibility for insurance and/or for the Insurance

	Company to determine its obligations under the policy issued in connection with this application.
b. The Insurance Company, its reinsurers, insurance support organizations, consumer reporting agencies and their authorized entities may obtain
data about my health, prescription medication history, and related information, mode of living (except as may be related directly or indirectly

	to sexual orientation), avocations, and any other medical or non-medical information.
c. Any doctor, medical practitioner, medical or medically related facility, laboratory, Pharmacy Benefit Managers, the Veterans Administration, the
Medical Information Bureau, Inc. (MIB, Inc.), viatical settlement company, employer, consumer reporting agency, creditor, government agency,
insurance or reinsurance company which has such data about me may give such data to the Insurance Company and its reinsurers when this
authorization or a copy of it is shown. All sources but the MIB, Inc. may give such data to agencies that the Insurance Company has hired to
retrieve the information. The information as provided herein pursuant to the authorization will not be redisclosed unless authorized by you or
otherwise required by law. Covered Entities, as defined by the Health Insurance Portability and Accountability Act of 1996, may not condition

	treatment, payment or enrollment on whether this Authorization is signed.
d. Any request by the Insurance Company for medical records is on my behalf; the information must be provided within any requirements

	imposed by applicable state statutes governing patient access to medical records.

	e. Data about mental illness, alcoholism, sexually transmitted diseases and the use of drugs are to be included.

	f. The Insurance Company or its reinsurers may make a brief report about me to the MIB, Inc.

	g. This authorization is good for 24 months after it is signed.

	h. The Insurance Company may obtain an investigative consumer report (“inspection report”) on me.

	  Yes, I want to be interviewed if such a report is obtained.
i. I have read this authorization and know I may request a copy of it. I may revoke this authorization by writing to the Insurance Company.

	TLICAPP (01-2007) 3

 

 

	000000
FRAUD NOTICE
Required State Disclosures
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,
fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the
purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award
payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.

	Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime.
Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma: Warning: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes a claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of insurance fraud.
Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Texas: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud, as determined by a court of
competent jurisdiction.
All other states: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

	SIGNATURES OF PROPOSED INSURED / OWNER

	X) Signed at            On
Signature of Proposed Insured if age 18 or older (City, State) (Month, Day, Year)

	X) X)
Signature of Owner if other than Proposed Insured Signature of parent or guardian

	if Proposed Insured age 17 or younger

	AGENT’S STATEMENT AND SIGNATURE
I, the undersigned agent(s), certify that

	1. I have witnessed the signature of the applicant and/or any proposed insured;
2. I have asked each proposed insured each question on the application. The answers have been recorded by me exactly as stated and I

	know of nothing affecting the insurability of any proposed insured which is not fully recorded in this application.

	3. Replacement

	  IS

	  IS NOT            Date:

	involved with this application

	X)
Signature of licensed agent 1 Agent Code # Name of licensed agent or representative (Please Print)

	X)
Signature of licensed agent 2 Agent Code # Name of licensed agent or representative (Please Print)

	APPLICATION FOR LIFE INSURANCE

	7633 East 63rd Place, Suite 230

	Tulsa, OK 74133

	Phone: (918) 249-2438

	Fax: (918) 249-2478

	TLICAPP (01-2007) 4

	7633 East 63rd Place, Suite 230

 

 

	Tulsa, OK 74133

	HIPAA C            OMPLIANT            A            UTHORIZATION            FOR          
  R            
ELEASE            OF            M            EDICAL            I            NFORMATION

	Proposed Insured / Patient Date of Birth Social Security Number

	Month Day Year

	I authorize any health plan, physician, health care professional, hospital, Veterans Administration, clinic, laboratory, pharmacy or

	pharmacy benefit manager, medical facility, insurance company, insurance support organization (such as MIB), or other health

	care provider that has provided payment, treatment or services to me or on my behalf within the past 10 years (collectively, “My

	Providers”) to disclose my entire medical record, medication history, and any other protected health information concerning me

	to Trinity Life Insurance Company, or its designee,

	Name of designee (if applicable)

	This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency

	Syndrome (AIDS) and Sexually Transmitted Diseases (STDs). This also includes information on the diagnosis and treatment of

	mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes.

	By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply

	to this authorization and I instruct My Providers to release and disclose my entire medical record without restriction.

	This protected health information is to be disclosed under this Authorization so that Trinity Life Insurance Company may: (1)

	underwrite my application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; (2) obtain

	reinsurance; (3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; (4) administer

	coverage; and (5) conduct other legally permissible activities that relate to any coverage I have or have applied for with Trinity

	Life Insurance Company.

	This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this authorization

	is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a

	written request for revocation to Trinity Life Insurance Company, 7633 East 63rd Place, Suite 230, Tulsa, OK 74133 Attn: General

	Counsel. I understand that a revocation is not effective to the extent that any of My Providers has already relied on this

	Authorization or to the extent that Trinity Life Insurance Company has a legal right to contest a claim under an insurance policy or

	to contest the policy itself. I understand that any information disclosed pursuant to this authorization may be subject to redisclosure

	by the recipient and may no longer be protected by federal rules governing privacy and confidentiality of health information.

	However, Trinity Life Insurance Company will protect the privacy of health information in accordance with other applicable state

	and federal privacy laws and their own privacy policies.

	I understand that My Providers may not refuse to provide treatment or payment for health care services because I refuse to sign

	this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record, Trinity Life

	Insurance Company may not be able to process my application, or if coverage has been issued, may not be able to make any

	benefit payments. I understand that I am entitled to a copy of this signed authorization.

	Date:

	X)

	Signature of Primary Proposed Insured / patient or personal representative

	X)

	Signature of Additional Proposed Insured / patient or personal representative

	TLICAPP (01-2007) 5

 

 

	AGENT’S REPORT
EXAM INFORMATION

	1. If required, have you ordered or obtained:   Exam    Blood Profile   Urine Specimen    Oth
er
2. Provide name of paramedical company or examiner 3. Date scheduled or completed
PROPOSED INSURED INFORMATION

	1. Contact Proposed Insured(s) at   Home   Business or   Other            Telephone number ( ) -

	2. Best time to contact Proposed Insured(s)   9am — 12pm   1pm — 4pm   5pm — 9pm
3. How long have you known the Proposed Insured(s)?    Friend   Acquaintance            Existing Client   Relative   Just met
4. Annual income of Proposed Insured $        Net Worth of Proposed Insured $
5. Prior residence address if current is less than five years
6. Did you personally interview the Proposed Insured(s) and complete the application in his or her presence?    Yes   No
AGENT CHECKLIST
Explain all “Yes” answers in Section 6 — Agent Remarks / Explanations.

	1. Do you know anything not disclosed which affects the underwriting of this risk?   Yes   No
2. Is there another application currently pending or being submitted to any other life insurance company? ...   Yes   No
3. Has any Proposed Insured applied elsewhere for any insurance coverage within the past 6 months?   Yes   No
PROPOSED INSURED UNDER AGE 18
Explain all “No” answers in Section 6 — Agent Remarks / Explanations.

	1. Did you see the child proposed for insurance?   Yes   No
2. Do all the children proposed for insurance appear to be in good health?   Yes   No
3. Are all brothers and sisters insured for equal amounts?   Yes   No
4. Are the parents insured for at least as much as that applied for and in force on the child?   Yes   No
PURPOSE OF INSURANCE

	  Family security   Business loan   Buy-sell agreement   Key Person   Personal loan or residential mortgage   Other
TRINTIY LIFE INSURANCE INFORMATION

	1. Does the Proposed Insured own a Trinity Life Insurance Company Policy?   Yes   No
If “Yes”, Face Amount: $
2. Shareholder   Yes   No
3. County
4. Commission Split: Agent #1 Agent Code            Percentage      %
Agent #2 Agent Code            Percentage      %
AGENT REMARKS / EXPLANATIONS TO ANSWERS ABOVE
AGENT CERTIFICATION

	I certify that
(1) I have asked each question separately, the answers were recorded as given, and they are complete and accurate to the best of my
knowledge and belief;
(2) I have complied with state and federal laws on disclosure, cost comparison and replacement; and
(3) I have given the applicant a copy of the Notice of Information Practices.
Date:

	X)
Signature of licensed agent 1 Agent Code # Name of licensed agent or representative (Please Print)
X)
Signature of licensed agent 2 Agent Code # Name of licensed agent or representative (Please Print)
TLICAPP (01-2007) 6

 

 

	Trinity Life Insurance Company

	7633 East 63rd Place, Suite 230 * Tulsa, OK 74133

	CONDITIONAL INSURANCE RECEIPT

	This Conditional Receipt provides a limited amount of life insurance coverage, for a limited period of time, subject to the terms of

	this receipt. This Conditional Receipt may not be given if the age of any proposed insured is under 15 days or over 70 years of age.

	AMOUNT LIMITATION. The maximum amount of life insurance, including accidental death, which will become effective under this

	receipt will be the smaller of the face amount of insurance applied for or $100,000. This includes any pending and in force

	insurance.

	CONDITIONS

	1. A minimum advance payment equal to one month’s premium for the insurance applied for must be made.

	2. Any check given in payment must be honored when first presented to the bank.

	3. All medical examinations and tests required by the Company’s initial underwriting requirements must be completed and

	received at our Home Office during the lifetime of any individual proposed for insurance, and prior to the Company’s termination

	of the application, but in any case within sixty days from the completion of the application.

	4. If any person proposed for insurance dies by suicide or if the application contains any material misrepresentations, then the

	Company’s liability under this receipt is limited to a refund of the premium paid.

	5. Each person proposed for insurance must be a risk insurable on the application date in accordance with the Company’s rules,

	limits and standards for the plan and the amount applied for without modification either as to plan, amount, riders, supplemental

	agreements and/or the rate of premium paid.

	TLICAPP (01-2007) Conditional Receipt

	Trinity Life Insurance Company

	7633 East 63rd Place, Suite 230 * Tulsa, OK 74133

	Phone: (918) 249-2438 * Fax: (918) 24902478

	NOTICE OF INFORMATION PRACTICES

	(This Notice Must Be Given To Proposed Insured)

	INSURANCE INFORMATION PRACTICES

	We will rely primarily on the information you give to us. We may also get information from other sources, such as doctors, or

	other medical professionals who have treated you. In some cases, we may ask a consumer reporting agency to gather information

	and send us an investigative consumer report as explained in the Fair Credit Reporting Act below. You may ask to be interviewed

	as part of the preparation of any such report.

	MEDICAL INFORMATION BUREAU

	Information regarding your insurability will be treated as confidential. Trinity Life Insurance Company, or its reinsurers may,

	however, make a brief report thereon to MIB, a not-for-profit membership organization of insurance companies, which operates an

	information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance

	coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information

	in its file.

	Upon receipt of a request from you MIB will arrange disclosure of any information it may have in your file. Please contact MIB

	at 866-692-6901 (TTY 866-346-3642). If you question the accuracy of 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 Post Office Box 105, Essex Station, Boston, Massachusetts 02112.

	Trinity Life Insurance Company, or its reinsurers, may also release information in its file to other insurance companies to whom

	you may apply for life or health insurance, or to whom a claim for benefits may be submitted.

	FAIR CREDIT REPORTING ACT

	INVESTIGATIVE CONSUMER REPORTS

	In compliance with the Fair Credit Reporting Act, you are hereby notified that an investigative report may be made. Information

	may be obtained through personal interviews with neighbors, friends, associates or other persons with whom you are acquainted.

	This inquiry includes information as to the character, general reputation, personal characteristics, and mode of living (except as

	may be related to sexual orientation) of any person proposed for insurance. You have the right to make a written request to

	Investors Heritage Life Insurance within a reasonable period of time for a complete and accurate disclosure of additional information

	concerning the nature and scope of the investigation. Upon your written request, you will be informed whether or not an investigation

	was made by us. If so, you will receive the name and address of the consumer reporting agency involved. You may receive and

	inspect a copy of the Investigative Consumer Report by contacting the consumer reporting agency.

	PERSONAL HISTORY INTERVIEW

	We may also conduct a personal history interview. This is a phone call placed from our underwriting office. Its purpose is to

	make sure that the information on the application is correct. Our interviewers are trained to conduct their calls in a friendly,

	professional manner. The nature of the information discussed is always treated as personal and confidential and will only be used

	to help determine your eligibility for insurance.

	TLICAPP (01-2007) 7

 

 

	Trinity Life Insurance Company

	7633 East 63rd Place, Suite 230 * Tulsa, OK 74133 * (918) 249-2438 000000

	CONDITIONAL INSURANCE RECEIPT (continued from front)

	BEGINNING DATE. If all conditions in this receipt have been fulfilled exactly, coverage under the policy applied for, subject to the

	Amount Limitations, may begin on the later of:

	1. The date of completion of the application;

	2. The date of completion of all medical examinations, tests and other evidence required by the Company; or

	3. The policy date, if any, requested in the application.

	TERMINATION DATE. Coverage under this receipt, if it has begun, will terminate automatically on the earliest of (1) sixty days from

	the date of this receipt; or (2) the date the insurance takes effect under the applied for policy.

	If the policy is not issued exactly as applied for, it will become effective when it is delivered to and accepted by the applicant. Upon

	delivery and acceptance, the first full premium must be paid. If the application is declined or not approved within sixty days of its

	completion, no insurance will have been in force. Any premium paid will be returned. No agent of our Company has the authority

	to change or modify any of the provisions of this receipt.

	ALL PREMIUM CHECKS MUST BE PAYABLE TO THE COMPANY. DO NOT MAKE CHECK PAYABLE TO THE AGENT OR

	LEAVE THE PAYEE BLANK. THIS RECEIPT IS NOT VALID UNLESS SIGNED BY A LICENSED AGENT OF TRINITY LIFE

	INSURANCE COMPANY.

	RECEIVED FROM THE SUM OF $

	BY (LICENSED REPRESENTATIVE OF TRINITY LIFE INSURANCE COMPANY)

	TLICAPP (01-2007) Conditional Receipt

	NOTICE OF INFORMATION PRACTICES (continued)

	MEDICAL EXAMS

	As part of the underwriting process we may ask for medical tests or exams to be completed at our expense. Common tests

	include a paramedical exam, which will consist of questions about your medical history and measurement of your body height,

	weight, blood pressure, and pulse. Blood tests, and in some instances, an EKG (electrocardiogram) may be required. If you have

	any questions about the specific tests that will be required of you, please feel free to contact your agent.

	CONTESTABILITY

	You are strongly urged to review the completed application for accuracy. A claim may be denied if the application contains false

	statements or misrepresentations or fails to disclose material facts. In such a case, the policy could be void and coverage could

	be lost or denied.

	YOUR RIGHTS TO ACCESS AND CORRECTION

	You can obtain access to personal information about you contained in our policy files by sending us a written request. You may

	also request any necessary corrections, amendments or deletion of any information in our files which you believe to be inaccurate

	or irrelevant.

	FRAUD NOTICE

	Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance

	company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,

	fines, denial of insurance, and civil damages. Any insurance Company or agent of an insurance company who

	knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the

	purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award

	payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of

	Regulatory Agencies.

	Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for

	insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact

	material thereto commits a fraudulent insurance act, which is a crime.

	Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or

	files a claim containing a false or deceptive statement is guilty of insurance fraud.

	Oklahoma: Warning: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes a claim for the

	proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of insurance fraud.

	Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

	purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

	Texas: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an

	application or files a claim containing a false or deceptive statement is guilty of insurance fraud, as determined by a court of

	competent jurisdiction.

	All other states: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

	presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

	TLICAPP (01-2007) 8

 

 

Underwriting Guidelines

Age-Amount Requirements

Medical requirements should be completed based on the age-amount

Paramedical and MD Exams

The agent is responsible for arranging the required paramedical and medical
exams. Explain to the proposed insured that a paramedic will contact them for an
appointment. Then call the paramedical company or contact their Web site and
supply the required information. Use only paramedical companies that have been
approved by the Company. Approved companies will be listed in the Company
newsletter from time to time. For immediate information, contact the Underwriting
Department. If MD exams are required, paramedical companies will make the
arrangements. If this service is not available in your area, contact the
Underwriting Department.

Blood Profile

A blood profile will include an HIV test with other routine blood tests. A
Notice and Consent Form of AIDS Virus (HIV) Anti-body Testing is required with
every blood test. This form is a pre-test notice and must be completed and signed
by the proposed insured before the blood is drawn. It is the agent’s
responsibility to have this form completed, to give a copy to the proposed
insured and submit the original to the Underwriting Department with the
application. Use the version of Form HIV appropriate in your state.

Non-medical Insurance

In order to offer insurance on a non-medical basis, the Company relies on its
agents to develop and submit to the Home Office all pertinent information
affecting the acceptance of the risk. Agents are expected to select prospects
carefully and complete all questions on the application fully and accurately. The
Company reserves the right to order medical records, request exams, blood
profiles, EKGs or other studies where indicated during the underwriting process.

Telephone Interview and Commercial Inspection

Our own FOCUS telephone interview unit will be used for amounts through
$250,000. Commercial inspection reports will be used for amounts over $250,000.

Conditional Receipt Limitations

Agents are authorized to accept initial premium, provided the amount applied
for does not exceed $250,000 and the case appears to be non-rated.

Underwriting

Guide

MEDICAL REQUIREMENTS

 

Home Office:

7633 East 63rd Place, Suite 230

Tulsa, Oklahoma 74133

(918) 249-2438

Administrative Office:

PO Box 5205

Frankfort, Kentucky 40602-5205

(866) 440-1357

Any questions?

Please contact the Underwriting Department

866 440-1357

fax (502) 227-7205

Form TLIC 1010 (2-2007)

 

 

Age-Amount Medical and Non-Medical Requirements

	 	 	 	 	 	 	 	 	 	 	 	 	 
	AMOUNT	 	AGE
	 	 	0—20	 	21—35	 	36—50	 	51—55	 	56—60	 	61—80
	-0-

to

$50,000
	 	Non-medical
	 	Non-medical
	 	Non-medical
	 	Non-medical
	 	Non-medical
	 	Paramedical

HOS
	 
	$50,001

to

$55,000
	 	Non-medical
	 	Non-medical
	 	Non-medical
	 	Non-medical
	 	HOS
	 	Paramedical

HOS
	 
	$55,001

to

$99,999
	 	Non-medical
	 	Non-medical
	 	Non-medical
	 	HOS
	 	Paramedical

HOS
	 	Paramedical

HOS
	 
	$100,000

to

$250,000
	 	Saliva

HOS
	 	Saliva

HOS
	 	Paramedical

HOS

Blood Profile
	 	Paramedical

HOS

Blood Profile
	 	Paramedical

HOS

Blood Profile
	 	Paramedical

HOS

Blood Profile
	 
	$250,001

to

$500,000
	 	Paramedical

HOS

Blood Profile
	 	Paramedical

HOS

Blood Profile
	 	Paramedical

HOS

Blood Profile

EKG
	 	Paramedical

HOS

Blood Profile

EKG
	 	MD Exam

HOS

Blood Profile

EKG
	 	MD Exam

HOS

Blood Profile

EKG
	 
	$500,001

to

$1,000,000
	 	MD Exam

HOS

Blood Profile

EKG
	 	MD Exam

HOS

Blood Profile

EKG
	 	MD Exam

HOS

Blood Profile

EKG
	 	MD Exam

HOS

Blood Profile

EKG
	 	MD Exam

HOS

Blood Profile

EKG
	 	MD Exam

HOS

Blood Profile

EKG
	 
	$1,000,001

plus
	 	Consult

Underwriting
	 	Consult

Underwriting
	 	Consult

Underwriting
	 	Consult

Underwriting
	 	Consult

Underwriting
	 	Consult

Underwriting

Form TLIC 1010 (2-2007)

 

 

UNDERWRITING REQUIREMENTS

TRINITY LIFE INSURANCE COMPANY

UNDERWRITING GUIDELINES

ORDINARY PLANS

Focus

Requirements for Telephone Interviews (FOCUS)

Ordinary

2 Full Units or $150,000 (whichever is less)             Telephone interview required

All amounts           An interview may be conducted for any amount at the underwriter’s discretion.
Underwriter’s discretion means there is some reason or “red flag” that prompts the interview.

The following are some examples of reasons an underwriter would request an interview for 150,000/2
units or less:

	 	•	 	Amount applied for plus amount in force over 150,000
	 
	 	•	 	MIB code received and the information pertaining to it is not listed on the application;
or if it is listed, needs developing
	 
	 	•	 	Occupation – left blank, disabled, retired at an early age, the occupation is
potentially hazardous
	 
	 	•	 	Medical condition is listed on application but no details given (i.e. dates, meds or
treatment, results, names of physicians or medical facility)
	 
	 	•	 	Medical condition listed on application that may be considered without an APS or paramed
if can develop information needed for a decision from telephone interview (Treatment for
high blood pressure is a common one.)
	 
	 	•	 	Very small amounts of insurance applied for but the medical information given on the
application requires an APS or paramed. The underwriter might conduct a telephone
interview to try to develop enough information to eliminate the APS or paramed.

So that the customer will not be surprised by a call, at the time of sale the agent should prepare
the proposed insured by saying that someone from the home office may call to confirm the
information on the application or to obtain additional information.

 

 

Focus Interview will be ordered on proposed insured’s that are applying for 2 units or $150,000
(whichever is less). I’m not sure they know what the face amount is per unit.

Here are the death benefits for 2 units for selected issue ages:

	 	 	 	 	 
	Issue Age	 	Death Benefit
	0
	 	 	80,000	 
	5
	 	 	70,000	 
	10
	 	 	60,000	 
	15
	 	 	50,000	 
	20
	 	 	40,000	 
	25
	 	 	220,000	 
	30
	 	 	206,000	 
	35
	 	 	190,000	 
	40
	 	 	176,000	 
	45
	 	 	160,000	 
	50
	 	 	140,000	 
	55
	 	 	100,000	 
	60
	 	 	90,000	 
	65
	 	 	80,000	 
	70
	 	 	50,000	 
	75
	 	 	46,000	 
	80
	 	 	42,000	 

 

 

MOTOR VEHICLE REPORT (MVR)

Ordinary Underwriting Requirements – Motor Vehicle Report

A motor vehicle report is ordered on

	 	•	 	Any application over 100,000.
	 
	 	•	 	Any application indicating driving criticism (speeding tickets, DUI, etc.)
	 
	 	•	 	Any application indicating the proposed insured participates in auto racing as an avocation.
	 
	 	•	 	Younger ages (usually age 25 or younger)

A motor vehicle report may be ordered on any application at the underwriter’s discretion.

 

 

SBSI – INSPECTION REPORTS

A Focus interview is required for 2 units or $150,000 up to $250,000. An inspection report is
required for amounts over $250,000.

Below are the types of inspections reports completed by our vendor.

	 	 	 
	OVER 250,000

	 	AMPLIFIED REPORT
	 

	 	Includes more financial information and a narrative report.
	 
	 	 
	ANY AMOUNT

	 	CRIMINAL REPORT
	 

	 	Would be ordered by the underwriter if any reason to believe there Would be a criminal record.
	 

	 	 

 

 

ATTENDING PHYSICIAN’S STATEMENT (APS)

An APS is ordered by the underwriter at their discretion.

Examples of why an underwriter would require an APS:

Medical condition listed on application or revealed in the phone interview that would require
Multiple doctors visits, such as diabetes, asthma, etc.

Medical condition indicated by MIB.

A combination of medical conditions.

Children – an APS is required when the proposed insured is a child and the volume is
$100,000 and over.

A HIPPA Form is required before ordering an APS.

NON-MEDICAL LIMITS

The non-medical limits are published in the Underwriting Guide-Medical Requirements.

A Notice and Consent Form of AIDS Virus (HIV) Antibody Testing is required with every blood test.

 

 

Internal Exchange/Replacement Procedures

There are no exchange programs associated with the modified whole life product covered under
this reinsurance agreement; therefore, there are no Internal Exchange/Replacement Procedures to
include in this Exhibit C – Forms, Manuals, and Issue Rules.

 

 

7633 East 63rd Place, Suite 230

Tulsa, OK 74133

Phone: (918) 249-2438       Fax: (918) 249-2478

CIGARETTE SMOKING QUESTIONNAIRE

	 	 	 	 	 	 	 
	PROPOSED INSURED:

	 	 	 	 BIRTHDATE	 	 
	 

	 	 
	 	 	 	 

	 	 	 	 	 	 	 	 	 
	 

	 	1. Are you now a cigarette smoker?
	 	 	 	o YES
	 	o NO
	 
	 	 	 	 	 	 	 	 
	 

	 	2. Have you ever been a cigarette smoker and quit?
	 	 	 	o YES
	 	o NO
	 
	 	 	 	 	 	 	 	 
	 	 	3. If yes, when did you quit?	 	Month:
                     Day:                      Year:                     
	 
	 	 	 	 	 	 	 	 
	 

	 	4. Did, or do, you smoke more than one pack daily?
	 	 	 	o YES
	 	o  NO
	 
	 	 	 	 	 	 	 	 
	 

	 	5. Do you use tobacco in any other form?
	 	 	 	o YES
	 	o  NO

I hereby represent, to the best of my knowledge and belief, that all answers to all the above
questions are complete and true, and I agree that they shall form a part of the application and
become a part of the application and become a part of any contract of insurance issued as a result
of such application.

	 	 	 	 	 	 	 
	Dated at:

	 	 	 	Date:	 	 
	 

	 	 
	 	 	 	 

	 	 	 
	 

	 	 
	Signature of Agent

	 	Signature of Proposed Insured

 

 

7633 East 63rd Place, Suite 230

Tulsa, OK 74133

NOTICE TO APPLICANTS REGARDING REPLACEMENT OF LIFE INSURANCE.

THIS NOTICE IS FOR YOUR BENEFIT AND IS REQUIRED BY REGULATION.

	1.	 	If you are urged to purchase life insurance and to surrender, lapse or in any other way
change the status of existing life insurance, the agent is required to give you this Notice
and a written, signed Disclosure Statement. This Statement must set forth the pertinent facts
of the proposal and the advantages and disadvantages of making the change.
	 
	2.	 	It is to your advantage to receive the advice of the present life insurance company regarding
the proposed replacement or change of existing policies. The life insurance company to whom
you are applying for the new policy is required by regulation to advise the home office of the
company or companies which sold the existing policy or policies of the proposed replacement.
	 
	3.	 	As a general rule, it is not advantages to drop or change existing life insurance in favor of
new life insurance, whether issued by the same or a different insurance company. Some of the
reasons it may be disadvantages are:

	 	(a)	 	The amount of the annual premium under an existing policy may be lower than that called for
by a new policy having the same or similar benefits. Any replacement of the same type of policy
will normally be at a higher premium rate based upon the insured’s then attained age.
	 
	 	(b)	 	Since the initial costs of life insurance policies are charged against the cash value
increases in the earlier policy years, the replacement of an old policy by a new one results in
the policyholder sustaining the burden of these costs twice.
	 
	 	(c)	 	The incontestable and suicide clauses begin anew in a new policy. This could result in a
claim under a new policy being denied by the company which would have been paid under the policy
which was replaced.
	 
	 	(d)	 	Existing policies often have more favorable provisions than new policies in such areas as
settlement options and disability benefits.
	 
	 	(e)	 	In addition to any cash value, an existing policy may have a reserve value which may be of
some benefit.
	 
	 	(f)	 	The present insurance company can often make a desired change on terms which would be more
favorable than if your replaced existing insurance with new insurance.

	4.	 	For the same reasons, it is generally not advantageous to change an existing policy to reduce
paid-up or extended term insurance or to borrow against its loan value beyond your expected
ability or intention to repay in order to obtain funds for premiums on a new policy.
	 
	5.	 	There may be a situation when a replacement is advantageous. However, for your protection you
should receive the comments of the present insurance company before arriving at a decision in
this important financial matter.
	 
	 	 	If, on the negotiation to replace existing insurance, it is suggested by an agent or employee of
the present company that the existing insurance not be replaced, you are entitled to request in
writing, and receive directly from the person making the suggestion, a written statement setting
forth all the pertinent facts bearing on the advantages of the suggestion.

	 	 	 	 	 	 	 
	Signed

	 	 	 	Date 	 	 
	 

	 	 
	 	 	 	 
	 

	 	Applicant	 	 	 	 

TLIC 655 (01-2007) 

 

 

7633 East 63rd Place, Suite 230

Tulsa, OK 74133

Phone: (918) 249-2438 Fax: (918) 249-2478

STATEMENT OF HEALTH AND INSURABILITY

COMPLETED AS A CONDITION TO THE DELIVERY OR CHANGE OF

	 	 	 
	 

	 	 
	POLICY NUMBER

	 	PROPOSED INSURED

Since the date of the original application for the above policy, each person proposed for Life
Insurance in such application has continued in good health and no person proposed for Life or
Health Insurance or both:

	 	1.	 	has made application to another company for Life or Health Insurance (2) which
has been issued, declined, postponed or modified, or (b) which is pending at the present
time, or;
	 
	 	2.	 	has consulted or been examined or treated by a physician or practitioner, or;
	 
	 	3.	 	has had any change in health or insurability as a Life or Health Insurance risk
because of any event or circumstance.

If there are any exceptions to any of the above statement, give full details in space
provided:

EXCEPTIONS

The person named as the Insured and the Applicant (if other than such person) represent that the
foregoing statements are true and complete and that all exceptions have been stated.

	 	 	 	 	 	 	 
	Dated at:
	 	 	 	 	 	 
	 

	 	 
	 	 	 	 
	 

	 	(City and State)
	 	 	 	Signature of the Insured

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	This

	 	 
 

DAY
	 	of
	 	 
 

MONTH
	,
 	 	 	 
 

YEAR
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	Signature of Applicant if Other

Than the Above Person

	 	 	 
	 

Signature of Agent

	 	 

TLIC 516 (01-2007) 

 

 

	7633 East 63rd Place, Suite 230 Tulsa, OK 74133
Phone: (918) 249-2438 Fax: (918) 249-2478
RESET FORM
EPILEPSY (CONVULSIONS) QUESTIONNAIRE – APPLICANT TO COMPLETE
NAME FILE NUMBER DATE OF BIRTH
1. Has the doctor given you a name for your seizure disorder? (grand mal epilepsy, petit mal epilepsy, Jacksonian epilepsy, psychomotor or temporal lobe seizures) Does he know the cause?
2. When did you have your first seizure? Date: 3. When was your last seizure? Date:
4. How often do you have seizures (number weekly, monthly, yearly)?
5. If possible, please describe the seizures. Do you have any warning?
6. What type of treatment? Medications? Hospitalizations?
7. How long have you been taking medication? Any change in medicine?
8. Name and address of doctor who treated or is treating you:
9. Date of last visit?
DATE:
Signature of Applicant

 

 

	7633 East 63rd Place, Suite 230

	Tulsa, OK 74133

	Phone: (918) 249-2438 Fax: (918) 249-2478

	CONFIDENTIAL FINANCIAL QUESTIONNAIRE APPLICATION SUPPLEMENT

	Please complete questions 1 thru 6 for personal insurance or questions 1 thru 11 if the insurance
is for business purposes, then date and sign the questionnaire.

	1. Proposed Insured:
First Name Middle Initial Last Name
2. Your Income (Before Income Tax) CURRENT FISCAL            PREVIOUS
YEAR TO DATE            FISCAL YEAR
thru
A. Salary or Wages......................................................... $ $
B. Bonuses and/or Commissions..........................................
C. Net Business or Professional Income (i.e. Gross Income less
Business Expenses, but before Personal Income Taxes).......
D. Other Earned Income (Give details in “Remarks” below)......
E. Unearned Income (Interest and dividends, net real estate
income, etc. Give details in “Remarks” below).....................
F. Spouse’s Income...........................................................
TOTAL: $ $
3. What is your approximate Net Worth, i.e., assets minus liabilities? Assets $
Liabilities $
Net Worth $
4. Estimated Tax Liabilities at Death (Include potential Estate Taxes, $
Inheritance Taxes and Capital Gains Taxes, both Federal & State)
5. If not covered on the application:
Amount of Insurance applied for with this company $
Amount of Insurance applied for with other companies $
Amount of Life Insurance already in force $
Amount you intend to have in force $
6. How was the need for this new amount of coverage determined?
Remarks (Questions 2 to 6):

 

 

	CONFIDENTIAL FINANCIAL QUESTIONNAIRE APPLICATION SUPPLEMENT (continued)

	7. Purpose of Business Insurance
Key Executive Deferred Compensation Buy-Sell Agreement/Stock Repurchase
Is there a written Buy/Sell agreement in effect? (If yes, attach copy.) Yes No
Is there a Buy/Sell agreement contemplated? Yes No
Creditor: Name of Lender
Is insurance requested by lender? Yes            No Coverage Amount required by Creditor: $
—

	Type of loan? Line of Credit            Mortgage Other (explain)
If line of Credit
Amount of credit extended $
—
Amount activated to date $        Duration of loan
—
If other than Line of Credit: Amount of loan $        Duration of loan
—
Purpose of loan:

	Other Purposes – Explain:

	(Use “Remarks” below for further details)
8, Are other Corporate Officers or Partners being insured? Yes No
If Yes, give details. If No, explain:

	9. What Percentage of the business do you own? %
—
10. Estimated Fair Market Value $
—
(In “Remarks,” state how this value was determined)
11. Financial Details of Business: CURRENT FISCAL            PREVIOUS
YEAR TO DATE            FISCAL YEAR

	thru
A. Total Assets.......................................................... $ $
 —  —
B. Total Liabilities.......................................................
C. Gross Sales or Revenue.......................................
D. Net Income (before taxes)........................................
PLEASE SUBMIT A COPY OF THE MOST RECENT BALANCE SHEET AND INCOME STATEMENT (Year or Quarter).

	Remarks (Questions 7 to11):

	I understand that Trinity Life Insurance Company will rely on the above statements in determining the need and justification for the insurance applied for, and I represent that all answers are true and
accurate statements
to the best of my knowledge and belief as of the date of the application for life insurance. A photographic copy of this statement may be attached to and made part of any insurance contract issued:

	Signature of Proposed Insured: Date
Signature of Applicant: Date
Witnessed by            Date

 

 

	You can only enter Name, File Number Trinity Life Insurance Company and Date. This form is for
the Physician 7633 East 63rd Place, Suite 230 to complete. Tulsa, OK 74133 Phone: (918) 249-2438
Fax: (918) 249-2478 DIABETIC QUESTIONNAIRE — COMPLETED BY PHYSICIAN FILE NUMBER DATE I NAME 1.
Period of Time under your observation as patient? FROM: TO: —— 2. If known, please give date
diabetes diagnosed. 3. Does the patient report regularly for examination and advice? 0 YES 0 NO How
often? Date of Last Visit? 4. What are the diet and insulin or oral agent prescriptions? DIET
INSULIN ORAL AGENT II I: Carbohydrate Gms. Type? Kind? Protein Gms. Total units per day? Tablets
per day? I Fat Gms. None? 0 None? 0 j If diet is not calculated in grams of carbohydrate, protein,
and fat, or not measured or estimated from appropriate food exchange lists, what diet program is
followed? Does the patient disregard your advice concerning the diet, and insulin or oral agent
prescriptions, Or make changes without prior discussion with you? 0 YES 0 NO Has it been necessary
to increase the amount of insulin or oral agent without an increase in the Diet? 0 YES 0 NO 5. What
levels of blood and urine sugar have been recorded in the past 2 years? BLOOD SUGARS URINE SUGARS
DATE: DATE: FASTING: FASTING: NON-FAST: NON-FAST: I 6. Is there evidence or history of: Repeated
infections? D Yes D No Impaired circulation? D Yes D No Kidney Disease? D Yes D No Gain or loss of
weight? D Yes D No Heart disease? D Yes D No Retinitis? D Yes D No Elevated blood pressure? D Yes D
No Diabetic Coma? D Yes D No Arteriosclerosis? D Yes D No Shock or frequent insulin or hypoglycemic
reactions? D Yes D No Other Illness? 7. Have any electrocardiograms been made on this patient? D
Yes D No If available, we would appreciate your mailing them to use for our review. They will be
returned promptly. If not available, please include findings under number 8 below or on the reverse
side. 8. Please use this space or reverse side to amplify answers to the above and for any comments
your care to make regarding your patient’s ability to handle this disease. Date: SIGNATURE:

 

7633 East 63rd Place, Suite 230

Tulsa, OK 74133

Phone: (918) 249-2438 Fax: (918) 249-2478

Military Service Questionnaire

	 	 	 	 	 	 	 	 	 
	 	Proposed Insured

	 	 	Policy Number
	 	 	Date

	 
	 

If you are on active duty as a member of any state National Guard or as a member, regular or
reserve, of the Army, Navy, Air Force, Marine Corps, or Coast Guard; or if you have been alerted or
called to duty, complete the following:

	 	 	 	 	 	 	 
	1.

	 	Branch of Service:	 	 	 	 
	 	 	 	 	 
	 	 	If branch is Army, indicate arm or component (e.g., Artillery, Infantry, etc.)
	 
	 	 	 	 	 	 
	2.

	 	Rank and pay grade:	 	 	 	 
	 

	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	3.

	 	Date of active duty:	 	 	 	 
	 

	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	4.

	 	Date you will be released:	 	 	 	 
	 

	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	5.

	 	Where are you stationed:	 	 	 	 
	 

	 	 	 	 	 	 
	 

	 	Complete military address:	 	 	 	 
	 

	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	 	 	 
	 
	 	 	 	 	 	 
	6.	 	Duties (If in training or attending school, state for what job or duties)
	 
	 	 	 	 	 	 
	 	 	 
	 
	 	 	 	 	 	 
	7.	 	Have you been alerted, received orders, or volunteered for duty outside the United States?
	 	 	o Yes   o No

	 	 	Do you expect or have you had any other indication that you will be assigned outside the US?
	 	 	o Yes   o No

	 	 	If yes to either of the above questions, explain in detail:
	 
	 	 	 	 	 	 
	 	 	 
	 
	 	 	 	 	 	 
	 	 	 
	 
	 	 	 	 	 	 
	8.	 	Do you plan to re-enlist? o Yes   o No

I hereby represent that all the above statements and answers to all the above questions are
complete and true, and I agree that they shall form a part of my application and become a part of
any contract or insurance issued on such application.

	 	 	 	 	 	 	 	 	 	 	 	 	 
	Dated at

	 	 	 	this
	 	 	 	day of	 	 	 	 
	 

	 	 
	 	 	 	 
	 	 	 	 
	 	 
	 

	 	Place
	 	 	 	Day
	 	 	 	Month
	 	Year

	 	 	 
	 

	 	 
	Signature of Agent

	 	Signature of Proposed Insured

TLIC
177 (01-2007) 

 

 

7633 East 63rd Place, Suite 230

Tulsa, OK 74133

Phone: (918) 249-2438    Fax: (918) 249-2478

PARENTAL CONSENT AGREEMENT

We, the undersigned, who are the father and mother of

 

(PROPOSED INSURED)

minor, do hereby give our full consent to the issuance, and continuance in force of Policy
Number                      issued by Trinity Life Insurance Company, on the life of said minor; said
Policy having been issued upon the application made by:

 

(NAME OF APPLICANT)

	 	 	 	 	 
	 
	(STREET ADDRESS)
	 	(CITY)
	 	(STATE)

who is the                      (RELATIONSHIP) of said minor, and we hereby authorize
Trinity Life Insurance Company to pay the benefits and/or proceeds under said policy to the person
or persons entitled thereto according to the terms of said policy, and any riders or attachments
thereto.

Witness our hands this                                          (day) of                 
         
                                    (month),                      (year)

	 	 	 
	 
	 	 
	(WITNESS)
	 	(SIGNATURE OF FATHER)
	 	 	 
	 
	 	 
	(ADDRESS)
	 	(ADDRESS)
	 	 	 

	 	 	 
	 
	 	 
	 
	 
	 	 
	(WITNESS)
	 	(SIGNATURE OF MOTHER)
	 	 	 
	 
	 	 
	(ADDRESS)
	 	(ADDRESS)

TLIC 64 (01-2007)

 

 

	7633 East 63rd Place, Suite 230
Tulsa, OK 74133
Phone: (918) 249-2438    Fax: (918) 249-2478
DIABETIC QUESTIONNAIRE — COMPLETED BY APPLICANT
NAME FILE NUMBER DATE
1. (a) Height? Ft. In. (b) Weight? Lbs. (c) Weight one
year ago? Lbs.
2. Date diabetes diagnosed?
3. Name and address of Doctor supervising your diabetic program?
NAME
ADDRESS
How long have you been under his care? Date of Last Visit? How
often do you consult him for examination and advise?
Have you consulted any other doctors about diabetes in the past 3 years? YES NO
If yes, give names and addresses under 11 below or on reverse side.
4. What is your daily diet prescription? Carbohydrates gms.
Protein gms. Fat gms.
Do you measure or estimate your food portions from an exchange list? Measure? Estimate
5. Do you take Insulin? YES NO If yes, Type? Daily Dose?
Do you take medication? YES NO List medication Names?
6. How often do you test your urine for sugar?
At what time of the day do you do so?
What percentage of tests are positive for sugar?
7. How often do you have blood sugar determinations made? Give results of the test
made
In the past two years, indicate whether fasting or other times.
DATE RESULTS DATE RESULTS
Fasting Other Times Fasting Other Times
1. 1.
2 2.
8. Date you last had an electrocardiogram made? An X-ray of Chest?
(Give name and address of physician who made tests under number 11 below)
9. How many times have you been in diabetic coma, or had acidosis severe enough to require
Hospitalization?
Have you ever had insulin shock, or do you have frequent insulin reactions?
10. Have you ever had: Elevated Blood Pressure? YES NO Heart trouble? YES NO
Kidney trouble? YES NO Recurrent infections? YES NO
Other Prolonged illness? YES NO (If yes, give details under 11 below or on reverse side)
11. Use this space for additional explanations. Give complete information, including dates, names
and address of attending physicians and hospitals. Use reverse side if additional space is needed.

Date: SIGNATURE:

 

 

	Insured’s Full Name:___Home Telephone Number: ( )
___Current Address:
___Policy
Number(s): ___Social Security No: ___
APPLICATION FOR REINSTATEMENT
INSTRUCTIONS: Complete separate reinstatement application for each covered person.
IF ANSWERED
“YES” GIVE
To the best of your knowledge and belief, since the date of this policy: DETAILS BELOW
1. Have you been diagnosed with any terminal illness?
YES
NO2. Are you currently bedridden at home, confined in a hospital, nursing home, or long-term care
facility or receiving Hospice care?YES
NO

3. Have you had or been treated for, or are you taking medication for any of the following: a)
Heart disease or disorder, heart attack, stroke, chest pain, heart surgery, angioplasty, high
blood pressure, diabetes or congestive heart failure?
YES

NO
 b) Cancer or melanoma, leukemia, kidney failure or dialysis, alcoholism, drug abuse, liver
disease or cirrhosis, chronic lung disease, or tuberculosis?
YES
NO
 c) Alzheimer’s Disease, Parkinson’s Disease, Down’s Syndrome, Lou Gehrig’s Disease (ALS),
Multiple Sclerosis (MS), seizure disorder or any other disorder of the brain or nervous
system?...
YES
NO
4. Have you ever been diagnosed by a member of the medical profession as having, or have you
tested positive for, or been treated by a member of the medical profession, for any of the
following: Acquired Immune Deficiency Syndrome (AIDS), Aids Related Complex (ARC), Human
Immunodeficiency Virus(HIV Virus), or any other disease or disorder of the immune system?
YES
NO
5. Been in a hospital, clinic, or institution for examination, observation, diagnosis, operation
or treatment?
YES
NO
6. Consulted or been treated by any physician or practitioner or had any physical
impairment,sickness, injury, surgery or mental disorder not mentioned above?
YES
NO
7. Had any life or health insurance declined, postponed, or rated or refused reinstatement or
renewal?
YES
NO
8. Had two or more moving violations, or had a driver’s license suspended or revoked within the
past
5 years?
YES
NO
9. Driver’s License Number___State of:___
10. Engaged in or expect to engage in aviation activities or hazardous sports, avocations or
hobbies?
YES
NO 11. Changed occupations? If yes, give present occupations and employers and duties below
YES
NO 12. Are you now a cigarette smoker?
YES
NO a. If “YES”, number of packs daily? ___b. Have you ever been a cigarette smoker and quit?
YESNO c. If “YES”, when did you quit? Date (month/year) ___d. Do you use tobacco in
any other form? If “YES”, Type: ___
YES
NO 13. Height:___ft. and ___inches Weight:___lbs.
GIVE COMPLETE DETAILS BELOW FOR ANY “YES” ANSWERS ABOVE:
Details
Question Date(s) Condition, operation performed, hospitalization, Names & addresses of doctors,
Number medications, other details hospitals or clinics involved
TLIC 21001 OK (01-2007)

NOTICE OF INFORMATION PRACTICES

This Notice To Be Detached and Retained by Insured

(Including Medical Information Bureau Notice and Fair Credit Reporting Act notice)

     In considering your application, information from various sources will be considered.
These include your statements, the results of your physical examination (if required), and reports
we get from doctors or medical facilities which have attended you.

     Information about your insurability will be treated as confidential. We, or our reinsurer(s),
may, however, make a brief report of this to the Medical Information Bureau, a nonprofit membership
organization of life insurance companies, which operates an information exchange on behalf of its
members. If you apply to another Bureau member company for life or health insurance coverage, or a
claim for benefits is submitted to such a company, the Bureau, upon request, will supply such
company with the information in its file.

     Upon the receipt of a request from you, the Bureau will arrange disclosure of any information
it may have in your file. If you question the accuracy of the information in the Bureau’s file, you
may contact the Bureau and seek a correction in accordance with the procedures set forth in the
Federal Fair Credit Reporting Act. The address of the Bureau’s information office is Post Office
Box 105, Essex Station, Boston, Massachusetts 02112, telephone number (617) 426-3660.

TLIC 21001 OK (01-2007)

 

 

I (We) represent that all statements and answers in this application are full, complete and true to
the best of my (our) knowledge and belief. I (we) understand that said statements and answers are
submitted as evidence of insurability of each person insured under the policy. It is agreed that
this policy will not be reinstated and the company will have no liability until (1) all money
required for reinstatement of this policy has been paid; (2) this application has been approved by
Trinity Life Insurance Company Home Office during the lifetime of all persons who would be insured
under this policy if reinstated. It is further agreed that with regard to the statements and
answers provided above, any period of contestability provided in the policy shall run anew from the
effective date of reinstatement.

I HEREBY AUTHORIZE any licensed physician, medical practitioner, hospital, clinic or other medical
or medically related facility, insurance company, consumer reporting agency, the Department of
Motor Vehicles (or other appropriate state agency), or the Medical Information Bureau that has any
records or knowledge of me or my health, to give Trinity Life Insurance Company, or its
reinsurer(s), such information as may be needed to consider my application for insurance. Such
information may include records or knowledge of my health, motor vehicle records, aviation
activities, hazardous sports or hobbies or avocations, and occupation. A photographic copy of this
authorization shall be as valid as the original. The purpose for which this information is being
collect is to consider your application for insurance. You or your authorized representative is
entitled to receive a copy of this authorization.

This authorization shall be valid for 24 months from the date shown below. A photographic copy
shall be as valid as the original. I have the right to revoke this authorization at anytime by
sending a revocation in writing to Trinity Life Insurance Company, 7633 East 63rd Place, Suite 230,
Tulsa, OK 74133. Attention: Underwriting Department. I have received a copy of the Notice of
Information Practices.

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR
KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIME AND
MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

	 	 	 	 	 	 	 
	DATE:
	 	 	 	 	 	 
	 

	 	 
	 	 	 	 
	 

	 	 	 	 	 	Signature of Owner (Always Required)

	 	 	 	 	 	 	 
	WITNESS:
	 	 	 	 	 	 
	 

	 	 
	 	 	 	 
	 

	 	 	 	 	 	Signature of Insured, if other than Owner

(or Parent if insured is minor)

TLIC 21001 OK (01-2007)

 

NOTICE OF INFORMATION PRACTICES continued

     We or our reinsurer(s), may also release information to other life insurance companies
to whom you apply for life or health insurance, or to whom a claim is submitted.

     In addition, we may get an investigative report from a consumer reporting agency. This report
requires personal interviews with your neighbors, friends, or other acquaintances for information
as to your general reputation, personal characteristics and mode of living. As part of your
application, you have authorized us to do this. You have the right to be personally interviewed and
to make a written request within a reasonable period about the nature and scope of this
investigation. Upon written request you will be told if such a report has actually been ordered,
and if it has, we will give you the name and address of the consumer reporting agency. You may
contact this consumer reporting agency and ask for a copy of such report. Unless a legitimate
business need exists or we are required to do so by law, the information we get in this report, as
well as any other information which we later acquire, will not be disclosed to anyone else without
your consent. You may request a copy of all information acquired by us and have a right to correct
any personal information which you feel is inaccurate. We will, if required by law, give you a more
detailed notice of the types of personal information which we get in considering your application,
as well as any additional rights which you may have.

     If you need any assistance, please feel free to contact your agent or call or write to us at
Investors Heritage Life Insurance Company, Underwriting Department, 200 Capital Avenue, PO Box 717,
Frankfort, Kentucky 40602-0717.

TLIC 21001 OK (01-2007)

 

 

HOME OFFICE

7633 East 63rd Place, Suite 230, Tulsa, Oklahoma 74133

Phone: (918) 249-2438
• Fax: (918) 249-2478

ADMINISTRATIVE OFFICE

PO BOX 5205 • FRANKFORT, KY 40602-5205

Phone: (866) 440-1357 • Fax: (502) 875-7084

PROPOSED INSURED CONSENT FORM

	 	 	 	 	 	 	 	 	 
	PROPOSED INSURED:	 	 	 	 
	 	 	 	 	 	 	 
	OWNER:
	 	 	 	 	 	 	 	 
	 	 	 
	CO-OWNER:	 	 	 	 	 	 
	 	 	 	 	 

This is to certify that the undersigned Proposed Insured gives full permission to the
application for life insurance on his/her life.

AUTHORIZATION

With this form (or a photographic copy of it), I authorize any licensed physician, medical
practitioner, clinic, hospital or other medical or medically-related facility, insurance company,
reinsurer, the Medical Information Bureau, or other person, organization or institution, that has
any records for knowledge of me for whom the application is made or my health, to give to Trinity
Life Insurance Company, or it’s reinsurers, any such information and to testify as to such
information, all to the extent permitted by law. This authorization shall be valid for 24 months
from the date signed. I understand that I may revoke this authorization by so stating in writing
sent to Trinity Life Insurance Company’s Underwriting Department at the Administrative Office.

I also acknowledge receipt of the notices required by the Fair Credit Reporting Act and the Medical
Information Bureau. A photographic copy of this authorization shall be as valid as the original.

I acknowledge that I have been given a copy of the application and to verify that all information
on the application is complete and true as of the date of this Consent to the best of my knowledge,
except for:

EXCEPTIONS: (If none, state “NONE”) (If more space is needed to completely and accurately supply
the information requested, attach additional paper.)

 

 

 

 

 

	 	 	 
	 
	 	 
	Date
	 	Signature of Proposed Insured
	 	 	 
	 
	 	 
	 
	 	Witness

TLIC PICF-01(03-2007)

 

 

NOTICE AND CONSENT FORM FOR AIDS VIRUS (HIV) ANTIBODY TESTING

INSURER

Trinity Life Insurance Company

7633 East 63rd Place, Suite 230

Tulsa, OK 74133

Phone: (918) 249-2438

Fax: (918) 249-2478

To evaluate your eligibility for insurance coverage, it is requested by the Insurer named above
that you provide a sample of your blood for testing to determine the presence of the human
immunodeficiency virus (HIV) antibodies. By signing and dating this form you agree that this test
may be performed and that underwriting decisions will be based on the results. You may refuse to
be tested; however, such refusal may be used to deny coverage or issuance of the policy.

PRE-TESTING CONSIDERATIONS

Many public health organizations have recommended that before taking the AIDS related blood test a
person seek counseling to become informed concerning the implications of such test. You may wish to
consider counseling, at your expense, prior to being tested. To obtain information regarding
counseling, you should contact your local health department.

MEANING OF POSITIVE TEST RESULTS

The test is not a test for AIDS. It is a test for antibodies to the HIV virus, the causative agent
for AIDS, and shows whether you have been exposed to the virus. A positive result does not mean
that you have AIDS, but that you are at a significantly increased risk of developing problems with
your immune system. The test for HIV antibodies is very sensitive. Errors are rare; however, they
do occur. Your private physician, public health clinic, or an AIDS information organization may
provide you with further information on the medical implications concerning a positive test result.

DISCLOSURE OF TEST RESULTS

All test results will be treated confidentially. They will be reported by the laboratory to the
Insurer. The test results may be disclosed as required by law or may be disclosed to employees of
the Insurer who have the responsibility to make underwriting decisions on behalf of the Insurer and
to medical personnel, laboratories, and to outside counsel who needs such information to
effectively represent the Insurer in regard to your application. The results may also be disclosed
to a reinsurer if the reinsurer is involved in the underwriting process. The results may be
released to an insurance medical information bureau under procedures designed to assure
confidentiality, including the use of general codes that also cover results for the other diseases
or conditions not related to AIDS, or for the preparation of statistical reports that do not
disclose the identity to any particular person.

NOTIFICATION OF RESULTS (This section must be completed):

In the event a test is positive, you authorize disclosure of the result to the following physician:

	 	 	 	 	 
	NAME
	 	 	 	 
	 	 	 
	ADDRESS
	 	 	 	 
	 	 	 
	CITY, STATE, ZIP:
	 	 	 	 
	 	 	 

INFORMED CONSENT

I HAVE READ AND UNDERSTAND THIS NOTICE AND CONSENT FORM FOR AIDS VIRUS (HIV) TESTING. I
VOLUNTARILY CONSENT TO TESTING AND DISCLOSURE AS DESCRIBED ABOVE. I UNDERSTAND THAT I HAVE THE
RIGHT TO REQUEST AND TO RECEIVE A COPY OF THIS FORM. A PHOTOCOPY OF THIS FORM SHALL BE AS VALID AS
THE ORIGINAL.

	 	 	 	 	 
	 

	 	 	 	 
	(Date)

	 	 	 	Signature of Proposed Insured or Parent/Guardian

TLIC HIV (01/2007)

 

 

ADMINISTRATIVE OFFICE

PO BOX 5205 • FRANKFORT, KY 40602-5205

Phone: (866) 440-1357 • Fax: (502) 875-7084

HIPAA Compliant Authorization for Release of Medical Information

	 	 	 	 	 
	 
	 	   -          -	 	     /     /     
	 
	 	 
	 	 
	Name of proposed insured/ patient
	 	Social Security Number
	 	Date of Birth
	 	 	 	 	 
	 

Policy or Claim Number (if known)
	 	 
	 	 

I authorize any health plan, physician, health care professional, hospital, Veterans
Administration, clinic, laboratory, pharmacy or pharmacy benefit manager, medical facility,
insurance company, insurance support organization such as MIB), or other health care provider that
has provided payment, treatment or services to me or on my behalf within the past 10 years
(collectively, “My Providers”) to disclose my entire medical record, medication history, and any
other protected health information concerning me to Trinity Life Insurance Company, or its
designee,

 

Name of designee (if applicable)

This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV),
Acquired Immune Deficiency Syndrome (AIDS) and Sexually Transmitted Diseases (STDs.) This also
includes information on the diagnosis and treatment of mental illness and the use of alcohol,
drugs, and tobacco, but excludes psychotherapy notes.

By my signature below, I acknowledge that any agreements I have made to restrict my protected
health information do not apply to this authorization and I instruct My Providers to release and
disclose my entire medical record without restriction.

This protected health information is to be disclosed under this Authorization so that Trinity Life
Insurance Company may: (1) underwrite my application for coverage, make eligibility, risk rating,
policy issuance and enrollment determinations; (2) obtain reinsurance; (3) administer claims and
determine or fulfill responsibility for coverage and provision of benefits; (4) administer
coverage; and (5) conduct other legally permissible activities that relate to any coverage I have
or have applied for with Trinity Life Insurance Company.

This authorization shall remain in force for 24 months following the date of my signature below,
and a copy of this authorization is as valid as the original. I understand that I have the right to
revoke this authorization in writing, at any time, by sending a written request for revocation to
Trinity Life Insurance Company, Administrative Office, P.O. Box 5205, Frankfort, KY 40602-5205,
Attn: General Counsel. I understand that a revocation is not effective to the extent that any of My
Providers has already relied on this Authorization or to the extent that Trinity Life Insurance
Company has a legal right to contest a claim under an insurance policy or to contest the policy
itself. I understand that any information disclosed pursuant to this authorization may be subject
to redisclosure by the recipient and may no longer be protected by federal rules governing privacy
and confidentiality of health information. However, Trinity Life Insurance Company will protect the
privacy of health information in accordance with other applicable state and federal privacy laws
and their own privacy policies.

I understand that My Providers may not refuse to provide treatment or payment for health care
services because I refuse to sign this authorization. I further understand that if I refuse to sign
this authorization to release my complete medical record, Trinity Life Insurance Company may not be
able to process my application, or if coverage has been issued, may not be able to make any benefit
payments. I understand that I am entitled to a copy of this signed authorization.

	 	 	 
	 

	 	 
	Signature of Proposed Insured/Patient or Personal Representative

	 	Date
	 
	 	 
	 

Description of Personal Representative’s Authority or Relationship to Patient

(For death claims, please attach copy of appointment of executor of estate.)

	 	 

TLIC HIPAA ARM (3-2007)

 

 

	7633 East 63rd Place, Suite 230 Tulsa, OK 74133
Phone: (918) 249-2438 Fax: (918) 249-2478

	HIGH BLOOD PRESSURE QUESTIONNAIRE
APPLICANT TO COMPLETE

	NAME            DATE OF BIRTH            POLICY NUMBER

	1. (a) Height? ft            in (b) Weight? lbs

	(c) Weight one year ago? lbs

	2. Date high blood pressure diagnosed?

	Age at onset?

	3. Name and address of doctor supervising your high blood pressure program?

	How long have you been under his care? Date of last visit?
How often do you consult him for examination and advice?
4. What was your highest blood pressure reading? Date:
5. What was your recent blood pressure reading? Date:
6. What medications are you taking? (Dosage and frequency) How long have you
been taking medication for high blood pressure. Any changes in medication? Any
other treatments?

	7. Has your doctor done any diagnostic studies? (EKG, x-rays, blood tests, etc.) When and What were the findings?

	8. When the doctor checks, are your blood pressure readings:

	Usually high            Usually normal? They vary?
9. Have you ever had: Diabetes? Yes            No            Heart trouble? Yes            No
Eye trouble? Yes            No            Kidney trouble? Yes            No
Recurrent infections? Yes            No            Other prolonged illness? Yes            No
Please give details, if yes.

	10. Have you ever been hospitalized for high blood pressure? Yes No If yes, give dates and name
and address of hospital.

 

 

	1. Provide details of previous foreign travel including holidays and short business trips
within the last two years:

	Date(s) of visit(s) Countries            Regions            Reason(s) for visit(s) Frequency            Duration of visit(s)

	2. Provide details of your intentions for future foreign travel including holidays, and
business trips:

	Date(s) of visit(s) Countries            Regions            Reason(s) for visit(s) Frequency            Duration of visit(s)

	3. Give a description of your duties while traveling or residing abroad:

	4. Do you expect to visit non-urban areas? YES            NO
If YES, give details of:
a. Your likely accommodations:
b. The availability of medical facilities:
c.Your travel arrangements, e.g. light aircraft, boat, etc.:

	5. Would you consider traveling to war zones or hazardous areas? YES NO If YES, give details:

	Dated at            this            day of
P            LACE            D            AY            M            ONTH            Y  
         
 EAR

	S            IGNATURE OF            A            GENT            S            IGNATURE OF     
       P 
           ROPOSED            I            NSURED

 

 

BENEFIT PAYMENTS

Claims Procedure Manual

HOME OFFICE

7633 EAST 63RD PLACE, SUITE 230 Ÿ TULSA, OK Ÿ 74133

Phone: (918) 249-2438

Fax: (918) 249-2478

ADMINISTRATIVE OFFICE

PO BOX 5205 Ÿ FRANKFORT, KY Ÿ 40602-5205

Phone: (866) 440-1357

Primary Fax: (502) 875-7084

Secondary Exclusive Claim Fax: (502) 223-6575

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	INTRODUCTION
	 	 	3	 
	DESCRIPTION OF DUTIES
	 	 	4	 
	Senior Claims Analyst:
	 	 	4	 
	Assistant Claims Analyst:
	 	 	5	 
	Claims Clerical Assistant:
	 	 	6	 
	NON-CONTESTABLE CLAIMS
	 	 	7	 
	CONTESTABLE CLAIMS
	 	 	7	 
	COMPUTER SYSTEM TRANSACTIONS
	 	 	9	 
	OBAS – Policy Master – Information by Policy Number
	 	 	9	 
	BCMM – Claim Master Maintenance
	 	 	9	 
	BCIM – Claim Information Maintenance
	 	 	9	 
	BCPM – Benefit Claims Payee Maintenance
	 	 	9	 
	BCPB – Payee Benefit Calculation
	 	 	10	 
	CHECKLIST FOR CLAIMS
	 	 	10	 
	CLAIM DOCUMENTATION REQUIREMENTS
	 	 	11	 
	Memos (OMEM)
	 	 	11	 
	BENEFICIARIES UNDER THE AGE OF 18:
	 	 	11	 
	CLAIMANT’S STATEMENT
	 	 	12	 
	Who signs a claimant statement?
	 	 	15	 
	DIAGNOSTIC CODES
	 	 	16	 

2

 

Benefit Payments Procedure Manual

Ordinary Life Claims

Introduction

Trinity Life Insurance Company (“Trinity”), Tulsa, Oklahoma has contracted Investors Heritage
Life Insurance Company (“Administrator”), Frankfort, Kentucky to provide life administrative
services for their life products.

Claims will be submitted and processed at the Administrator’s office in Frankfort, Kentucky. Any
benefit checks issued will be printed in another department and mailed with the Explanation of
Benefits. Benefit Payment employees are not authorized to handle checks.

The Administrator can authorize the payment of all claims up to $25,000. Claims over $25,000 are
reported to the Claims Committee monthly for review. Claims over $25,000 must be approved at
Trinity’s Home Office by Gregg Zahn or Sherman Lay.

Members of the Claims Committee at the Administrator’s office are:

Harry Lee Waterfield II – President and CEO

Jane Jackson – Corporate Secretary

Robert M Hardy, Jr. – Legal Counsel

Roland Herzel – Senior Claims Analyst

3

 

Benefit Payments Procedure Manual

Ordinary Life Claims

Description of Duties

Senior Claims Analyst:

	 	•	 	The senior claims analyst is responsible for:

	 	o	 	Processing all contestable claims and conducting medical inquiries
	 
	 	o	 	Helping with non-contestable claims as time permits
	 
	 	o	 	Processing waiver of premium, life, and reinsurance claims
	 
	 	o	 	Drafting all non-programmed correspondence
	 
	 	o	 	Proofreading all claims before payment
	 
	 	o	 	Filing all reinsurance claims

Processing a Claim:

	 	•	 	As the claim folder is received from the Claims Clerical Assistant, review the claim
for beneficiary information, assignment information, death benefit and any additional
information that is needed.
	 
	 	•	 	If medical records are needed the Senior Claims Analyst will request the records from
the appropriate source and follow up until resolution.
	 
	 	•	 	Once all the information is received and the claim is ready for payment, Senior Claims
Analyst prepares payment and the release of the benefit check.
	 
	 	•	 	If the claim is to be denied or the policy rescinded, the appropriate letter will be
drafted by the Senior Claims Analyst and mailed.

The Senior Claims Analyst can authorize the payment of all claims up to $25,000. Claims over
$25,000 are reported to the Claims Committee monthly for review. Claims over $25,000 must be
approved by Gregg Zahn or Sherman Lay.

Members of the Claims Committee at the Administrator’s office are Harry Lee Waterfield II, Jane
Jackson, Robert M. Hardy, Jr., and Roland Herzel.

4

 

Benefit Payments Procedure Manual

Ordinary Life Claims

Assistant Claims Analyst:

	 	•	 	The Assistant Claims Analyst is responsible for:

	 	•	 	Processing all non-contestable claims

	 
	 	§	 	Inputting claim information onto the computer claims system
	 
	 	§	 	Preparing the claim for payment

Processing a Claim:

	 	•	 	As the claim folder is received from the Claims Clerical Assistant, review the claim to
verify the receipt of information needed to process the claim; for example, beneficiary
information, assignment information, and death benefit. Input the claim information on
the claims computer system.
	 
	 	•	 	If other information is needed, this information will be requested from the Claims
Clerical Assistant. Make a note on the claims cover sheet of the information needed and
from whom the information should be requested, and return the claim file to the Claims
Clerical Assistant.
	 
	 	•	 	Incomplete claims are logged in. A letter is generated requesting missing documents.
A letter is generated from a programmed suspense list every 30 days until response.
	 
	 	•	 	Once all information is received and if the claim is ready for payment, forward the
claim to the Senior Analyst for payment and the release of the benefit check.
	 
	 	•	 	If a claim is not approved the appropriate letter will be generated by the Assistant
Claims Analyst and mailed.

The Assistant Claims Analyst prepares all claims for payment, then the Senior Claims Analyst
approves and releases checks to the printer.

5

 

Benefit Payments Procedure Manual

Ordinary Life Claims

Claims Clerical Assistant:

	 	•	 	The Claims Clerical Assistant is responsible for:

	 	o	 	Date stamping all envelopes
	 
	 	o	 	Date stamping all documents received
	 
	 	o	 	Verifying that the policy number on the claimant statement is the
policy number of the Insured/Deceased by checking the OBAS screen against the
claim
	 
	 	o	 	Preparing a file folder for each claim received
	 
	 	o	 	Distributing contestable and non-contestable claims, complete and
incomplete, to the Analysts
	 
	 	o	 	Requesting additional claim information by telephone as instructed by
the Analyst
	 
	 	o	 	Requesting information from microfilm/image as instructed by the
Analyst or as needed
	 
	 	o	 	Imaging paid claim folders
	 
	 	o	 	Reviewing pending drawer for continuing delay notice mailings which
come up on daily programmed suspense list

Processing a Claim:

	 	•	 	As the unopened mail is received in the Benefit Payments Department, the Claims
Clerical Assistant will date stamp the envelopes and each document in the envelope. This
is done to verify when a given document was received in the department.
	 
	 	•	 	After a complete claim has been received and verified, meaning the policy number on the
claim form is the policy number for the deceased, a claim folder will be made for each
claim filed. Contestable claims and non-contestable claims will be put in their
appropriate location for processing by the Analyst.
	 
	 	•	 	If an incomplete claim is received, the Claims Clerical Assistant will request the
additional information as instructed by the Analysts. Additional information requests are
made by using the “Your Claim Was Received Incomplete” form. After the additional
information is requested, the incomplete claim will be filed in the pending claims drawer.
	 
	 	•	 	Upon receipt of the additional information requested, the claim file will be pulled
from the claims pending drawer and put in the appropriate location for processing by the
Senior Claims Analyst or the Assistant Claims Analyst.
	 
	 	•	 	Paid claims are placed daily in the paid claims basket to be imaged for permanent
storage.
	 
	 	•	 	Paid claims are imaged daily. Medical or other confidential records are imaged in a
separate channel accessible only to authorized persons.
	 
	 	•	 	Pending claims need to be reviewed weekly for follow up delay notice mailings.

6

 

 
Benefit Payments Procedure Manual

Ordinary Life Claims

Non-contestable claims

	 	•	 	The assistant claims analyst will review all non-contestable
claims. If insured’s death occurred after the first two
policy years, the policy is in force, and all necessary
information has been received to pay the claim, input the
correct claim information into the claim system. If all
requested documents are not received with the initial
notification of loss, but there is sufficient claim
information to enter the claim into the computer, do so on
BCMM and use the memo screen to indicate the reason for the
delay in the processing of the claim.
	 
	 	•	 	Send notification to the Claimant regarding the incomplete
claim. The incomplete claim will be filed in the central
pending drawer alphabetically. Notification of the pending
claim should be sent out every fifteen (15) days until the
needed information is received. The claim system will
generate the delay notices by a suspense list requiring
action by the Analyst.
	 
	 	•	 	Upon receipt of documents needed to complete the
non-contestable claim, pull the incomplete claim file from
the pending drawer. Date stamp the documents upon receipt
and forward the file to the Analyst. The Claims Analyst
reviews the documents for accuracy and completeness and
proceeds with processing the claim.
	 
	 	•	 	The claim folder is then forwarded to the Senior Claims
Analyst for review and release of the benefit check. The
claim folder will be returned to the Claim Clerical Assistant
after payment to await imaging.
	 
	 	•	 	If a non-contestable claim is denied, a letter must be sent
to the claimant explaining the reason(s) for the denial, the
most common reason being that the policy lapsed prior to the
insured’s death. A copy of the letter is placed in the file
and then imaged.

Contestable claims

	 	•	 	The Senior Claims Analyst will review all contestable claims. If the policy is in the contestable period, meaning
that the death of the insured has occurred within the first two policy years, medical records must be requested
from the doctors and/or hospitals listed on the claimant statement or from other sources. The Claims Analyst
requests the medical records through Infolink Services of Kansas City.
	 
	 	•	 	If there is going to be a delay in processing the claim due to incomplete forms or the need to request medical
records, delay notices must be sent to the claimant. Delayed or pending claims should be filed in the
appropriate drawer. Claims pending due to medical records requests should be put in the medical records drawer
and claims pending due to an incomplete claim will be put in a centralized pending drawer.
	 
	 	•	 	All delay notices are in a business-like format and are on the computer in Microsoft Word for easy access.
Various letters can be used depending upon the claim situation. After the initial delay notice, future notices
will be sent out every thirty (30) days until the information is received.

7

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	•	 	Upon receipt of medical records requested for a contestable claim, the records will be date stamped by the Claims
Clerical assistant and the claim pulled from the claim pending drawer. Medical records must then be reviewed by
the Senior Claims Analyst for a decision to pay the claim or deny the claim and rescind the policy. If the
Analyst has any questions concerning the medical background of the insured, the Company Medical Director can also
review the medical records.
	 
	 	•	 	If a contestable claim is to be rescinded, a letter must be sent to the Claimant explaining the reason(s) for the
rescission. A copy of the letter and enclosures is placed in the claim file.
	 
	 	•	 	After a claim is completed, the file will be imaged and destroyed.
	 
	 	•	 	A rescinded policy is subject to rebuttal and further review if requested by the claimant. The Senior Analyst
will consult General Counsel in such cases, and a meeting of the full Claims Committee may also be called.

8

 

Benefit Payments Procedure Manual

Ordinary Life Claims

Computer System Transactions

Information regarding the claim must be entered into the computer on the following screens:

OBAS – Policy Master – Information by Policy Number

	 	a.	 	Screen should be printed and kept in claim file
	 
	 	b.	 	Contains policy information
	 
	 	c.	 	Identify insured and decedent by name and birthdate
	 
	 	d.	 	Use this screen for assignment and/or beneficiary information

BCMM – Claim Master Maintenance

	 	a.	 	Requires policy number, Social Security number, and claim code

	 	i.	 	P = primary insured
	 
	 	ii.	 	S = secondary/joint
	 
	 	iii.	 	R = rider

	 	b.	 	Zip code and birth date are then cross-checked with policy master
	 
	 	c.	 	Incurred date, death code, and occupation code must then be entered

BCIM – Claim Information Maintenance

	 	a.	 	Accessed by using ‘F9’ from BCMM
	 
	 	b.	 	Used to indicate if a certain document has been received or the need
for this document waived
	 
	 	c.	 	After entering the required information, ‘F2’ will return you to BCMM

BCPM – Benefit Claims Payee Maintenance

	 	a.	 	Accessed by using ‘F10’ from BCMM

	 
	 	b.	 	Used to show to whom the policy proceeds will be paid.

	 	i.	 	Payee type (1) – Used for any portion of the
proceeds payable to an assignee OAGM can be used to complete this
screen if the assignee is an agent of IHLICIf tax ID number on claim
form is different from one on OAGM contact Credit Life Accounting for
verification
	 
	 	ii.	 	Payee type (2) – Used only for premium refund
and is always paid to the owner or the Estate of the Insured.
	 
	 	iii.	 	Payee type (3) – Used when proceeds are payable
to the beneficiary. An ‘X’ will appear under ‘BNF’ on the OBAS if
beneficiary information is available via the computer system (PF23).

	 	c.	 	Fields to be completed on BCPM are payee type, SSN code, attorney,
relationship, and % of proceeds going to the claimant. Typically a dollar amount
is used to pay the assignee and 100% is entered for the beneficiary.
	 
	 	d.	 	It is possible to use any or all of the payee types on one claim.
	 
	 	e.	 	‘F2’ will return you to BCMM

9

 

Benefit Payments Procedure Manual

Ordinary Life Claims

BCPB – Payee Benefit Calculation

	 	a.	 	Accessed by using ‘PF14’ from BCMM
	 
	 	b.	 	Screen is already completed
	 
	 	c.	 	Just an informational screen, it describes the amount of proceeds to
be paid
	 
	 	d.	 	Check to see that the amounts appear to be correct
	 
	 	e.	 	F11 will indicate that the claim has been validated for release

Checklist for Claims

	 	1.	 	Make sure date of birth, name, and Social Security number agree on the following
documents:

	 	a.	 	Death certificate
	 
	 	b.	 	Claimant Statement
	 
	 	c.	 	OBAS screen

	 	2.	 	Check for reasonableness of claim amount
	 
	 	3.	 	Check beneficiary. If no policy or beneficiary change is included in the file or
showing on OBAS, the application or endorsement should be copied from microfiche and
placed in the file.
	 
	 	4.	 	Check for assignment.
	 
	 	5.	 	Verify payee addresses.
	 
	 	6.	 	Return of premium should first go to the owner of the policy, then to the beneficiary
or assignee, in that order.
	 
	 	7.	 	Check for policy loans.
	 
	 	8.	 	Check to see that the agent number or assignment number was used on the payee type 1
screen on BCMM if applicable.

Make sure all FEINs and SSNs are input on the payee screens on BCMM. If TIN/EIN/SSN cannot be
obtained, the default entry is zeroes, and federal tax is withheld and a 1099 issued at year end.

10

 

Benefit Payments Procedure Manual

Ordinary Life Claims

Claim Documentation Requirements

Exclusive Claim Fax Number: (502) 223-6575

Contestable Policies

(Documents accepted by mail only for accidental death in first two policy years)

	 	•	 	Claimant Statement (TLIC 46C Revised 5/2007)
	 
	 	•	 	Certified death certificate
	 
	 	•	 	Policy or lost policy affidavit required for claims greater than $25,000

Memos (OMEM)

	•	 	All memos to the file must be entered and maintained on the
system. It is imperative that the memo is recorded as the
transaction occurs. It is also important to only enter
relevant information – do not editorialize

	•	 	The shift-F3 key from OBAS is used for any memos concerning
policy information up to and including reporting the death of
the insured. Any memos after the death claim should be put
on the BCMM memo screen (F11).

	•	 	Memos should contain enough information so that anyone
reviewing the screen will understand circumstances concerning
the claim without having the file in front of them.

Beneficiaries under the Age of 18:

	•	 	When paying any beneficiary under the age of 18, proceeds must be paid to the guardian
of the beneficiary, with proof of appointment. For example: John Doe, Guardian for Jimmy
Doe.

11

 

 

 

Benefit Payments Procedure Manual

Ordinary Life Claims

 

HIPAA COMPLIANT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I authorize any health plan, physician, health care professional, hospital, Veterans
Administration, clinic, laboratory, pharmacy or pharmacy benefit manager, medical facility,
insurance company, insurance support organization such as MIB), or other health care provider that
has provided payment, treatment or services to me or on my behalf within the past 10 years
(collectively, “My Providers”) to disclose my entire medical record, medication history, and any
other protected health information concerning me to Trinity Life Insurance Company, or its
designee,

 

This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV),
Acquired Immune Deficiency Syndrome (AIDS) and Sexually Transmitted Diseases (STDs.) This also
includes information on the diagnosis and treatment of mental illness and the use of alcohol,
drugs, and tobacco, but excludes psychotherapy notes.

By my signature below, I acknowledge that any agreements I have made to restrict my protected
health information do not apply to this authorization and I instruct My Providers to release and
disclose my entire medical record without restriction.

This protected health information is to be disclosed under this Authorization so that Trinity Life
Insurance Company may; (1) underwrite my application for coverage, make eligibility, risk rating,
policy issuance and enrollment determinations; (2) obtain reinsurance; (3) administer claims and
determine or fulfill responsibility for coverage and provision of benefits; (4) administer
coverage; and (5) conduct other legally permissible activities that relate to any coverage I have
or have applied for with Trinity Life Insurance Company.

This authorization shall remain in force for 24 months following the date of my signature below,
and a copy of this authorization is as valid as the original. I understand that I have the right to
revoke this authorization in writing, at any time, by sending a written request for revocation to
Investors Heritage Life Insurance Company, P.O. Box 717, Frankfort, KY 40602, Attn: General
Counsel. I understand that a revocation is not effective to the extent that any of My Providers has
already relied on this Authorization or to the extent that Trinity Life Insurance Company has a
legal right to contest a claim under an insurance policy or to contest the policy itself. I
understand that any information disclosed pursuant to this authorization may be subject to
redisclosure by the recipient and may no longer be protected by federal rules governing privacy and
confidentiality of health information. However, Trinity Life Insurance Company will protect the
privacy of health information in accordance with other applicable state and federal privacy laws
and their own privacy policies.

I understand that My Providers may not refuse to provide treatment or payment for health care
services because I refuse to sign this authorization. I further understand that if I refuse to
sign this authorization to release my complete medical record. Trinity Life Insurance Company may
not be able to process my application, or if coverage has been issued, may not be able to make any
benefit payments. I understand that I am entitled to a copy of this signed authorization.

	 	 	 
	 

	 	 
	Signature of Personal Representative

	 	Date

 

Description of Personal Representative’s Authority or
Relationship to Patient
 (For death claims, please attach copy of
appointment of executor of estate.)

 

INSTRUCTIONS FOR COMPLETING PROOFS OF DEATH

It is not necessary to employ any person, firm or corporation for collection of any claim
under this policy. In addition to completing the CLAIMANT’S STATEMENT on the front of this form,
please furnish:

	•	 	Official Death Certificate, certificate with raised seal.

	•	 	The Policy. If the policy(ies) is (are) last or destroyed, you must so certify on a separate sheet of paper.

	•	 	Evidence of change of name of insured or beneficiary (if applicable).

If death was violent or accidental, consideration of such claim can be facilitated by furnishing a
police report, newspaper account, autopsy report and coroner’s verdict, in addition to the
foregoing.

TLIC 46C
05-2007

13

 

Benefit Payments Procedure Manual

Ordinary Life Claims

INSTRUCTIONS FOR COMPLETING CLAIMANT’S STATEMENT 

Every question must be distinctly and fully answered.

1. Complete Section A and C for all death claims. Complete Section B only if (1) any policy was
issued within two years of the date of death or (2) any policy contains an Accidental Death
Provision and there is a possibility that death was caused by
accidental bodily injury. If Section B is completed, the AUTHORIZATION for release of medical and employment information must
also be completed. The Company reserves the right to obtain further information should it be
deemed necessary

2. The form must be completed by the persons to whom the insurance is payable. If the amount
payable is to be divided among several beneficiaries, a separate form for each will be furnished,
or if desired, two beneficiaries may sign one statement. When two beneficiaries join in one
statement, question 8a of Section A pertains to one of them and question 8b applies to the other.
Both must sign the form.

3. If a claimant is a minor, the Claimant’s Statement Is to be completed by the minor’s legally
appointed guardian, a certificate of whose appointment and authority must be furnished. In such
case, question 8a should show the minor’s information, and question 8b should show the legal
guardians’ information. Both must sign the form, if possible.

4. When policy proceeds are payable to “children” or others of a class, no names being specified, a
sworn statement must be furnished, giving names and dates of birth of each; and if any died, the
sworn statement must give the date and place of death and must state whether they died without a
will, unmarried and without children.

5. When
policy proceeds are payable to the estate of the insured, this statement must be made by an
executor or administrator, a certificate of whose appointment and authority must be furnished.

6. When a policy has been assigned, this statement must be made by the assignee who must submit the
original assignment. If the assignment of the policy is collateral in intent, regardless of
whether absolute in form, the statement must be completed jointly by the Beneficiary showing
information in question 8a and assignee information in question 8b, A statement of the amount
claimed by the assignee, assented to by the beneficiary, must be furnished if separate checks are
desired.

7. When
policy proceeds are payable to someone who dies before the insured, a certified death
certificate issued by the State Bureau of Vital Statistics must be furnished, giving the place and
date of death of the deceased person. This requirement may be disregarded when the Company has
received a prior claim on such person.

8. When policy proceeds are payable to a corporation or firm, this statement must be made by a duly
qualified officer who has the power and right to make such claim in the name of the corporation or
firm.

TLIC 46C
Instructions (5-07)

14

 

Benefit Payments Procedure Manual

Ordinary Life Claims

Who signs a claimant statement?

	•	 	The primary beneficiary (or contingent beneficiary/estate administrator if primary
is deceased) must sign the claimant statement.

	•	 	If the designated beneficiary is deceased, request a copy of the beneficiary’s death
certificate.

	•	 	If a contingent beneficiary has been named, and is also deceased, request the death
certificate of the contingent and pay the proceeds to the estate or assignee.

	•	 	Request executor or administration papers if paying an estate or if someone designated
as the administrator is assigning the proceeds to a funeral home.

15

 

Benefit Payments Procedure Manual

Ordinary Life Claims

Diagnostic Codes

	 	 	 	 	 
	40

	 	AAV
	 	AIDS
	61

	 	Abcess of lung
	 	Emphysema
	61

	 	Abcess of mediastinum
	 	Emphysema
	72

	 	Abcess of pancreas
	 	Other Digestive Diseases
	54

	 	Abdominal aneurysm
	 	Arteries, Arterioles, Capillaries
	69

	 	Abdominal angina
	 	Gastgro-enteritis, Colitis
	54

	 	Abdominal Aortic Aneurysm
	 	Arteries, Arterioles, Capillaries
	69

	 	Abdominal Fistulas
	 	Gastgro-enteritis, Colitis
	7

	 	Abdominal Infection
	 	Septicemia
	38

	 	Abetalipoproteinemia
	 	Nutritional, Metabolic & Immunity Disorders
	72

	 	Abscess of liver
	 	Other Digestive Diseases
	89

	 	Accident — Aircraft
	 	Aircraft Accidents
	96

	 	Accident — Animal being ridden
	 	Accident — Other
	96

	 	Accident — Animal bite
	 	Accident — Other
	96

	 	Accident — Animal Drawn Vehicle
	 	Accident — Other
	96

	 	Accident — Bicycle
	 	Accident — Other
	96

	 	Accident — Boating
	 	Accident — Other
	93

	 	Accident — Burns
	 	Accidental Fires
	88

	 	Accident — Car vs. Pedestrian
	 	Motor Vehicle Accidents
	88

	 	Accident — Car vs. Train
	 	Motor Vehicle Accidents
	96

	 	Accident — Choking
	 	Accident — Other
	93

	 	Accident — Combustible Material
	 	Accidental Fires
	93

	 	Accident — Corrosive Liquid
	 	Accidental Fires
	95

	 	Accident — Drowning
	 	Accidental Drowning
	90

	 	Accident — Drug Poisoning
	 	Accidental Poisoning
	91

	 	Accident — Fall
	 	Accidental Falls
	93

	 	Accident — Fire
	 	Accidental Fires
	94

	 	Accident — Firearms
	 	Accident — Firearms
	96

	 	Accident — Freezing
	 	Accident — Other
	94

	 	Accident — Guns
	 	Accident — Firearms
	93

	 	Accident — Hot Liquid
	 	Accidental Fires
	93

	 	Accident — House Fire
	 	Accidental Fires
	96

	 	Accident — Involving machinery
	 	Accident — Other
	88

	 	Accident — Motor Vehicle
	 	Motor Vehicle Accidents
	88

	 	Accident — Motor Vehicle Collision
	 	Motor Vehicle Accidents
	88

	 	Accident — Motorcycle
	 	Motor Vehicle Accidents
	96

	 	Accident — Other
	 	Accident — Other
	90

	 	Accident — Poisoning
	 	Accidental Poisoning
	93

	 	Accident — Radiation
	 	Accidental Fires
	96

	 	Accident — Railway
	 	Accident — Other
	96

	 	Accident — Self-inflicted not intentional
	 	Accident — Other
	93

	 	Accident — Steam
	 	Accidental Fires
	95

	 	Accident — Submersion
	 	Accidental Drowning
	96

	 	Accident — Sunstroke
	 	Accident — Other
	96

	 	Accident — Surgical & Medical Procedure
	 	Accident — Other
	96

	 	Accident — Therapeutic misadventure
	 	Accident — Other
	96

	 	Accident — Tree-cutting
	 	Accident — Other
	96

	 	Accident — Venomous bite
	 	Accident — Other
	95

	 	Accidental Drowning
	 	Accidental Drowning
	90

	 	Accidental Poisoning
	 	Accidental Poisoning
	37

	 	Achard-Thiers syndrome
	 	Diabetes Mellitus — Endocrine Disorders
	72

	 	Achlorhydria
	 	Other Digestive Diseases
	38

	 	Acidosis
	 	Nutritional, Metabolic & Immunity Disorders
	40

	 	Acquired Immune Deficiency Syndrome
	 	AIDS
	81

	 	Acrosclerosis
	 	Other Skin & Musculoskeletal Diseases

16

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	17

	 	Actimonycotic infection
	 	Other Infective or Parasitic Diseases
	3

	 	Adbominal Aortic Aneurysm due to Syphilis
	 	Syphilis
	76

	 	Adenofibromatous hypertrophy of prostate
	 	Hyperplasia of Prostate
	76

	 	Adenoma of prostate (benign)
	 	Hyperplasia of Prostate
	35

	 	Adenomatous goiter
	 	Goiter
	52

	 	Adherent pericardium
	 	Other Heart Disease
	52

	 	Adhesive pericarditis
	 	Other Heart Disease
	31

	 	Adrenal Gland Cancer
	 	Cancer — Other
	37

	 	Adrenal gland disorders
	 	Diabetes Mellitus — Endocrine Disorders
	37

	 	Adrenal Infarction
	 	Diabetes Mellitus — Endocrine Disorders
	37

	 	Adrenogenital disorders
	 	Diabetes Mellitus — Endocrine Disorders
	63

	 	Adult respiratory distress syndrome
	 	Other Respiratory
	67

	 	Adynamic ileus
	 	Intestinal Obstruction, Hernia
	41

	 	Affective Disorders
	 	Mental, Drugs, Alcohol
	38

	 	Agammaglobulinemia
	 	Nutritional, Metabolic & Immunity Disorders
	40

	 	AIDS
	 	AIDS
	40

	 	AIDS-related complex
	 	AIDS
	89

	 	Aircraft Accidents
	 	Aircraft Accidents
	38

	 	Alaninemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Albinism
	 	Nutritional, Metabolic & Immunity Disorders
	52

	 	Alcoholic cardiomyopathy
	 	Other Heart Disease
	70

	 	Alcoholic Cirrhosis of Liver
	 	Cirrhosis of Liver
	41

	 	Alcoholic dementia
	 	Mental, Drugs, Alcohol
	70

	 	Alcoholic Fatty Liver
	 	Cirrhosis of Liver
	68

	 	Alcoholic gastritis
	 	Gastritis, Duodenitis
	70

	 	Alcoholic Hepatitis of Liver
	 	Cirrhosis of Liver
	70

	 	Alcoholic Liver Damage
	 	Cirrhosis of Liver
	41

	 	Alcoholic psychoses
	 	Mental, Drugs, Alcohol
	41

	 	Alcoholic Withdrawal
	 	Mental, Drugs, Alcohol
	41

	 	Alcoholism
	 	Mental, Drugs, Alcohol
	37

	 	Aldosteronism
	 	Diabetes Mellitus — Endocrine Disorders
	32

	 	Aleukemic Leukemia
	 	Leukemia
	32

	 	Aleukemic myelosis
	 	Leukemia
	81

	 	Algoneurodystrophy
	 	Other Skin & Musculoskeletal Diseases
	38

	 	Alkalosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Alkaptonuria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Alkaptonuric ochronosis
	 	Nutritional, Metabolic & Immunity Disorders
	63

	 	Allergic alveolitis
	 	Other Respiratory
	63

	 	Allergic rhinitis
	 	Other Respiratory
	47

	 	Alper’s disease
	 	Other Nervous System
	38

	 	Alpha 1-antitrypsin deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Alpha-lipoproteinemia
	 	Nutritional, Metabolic & Immunity Disorders
	63

	 	Alveolar capillary block
	 	Other Respiratory
	86

	 	Alzheimer’s Disease
	 	Alzheimer’s Disease
	86

	 	Alzheimer’s Type Dementia
	 	Alzheimer’s Disease
	5

	 	Amebiasis
	 	Intestinal Infections — Other
	5

	 	Amebic dysentery
	 	Intestinal Infections — Other
	5

	 	Amebic nondysenteric colitis
	 	Intestinal Infections — Other
	78

	 	Amnion Infarction
	 	Complications of Pregnancy
	82

	 	Amyelencephalus
	 	Congenital Anomalies
	38

	 	Amyloidosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Amylopectinosis
	 	Nutritional, Metabolic & Immunity Disorders
	47

	 	Amyotrophic lateral sclerosis
	 	Other Nervous System
	72

	 	Anal abscess
	 	Other Digestive Diseases
	72

	 	Anal fissure
	 	Other Digestive Diseases
	72

	 	Anal fistula
	 	Other Digestive Diseases
	38

	 	Anderson’s lipidoses
	 	Nutritional, Metabolic & Immunity Disorders

17

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	39

	 	Anemia
	 	Anemia, Thalassemia
	82

	 	Anencephalus
	 	Congenital Anomalies
	3

	 	Aneurysm of Abdominal Aorta due to Syphilis
	 	Syphilis
	54

	 	Aneurysm of aorta
	 	Arteries, Arterioles, Capillaries
	50

	 	Aneurysm of coronary vessels
	 	Ischemic & Coronary Heart Disease
	50

	 	Aneurysm of heart
	 	Ischemic & Coronary Heart Disease
	54

	 	Aneurysm of iliac artery
	 	Arteries, Arterioles, Capillaries
	54

	 	Aneurysm of other artery
	 	Arteries, Arterioles, Capillaries
	52

	 	Aneurysm of pulmonary artery
	 	Other Heart Disease
	54

	 	Aneurysm of renal artery
	 	Arteries, Arterioles, Capillaries
	54

	 	Aneurysmal varix
	 	Arteries, Arterioles, Capillaries
	50

	 	Angina
	 	Ischemic & Coronary Heart Disease
	50

	 	Angina decubitus
	 	Ischemic & Coronary Heart Disease
	50

	 	Angina pectoris
	 	Ischemic & Coronary Heart Disease
	71

	 	Angiocholecystitis
	 	Cholelithiasis, Cholecystitis
	38

	 	Angioedema — hereditary
	 	Nutritional, Metabolic & Immunity Disorders
	41

	 	Anorexia
	 	Mental, Drugs, Alcohol
	47

	 	Anoxic Brain Damage
	 	Other Nervous System
	47

	 	Anoxic Brain Injury
	 	Other Nervous System
	47

	 	Anterior horn cell disease
	 	Other Nervous System
	17

	 	Anthrax
	 	Other Infective or Parasitic Diseases
	22

	 	Anus Cancer
	 	Cancer — Rectum, Recto Sigmoid
	54

	 	Aorta-Saddle Embolus
	 	Arteries, Arterioles, Capillaries
	54

	 	Aortic aneurysm
	 	Arteries, Arterioles, Capillaries
	54

	 	Aortic arch arteritis
	 	Arteries, Arterioles, Capillaries
	54

	 	Aortic atherosclerosis
	 	Arteries, Arterioles, Capillaries
	54

	 	Aortic bifurcation syndrome
	 	Arteries, Arterioles, Capillaries
	54

	 	Aortic dissection
	 	Arteries, Arterioles, Capillaries
	50

	 	Aortic insufficiency
	 	Ischemic & Coronary Heart Disease
	50

	 	Aortic stenosis
	 	Ischemic & Coronary Heart Disease
	50

	 	Aortic valve disease
	 	Ischemic & Coronary Heart Disease
	50

	 	Aortic valve insufficiency
	 	Ischemic & Coronary Heart Disease
	50

	 	Aortic valve regurgitation
	 	Ischemic & Coronary Heart Disease
	50

	 	Aortic valve stenosis
	 	Ischemic & Coronary Heart Disease
	54

	 	Aortitis
	 	Arteries, Arterioles, Capillaries
	54

	 	Aortoiliac obstruction
	 	Arteries, Arterioles, Capillaries
	39

	 	Aplastic anemia
	 	Anemia, Thalassemia
	53

	 	Apoplectic attack
	 	Cerebrovascular Diseases
	53

	 	Apoplectic seizure
	 	Cerebrovascular Diseases
	53

	 	Apoplexy
	 	Cerebrovascular Diseases
	66

	 	Appendicitis
	 	Appendicitis
	66

	 	Appendix — other diseases
	 	Appendicitis
	21

	 	Appendix Cancer
	 	Cancer — Colon, Cecum, Sigmoid
	40

	 	ARC
	 	AIDS
	40

	 	ARDs
	 	AIDS
	38

	 	Argininosuccinic aciduria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Ariboflavinosis
	 	Nutritional, Metabolic & Immunity Disorders
	82

	 	Arnold-chiari syndrome w hydrocephalus
	 	Congenital Anomalies
	52

	 	Arrhythmia
	 	Other Heart Disease
	54

	 	Arterial degeneration
	 	Arteries, Arterioles, Capillaries
	54

	 	Arterial embolism
	 	Arteries, Arterioles, Capillaries
	54

	 	Arterial embolism
	 	Arteries, Arterioles, Capillaries
	54

	 	Arterial infarction
	 	Arteries, Arterioles, Capillaries
	54

	 	Arterial occlusive disease
	 	Arteries, Arterioles, Capillaries
	54

	 	Arterial thrombosis
	 	Arteries, Arterioles, Capillaries
	54

	 	Arterial thrombosis
	 	Arteries, Arterioles, Capillaries
	51

	 	Arteriolar nephritis
	 	Hypertensive Disease

18

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	52

	 	Arteriorsclerotic cardiovascular disease
	 	Arteries, Arterioles, Capillaries
	51

	 	Arteriosclerosis
	 	Hypertensive Disease
	51

	 	Arteriosclerosis of kidney
	 	Hypertensive Disease
	51

	 	Arteriosclerosis of renal arterioles
	 	Hypertensive Disease
	50

	 	Arteriosclerotic Cardiovascular Disease
	 	Ischemic & Coronary Heart Disease
	50

	 	Arteriosclerotic heart disease
	 	Ischemic & Coronary Heart Disease
	51

	 	Arteriosclerotic nephritis
	 	Hypertensive Disease
	54

	 	Arteriosclerotic vascular disease
	 	Arteries, Arterioles, Capillaries
	54

	 	Arteriosclerotic vascular disease
	 	Arteries, Arterioles, Capillaries
	54

	 	Arteriovascular degeneration
	 	Arteries, Arterioles, Capillaries
	54

	 	Arteriovenous aneurysm
	 	Arteries, Arterioles, Capillaries
	54

	 	Arteriovenous fistula
	 	Arteries, Arterioles, Capillaries
	54

	 	Arteritis
	 	Arteries, Arterioles, Capillaries
	52

	 	Arterosclerotic cardiovascular disease
	 	Other Heart Disease
	52

	 	Arterovenous fistula of pulmonary vessels
	 	Other Heart Disease
	17

	 	Arthropod-borne hemorrhagic fever
	 	Other Infective or Parasitic Diseases
	40

	 	ARV
	 	AIDS
	63

	 	Asbestosis
	 	Other Respiratory
	38

	 	Ascorbic aciden deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	52

	 	ASCVD
	 	Other Heart Disease
	50

	 	ASHD
	 	Ischemic & Coronary Heart Disease
	57

	 	Aspiration Bronchopneumonia
	 	Pneumonia
	57

	 	Aspriation Pneumonia
	 	Pneumonia
	98

	 	Assault
	 	Homicide
	63

	 	Asthma
	 	Other Respiratory
	63

	 	Asthmatic bronchitis
	 	Other Respiratory
	63

	 	Atelectasis
	 	Other Respiratory
	54

	 	Atheroma
	 	Arteries, Arterioles, Capillaries
	50

	 	Atherosclerosis
	 	Ischemic & Coronary Heart Disease
	50

	 	Atherosclerotic Cardiovascular Disease
	 	Ischemic & Coronary Heart Disease
	50

	 	Atherosclerotic Heart Disease
	 	Ischemic & Coronary Heart Disease
	50

	 	Atherosclerotic Vascular Disease
	 	Ischemic & Coronary Heart Disease
	47

	 	Athetoid cerebral palsy
	 	Other Nervous System
	77

	 	Atony of bladder
	 	Other Genito-Urinary
	72

	 	Atony of colon
	 	Other Digestive Diseases
	52

	 	Atrial fibrillation
	 	Other Heart Disease
	52

	 	Atrial flutter
	 	Other Heart Disease
	52

	 	Atrioventricular block
	 	Other Heart Disease
	52

	 	Atrioventricular dissociation
	 	Other Heart Disease
	52

	 	Atrioventricular excitation
	 	Other Heart Disease
	82

	 	Atrioventricular malformation
	 	Congenital Anomalies
	50

	 	Atrium infarction
	 	Ischemic & Coronary Heart Disease
	68

	 	Atrophic gastritis
	 	Gastritis, Duodenitis
	77

	 	Atrophy of Prostate
	 	Other Genito-Urinary
	31

	 	Auditory Tube Cancer
	 	Cancer — Other
	41

	 	Autism
	 	Mental, Drugs, Alcohol
	38

	 	Autoimmune disease
	 	Nutritional, Metabolic & Immunity Disorders
	88

	 	Automobile Accident
	 	Motor Vehicle Accidents
	102

	 	Autopsy Pending
	 	Autopsy Pending
	82

	 	Autosomal deleterion syndromes
	 	Congenital Anomalies
	82

	 	AV Malformation
	 	Congenital Anomalies
	38

	 	Avitaminosis
	 	Nutritional, Metabolic & Immunity Disorders
	73

	 	Azotemia
	 	Nephritis, Renal Scleroris
	73

	 	Azotemic osteodystrophy
	 	Nephritis, Renal Scleroris
	5

	 	Bacillary dysentery
	 	Intestinal Infections — Other
	52

	 	Bacterial endocarditis
	 	Other Heart Disease
	5

	 	Bacterial enteritis
	 	Intestinal Infections — Other

19

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	5

	 	Bacterial Food Poisoning
	 	Intestinal Infections — Other
	43

	 	Bacterial meningitis
	 	Meningitis
	57

	 	Bacterial pneumonia
	 	Pneumonia
	77

	 	Bacterimia
	 	Other Genito-Urinary
	77

	 	Bacteriuria
	 	Other Genito-Urinary
	63

	 	Bagassosis
	 	Other Respiratory
	77

	 	Balanitis
	 	Other Genito-Urinary
	77

	 	Balanoposthitis
	 	Other Genito-Urinary
	5

	 	Balantidiasis
	 	Intestinal Infections — Other
	47

	 	Balo’s concentric sclerosis
	 	Other Nervous System
	81

	 	Bamberger-Marie disease
	 	Other Skin & Musculoskeletal Diseases
	38

	 	Barraquer-Simons disease
	 	Nutritional, Metabolic & Immunity Disorders
	37

	 	Bartter’s syndrome
	 	Diabetes Mellitus — Endocrine Disorders
	53

	 	Basal Ganglia Stroke
	 	Cerebrovascular Diseases
	36

	 	Basedow’s disease
	 	Thyrotoxicosis
	53

	 	Basilar artery hemorrhage
	 	Cerebrovascular Diseases
	55

	 	Basilar Artery Ischemia
	 	Veins, Other Circulatory
	53

	 	Basilar artery syndrome
	 	Cerebrovascular Diseases
	38

	 	Bassen-Kornzweign syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	47

	 	Batten Disease
	 	Other Nervous System
	17

	 	Battey Disease
	 	Other Infective or Parasitic Diseases
	2

	 	Bazin’s Disease
	 	Tuberculosis — Nonrespiratory
	51

	 	Benign hypertension
	 	Hypertensive Disease
	47

	 	Benign intracranial hypertension
	 	Other Nervous System
	34

	 	Benign Neoplasms
	 	Benign Neoplasms
	38

	 	Benign paroxysmal peritonitis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Beriberi
	 	Nutritional, Metabolic & Immunity Disorders
	62

	 	Bilateral pleural effusion
	 	Pleurisy
	57

	 	Bilateral Pneumonia
	 	Pneumonia
	31

	 	Bile Duct Cancer
	 	Cancer — Other
	71

	 	Bile Duct Obstruction
	 	Cholelithiasis, Cholecystitis
	70

	 	Biliary cirrhosis
	 	Cirrhosis of Liver
	71

	 	Biliary dyskinesia
	 	Cholelithiasis, Cholecystitis
	83

	 	Birth Injuries
	 	Birth Injuries
	38

	 	Bisalbuminemia
	 	Nutritional, Metabolic & Immunity Disorders
	63

	 	Black lung disease
	 	Other Respiratory
	16

	 	Blackwater Fever
	 	Malaria
	31

	 	Bladder Cancer
	 	Cancer — Other
	77

	 	Bladder fistula
	 	Other Genito-Urinary
	77

	 	Bladder hemorrhage
	 	Other Genito-Urinary
	77

	 	Bladder obstruction
	 	Other Genito-Urinary
	32

	 	Blast Cell Leukemia
	 	Leukemia
	17

	 	Blastomycotic infection
	 	Other Infective or Parasitic Diseases
	72

	 	Blind loop syndrome
	 	Other Digestive Diseases
	30

	 	Bone Cancer
	 	Cancer — Bone, Cartilage
	80

	 	Bone infections
	 	Osteomyelitis, periostitis
	81

	 	Bone Ischemia
	 	Other Skin & Musculoskeletal Diseases
	9

	 	Bordetella pertussis
	 	Whooping Cough
	5

	 	Botulism
	 	Intestinal Infections — Other
	82

	 	Bourneville’s disease
	 	Congenital Anomalies
	69

	 	Bowel Infarction
	 	Gastgro-enteritis, Colitis
	69

	 	Bowel Ischemia
	 	Gastgro-enteritis, Colitis
	52

	 	Brady Tachy Syndrome
	 	Other Heart Disease
	52

	 	Bradycardia-tachycardia syndrome
	 	Other Heart Disease
	31

	 	Brain Cancer
	 	Cancer — Other
	53

	 	Brain Embolism
	 	Cerebrovascular Diseases
	53

	 	Brain Ischemia
	 	Cerebrovascular Diseases

20

 

 
Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	31

	 	Brain Tumor
	 	Cancer — Other
	53

	 	Brainstem Infarction
	 	Cerebrovascular Diseases
	25

	 	Breast Cancer
	 	Cancer — Breast
	77

	 	Breast Infarction
	 	Other Genito-Urinary
	77

	 	Brewer’s Infarction
	 	Other Genito-Urinary
	15

	 	Brill’s disease
	 	Typhus and Ricketsiosis
	33

	 	Brill-Symmers disease
	 	Lymphosarcoma, Etc
	15

	 	Brill-Zinsser disease
	 	Typhus and Ricketsiosis
	80

	 	Brodie’s abscess
	 	Osteomyelitis, periostitis
	81

	 	Broken bone
	 	Other Skin & Musculoskeletal Diseases
	1

	 	Bronchial Tuberculosis
	 	Tuberculosis — Respiratory System
	63

	 	Bronchiectasis
	 	Other Respiratory
	60

	 	Bronchiolitis
	 	Bronchitis
	60

	 	Bronchitis
	 	Bronchitis
	61

	 	Bronchocutaneous fistula
	 	Emphysema
	63

	 	Broncholithiasis
	 	Other Respiratory
	61

	 	Bronchopleural fistula
	 	Emphysema
	57

	 	Bronchopneumonia
	 	Pneumonia
	38

	 	Bronzed diabetes
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Brucellosis
	 	Other Infective or Parasitic Diseases
	38

	 	Bruton’s type agammaglobulinemia
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Bubonic Plague
	 	Other Infective or Parasitic Diseases
	55

	 	Budd-Chiari syndrome
	 	Veins, Other Circulatory
	54

	 	Buerger’s disease
	 	Arteries, Arterioles, Capillaries
	81

	 	Bullous dermatoses
	 	Other Skin & Musculoskeletal Diseases
	38

	 	Burger-Grutz syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	33

	 	Burkitt’s tumor
	 	Lymphosarcoma, Etc
	17

	 	Buruli ulcer
	 	Other Infective or Parasitic Diseases
	39

	 	Cachexia
	 	Anemia, Thalassemia
	50

	 	CAD
	 	Ischemic & Coronary Heart Disease
	63

	 	Calcification of Lung
	 	Other Respiratory
	52

	 	Calcification of pericardium
	 	Other Heart Disease
	62

	 	Calcification of pleura
	 	Pleurisy
	38

	 	Calcinosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Calcium deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	75

	 	Calculous pyelonephritis
	 	Urinary System Infections
	75

	 	Calculus in diverticulum of bladder
	 	Urinary System Infections
	75

	 	Calculus in urethra
	 	Urinary System Infections
	75

	 	Calculus of kidney
	 	Urinary System Infections
	75

	 	Calculus of ureter
	 	Urinary System Infections
	38

	 	Calorie deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	31

	 	Cancer — Adrenal Gland
	 	Cancer — Other
	22

	 	Cancer — Anus
	 	Cancer — Rectum, Recto Sigmoid
	21

	 	Cancer — Appendix
	 	Cancer — Colon, Cecum, Sigmoid
	31

	 	Cancer — Auditory Tube
	 	Cancer — Other
	31

	 	Cancer — Bile Duct
	 	Cancer — Other
	31

	 	Cancer — Bladder
	 	Cancer — Other
	30

	 	Cancer — bone
	 	Cancer — Bone, Cartilage
	31

	 	Cancer — Brain
	 	Cancer — Other
	25

	 	Cancer — Breast
	 	Cancer — Breast
	31

	 	Cancer — Carotid Body
	 	Cancer — Other
	21

	 	Cancer — Cecum
	 	Cancer — Colon, Cecum, Sigmoid
	26

	 	Cancer — Cervix
	 	Cancer — Cervix Uteri
	26

	 	Cancer — Cervix uteri
	 	Cancer — Cervix Uteri
	21

	 	Cancer — Colon
	 	Cancer — Colon, Cecum, Sigmoid
	21

	 	Cancer — Colorectal
	 	Cancer — Colon, Cecum, Sigmoid
	31

	 	Cancer — Corneal
	 	Cancer — Other

21

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	21

	 	Cancer — Duodenum
	 	Cancer — Colon, Cecum, Sigmoid
	26

	 	Cancer — Endocervix
	 	Cancer — Cervix Uteri
	27

	 	Cancer — endometrium
	 	Cancer — Other Uterine
	18

	 	Cancer — Epiglottis
	 	Cancer — Mouth, Throat, Pharynx
	19

	 	Cancer — Esophagus
	 	Cancer — Esophagus
	26

	 	Cancer — Exocervix
	 	Cancer — Cervix Uteri
	31

	 	Cancer — Eye
	 	Cancer — Other
	31

	 	Cancer — Fallopian Tube
	 	Cancer — Other
	31

	 	Cancer — Gallbladder
	 	Cancer — Other
	20

	 	Cancer — Gastric
	 	Cancer — Stomach
	23

	 	Cancer — Glottix
	 	Cancer — Larynx
	18

	 	Cancer — Gums
	 	Cancer — Mouth, Throat, Pharynx
	24

	 	Cancer — Heart
	 	Cancer — Lung, Trachea
	18

	 	Cancer — Hypopharynx
	 	Cancer — Mouth, Throat, Pharynx
	31

	 	Cancer — Intestinal Tract
	 	Cancer — Other
	31

	 	Cancer — Kidney
	 	Cancer — Other
	23

	 	Cancer — Larynx
	 	Cancer — Larynx
	18

	 	Cancer — Lips
	 	Cancer — Mouth, Throat, Pharynx
	31

	 	Cancer — Liver
	 	Cancer — Other
	24

	 	Cancer — Lung
	 	Cancer — Lung, Trachea
	30

	 	Cancer — Mandible
	 	Cancer — Bone, Cartilage
	18

	 	Cancer — Mouth
	 	Cancer — Mouth, Throat, Pharynx
	31

	 	Cancer — Nasal Cavity
	 	Cancer — Other
	18

	 	Cancer — Nasopharynx
	 	Cancer — Mouth, Throat, Pharynx
	18

	 	Cancer — oropharynx
	 	Cancer — Mouth, Throat, Pharynx
	31

	 	Cancer — Ovary
	 	Cancer — Other
	31

	 	Cancer — Pancreas
	 	Cancer — Other
	31

	 	Cancer — Parametrium
	 	Cancer — Other
	31

	 	Cancer — parathyroid
	 	Cancer — Other
	31

	 	Cancer — Peritoneum
	 	Cancer — Other
	18

	 	Cancer — Pharynx
	 	Cancer — Mouth, Throat, Pharynx
	31

	 	Cancer — Pineal Gland
	 	Cancer — Other
	27

	 	Cancer — Placenta
	 	Cancer — Other Uterine
	24

	 	Cancer — Pleura
	 	Cancer — Lung, Trachea
	28

	 	Cancer — Prostate
	 	Cancer — Prostate
	20

	 	Cancer — Pylorus
	 	Cancer — Stomach
	22

	 	Cancer — Recto sigmoid
	 	Cancer — Rectum, Recto Sigmoid
	22

	 	Cancer — Rectum
	 	Cancer — Rectum, Recto Sigmoid
	31

	 	Cancer — Renal Cell
	 	Cancer — Other
	31

	 	Cancer — Retroperitoneum
	 	Cancer — Other
	18

	 	Cancer — Salivary Gland
	 	Cancer — Mouth, Throat, Pharynx
	29

	 	Cancer — Skin
	 	Cancer — Skin, Melanoma
	21

	 	Cancer — Small Intestine
	 	Cancer — Colon, Cecum, Sigmoid
	31

	 	Cancer — Spleen
	 	Cancer — Other
	20

	 	Cancer — Stomach
	 	Cancer — Stomach
	23

	 	Cancer — Subglottis
	 	Cancer — Larynx
	23

	 	Cancer — Supraglottis
	 	Cancer — Larynx
	31

	 	Cancer — Testicular
	 	Cancer — Other
	31

	 	Cancer — Testis
	 	Cancer — Other
	24

	 	Cancer — Thymus
	 	Cancer — Lung, Trachea
	18

	 	Cancer — Tongue
	 	Cancer — Mouth, Throat, Pharynx
	18

	 	Cancer — Tongue
	 	Cancer — Mouth, Throat, Pharynx
	18

	 	Cancer — Tonsil
	 	Cancer — Mouth, Throat, Pharynx
	24

	 	Cancer — Trachea
	 	Cancer — Lung, Trachea
	31

	 	Cancer — Unknown Origin
	 	Cancer — Other
	24

	 	Cancer — Upper Respiratory
	 	Cancer — Lung, Trachea
	31

	 	Cancer — Ureter
	 	Cancer — Other

22

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	31

	 	Cancer — Urethra
	 	Cancer — Other
	27

	 	Cancer — Uterine
	 	Cancer — Other Uterine
	31

	 	Cancer — Vaginal
	 	Cancer — Other
	30

	 	Cancer — Vertebral
	 	Cancer — Bone, Cartilage
	31

	 	Cancer — Vocal Cords
	 	Cancer — Other
	31

	 	Cancer — Vulva
	 	Cancer — Other
	31

	 	Cancer of unknown origin
	 	Cancer — Other
	17

	 	Candidiasis
	 	Other Infective or Parasitic Diseases
	54

	 	Capillary disease
	 	Arteries, Arterioles, Capillaries
	54

	 	Capillary Embolism
	 	Arteries, Arterioles, Capillaries
	54

	 	Capillary hemorrhage
	 	Arteries, Arterioles, Capillaries
	54

	 	Capillary hyperpermeability
	 	Arteries, Arterioles, Capillaries
	60

	 	Capillary pneumonia
	 	Bronchitis
	54

	 	Capillary thrombosis
	 	Arteries, Arterioles, Capillaries
	81

	 	Caplan’s syndrome
	 	Other Skin & Musculoskeletal Diseases
	31

	 	Carcinomatosis
	 	Cancer — Other
	38

	 	Cardiac amyloidosis — Hereditary
	 	Nutritional, Metabolic & Immunity Disorders
	52

	 	Cardiac arrest
	 	Other Heart Disease
	52

	 	Cardiac arrhythmia
	 	Other Heart Disease
	52

	 	Cardiac asthma
	 	Other Heart Disease
	52

	 	Cardiac dilatation
	 	Other Heart Disease
	52

	 	Cardiac dysrhythmia
	 	Other Heart Disease
	50

	 	Cardiac Embolism
	 	Ischemic & Coronary Heart Disease
	52

	 	Cardiac failure
	 	Other Heart Disease
	52

	 	Cardiac hypertrophy
	 	Other Heart Disease
	50

	 	Cardiac Infarcation
	 	Ischemic & Coronary Heart Disease
	50

	 	Cardiac Ischemia
	 	Ischemic & Coronary Heart Disease
	52

	 	Cardiac sarcoidosis
	 	Other Heart Disease
	52

	 	Cardiac tamponade
	 	Other Heart Disease
	87

	 	Cardiogenic shock
	 	Unknown Causes & Ill-Defined Causes
	52

	 	Cardiomegaly
	 	Other Heart Disease
	52

	 	Cardiomyopathy
	 	Other Heart Disease
	52

	 	Cardiopulmonary collapse
	 	Other Heart Disease
	52

	 	Cardiopulmonary disease
	 	Other Heart Disease
	51

	 	Cardiorenal disease
	 	Hypertensive Disease
	52

	 	Cardiorespiratory arrest
	 	Other Heart Disease
	87

	 	Cardiorespiratory collapse
	 	Unknown Causes & Ill-Defined Causes
	52

	 	Cardiovascular Accident
	 	Other Heart Disease
	52

	 	Cardiovascular collagenosis
	 	Other Heart Disease
	87

	 	Cardiovascular collapse
	 	Unknown Causes & Ill-Defined Causes
	52

	 	Cardiovascular disease
	 	Other Heart Disease
	51

	 	Cardiovascular renal disease
	 	Hypertensive Disease
	51

	 	Cardiovascular renal disorder
	 	Hypertensive Disease
	52

	 	Cardiovascular sclerosis
	 	Other Heart Disease
	3

	 	Cardiovascular syphilis
	 	Syphilis
	52

	 	Carditis
	 	Other Heart Disease
	38

	 	Carnosinemia
	 	Nutritional, Metabolic & Immunity Disorders
	53

	 	Carotid Artery Ischemia
	 	Cerebrovascular Diseases
	31

	 	Carotid body Cancer
	 	Cancer — Other
	60

	 	Catarrhal bronchitis
	 	Bronchitis
	101

	 	Cause Not Listed on Certificate
	 	Incomplete Death Certificate
	21

	 	Cecum Cancer
	 	Cancer — Colon, Cecum, Sigmoid
	54

	 	Celiac artery compression syndrome
	 	Arteries, Arterioles, Capillaries
	54

	 	Celiac axis syndrome
	 	Arteries, Arterioles, Capillaries
	72

	 	Celiac disease
	 	Other Digestive Diseases
	79

	 	Cellulitis
	 	Skin Infections
	47

	 	Central pontine myelinosis
	 	Other Nervous System

23

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	47

	 	Cerebellar ataxia
	 	Other Nervous System
	53

	 	Cerebral aneurysm
	 	Cerebrovascular Diseases
	47

	 	Cerebral anoxia
	 	Other Nervous System
	53

	 	Cerebral arteritis
	 	Cerebrovascular Diseases
	53

	 	Cerebral artery occlusion
	 	Cerebrovascular Diseases
	53

	 	Cerebral atherosclerosis
	 	Cerebrovascular Diseases
	47

	 	Cerebral edema
	 	Other Nervous System
	53

	 	Cerebral embolism
	 	Cerebrovascular Diseases
	31

	 	Cerebral Glioblastoma
	 	Cancer — Other
	53

	 	Cerebral infarction
	 	Cerebrovascular Diseases
	53

	 	Cerebral ischemia
	 	Cerebrovascular Diseases
	47

	 	Cerebral lipidoses
	 	Other Nervous System
	47

	 	Cerebral Palsy
	 	Other Nervous System
	53

	 	Cerebral seizure
	 	Cerebrovascular Diseases
	53

	 	Cerebral thrombosis
	 	Cerebrovascular Diseases
	47

	 	Cerebrospinal fluid rhinorrhea
	 	Other Nervous System
	53

	 	Cerebrovascular Accident
	 	Cerebrovascular Diseases
	53

	 	Cerebrovascular Disease
	 	Cerebrovascular Diseases
	53

	 	Cerebrovascular insufficiency
	 	Cerebrovascular Diseases
	53

	 	Cerebrovascular Ischemia
	 	Cerebrovascular Diseases
	53

	 	Cerebrovasuclar lesion
	 	Cerebrovascular Diseases
	26

	 	Cervical Cancer
	 	Cancer — Cervix Uteri
	26

	 	Cervix uteri Cancer
	 	Cancer — Cervix Uteri
	17

	 	Cestode infection
	 	Other Infective or Parasitic Diseases
	17

	 	Chagas’ disease
	 	Other Infective or Parasitic Diseases
	47

	 	Charcot-Marie-Tooth disease
	 	Other Nervous System
	52

	 	CHF
	 	Other Heart Disease
	17

	 	Chickenpox
	 	Other Infective or Parasitic Diseases
	98

	 	Child Abuse
	 	Homicide
	78

	 	Childbirth complications
	 	Complications of Pregnancy
	32

	 	Chloroma
	 	Leukemia
	72

	 	Cholangitis
	 	Other Digestive Diseases
	71

	 	Cholecystitis
	 	Cholelithiasis, Cholecystitis
	71

	 	Cholelithiasis
	 	Cholelithiasis, Cholecystitis
	5

	 	Cholera
	 	Intestinal Infections — Other
	71

	 	Cholesterolisis of gallbladder
	 	Cholelithiasis, Cholecystitis
	27

	 	Choriocarcinoma
	 	Cancer — Other Uterine
	63

	 	Chronic Lung Disease
	 	Other Respiratory
	43

	 	Chronic meningitis
	 	Meningitis
	63

	 	Chronic Obstructive Lung Disease
	 	Other Respiratory
	63

	 	Chronic Obstructive Pulmonary Disease
	 	Other Respiratory
	63

	 	Chronic Obstructive Pulmonary Failure
	 	Other Respiratory
	72

	 	Chronic passive congestion of liver
	 	Other Digestive Diseases
	63

	 	Chronic respiratory disease
	 	Other Respiratory
	70

	 	Chronic yellow atrophy
	 	Cirrhosis of Liver
	70

	 	Cirrhosis of Liver
	 	Cirrhosis of Liver
	72

	 	Cirrhosis of pancreas
	 	Other Digestive Diseases
	38

	 	Citrullinemia
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Clonochiasis
	 	Other Infective or Parasitic Diseases
	51

	 	Cocaine Hypertension
	 	Hypertensive Disease
	17

	 	Coccidioidomycosis
	 	Other Infective or Parasitic Diseases
	69

	 	Colitis
	 	Gastgro-enteritis, Colitis
	69

	 	Colitis of large intestine
	 	Gastgro-enteritis, Colitis
	81

	 	Collagen disease
	 	Other Skin & Musculoskeletal Diseases
	81

	 	Collagen disease (progressive)
	 	Other Skin & Musculoskeletal Diseases
	21

	 	Colon Cancer
	 	Cancer — Colon, Cecum, Sigmoid
	69

	 	Colon Infarction
	 	Gastgro-enteritis, Colitis

24

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	69

	 	Colon Ischemia
	 	Gastgro-enteritis, Colitis
	21

	 	Colorectal Cancer
	 	Cancer — Colon, Cecum, Sigmoid
	63

	 	Common cold
	 	Other Respiratory
	63

	 	Compensatory emphysema
	 	Other Respiratory
	78

	 	Complications of Pregnancy
	 	Complications of Pregnancy
	52

	 	Concato’s disease
	 	Other Heart Disease
	52

	 	Conduction disorder
	 	Other Heart Disease
	82

	 	Congenital Anomalies
	 	Congenital Anomalies
	82

	 	Congenital anomalies of repiratory system
	 	Congenital Anomalies
	82

	 	Congenital anomalies of veins, etc.
	 	Congenital Anomalies
	82

	 	Congenital cerebral cyst
	 	Congenital Anomalies
	82

	 	Congenital cystic lung
	 	Congenital Anomalies
	39

	 	Congenital folate malabsorption
	 	Anemia, Thalassemia
	82

	 	Congenital Heart disease
	 	Congenital Anomalies
	39

	 	Congenital hemolytic anemia
	 	Anemia, Thalassemia
	82

	 	Congenital hydrocephalus
	 	Congenital Anomalies
	82

	 	Congenital polycystic disease of liver
	 	Congenital Anomalies
	3

	 	Congenital Syphilis
	 	Syphilis
	82

	 	Congential honeycomb lung
	 	Congenital Anomalies
	52

	 	Congestive cardiomyopathy
	 	Other Heart Disease
	52

	 	Congestive heart disease
	 	Other Heart Disease
	52

	 	Congestive Heart Failure
	 	Other Heart Disease
	37

	 	Conn’s syndrome
	 	Diabetes Mellitus — Endocrine Disorders
	72

	 	Constipation
	 	Other Digestive Diseases
	52

	 	Constrictive cardiomyopathy
	 	Other Heart Disease
	52

	 	Constrictive pericarditis
	 	Other Heart Disease
	39

	 	Cooley’s Anemia
	 	Anemia, Thalassemia
	63

	 	COPD
	 	Other Respiratory
	52

	 	Cor Pulmonale
	 	Other Heart Disease
	31

	 	Corneal Cancer
	 	Cancer — Other
	50

	 	Coronary arteriosclerosis
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary arteritis
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary artery disease
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary artery embolism
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary Artery Infarction
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary artery occlusion
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary artery rupture
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary artery thrombosis
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary atheroma
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary atherosclerosis
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary insufficiency
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary Ischemia
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary occlusion
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary sclerosis
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary stricture
	 	Ischemic & Coronary Heart Disease
	50

	 	Coronary thrombosis
	 	Ischemic & Coronary Heart Disease
	103

	 	Coroner’s Inquiry
	 	Coroner’s Inquiry
	37

	 	Corticoadrenal insufficiency
	 	Diabetes Mellitus — Endocrine Disorders
	8

	 	Corynebacterium diphtheriae
	 	Diptheria
	17

	 	Cowpox
	 	Other Infective or Parasitic Diseases
	17

	 	Coxsackie virus
	 	Other Infective or Parasitic Diseases
	54

	 	Cranial arteritis
	 	Arteries, Arterioles, Capillaries
	82

	 	Craniorachischisis
	 	Congenital Anomalies
	87

	 	Crib death
	 	Unknown Causes & Ill-Defined Causes
	82

	 	Cri-du-chat syndrome
	 	Congenital Anomalies
	38

	 	Crigler-Najjar syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Crimean hemorrhagic fever
	 	Other Infective or Parasitic Diseases

25

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	69

	 	Crohn’s disease
	 	Gastgro-enteritis, Colitis
	63

	 	Croup
	 	Other Respiratory
	63

	 	Croup syndrome
	 	Other Respiratory
	60

	 	Croupous bronchitis
	 	Bronchitis
	82

	 	Crouzon’s disease
	 	Congenital Anomalies
	81

	 	CRST syndrome
	 	Other Skin & Musculoskeletal Diseases
	38

	 	Cryoglobulinemic purpura
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Cryoglobulinemic vasculitis
	 	Nutritional, Metabolic & Immunity Disorders
	43

	 	Cryptococcal meningitis
	 	Meningitis
	37

	 	Cushing’s syndrome
	 	Diabetes Mellitus — Endocrine Disorders
	53

	 	CVA
	 	Cerebrovascular Diseases
	53

	 	CVD
	 	Cerebrovascular Diseases
	38

	 	Cyanocobalamin deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Cystathioninemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Cystathioninuria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Cystic Fibrosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Cystinosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Cystinuria
	 	Nutritional, Metabolic & Immunity Disorders
	77

	 	Cystitis
	 	Other Genito-Urinary
	77

	 	Cystitis cystica
	 	Other Genito-Urinary
	17

	 	Darling’s disease
	 	Other Infective or Parasitic Diseases
	81

	 	Decubitis Ulcers
	 	Other Skin & Musculoskeletal Diseases
	55

	 	Deep vein thrombosis
	 	Veins, Other Circulatory
	52

	 	Degenerative heart disease
	 	Other Heart Disease
	38

	 	Dehydration
	 	Nutritional, Metabolic & Immunity Disorders
	47

	 	Dejerine-Thomas Syndrome
	 	Other Nervous System
	85

	 	Dementia
	 	Senility
	17

	 	Dengue
	 	Other Infective or Parasitic Diseases
	36

	 	deQuervain’s thyroiditis
	 	Thyrotoxicosis
	81

	 	Dermatitis
	 	Other Skin & Musculoskeletal Diseases
	81

	 	Dermatitis medicamentosa
	 	Other Skin & Musculoskeletal Diseases
	17

	 	Dermatophytosis
	 	Other Infective or Parasitic Diseases
	81

	 	Dermatosis herpetiformis
	 	Other Skin & Musculoskeletal Diseases
	32

	 	Di Guglielmo’s disease
	 	Leukemia
	37

	 	Diabetes
	 	Diabetes Mellitus — Endocrine Disorders
	37

	 	Diabetes Mellitus
	 	Diabetes Mellitus — Endocrine Disorders
	37

	 	Diabetic acidosis
	 	Diabetes Mellitus — Endocrine Disorders
	37

	 	Diabetic ketosis
	 	Diabetes Mellitus — Endocrine Disorders
	73

	 	Diabetic nephropathy
	 	Nephritis, Renal Scleroris
	37

	 	Diabets insipidus
	 	Diabetes Mellitus — Endocrine Disorders
	67

	 	Diaphragmatic hernia
	 	Intestinal Obstruction, Hernia
	63

	 	Diaphragmitis
	 	Other Respiratory
	69

	 	Diarheal Illness
	 	Gastgro-enteritis, Colitis
	82

	 	Diastematomyelia
	 	Congenital Anomalies
	38

	 	DiGeorge’s syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	54

	 	Dilatation of aorta
	 	Arteries, Arterioles, Capillaries
	72

	 	Dilatation of colon
	 	Other Digestive Diseases
	13

	 	Diphasic meningoencephalitis
	 	Encephalitis
	8

	 	Diptheria
	 	Diptheria
	54

	 	Disseminated necrotizing periarteritis
	 	Arteries, Arterioles, Capillaries
	69

	 	Diverticulitis of colon or small intestine
	 	Gastgro-enteritis, Colitis
	77

	 	Diverticulum of bladder
	 	Other Genito-Urinary
	72

	 	Diverticulum of esophagus
	 	Other Digestive Diseases
	82

	 	Down’s Syndrome
	 	Congenital Anomalies
	95

	 	Drowning — Accident
	 	Accidental Drowning
	41

	 	Drug Addiction
	 	Mental, Drugs, Alcohol
	41

	 	Drug psychoses
	 	Mental, Drugs, Alcohol

26

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	41

	 	Drug Withdrawals
	 	Mental, Drugs, Alcohol
	38

	 	Dubbin-Johnson syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	81

	 	Duhring’s disease
	 	Other Skin & Musculoskeletal Diseases
	17

	 	Dukes-Filatow disease
	 	Other Infective or Parasitic Diseases
	72

	 	Duodenal ileus
	 	Other Digestive Diseases
	72

	 	duodenal obstruction
	 	Other Digestive Diseases
	72

	 	Duodenal rupture
	 	Other Digestive Diseases
	65

	 	Duodenal Ulcer
	 	Duodenal Ulcer
	68

	 	Duodenitis
	 	Gastritis, Duodenitis
	21

	 	Duodenum Cancer
	 	Cancer — Colon, Cecum, Sigmoid
	38

	 	Dysgammaglobulinemia
	 	Nutritional, Metabolic & Immunity Disorders
	36

	 	Dyshormonogenic goit
	 	Thyrotoxicosis
	72

	 	Dyskinesia of esophagus
	 	Other Digestive Diseases
	72

	 	Dyspepsia
	 	Other Digestive Diseases
	87

	 	Dysphagia
	 	Unknown Causes & Ill-Defined Causes
	41

	 	Dysphagia — Functional
	 	Mental, Drugs, Alcohol
	41

	 	Dysphagia — Hysterical
	 	Mental, Drugs, Alcohol
	41

	 	Dysphagia — Nervous
	 	Mental, Drugs, Alcohol
	41

	 	Dysphagia — Psychogenic
	 	Mental, Drugs, Alcohol
	39

	 	Dysphagia — Sideropenic
	 	Anemia, Thalassemia
	72

	 	Dysphagia — Spastica
	 	Other Digestive Diseases
	37

	 	Dyspituitarism
	 	Diabetes Mellitus — Endocrine Disorders
	82

	 	Ebstein’s anomaly
	 	Congenital Anomalies
	17

	 	Echinococcosis
	 	Other Infective or Parasitic Diseases
	17

	 	ECHO virus
	 	Other Infective or Parasitic Diseases
	47

	 	Edema of spinal cord
	 	Other Nervous System
	82

	 	Edward’s syndrome
	 	Congenital Anomalies
	38

	 	Electrolyte imbalance
	 	Nutritional, Metabolic & Immunity Disorders
	55

	 	Elephantiasis
	 	Veins, Other Circulatory
	54

	 	Embolic infarction
	 	Arteries, Arterioles, Capillaries
	54

	 	Embolism
	 	Arteries, Arterioles, Capillaries
	54

	 	Embolism — Aorta
	 	Arteries, Arterioles, Capillaries
	54

	 	Embolism — Artery
	 	Arteries, Arterioles, Capillaries
	53

	 	Embolism — Basilar artery
	 	Cerebrovascular Diseases
	53

	 	Embolism — Brain
	 	Cerebrovascular Diseases
	54

	 	Embolism — Capillary
	 	Arteries, Arterioles, Capillaries
	50

	 	Embolism — Cardiac
	 	Ischemic & Coronary Heart Disease
	53

	 	Embolism — Carotid artery
	 	Cerebrovascular Diseases
	53

	 	Embolism — Cerebral
	 	Cerebrovascular Diseases
	69

	 	Embolism — Mesenteric
	 	Gastgro-enteritis, Colitis
	69

	 	Embolism — Mesenteric Artery
	 	Gastgro-enteritis, Colitis
	52

	 	Embolism — Pulmonary
	 	Other Heart Disease
	54

	 	Embolism — Thrombosis
	 	Arteries, Arterioles, Capillaries
	55

	 	Embolism — Vein
	 	Veins, Other Circulatory
	53

	 	Embolism — Vertebral Artery
	 	Cerebrovascular Diseases
	61

	 	Emphysema
	 	Emphysema
	77

	 	Emphysematous cystitis
	 	Other Genito-Urinary
	61

	 	Empyema
	 	Emphysema
	71

	 	Empyema of gallbladder
	 	Cholelithiasis, Cholecystitis
	13

	 	Encephalitis
	 	Encephalitis
	47

	 	Encephalitis
	 	Other Nervous System
	47

	 	Encephalitis periaxialis
	 	Other Nervous System
	82

	 	Encephalocele
	 	Congenital Anomalies
	53

	 	Encephalomalacia
	 	Cerebrovascular Diseases
	47

	 	Encephalomyelitis
	 	Other Nervous System
	47

	 	Encephalopathy
	 	Other Nervous System
	72

	 	Encephalopathy — hepatic
	 	Other Digestive Diseases

27

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	56

	 	Encephalopathy due to influenza
	 	Influenza
	77

	 	Encysted hydrocele
	 	Other Genito-Urinary
	77

	 	End Stage Renal Disease
	 	Other Genito-Urinary
	54

	 	Endarteritis
	 	Arteries, Arterioles, Capillaries
	54

	 	Endarteritis deformans
	 	Arteries, Arterioles, Capillaries
	54

	 	Endarteritis obliterans
	 	Arteries, Arterioles, Capillaries
	52

	 	Endocarditis
	 	Other Heart Disease
	26

	 	Endocervix Cancer
	 	Cancer — Cervix Uteri
	63

	 	Endogenous lipoid pneumonia
	 	Other Respiratory
	27

	 	Endometrium Cancer
	 	Cancer — Other Uterine
	52

	 	Endomyocardial fibrosis
	 	Other Heart Disease
	55

	 	Endophlebitis
	 	Veins, Other Circulatory
	87

	 	Endotoxic Shock
	 	Unknown Causes & Ill-Defined Causes
	76

	 	Enlargement of prostate
	 	Hyperplasia of Prostate
	69

	 	Enteritis
	 	Gastgro-enteritis, Colitis
	67

	 	Enterostenosis
	 	Intestinal Obstruction, Hernia
	77

	 	Enterovesical fistula
	 	Other Genito-Urinary
	38

	 	Enzymopathy
	 	Nutritional, Metabolic & Immunity Disorders
	63

	 	Eosinophilic asthma
	 	Other Respiratory
	32

	 	Eosinophilic leukemia
	 	Leukemia
	43

	 	Eosinophilic meningitis
	 	Meningitis
	77

	 	Epididymitis
	 	Other Genito-Urinary
	53

	 	Epidural hemorrhage
	 	Cerebrovascular Diseases
	18

	 	Epiglottis Cancer
	 	Cancer — Mouth, Throat, Pharynx
	63

	 	Epiglottitis
	 	Other Respiratory
	45

	 	Epilepsy
	 	Epilepsy
	82

	 	Epiloia
	 	Congenital Anomalies
	17

	 	Erysipelas
	 	Other Infective or Parasitic Diseases
	17

	 	Erysipelothrix infection
	 	Other Infective or Parasitic Diseases
	81

	 	Erythema nodosum
	 	Other Skin & Musculoskeletal Diseases
	81

	 	Erythema venenatum
	 	Other Skin & Musculoskeletal Diseases
	81

	 	Erythematosquamous dermatosis
	 	Other Skin & Musculoskeletal Diseases
	32

	 	Erythremic myelosis
	 	Leukemia
	19

	 	Esophageal Cancer
	 	Cancer — Esophagus
	72

	 	Esophageal Diseases
	 	Other Digestive Diseases
	19

	 	Esophagus Cancer
	 	Cancer — Esophagus
	77

	 	ESRD
	 	Other Genito-Urinary
	38

	 	Ethanolaminuria
	 	Nutritional, Metabolic & Immunity Disorders
	63

	 	ethmoiditis
	 	Other Respiratory
	46

	 	Eustachian salpingitis
	 	Otitis media and mastoiditis
	46

	 	Eustachian tube disorders
	 	Otitis media and mastoiditis
	30

	 	Ewing’s Sarcoma
	 	Cancer — Bone, Cartilage
	26

	 	Exocervix Cancer
	 	Cancer — Cervix Uteri
	36

	 	Exophthalmic goiter
	 	Thyrotoxicosis
	53

	 	Extradural hemorrhage
	 	Cerebrovascular Diseases
	63

	 	Extrinsic allergic alveolitis
	 	Other Respiratory
	63

	 	Extrinsic asthma
	 	Other Respiratory
	31

	 	Eye Cancer
	 	Cancer — Other
	38

	 	Fabry’s Disease
	 	Nutritional, Metabolic & Immunity Disorders
	87

	 	Failure to Thrive
	 	Unknown Causes & Ill-Defined Causes
	31

	 	Fallopian Tube Cancer
	 	Cancer — Other
	52

	 	Familial cardiomyopathy
	 	Other Heart Disease
	82

	 	Familial dysautonomia
	 	Congenital Anomalies
	38

	 	Familial Mediterranean fever
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Fanconi (-de Toni) (-Debre) syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	63

	 	Farmers lung
	 	Other Respiratory
	17

	 	Fascioliasis
	 	Other Infective or Parasitic Diseases

28

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	72

	 	Fat necrosis of peritoneum
	 	Other Digestive Diseases
	70

	 	Fatty liver
	 	Cirrhosis of Liver
	39

	 	Favism
	 	Anemia, Thalassemia
	67

	 	Fecal impaction
	 	Intestinal Obstruction, Hernia
	81

	 	Felty’s syndrome
	 	Other Skin & Musculoskeletal Diseases
	67

	 	Femoral hernia
	 	Intestinal Obstruction, Hernia
	61

	 	Fibrinopurulent pleurisy
	 	Emphysema
	38

	 	Fibrocystic disease of pancreas
	 	Nutritional, Metabolic & Immunity Disorders
	52

	 	Fibroid myocarditis
	 	Other Heart Disease
	54

	 	Fibromuscular hyperplasia of arteries
	 	Arteries, Arterioles, Capillaries
	54

	 	Fibromuscular hyperplasia of renal artery
	 	Arteries, Arterioles, Capillaries
	72

	 	Fibrosis of pancreas
	 	Other Digestive Diseases
	52

	 	Fiedler’s myocarditis
	 	Other Heart Disease
	54

	 	Fistula of artery
	 	Arteries, Arterioles, Capillaries
	72

	 	Fistula of bile duct
	 	Other Digestive Diseases
	71

	 	Fistula of gallbladder
	 	Cholelithiasis, Cholecystitis
	52

	 	Fistula of pericardium
	 	Other Heart Disease
	38

	 	Fluid Overload
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Fluid retention
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Folic Acid Deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	77

	 	Follicular cystitis
	 	Other Genito-Urinary
	38

	 	Follicular keratoris due to Vitamin A deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	5

	 	Food poisoning
	 	Intestinal Infections — Other
	37

	 	Forbes-Albright syndrome
	 	Diabetes Mellitus — Endocrine Disorders
	38

	 	Fredrickson Type (all) hyperlipoproteinemia
	 	Nutritional, Metabolic & Immunity Disorders
	47

	 	Friedreich’s ataxia
	 	Other Nervous System
	53

	 	Front Lobe Infarction
	 	Cerebrovascular Diseases
	38

	 	Fructosemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Fucosidosis
	 	Nutritional, Metabolic & Immunity Disorders
	69

	 	Fulminant enterocolitis
	 	Gastgro-enteritis, Colitis
	38

	 	Galactose-1-phosphatase deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Galactosemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Galactosuria
	 	Nutritional, Metabolic & Immunity Disorders
	31

	 	Gallbladder Cancer
	 	Cancer — Other
	71

	 	Gallbladder disease
	 	Cholelithiasis, Cholecystitis
	71

	 	Gallbladder disorders
	 	Cholelithiasis, Cholecystitis
	71

	 	Gallbladder Infarction
	 	Cholelithiasis, Cholecystitis
	67

	 	Gallstone ileus
	 	Intestinal Obstruction, Hernia
	47

	 	Gangliosidosis
	 	Other Nervous System
	54

	 	Gangrene — general
	 	Arteries, Arterioles, Capillaries
	69

	 	Gangrene — Intestinal
	 	Gastgro-enteritis, Colitis
	87

	 	Gangrene — Lower Extremities
	 	Unknown Causes & Ill-Defined Causes
	87

	 	Gangrene — Unspecified Site
	 	Unknown Causes & Ill-Defined Causes
	71

	 	Gangrene of gallbladder
	 	Cholelithiasis, Cholecystitis
	71

	 	Gangrenous cholecystitis
	 	Cholelithiasis, Cholecystitis
	61

	 	Gangrenous pneumonia
	 	Emphysema
	38

	 	Gargoylism
	 	Nutritional, Metabolic & Immunity Disorders
	20

	 	Gastric Cancer
	 	Cancer — Stomach
	72

	 	Gastric diverticulum
	 	Other Digestive Diseases
	64

	 	Gastric Hemorhage
	 	Ulcer, Gastric Hemorrhage
	72

	 	Gastric hemorrhage
	 	Other Digestive Diseases
	72

	 	Gastric rupture
	 	Other Digestive Diseases
	64

	 	Gastric Ulcer
	 	Ulcer, Gastric Hemorrhage
	68

	 	Gastritis
	 	Gastritis, Duodenitis
	72

	 	Gastrocolic fistula
	 	Other Digestive Diseases
	64

	 	Gastroduodenal ulcer
	 	Ulcer, Gastric Hemorrhage
	69

	 	Gastroenteritis
	 	Gastgro-enteritis, Colitis

29

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	72

	 	Gastroesophageal reflux disease
	 	Other Digestive Diseases
	72

	 	Gastroesophagel laceration-hemmorhage
	 	Other Digestive Diseases
	72

	 	Gastrointestinal bleeding
	 	Other Digestive Diseases
	72

	 	Gastrointestinal hemorrhage
	 	Other Digestive Diseases
	72

	 	Gastrojejunal ulcer
	 	Other Digestive Diseases
	72

	 	Gastrojejunocolic fistula
	 	Other Digestive Diseases
	72

	 	Gastroptosis
	 	Other Digestive Diseases
	38

	 	Gaucher’s disease
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Gaucher’s splenomegaly
	 	Nutritional, Metabolic & Immunity Disorders
	72

	 	Gee-(Herter) disease
	 	Other Digestive Diseases
	17

	 	Genial herpes
	 	Other Infective or Parasitic Diseases
	17

	 	German Measles
	 	Other Infective or Parasitic Diseases
	72

	 	GI Bleeding
	 	Other Digestive Diseases
	72

	 	GI hemorrhage
	 	Other Digestive Diseases
	54

	 	Giant cell arteritis
	 	Arteries, Arterioles, Capillaries
	5

	 	Giardiasis
	 	Intestinal Infections — Other
	38

	 	Gilbert’s syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Glanders
	 	Other Infective or Parasitic Diseases
	77

	 	Glandularis cystitis
	 	Other Genito-Urinary
	31

	 	Glioblastoma
	 	Cancer — Other
	73

	 	Glomerulitis
	 	Nephritis, Renal Scleroris
	73

	 	Glomerulonephritis
	 	Nephritis, Renal Scleroris
	23

	 	Glottix Cancer
	 	Cancer — Larynx
	38

	 	Glucoglycinuria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Glucose-6-phosphatase deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	72

	 	Gluten enteropathy
	 	Other Digestive Diseases
	38

	 	Glycinemia (with methylmalonic acidemia)
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Glycinuria (renal)
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Glycogen storage disease
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Glycogenosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Glycolic aciduria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Glycoprolinuria
	 	Nutritional, Metabolic & Immunity Disorders
	35

	 	Goiter
	 	Goiter
	36

	 	Goiter — Exophthalmic
	 	Thyrotoxicosis
	36

	 	Goiter — Toxic Diffuse
	 	Thyrotoxicosis
	36

	 	Goiter — Toxic uninodular
	 	Thyrotoxicosis
	36

	 	Goitrous cretinism
	 	Thyrotoxicosis
	17

	 	Gonococcal infections
	 	Other Infective or Parasitic Diseases
	54

	 	Goodpasture’s Syndrome
	 	Arteries, Arterioles, Capillaries
	38

	 	Gout
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Gouty arthropathy
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Gouty iritis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Gouty nephropathy
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Gouty neuritis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Gouty tophi of ear
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Gouty tophi of other sites
	 	Nutritional, Metabolic & Immunity Disorders
	7

	 	Gram-negative septicemia
	 	Septicemia
	45

	 	Grand mal epilepsy
	 	Epilepsy
	32

	 	Granulocytic sarcoma
	 	Leukemia
	36

	 	Graves’ disease
	 	Thyrotoxicosis
	18

	 	Gum Cancer
	 	Cancer — Mouth, Throat, Pharynx
	33

	 	Hairy-cell leukemia
	 	Lymphosarcoma, Etc
	47

	 	Hallervorden-Spatz Disease
	 	Other Nervous System
	63

	 	Hamman-Rich syndrome
	 	Other Respiratory
	38

	 	Hand-Schuller-Christian disease
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Hansen’s Disease
	 	Other Infective or Parasitic Diseases
	38

	 	Hartnup disease
	 	Nutritional, Metabolic & Immunity Disorders

30

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	36

	 	Hashimoto’s disease
	 	Thyrotoxicosis
	63

	 	Hay fever
	 	Other Respiratory
	39

	 	Hb-Bart’s Disease
	 	Anemia, Thalassemia
	39

	 	Hb-C disease
	 	Anemia, Thalassemia
	39

	 	Hb-D disease
	 	Anemia, Thalassemia
	39

	 	Hb-S disease
	 	Anemia, Thalassemia
	50

	 	Heart attack
	 	Ischemic & Coronary Heart Disease
	52

	 	Heart block
	 	Other Heart Disease
	24

	 	Heart Cancer
	 	Cancer — Lung, Trachea
	52

	 	Heart Disease
	 	Other Heart Disease
	52

	 	Heart Failure
	 	Other Heart Disease
	52

	 	Heart Failure not otherwise explained
	 	Other Heart Disease
	50

	 	Heart Infarction
	 	Ischemic & Coronary Heart Disease
	50

	 	Heart Ischemia
	 	Ischemic & Coronary Heart Disease
	32

	 	Heilmeyer-Schoner disease
	 	Leukemia
	41

	 	Heller’s Syndrome
	 	Mental, Drugs, Alcohol
	30

	 	Hemangiopericytoma
	 	Cancer — Bone, Cartilage
	72

	 	Hematemesis
	 	Other Digestive Diseases
	47

	 	Hematomyelia
	 	Other Nervous System
	38

	 	Hematoporphyria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hematoporphyrinuria
	 	Nutritional, Metabolic & Immunity Disorders
	77

	 	Hematuria
	 	Other Genito-Urinary
	47

	 	Hemiballism(us)
	 	Other Nervous System
	47

	 	Hemiplegia
	 	Other Nervous System
	38

	 	Hemochromatosis
	 	Nutritional, Metabolic & Immunity Disorders
	52

	 	Hemopericardium
	 	Other Heart Disease
	72

	 	Hemoperitoneum
	 	Other Digestive Diseases
	43

	 	Hemophilus meningitis
	 	Meningitis
	62

	 	Hemopneumothorax
	 	Pleurisy
	72

	 	Hemorrhage of esophagus
	 	Other Digestive Diseases
	77

	 	Hemorrhage of prostate
	 	Other Genito-Urinary
	72

	 	Hemorrhage of rectum or anus
	 	Other Digestive Diseases
	69

	 	Hemorrhagic enterocolitis
	 	Gastgro-enteritis, Colitis
	69

	 	Hemorrhagic necrosis of intestine
	 	Gastgro-enteritis, Colitis
	54

	 	Hemorrhagic telangiectasia
	 	Arteries, Arterioles, Capillaries
	55

	 	Hemorrhoids
	 	Veins, Other Circulatory
	62

	 	Hemothorax
	 	Pleurisy
	70

	 	Hepatic Cirrhosis
	 	Cirrhosis of Liver
	72

	 	Hepatic coma
	 	Other Digestive Diseases
	72

	 	Hepatic encephalopathy
	 	Other Digestive Diseases
	72

	 	Hepatic failure
	 	Other Digestive Diseases
	72

	 	Hepatic Infarction
	 	Other Digestive Diseases
	70

	 	Hepatitis
	 	Cirrhosis of Liver
	70

	 	Hepatitis C
	 	Cirrhosis of Liver
	31

	 	Hepatoblastoma
	 	Cancer — Other
	72

	 	Hepatocerebral intoxication
	 	Other Digestive Diseases
	38

	 	Hepatolenticular degeneration
	 	Nutritional, Metabolic & Immunity Disorders
	61

	 	Hepatopleural fistura
	 	Emphysema
	77

	 	Hepatorenal Failure
	 	Other Genito-Urinary
	72

	 	Hepatorenal syndrome
	 	Other Digestive Diseases
	38

	 	Hereditary angioedema
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hereditary cardiac amyloidosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hereditary coproporphyria
	 	Nutritional, Metabolic & Immunity Disorders
	39

	 	Hereditary ellipocytosis
	 	Anemia, Thalassemia
	38

	 	Hereditary Fructose Intolerance
	 	Nutritional, Metabolic & Immunity Disorders
	39

	 	Hereditary leptocytosis
	 	Anemia, Thalassemia
	47

	 	Hereditary spastic paraplegia
	 	Other Nervous System

31

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	67

	 	Hernia
	 	Intestinal Obstruction, Hernia
	17

	 	Herpes zoster
	 	Other Infective or Parasitic Diseases
	17

	 	Herpetic septicemia
	 	Other Infective or Parasitic Diseases
	17

	 	Herpex simplex
	 	Other Infective or Parasitic Diseases
	17

	 	Heterophyiasis
	 	Other Infective or Parasitic Diseases
	38

	 	HG-PRT deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	67

	 	Hiatal hernia
	 	Intestinal Obstruction, Hernia
	51

	 	High Blood Pressure
	 	Hypertensive Disease
	38

	 	High-density lipoid deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Histidinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Histiocycosis X
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Histiocytosis
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Histoplasmosis
	 	Other Infective or Parasitic Diseases
	40

	 	HIV
	 	AIDS
	40

	 	HIV Complications
	 	AIDS
	33

	 	Hodgkin’s disease
	 	Lymphosarcoma, Etc
	38

	 	Hoffa’s disease
	 	Nutritional, Metabolic & Immunity Disorders
	98

	 	Homicide
	 	Homicide
	38

	 	Homocystinuria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Homogentisic acid defects
	 	Nutritional, Metabolic & Immunity Disorders
	54

	 	Horton’s disease
	 	Arteries, Arterioles, Capillaries
	51

	 	HTN
	 	Hypertensive Disease
	40

	 	Human Immunodeficiency virus
	 	AIDS
	40

	 	Human T-Cell Lymphotropic virus
	 	AIDS
	38

	 	Hunter’s syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	47

	 	Huntington’s chorea
	 	Other Nervous System
	38

	 	Hurler’s syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	54

	 	Hyaline necrosis of aorta
	 	Arteries, Arterioles, Capillaries
	77

	 	Hydrocalycosis
	 	Other Genito-Urinary
	77

	 	Hydrocele
	 	Other Genito-Urinary
	77

	 	Hydronephrosis
	 	Other Genito-Urinary
	62

	 	Hydropneumothorax
	 	Pleurisy
	71

	 	Hydrops of gallbladder
	 	Cholelithiasis, Cholecystitis
	62

	 	Hydrothorax
	 	Pleurisy
	77

	 	Hydroureter
	 	Other Genito-Urinary
	77

	 	Hydroureteronephrosis
	 	Other Genito-Urinary
	38

	 	Hydroxprolinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hydroxykynureninuria
	 	Nutritional, Metabolic & Immunity Disorders
	37

	 	Hyperaldosteronism
	 	Diabetes Mellitus — Endocrine Disorders
	38

	 	Hyperammonemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperbetalipoproteinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperbilirubinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypercalcemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypercalcinuria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypercapnia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperchloremia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypercholesterolemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperchylomicronemia
	 	Nutritional, Metabolic & Immunity Disorders
	77

	 	Hyperemia of bladder
	 	Other Genito-Urinary
	38

	 	Hypergammaglobulinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypergammaglobulinemic purpura
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperglyceridemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperglycinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperhistidinemia
	 	Nutritional, Metabolic & Immunity Disorders
	37

	 	Hyperinsulinism
	 	Diabetes Mellitus — Endocrine Disorders
	38

	 	Hyperkalemia
	 	Nutritional, Metabolic & Immunity Disorders
	52

	 	Hyperkinetic heart disease
	 	Other Heart Disease

32

 

 
Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	38

	 	Hyperlipidemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperlysinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypermagnesemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypermethioninemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypernatremia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperornithinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperosmolality
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperosmolar Coma
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperoxaluria
	 	Nutritional, Metabolic & Immunity Disorders
	37

	 	Hyperparathyroidism
	 	Diabetes Mellitus — Endocrine Disorders
	38

	 	Hyperphenylalaninemia
	 	Nutritional, Metabolic & Immunity Disorders
	51

	 	Hyperpiesia
	 	Hypertensive Disease
	51

	 	Hyperpiesis
	 	Hypertensive Disease
	37

	 	Hyperplasia of pancreas
	 	Diabetes Mellitus — Endocrine Disorders
	37

	 	Hyperplasia of pancreatic islet beta cells
	 	Diabetes Mellitus — Endocrine Disorders
	76

	 	Hyperplasia of Prostate
	 	Hyperplasia of Prostate
	54

	 	Hyperplasia of renal artery
	 	Arteries, Arterioles, Capillaries
	66

	 	Hyperplasica of appendix
	 	Appendicitis
	38

	 	Hyperpotassemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperprebetalipoproteinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyperprolinemia
	 	Nutritional, Metabolic & Immunity Disorders
	54

	 	hypersensitivity angiitis
	 	Arteries, Arterioles, Capillaries
	63

	 	Hypersensitivity pneumonitis
	 	Other Respiratory
	51

	 	Hypertension
	 	Hypertensive Disease
	51

	 	Hypertension — Benign
	 	Hypertensive Disease
	51

	 	Hypertension — Uremic
	 	Hypertensive Disease
	51

	 	Hypertensive cardiomegaly
	 	Hypertensive Disease
	51

	 	Hypertensive cardiopathy
	 	Hypertensive Disease
	51

	 	Hypertensive cardiovascular disease
	 	Hypertensive Disease
	51

	 	Hypertensive Disease
	 	Hypertensive Disease
	51

	 	Hypertensive heart disease
	 	Hypertensive Disease
	51

	 	Hypertensive heart & renal disease
	 	Hypertensive Disease
	51

	 	Hypertensive kidney disease
	 	Hypertensive Disease
	51

	 	Hypertensive nephropathy
	 	Hypertensive Disease
	51

	 	Hypertensive nephrosclerosis
	 	Hypertensive Disease
	51

	 	Hypertensive renal disease
	 	Hypertensive Disease
	51

	 	Hypertensive renal failure
	 	Hypertensive Disease
	51

	 	Hypertensive uremia
	 	Hypertensive Disease
	51

	 	Hypertensive vascular degeneration
	 	Hypertensive Disease
	51

	 	Hypertensive vascular disease
	 	Hypertensive Disease
	36

	 	Hyperthyroidism
	 	Thyrotoxicosis
	38

	 	Hypertriglyceridemia
	 	Nutritional, Metabolic & Immunity Disorders
	68

	 	Hypertrophic gastritis
	 	Gastritis, Duodenitis
	52

	 	Hypertrophic obstructive cardiomyopathy
	 	Other Heart Disease
	72

	 	Hypertrophic pyloric stenosis
	 	Other Digestive Diseases
	77

	 	Hypertrophy of Kidney
	 	Other Genito-Urinary
	63

	 	Hypertrophy of nasal turbinates
	 	Other Respiratory
	76

	 	Hypertrophy of prostate (benign)
	 	Hyperplasia of Prostate
	38

	 	Hypertryosinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypervalinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypoalphalipoproteinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypobetalipoproteinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypochloremia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypogammaglobulinemia
	 	Nutritional, Metabolic & Immunity Disorders
	37

	 	Hypoglycemia
	 	Diabetes Mellitus — Endocrine Disorders
	37

	 	Hypoglycemic coma
	 	Diabetes Mellitus — Endocrine Disorders
	37

	 	Hypoinsulinemia
	 	Diabetes Mellitus — Endocrine Disorders

33

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	38

	 	Hypokalemia
	 	Nutritional, Metabolic & Immunity Disorders
	73

	 	Hypokalemic nephropathy
	 	Nephritis, Renal Scleroris
	38

	 	Hypomagnesemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyponatremia
	 	Nutritional, Metabolic & Immunity Disorders
	37

	 	Hypoparathyroidism
	 	Diabetes Mellitus — Endocrine Disorders
	18

	 	Hypopharynx Cancer
	 	Cancer — Mouth, Throat, Pharynx
	38

	 	Hypophosphatasia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypophosphatemia
	 	Nutritional, Metabolic & Immunity Disorders
	37

	 	Hypophysis Infarction
	 	Diabetes Mellitus — Endocrine Disorders
	55

	 	Hypopiesis
	 	Veins, Other Circulatory
	37

	 	Hypopituitarism
	 	Diabetes Mellitus — Endocrine Disorders
	38

	 	Hypopotassemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hyposmolality
	 	Nutritional, Metabolic & Immunity Disorders
	55

	 	Hypotension
	 	Veins, Other Circulatory
	87

	 	Hypotensive Shock
	 	Unknown Causes & Ill-Defined Causes
	36

	 	Hypothroidism
	 	Thyrotoxicosis
	87

	 	Hypoventilation
	 	Unknown Causes & Ill-Defined Causes
	38

	 	Hypovitaminosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Hypovolemia
	 	Nutritional, Metabolic & Immunity Disorders
	87

	 	Hypoxemia
	 	Unknown Causes & Ill-Defined Causes
	36

	 	iatrongenic thyroiditis
	 	Thyrotoxicosis
	52

	 	Idiopathic cardiomyopathy
	 	Other Heart Disease
	52

	 	Idiopathic myocarditis
	 	Other Heart Disease
	52

	 	idiopathic pericarditis
	 	Other Heart Disease
	72

	 	Idiopathic steatorrhea
	 	Other Digestive Diseases
	47

	 	Idiopathic torsion dystonia
	 	Other Nervous System
	69

	 	Ileitis of small intestine
	 	Gastgro-enteritis, Colitis
	69

	 	Ileocolitis
	 	Gastgro-enteritis, Colitis
	67

	 	Ileus of intestine or bowel or colon
	 	Intestinal Obstruction, Hernia
	87

	 	Illegible death certificate
	 	Unknown Causes & Ill-Defined Causes
	38

	 	Imidazole aminoaciduria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Iminoacidopathy
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Immunity deficiencies
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Immunoglobulin deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	33

	 	Immunoproliferative neoplasm
	 	Lymphosarcoma, Etc
	67

	 	Impaction of colon
	 	Intestinal Obstruction, Hernia
	67

	 	Impaction of intestine
	 	Intestinal Obstruction, Hernia
	79

	 	Impetigo
	 	Skin Infections
	101

	 	Incomplete Death Certificate
	 	Incomplete Death Certificate
	38

	 	Indicanuria
	 	Nutritional, Metabolic & Immunity Disorders
	63

	 	Induration of lung
	 	Other Respiratory
	82

	 	Inencephaly
	 	Congenital Anomalies
	47

	 	Infantile cerebral palsy
	 	Other Nervous System
	47

	 	Infantile hemiplegia
	 	Other Nervous System
	47

	 	Infantile necrotizing encephalomyelopathy
	 	Other Nervous System
	37

	 	Infarction — Adrenal
	 	Diabetes Mellitus — Endocrine Disorders
	78

	 	Infarction — Amnion
	 	Complications of Pregnancy
	69

	 	Infarction — Bowel
	 	Gastgro-enteritis, Colitis
	53

	 	Infarction — Brainstem
	 	Cerebrovascular Diseases
	77

	 	Infarction — Breast
	 	Other Genito-Urinary
	53

	 	Infarction — Cerebral
	 	Cerebrovascular Diseases
	69

	 	Infarction — Colon
	 	Gastgro-enteritis, Colitis
	50

	 	Infarction — Coronary Artery
	 	Ischemic & Coronary Heart Disease
	54

	 	Infarction — Embolic
	 	Arteries, Arterioles, Capillaries
	53

	 	Infarction — Front Lobe
	 	Cerebrovascular Diseases
	71

	 	Infarction — Gallbladder
	 	Cholelithiasis, Cholecystitis
	50

	 	Infarction — Heart
	 	Ischemic & Coronary Heart Disease

34

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	72

	 	Infarction — Hepatic
	 	Other Digestive Diseases
	37

	 	Infarction — Hypophysis
	 	Diabetes Mellitus — Endocrine Disorders
	69

	 	Infarction — Intestinal
	 	Gastgro-enteritis, Colitis
	77

	 	Infarction — Kidney
	 	Other Genito-Urinary
	72

	 	Infarction — Liver
	 	Other Digestive Diseases
	52

	 	Infarction — Lung
	 	Other Heart Disease
	55

	 	Infarction — Lymph Node
	 	Veins, Other Circulatory
	53

	 	Infarction — Medullary
	 	Cerebrovascular Diseases
	69

	 	Infarction — Mesenteric
	 	Gastgro-enteritis, Colitis
	53

	 	Infarction — Midbrain
	 	Cerebrovascular Diseases
	50

	 	Infarction — Nontransmural
	 	Ischemic & Coronary Heart Disease
	69

	 	Infarction — Omentum
	 	Gastgro-enteritis, Colitis
	77

	 	Infarction — Ovary
	 	Other Genito-Urinary
	72

	 	Infarction — Pancreas
	 	Other Digestive Diseases
	37

	 	Infarction — Pituitary
	 	Diabetes Mellitus — Endocrine Disorders
	53

	 	Infarction — Pontine
	 	Cerebrovascular Diseases
	77

	 	Infarction — Prostate
	 	Other Genito-Urinary
	52

	 	Infarction — Pulmonary
	 	Other Heart Disease
	77

	 	Infarction — renal
	 	Other Genito-Urinary
	47

	 	Infarction — Spinal Cord
	 	Other Nervous System
	39

	 	Infarction — Spleen
	 	Anemia, Thalassemia
	37

	 	Infarction — suprarenal
	 	Diabetes Mellitus — Endocrine Disorders
	77

	 	Infarction — Testis
	 	Other Genito-Urinary
	55

	 	Infarction — Thrombotic
	 	Veins, Other Circulatory
	36

	 	Infarction — Thyroid
	 	Thyrotoxicosis
	77

	 	Infarction of prostate
	 	Other Genito-Urinary
	47

	 	Infarction of Spinal Cord
	 	Other Nervous System
	36

	 	Infarction of thyroid
	 	Thyrotoxicosis
	81

	 	Infection — Joint
	 	Other Skin & Musculoskeletal Diseases
	17

	 	Infectious mononucleosis
	 	Other Infective or Parasitic Diseases
	47

	 	Infective polyneuritis
	 	Other Nervous System
	56

	 	Influenza
	 	Influenza
	56

	 	Influenza A
	 	Influenza
	56

	 	Influenzal Bronchopneumonia
	 	Influenza
	56

	 	Influenzal laryngitis
	 	Influenza
	56

	 	Influenzal pharyngitis
	 	Influenza
	56

	 	Influenzal pneumonia
	 	Influenza
	56

	 	Influenzal respiratory infection
	 	Influenza
	67

	 	Inguinal hernia
	 	Intestinal Obstruction, Hernia
	87

	 	Instantaneous death
	 	Unknown Causes & Ill-Defined Causes
	77

	 	Interstitial cystitis
	 	Other Genito-Urinary
	63

	 	interstitial emphysema
	 	Other Respiratory
	63

	 	Interstitial lung disease
	 	Other Respiratory
	63

	 	Interstitial pneumonia
	 	Other Respiratory
	69

	 	Intestinal Gangrene
	 	Gastgro-enteritis, Colitis
	69

	 	Intestinal Infarction
	 	Gastgro-enteritis, Colitis
	5

	 	Intestinal Infections — Other
	 	Intestinal Infections — Other
	69

	 	Intestinal Ischemia
	 	Gastgro-enteritis, Colitis
	72

	 	Intestinal malabsorption
	 	Other Digestive Diseases
	67

	 	Intestinal Obstruction
	 	Intestinal Obstruction, Hernia
	31

	 	Intestinal Tract Cancer
	 	Cancer — Other
	5

	 	Intestinal trichomoniasis
	 	Intestinal Infections — Other
	77

	 	Intestinoureteral fistula
	 	Other Genito-Urinary
	77

	 	Intestinovesical fistula
	 	Other Genito-Urinary
	53

	 	Intracerebral hemorrhage
	 	Cerebrovascular Diseases
	53

	 	Intracranial hemorrhage
	 	Cerebrovascular Diseases
	67

	 	Intussusception
	 	Intestinal Obstruction, Hernia

35

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	67

	 	Invagination of intestine or colon
	 	Intestinal Obstruction, Hernia
	38

	 	Iodine deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	36

	 	Iodine hypothroidism
	 	Thyrotoxicosis
	77

	 	Irradiation cystitis
	 	Other Genito-Urinary
	72

	 	Irritable colon
	 	Other Digestive Diseases
	55

	 	Ischemia — Basilar Artery
	 	Veins, Other Circulatory
	81

	 	Ischemia — Bone
	 	Other Skin & Musculoskeletal Diseases
	69

	 	Ischemia — Bowel
	 	Gastgro-enteritis, Colitis
	53

	 	Ischemia — Brain
	 	Cerebrovascular Diseases
	50

	 	Ischemia — Cardiac
	 	Ischemic & Coronary Heart Disease
	53

	 	Ischemia — Carotid Artery
	 	Cerebrovascular Diseases
	53

	 	Ischemia — Cerebral
	 	Cerebrovascular Diseases
	53

	 	Ischemia — Cerebrovascular
	 	Cerebrovascular Diseases
	69

	 	Ischemia — Colon
	 	Gastgro-enteritis, Colitis
	50

	 	Ischemia — Coronary
	 	Ischemic & Coronary Heart Disease
	50

	 	Ischemia — Heart
	 	Ischemic & Coronary Heart Disease
	77

	 	Ischemia — Kidney
	 	Other Genito-Urinary
	47

	 	Ischemia — Labyrinth
	 	Other Nervous System
	81

	 	Ischemia — Legs
	 	Other Skin & Musculoskeletal Diseases
	81

	 	Ischemia — Lower Extremities
	 	Other Skin & Musculoskeletal Diseases
	50

	 	Ischemia — Myocardial
	 	Ischemic & Coronary Heart Disease
	77

	 	Ischemia — Renal
	 	Other Genito-Urinary
	47

	 	Ischemia — Retinal
	 	Other Nervous System
	69

	 	Ischemia — Small Bowel
	 	Gastgro-enteritis, Colitis
	47

	 	Ischemia — Spinal Cord
	 	Other Nervous System
	50

	 	Ischemia — Subendocardial
	 	Ischemic & Coronary Heart Disease
	53

	 	Ischemia — Vertebral Artery
	 	Cerebrovascular Diseases
	69

	 	Ischemic — Intestine
	 	Gastgro-enteritis, Colitis
	69

	 	Ischemic Bowel
	 	Gastgro-enteritis, Colitis
	50

	 	Ischemic cardiomyopathy
	 	Ischemic & Coronary Heart Disease
	69

	 	Ischemic colitis
	 	Gastgro-enteritis, Colitis
	50

	 	Ischemic congestive cardiomyopathy
	 	Ischemic & Coronary Heart Disease
	50

	 	Ischemic heart disease
	 	Ischemic & Coronary Heart Disease
	69

	 	Ischemic stricture of intestine
	 	Gastgro-enteritis, Colitis
	72

	 	Ischiorectal fistula
	 	Other Digestive Diseases
	81

	 	Jaccaud’s syndrome
	 	Other Skin & Musculoskeletal Diseases
	17

	 	Jakob-Creutzfeldt disease
	 	Other Infective or Parasitic Diseases
	47

	 	Jansky-Bielschowsky disease
	 	Other Nervous System
	81

	 	Joint Infection
	 	Other Skin & Musculoskeletal Diseases
	81

	 	Juvenile osteochondrosis
	 	Other Skin & Musculoskeletal Diseases
	33

	 	Kahler’s disease
	 	Lymphosarcoma, Etc
	17

	 	Kaposi’s syndrome
	 	Other Infective or Parasitic Diseases
	54

	 	Kawasaki disease
	 	Arteries, Arterioles, Capillaries
	15

	 	Kedani Fever
	 	Typhus and Ricketsiosis
	81

	 	Keratoconjunctivitis sicca
	 	Other Skin & Musculoskeletal Diseases
	31

	 	Kidney Cancer
	 	Cancer — Other
	77

	 	Kidney Infarction
	 	Other Genito-Urinary
	74

	 	Kidney Infection
	 	Kidney Infections
	77

	 	Kidney Ischemia
	 	Other Genito-Urinary
	73

	 	Kidney lesions
	 	Nephritis, Renal Scleroris
	73

	 	Kidney nephritis
	 	Nephritis, Renal Scleroris
	75

	 	Kidney stone
	 	Urinary System Infections
	73

	 	Kimmelstiel-Wilson syndrome
	 	Nephritis, Renal Scleroris
	82

	 	Klinefelter’s syndrome
	 	Congenital Anomalies
	45

	 	Kojevnikov’s epilepsy
	 	Epilepsy
	41

	 	Korsakoff’s psychosis
	 	Mental, Drugs, Alcohol
	47

	 	Krabbe’s disease
	 	Other Nervous System

36

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	77

	 	Kraurosis of penis
	 	Other Genito-Urinary
	47

	 	Kufs’ disease
	 	Other Nervous System
	47

	 	Kugelberg-Welander disease
	 	Other Nervous System
	38

	 	Kwashiorkor
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Kyasanur Forest Disease
	 	Other Infective or Parasitic Diseases
	38

	 	Kynureninase defects
	 	Nutritional, Metabolic & Immunity Disorders
	81

	 	Kyphoscoliosis wo heart disease
	 	Other Skin & Musculoskeletal Diseases
	52

	 	Kyphoscolitic heart disease
	 	Other Heart Disease
	47

	 	Labyrinth Ischemia
	 	Other Nervous System
	38

	 	Lactic acidosis
	 	Nutritional, Metabolic & Immunity Disorders
	13

	 	Langat encephalitis
	 	Encephalitis
	63

	 	Laryngitis
	 	Other Respiratory
	63

	 	Laryngopharyngitis
	 	Other Respiratory
	63

	 	Laryngotracheitis
	 	Other Respiratory
	23

	 	Larynx Cancer
	 	Cancer — Larynx
	38

	 	Launois-Bensaude’s lipomatosis
	 	Nutritional, Metabolic & Immunity Disorders
	82

	 	laurence-Moon-Biedl syndrome
	 	Congenital Anomalies
	40

	 	LAV
	 	AIDS
	52

	 	Left bundle branch hemiblock
	 	Other Heart Disease
	81

	 	Leg Ischemia
	 	Other Skin & Musculoskeletal Diseases
	98

	 	Legal execution
	 	Homicide
	30

	 	Leiomysarcoma
	 	Cancer — Bone, Cartilage
	17

	 	Leishmaniasis
	 	Other Infective or Parasitic Diseases
	17

	 	Lepromatous
	 	Other Infective or Parasitic Diseases
	17

	 	Leprosy
	 	Other Infective or Parasitic Diseases
	17

	 	Leptospirosis
	 	Other Infective or Parasitic Diseases
	54

	 	Leriche’s syndrome
	 	Arteries, Arterioles, Capillaries
	38

	 	Lesch-Nyhan syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	54

	 	Lethal midline granuloma
	 	Arteries, Arterioles, Capillaries
	33

	 	Letterer-Siwe disease
	 	Lymphosarcoma, Etc
	38

	 	Leucine-Induced hypoglycemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Leucinosis
	 	Nutritional, Metabolic & Immunity Disorders
	32

	 	Leukemia
	 	Leukemia
	47

	 	Leukodystrophy
	 	Other Nervous System
	77

	 	Leukoplakia of penis
	 	Other Genito-Urinary
	72

	 	Leukoplakiaa of esophagus
	 	Other Digestive Diseases
	33

	 	Leukosarcoma
	 	Lymphosarcoma, Etc
	33

	 	Leumkemis reticuloendotheliosis
	 	Lymphosarcoma, Etc
	81

	 	Libman-Sacks disease
	 	Other Skin & Musculoskeletal Diseases
	18

	 	Lip Cancer
	 	Cancer — Mouth, Throat, Pharynx
	38

	 	Lipidoses
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Lipochondrodystrophy
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Lipodystrophy
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Lipoid dermatoarthritis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Lipoid dermatoarthritis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Lipoid storage disease
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Lipoprotein deficiencies
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Liposynovitis prepatellaris
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Listeriosis
	 	Other Infective or Parasitic Diseases
	47

	 	Little’s disease
	 	Other Nervous System
	72

	 	Liver — abscess
	 	Other Digestive Diseases
	31

	 	Liver Cancer
	 	Cancer — Other
	72

	 	Liver Failure
	 	Other Digestive Diseases
	72

	 	Liver Infarction
	 	Other Digestive Diseases
	17

	 	Lobomycosis
	 	Other Infective or Parasitic Diseases
	57

	 	Lobular pneumonia
	 	Pneumonia
	63

	 	Loffler’s syndrome
	 	Other Respiratory

37

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	13

	 	Louping ill
	 	Encephalitis
	15

	 	Louse-borne typhus
	 	Typhus and Ricketsiosis
	81

	 	Lower extremity ischemia
	 	Other Skin & Musculoskeletal Diseases
	52

	 	Lown-Ganong-Levine syndrome
	 	Other Heart Disease
	24

	 	Lung Cancer
	 	Cancer — Lung, Trachea
	52

	 	Lung Infarction
	 	Other Heart Disease
	62

	 	Lung pleurisy
	 	Pleurisy
	63

	 	Lung Sarcoidosis
	 	Other Respiratory
	81

	 	Lupus erythematodes
	 	Other Skin & Musculoskeletal Diseases
	81

	 	Lupus erythematosis
	 	Other Skin & Musculoskeletal Diseases
	81

	 	Lyell’s syndrome
	 	Other Skin & Musculoskeletal Diseases
	55

	 	Lymph Node Infarction
	 	Veins, Other Circulatory
	79

	 	Lymphadenitis
	 	Skin Infections
	40

	 	Lymphadenopathy associated virus
	 	AIDS
	55

	 	Lymphangiectasis
	 	Veins, Other Circulatory
	55

	 	Lymphangitis
	 	Veins, Other Circulatory
	33

	 	Lymphatic Cancer
	 	Lymphosarcoma, Etc
	55

	 	Lymphedema
	 	Veins, Other Circulatory
	17

	 	Lymphocytic choriomeningitis
	 	Other Infective or Parasitic Diseases
	36

	 	Lymphocytic thyroiditis
	 	Thyrotoxicosis
	32

	 	Lymphoid Leukemia
	 	Leukemia
	33

	 	Lymphosarcoma
	 	Lymphosarcoma, Etc
	32

	 	Lymphosarcoma cell leukemia
	 	Leukemia
	38

	 	Macroglobulinemia
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Madura foot
	 	Other Infective or Parasitic Diseases
	16

	 	Malaria
	 	Malaria
	51

	 	Malignant hypertension
	 	Hypertensive Disease
	72

	 	Mallory-Weiss syndrome
	 	Other Digestive Diseases
	38

	 	Malnutrition
	 	Nutritional, Metabolic & Immunity Disorders
	30

	 	Mandible Cancer
	 	Cancer — Bone, Cartilage
	41

	 	Manic Depression
	 	Mental, Drugs, Alcohol
	38

	 	Mannosidosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Maple syrup urine disease
	 	Nutritional, Metabolic & Immunity Disorders
	54

	 	Marable’s syndrome
	 	Arteries, Arterioles, Capillaries
	82

	 	Marcus-Gunn syndrome
	 	Congenital Anomalies
	82

	 	Marfan’s syndrome
	 	Congenital Anomalies
	38

	 	Maroteaux-Lamy syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	33

	 	Mastocytoma
	 	Lymphosarcoma, Etc
	46

	 	Mastoiditis
	 	Otitis media and mastoiditis
	38

	 	McArdle’s disease
	 	Nutritional, Metabolic & Immunity Disorders
	54

	 	MCLS
	 	Arteries, Arterioles, Capillaries
	14

	 	Measles
	 	Measles
	21

	 	Meckel’s Diverticulus
	 	Cancer — Colon, Cecum, Sigmoid
	63

	 	Mediastinal emphysema
	 	Other Respiratory
	63

	 	Mediastinitis
	 	Other Respiratory
	52

	 	Mediastinopericarditis
	 	Other Heart Disease
	53

	 	Medullary Infarction
	 	Cerebrovascular Diseases
	47

	 	Medullary Paralysis
	 	Other Nervous System
	32

	 	Megakaryocytic myelosis
	 	Leukemia
	29

	 	Melanocarcinoma
	 	Cancer — Skin, Melanoma
	29

	 	Melanoma
	 	Cancer — Skin, Melanoma
	72

	 	Melena
	 	Other Digestive Diseases
	17

	 	Melioidosis
	 	Other Infective or Parasitic Diseases
	53

	 	Meningeal hemorrhage
	 	Cerebrovascular Diseases
	43

	 	Meningitis
	 	Meningitis
	10

	 	Meningococcal carditis
	 	Meningococcal Infection
	10

	 	Meningococcal Infection
	 	Meningococcal Infection

38

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	10

	 	Meningococcal meningitis
	 	Meningococcal Infection
	47

	 	Meningoencephalitis
	 	Other Nervous System
	47

	 	Meningomyelitis
	 	Other Nervous System
	41

	 	Mental Retardation
	 	Mental, Drugs, Alcohol
	69

	 	Mesenteric Embolus
	 	Gastgro-enteritis, Colitis
	69

	 	Mesenteric infarction
	 	Gastgro-enteritis, Colitis
	72

	 	Mesenteric saponiication
	 	Other Digestive Diseases
	38

	 	Metabolic acidosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Metabolic alkalosis
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Metagonimiasis
	 	Other Infective or Parasitic Diseases
	31

	 	Metastatic Adenocarcinoma
	 	Cancer — Other
	38

	 	Methioninemia
	 	Nutritional, Metabolic & Immunity Disorders
	50

	 	MI
	 	Ischemic & Coronary Heart Disease
	82

	 	Microcephalus
	 	Congenital Anomalies
	50

	 	Microinfarct of heart
	 	Ischemic & Coronary Heart Disease
	53

	 	Midbrain Infarction
	 	Cerebrovascular Diseases
	2

	 	Miliary tuberculosis
	 	Tuberculosis — Nonrespiratory
	38

	 	Mineral deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	39

	 	Minkowski-chauffad syndrome
	 	Anemia, Thalassemia
	50

	 	Mitral insufficiency
	 	Ischemic & Coronary Heart Disease
	50

	 	Mitral regurgitation
	 	Ischemic & Coronary Heart Disease
	50

	 	Mitral stenosis
	 	Ischemic & Coronary Heart Disease
	50

	 	Mitral valve disorder
	 	Ischemic & Coronary Heart Disease
	49

	 	Mitral valve insufficiency
	 	Rheumatic Heart Disease
	52

	 	Mobitz atrioventricular block
	 	Other Heart Disease
	54

	 	Monckeberg’s sclerosis
	 	Arteries, Arterioles, Capillaries
	55

	 	Mondor’s disease
	 	Veins, Other Circulatory
	82

	 	Mongolism
	 	Congenital Anomalies
	38

	 	Monoclonal gammopathy
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Monoclonal paraproteinemia
	 	Nutritional, Metabolic & Immunity Disorders
	32

	 	Monocytic leukemia
	 	Leukemia
	17

	 	Mononucleosis
	 	Other Infective or Parasitic Diseases
	38

	 	Morbid obesity
	 	Nutritional, Metabolic & Immunity Disorders
	14

	 	Morbilli
	 	Measles
	52

	 	Morbus cordis
	 	Other Heart Disease
	38

	 	Morquio-Brailsford disease
	 	Nutritional, Metabolic & Immunity Disorders
	54

	 	Moschcowitz’s syndrome
	 	Arteries, Arterioles, Capillaries
	13

	 	Mosquito-borne viral encephalitis
	 	Encephalitis
	47

	 	Motor neuron disease
	 	Other Nervous System
	88

	 	Motor Vehicle Accidents
	 	Motor Vehicle Accidents
	18

	 	Mouth Cancer
	 	Cancer — Mouth, Throat, Pharynx
	53

	 	Moyamoya disease
	 	Cerebrovascular Diseases
	17

	 	Mucocormycosis
	 	Other Infective or Parasitic Diseases
	54

	 	Mucocutaneous lymph node syndrome
	 	Arteries, Arterioles, Capillaries
	38

	 	Mucolipidosis III
	 	Nutritional, Metabolic & Immunity Disorders
	37

	 	Mucopolysaccharidosis
	 	Diabetes Mellitus — Endocrine Disorders
	38

	 	Mucopolysaccharidosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Mucoviscidosis
	 	Nutritional, Metabolic & Immunity Disorders
	31

	 	Multiform Cancer
	 	Cancer — Other
	87

	 	Multiple Medical Conditions
	 	Unknown Causes & Ill-Defined Causes
	33

	 	Multiple myeloma
	 	Lymphosarcoma, Etc
	87

	 	Multiple Organ Failure
	 	Unknown Causes & Ill-Defined Causes
	44

	 	Multiple Sclerosis
	 	Multiple Sclerosis
	63

	 	Multiple Upper Respiratory Infections
	 	Other Respiratory
	63

	 	Multiple URI
	 	Other Respiratory
	87

	 	Multi-System Failure
	 	Unknown Causes & Ill-Defined Causes
	17

	 	Mumps
	 	Other Infective or Parasitic Diseases

39

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	98

	 	Murder
	 	Homicide
	47

	 	Muscular dystrophy
	 	Other Nervous System
	47

	 	Myasthenia gravis
	 	Other Nervous System
	33

	 	Mycosis fungoides
	 	Lymphosarcoma, Etc
	47

	 	Myelitis
	 	Other Nervous System
	47

	 	Myelitis — transverse
	 	Other Nervous System
	32

	 	Myeloid leukemia
	 	Leukemia
	32

	 	Myeloid Sarcoma
	 	Leukemia
	33

	 	Myeloproliferative syndrome
	 	Lymphosarcoma, Etc
	52

	 	Myocardial decompensation
	 	Other Heart Disease
	52

	 	Myocardial decomposition
	 	Other Heart Disease
	52

	 	Myocardial degeneration
	 	Other Heart Disease
	52

	 	Myocardial disease
	 	Other Heart Disease
	52

	 	Myocardial failure
	 	Other Heart Disease
	50

	 	Myocardial Failure — possible infarction
	 	Ischemic & Coronary Heart Disease
	50

	 	Myocardial Failure — with arteriosclerosis
	 	Ischemic & Coronary Heart Disease
	50

	 	Myocardial Infarction
	 	Ischemic & Coronary Heart Disease
	52

	 	Myocardial Insufficiency
	 	Other Heart Disease
	50

	 	Myocardial Ischemia
	 	Ischemic & Coronary Heart Disease
	52

	 	Myocardiopathy
	 	Other Heart Disease
	52

	 	Myocarditis
	 	Other Heart Disease
	52

	 	Myocarditis with arteriosclerosis
	 	Other Heart Disease
	52

	 	Myocarditis without arteriosclerosis
	 	Other Heart Disease
	47

	 	Myoconic epilepsy
	 	Other Nervous System
	52

	 	Myoendocarditis
	 	Other Heart Disease
	47

	 	Myoneural disorder
	 	Other Nervous System
	52

	 	Myopericarditis
	 	Other Heart Disease
	81

	 	Myositis
	 	Other Skin & Musculoskeletal Diseases
	36

	 	Myxedema
	 	Thyrotoxicosis
	31

	 	Nasal Cavity Cancer
	 	Cancer — Other
	63

	 	Nasal polyps
	 	Other Respiratory
	63

	 	Nasopharyngitis
	 	Other Respiratory
	18

	 	Nasopharynx Cancer
	 	Cancer — Mouth, Throat, Pharynx
	87

	 	Natural Causes
	 	Unknown Causes & Ill-Defined Causes
	17

	 	Necrobacillosis
	 	Other Infective or Parasitic Diseases
	54

	 	Necrosis of artery
	 	Arteries, Arterioles, Capillaries
	80

	 	Necrosis of bone
	 	Osteomyelitis, periostitis
	69

	 	Necrosis of intestine
	 	Gastgro-enteritis, Colitis
	72

	 	Necrosis of liver
	 	Other Digestive Diseases
	72

	 	Necrosis of pancreas
	 	Other Digestive Diseases
	61

	 	Necrotic pneumonia
	 	Emphysema
	54

	 	Necrotizing angiitis
	 	Arteries, Arterioles, Capillaries
	73

	 	Nephritis
	 	Nephritis, Renal Scleroris
	73

	 	Nephritis — Kidney
	 	Nephritis, Renal Scleroris
	38

	 	Nephrocalcinosis
	 	Nutritional, Metabolic & Immunity Disorders
	73

	 	Nephrogenic diabetes insipidus
	 	Nephritis, Renal Scleroris
	75

	 	Nephrolithiasis
	 	Urinary System Infections
	73

	 	Nephropathy
	 	Nephritis, Renal Scleroris
	77

	 	Nephroptosis
	 	Other Genito-Urinary
	51

	 	Nephrosclerosis
	 	Hypertensive Disease
	51

	 	Nephrosclerosis — Hypertensive
	 	Hypertensive Disease
	73

	 	Nephrotic syndrome
	 	Nephritis, Renal Scleroris
	87

	 	Nerves
	 	Unknown Causes & Ill-Defined Causes
	47

	 	Neurological disorders
	 	Other Nervous System
	47

	 	Neuromyelitis optica
	 	Other Nervous System
	47

	 	Neuropathic muscular atrophy
	 	Other Nervous System
	3

	 	Neurosyphilis
	 	Syphilis

40

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	32

	 	Neutrophilic leukemia
	 	Leukemia
	54

	 	Nevus Non-neoplastic
	 	Arteries, Arterioles, Capillaries
	38

	 	Nezelof’s syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Nieman-Pick disease
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Nieman-Pick splenomegaly
	 	Nutritional, Metabolic & Immunity Disorders
	101

	 	No Cause Listed
	 	Incomplete Death Certificate
	100

	 	No Death Certificate
	 	No Death Certificate
	36

	 	Nodular Goiter
	 	Thyrotoxicosis
	43

	 	Nonpyogenic meningitis
	 	Meningitis
	35

	 	Nontoxic goiter
	 	Goiter
	50

	 	Nontransmural Infarction
	 	Ischemic & Coronary Heart Disease
	72

	 	Nontropical sprue
	 	Other Digestive Diseases
	38

	 	Nutritional atrophy
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Nutritional dwarfism
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Nutritional marasmus
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Oasthouse urine disease
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Obesity
	 	Nutritional, Metabolic & Immunity Disorders
	52

	 	Obliterative pericarditis
	 	Other Heart Disease
	72

	 	Obstruction of bile duct
	 	Other Digestive Diseases
	72

	 	Obstruction of esophagus
	 	Other Digestive Diseases
	71

	 	Obstruction of gallbladder
	 	Cholelithiasis, Cholecystitis
	67

	 	Obstruction of intestine or colon
	 	Intestinal Obstruction, Hernia
	52

	 	Obstructive cardiomyopathy
	 	Other Heart Disease
	77

	 	Obstructive uropathy
	 	Other Genito-Urinary
	72

	 	Occlusion of bile duct
	 	Other Digestive Diseases
	53

	 	Occlusion of cerebral arteries
	 	Cerebrovascular Diseases
	67

	 	Occulsion of intestine or colon
	 	Intestinal Obstruction, Hernia
	38

	 	Ochronosis
	 	Nutritional, Metabolic & Immunity Disorders
	87

	 	Old age
	 	Unknown Causes & Ill-Defined Causes
	47

	 	Olivopontocerebellar atrophy or degeneration
	 	Other Nervous System
	69

	 	Omentum Infarction
	 	Gastgro-enteritis, Colitis
	17

	 	Omsk hemorrhagic fever
	 	Other Infective or Parasitic Diseases
	17

	 	Opisthorchiasis
	 	Other Infective or Parasitic Diseases
	72

	 	Oral Cavity Diseases
	 	Other Digestive Diseases
	47

	 	Orbital cellulitis
	 	Other Nervous System
	47

	 	Orbital osteomyelitis
	 	Other Nervous System
	47

	 	Orbital periostitis
	 	Other Nervous System
	77

	 	Orchitis
	 	Other Genito-Urinary
	85

	 	Organic Brain Disease
	 	Senility
	41

	 	Organic Brain Syndrome
	 	Mental, Drugs, Alcohol
	52

	 	Organic Heart Disease
	 	Other Heart Disease
	17

	 	Ornithosis
	 	Other Infective or Parasitic Diseases
	18

	 	Oropharyngeal Cancer
	 	Cancer — Mouth, Throat, Pharynx
	18

	 	Oropharynx Cancer
	 	Cancer — Mouth, Throat, Pharynx
	55

	 	Orthostatic hypotension
	 	Veins, Other Circulatory
	81

	 	Osteoarthrosis
	 	Other Skin & Musculoskeletal Diseases
	38

	 	Osteochondrodystrophy
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Osteomalacia
	 	Nutritional, Metabolic & Immunity Disorders
	80

	 	Osteomyelitis
	 	Osteomyelitis, periostitis
	81

	 	Osteoporosis
	 	Other Skin & Musculoskeletal Diseases
	17

	 	Other Infective or Parasitic Diseases
	 	Other Infective or Parasitic Diseases
	46

	 	Otitis media
	 	Otitis media and mastoiditis
	31

	 	Ovarian Cancer
	 	Cancer — Other
	31

	 	Ovary Cancer
	 	Cancer — Other
	77

	 	Ovary Infarction
	 	Other Genito-Urinary
	38

	 	Oxalosis
	 	Nutritional, Metabolic & Immunity Disorders
	25

	 	Paget’s Disease of Breast
	 	Cancer — Breast

41

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	81

	 	Paget’s disease of the bone
	 	Other Skin & Musculoskeletal Diseases
	54

	 	Panarteritis
	 	Arteries, Arterioles, Capillaries
	31

	 	Pancreas Cancer
	 	Cancer — Other
	72

	 	Pancreas Infarction
	 	Other Digestive Diseases
	72

	 	Pancreatic diseases
	 	Other Digestive Diseases
	72

	 	Pancreatic steatorrhea
	 	Other Digestive Diseases
	72

	 	Pancreatitis
	 	Other Digestive Diseases
	72

	 	Pancreatolithiasis
	 	Other Digestive Diseases
	37

	 	Panhypopituitarism
	 	Diabetes Mellitus — Endocrine Disorders
	52

	 	Papillary muscle disorder
	 	Other Heart Disease
	67

	 	Paraesophageal hernia
	 	Intestinal Obstruction, Hernia
	17

	 	Paragonimiasis
	 	Other Infective or Parasitic Diseases
	57

	 	Parainfluenza
	 	Pneumonia
	63

	 	paralysis of diaphragm
	 	Other Respiratory
	67

	 	paralytic ileus
	 	Intestinal Obstruction, Hernia
	31

	 	Parametrium Cancer
	 	Cancer — Other
	41

	 	Paranoid Schizophrenia
	 	Mental, Drugs, Alcohol
	47

	 	Paraplegia
	 	Other Nervous System
	38

	 	Paraproteinemia
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	parascarlatina
	 	Other Infective or Parasitic Diseases
	31

	 	Parathyroid Cancer
	 	Cancer — Other
	37

	 	Parathyroid gland disorder
	 	Diabetes Mellitus — Endocrine Disorders
	37

	 	Parathyroiditis
	 	Diabetes Mellitus — Endocrine Disorders
	4

	 	Paratyphoid Fever
	 	Typhoid
	72

	 	Parenchymatous degeneration of liver
	 	Other Digestive Diseases
	47

	 	Parkinson’s disease
	 	Other Nervous System
	47

	 	Paroxysmal choreo-athetosis
	 	Other Nervous System
	52

	 	Paroxysmal supraventricular tachycardia
	 	Other Heart Disease
	52

	 	Paroxysmal ventricular tachycardia
	 	Other Heart Disease
	45

	 	Partial epilepsy
	 	Epilepsy
	63

	 	Passive pneumonia
	 	Other Respiratory
	17

	 	Pasteurellosis
	 	Other Infective or Parasitic Diseases
	82

	 	Patau’s syndrome
	 	Congenital Anomalies
	47

	 	Pelizaeus-Merzbaher disease
	 	Other Nervous System
	38

	 	Pellagra
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Pellagra — Alcoholic
	 	Nutritional, Metabolic & Immunity Disorders
	64

	 	Peptic ulcer
	 	Ulcer, Gastric Hemorrhage
	72

	 	Perforation of bile duct
	 	Other Digestive Diseases
	72

	 	Perforation of esophagus
	 	Other Digestive Diseases
	71

	 	Perforation of gallbladder
	 	Cholelithiasis, Cholecystitis
	72

	 	Perforation of intestine
	 	Other Digestive Diseases
	72

	 	Perianal abscess
	 	Other Digestive Diseases
	54

	 	Periarteritis
	 	Arteries, Arterioles, Capillaries
	52

	 	Pericardial effusion
	 	Other Heart Disease
	52

	 	Pericarditis
	 	Other Heart Disease
	52

	 	Periendocarditis
	 	Other Heart Disease
	74

	 	Perinephric abscess
	 	Kidney Infections
	47

	 	Periorbital cellulitis
	 	Other Nervous System
	80

	 	Periostitis
	 	Osteomyelitis, periostitis
	54

	 	Peripheral angiopathy
	 	Arteries, Arterioles, Capillaries
	47

	 	Peripheral neuropathy  — heriditary
	 	Other Nervous System
	54

	 	Peripheral vascular disease
	 	Arteries, Arterioles, Capillaries
	55

	 	Periphlebitis
	 	Veins, Other Circulatory
	72

	 	Perirectal abscess
	 	Other Digestive Diseases
	72

	 	Peritoneal adhesions
	 	Other Digestive Diseases
	67

	 	Peritoneal adhesions with obstruction
	 	Intestinal Obstruction, Hernia
	72

	 	peritoneal cyst
	 	Other Digestive Diseases

42

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	72

	 	Peritoneal effusion
	 	Other Digestive Diseases
	31

	 	Peritoneum Cancer
	 	Cancer — Other
	72

	 	Peritonitis
	 	Other Digestive Diseases
	47

	 	Peroneal muscular atrophy
	 	Other Nervous System
	9

	 	Pertussis
	 	Whooping Cough
	45

	 	Petit mal epilepsy
	 	Epilepsy
	46

	 	Petrositis
	 	Otitis media and mastoiditis
	38

	 	Pharyngeal pouch syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	63

	 	Pharyngitis
	 	Other Respiratory
	17

	 	Pharyngoconjunctival fever
	 	Other Infective or Parasitic Diseases
	18

	 	Pharynx Cancer
	 	Cancer — Mouth, Throat, Pharynx
	38

	 	Phenylketonuria
	 	Nutritional, Metabolic & Immunity Disorders
	55

	 	Phlebitis
	 	Veins, Other Circulatory
	72

	 	Phlebitis of portal vein
	 	Other Digestive Diseases
	55

	 	Phlebosclerosis
	 	Veins, Other Circulatory
	17

	 	Phlebotomus fever
	 	Other Infective or Parasitic Diseases
	73

	 	Phosphate-losing tubular disorder
	 	Nephritis, Renal Scleroris
	17

	 	Phycomycosis
	 	Other Infective or Parasitic Diseases
	47

	 	Pick’s Disease
	 	Other Nervous System
	52

	 	Pick’s disease of heart & liver
	 	Other Heart Disease
	38

	 	Pigmentary cirrhosis (of liver)
	 	Nutritional, Metabolic & Immunity Disorders
	31

	 	Pineal Gland Cancer
	 	Cancer — Other
	38

	 	Pipecolic acidemia
	 	Nutritional, Metabolic & Immunity Disorders
	37

	 	Pituitary disorders
	 	Diabetes Mellitus — Endocrine Disorders
	37

	 	Pituitary Infarction
	 	Diabetes Mellitus — Endocrine Disorders
	38

	 	PKU (Phenylketonuria)
	 	Nutritional, Metabolic & Immunity Disorders
	27

	 	Placenta Cancer
	 	Cancer — Other Uterine
	33

	 	Plasma cell leukemia
	 	Lymphosarcoma, Etc
	33

	 	Plasmacytic leukemia
	 	Lymphosarcoma, Etc
	24

	 	Pleura Cancer
	 	Cancer — Lung, Trachea
	62

	 	Pleural effusion
	 	Pleurisy
	62

	 	Pleural effusion
	 	Pleurisy
	61

	 	Pleurisy
	 	Emphysema
	57

	 	Pleurobronchopneumonia
	 	Pneumonia
	52

	 	Pleuropericarditis
	 	Other Heart Disease
	43

	 	Pneumococcal meningitis
	 	Meningitis
	52

	 	Pneumococcal myocarditis
	 	Other Heart Disease
	72

	 	Pneumococcal peritonitis
	 	Other Digestive Diseases
	62

	 	Pneumococcal pleurisy
	 	Pleurisy
	57

	 	Pneumococcal pneumonia
	 	Pneumonia
	7

	 	Pneumococcal septicemia
	 	Septicemia
	57

	 	Pneumonia
	 	Pneumonia
	52

	 	Pneumopericarditis
	 	Other Heart Disease
	57

	 	Pneumosepsis
	 	Pneumonia
	63

	 	Pneumothorax
	 	Other Respiratory
	12

	 	Polio
	 	Poliomyelitis
	12

	 	Poliomyelitis
	 	Poliomyelitis
	12

	 	Poliovirus
	 	Poliomyelitis
	54

	 	Polyarteritis nodosa
	 	Arteries, Arterioles, Capillaries
	38

	 	Polyclonal hypergammaglobulinemia
	 	Nutritional, Metabolic & Immunity Disorders
	81

	 	Polymyositis
	 	Other Skin & Musculoskeletal Diseases
	38

	 	Pompe’s disease
	 	Nutritional, Metabolic & Immunity Disorders
	53

	 	Pontine infarction
	 	Cerebrovascular Diseases
	38

	 	Porphyria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Porphyrinuria
	 	Nutritional, Metabolic & Immunity Disorders
	72

	 	Portal pyemia
	 	Other Digestive Diseases
	72

	 	Portal thrombophlebitis
	 	Other Digestive Diseases

43

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	55

	 	Portal vein obstruction
	 	Veins, Other Circulatory
	55

	 	Portal vein thrombosis
	 	Veins, Other Circulatory
	72

	 	Portal-system encephalopathy
	 	Other Digestive Diseases
	52

	 	Postcardiotomy syndrome
	 	Other Heart Disease
	72

	 	Postcholecystectomy syndrome
	 	Other Digestive Diseases
	55

	 	Postmastectomy lymphedema syndrome
	 	Veins, Other Circulatory
	77

	 	Postoperative urethral stricture
	 	Other Genito-Urinary
	37

	 	Postpancreatectomy hyperglycemia
	 	Diabetes Mellitus — Endocrine Disorders
	55

	 	Postphlebitic syndrome
	 	Veins, Other Circulatory
	65

	 	Postpyloric Ulcer
	 	Duodenal Ulcer
	55

	 	Postural hypotension
	 	Veins, Other Circulatory
	77

	 	Postural proteinuria
	 	Other Genito-Urinary
	52

	 	Postvalvulotomy syndrome
	 	Other Heart Disease
	38

	 	Potassium excess, intoxication, overload
	 	Nutritional, Metabolic & Immunity Disorders
	2

	 	Pott’s Disease
	 	Tuberculosis — Nonrespiratory
	13

	 	Powassan encephalitis
	 	Encephalitis
	78

	 	Pregnancy Complications
	 	Complications of Pregnancy
	54

	 	Presenile gangrene
	 	Arteries, Arterioles, Capillaries
	36

	 	Primary thyroid hyperplasia
	 	Thyrotoxicosis
	72

	 	Proctoptosis
	 	Other Digestive Diseases
	40

	 	Prodromal AIDs
	 	AIDS
	47

	 	Progressive bulbar palsy
	 	Other Nervous System
	81

	 	Progressive collagen disease
	 	Other Skin & Musculoskeletal Diseases
	38

	 	Progressive lipodystrophy
	 	Nutritional, Metabolic & Immunity Disorders
	47

	 	Progressive muscular atrophy
	 	Other Nervous System
	77

	 	Prolapse of urethra
	 	Other Genito-Urinary
	72

	 	Proliferative peritonitis
	 	Other Digestive Diseases
	38

	 	Prolinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Prolinuria
	 	Nutritional, Metabolic & Immunity Disorders
	28

	 	Prostate Cancer
	 	Cancer — Prostate
	77

	 	Prostate Infarction
	 	Other Genito-Urinary
	76

	 	Prostatic obstruction
	 	Hyperplasia of Prostate
	77

	 	Prostatitis
	 	Other Genito-Urinary
	77

	 	Prostatocystitis
	 	Other Genito-Urinary
	38

	 	Protocoproporphyria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Protoporphyria
	 	Nutritional, Metabolic & Immunity Disorders
	5

	 	Protozoal intestinal diseases
	 	Intestinal Infections — Other
	38

	 	Pseudo-Hurler’s disease
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Pseudohypoparathyroidism
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Pseudopseudohypoparathryoidism
	 	Nutritional, Metabolic & Immunity Disorders
	63

	 	Pulmolithiasis
	 	Other Respiratory
	63

	 	Pulmonary alveolar microlithiasis
	 	Other Respiratory
	63

	 	Pulmonary alveolar proteinosis
	 	Other Respiratory
	52

	 	Pulmonary apoplexy
	 	Other Heart Disease
	52

	 	Pulmonary arteritis
	 	Other Heart Disease
	54

	 	Pulmonary atherosclerosis
	 	Arteries, Arterioles, Capillaries
	63

	 	Pulmonary collapse
	 	Other Respiratory
	63

	 	Pulmonary congestion
	 	Other Respiratory
	63

	 	Pulmonary decompensation
	 	Other Respiratory
	63

	 	Pulmonary edema
	 	Other Respiratory
	52

	 	Pulmonary edema due to heart failure
	 	Other Heart Disease
	63

	 	Pulmonary edema (no heart failure)
	 	Other Respiratory
	52

	 	Pulmonary embolism
	 	Other Heart Disease
	63

	 	Pulmonary emphysema
	 	Other Respiratory
	52

	 	Pulmonary endarteritis
	 	Other Heart Disease
	63

	 	Pulmonary eosinophilia
	 	Other Respiratory
	63

	 	Pulmonary Fibrosis
	 	Other Respiratory

44

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	61

	 	Pulmonary gangrene
	 	Emphysema
	52

	 	Pulmonary heart disease
	 	Other Heart Disease
	52

	 	Pulmonary hypertension
	 	Other Heart Disease
	63

	 	Pulmonary infarction
	 	Other Respiratory
	52

	 	Pulmonary Infarction
	 	Other Heart Disease
	63

	 	Pulmonary insufficiency
	 	Other Respiratory
	61

	 	Pulmonary necrosis
	 	Emphysema
	52

	 	Pulmonary thrombosis
	 	Other Heart Disease
	1

	 	Pulmonary Tuberculosis
	 	Tuberculosis — Respiratory System
	50

	 	Pulmonary valve disorders
	 	Ischemic & Coronary Heart Disease
	52

	 	Pulmonary vessel rupture
	 	Other Heart Disease
	54

	 	Pulseless disease
	 	Arteries, Arterioles, Capillaries
	61

	 	Purulent pleurisy
	 	Emphysema
	74

	 	Pyelitis
	 	Kidney Infections
	74

	 	Pyelonephritis
	 	Kidney Infections
	74

	 	Pyeloureteritis cystica
	 	Kidney Infections
	45

	 	Pykno-epilepsy
	 	Epilepsy
	72

	 	Pylephlebitis
	 	Other Digestive Diseases
	72

	 	Pylethrombophlebitis
	 	Other Digestive Diseases
	72

	 	Pylorspasm
	 	Other Digestive Diseases
	20

	 	Pylorus Cancer
	 	Cancer — Stomach
	81

	 	Pyogenic arthritis
	 	Other Skin & Musculoskeletal Diseases
	52

	 	Pyopericardium
	 	Other Heart Disease
	61

	 	Pyopneumothorax
	 	Emphysema
	61

	 	Pyothorax
	 	Emphysema
	38

	 	Pyridoxal deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Pyridoxamine deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Pyridoxine deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Pyrroloporphyria
	 	Nutritional, Metabolic & Immunity Disorders
	77

	 	Pyuria
	 	Other Genito-Urinary
	15

	 	Q Fever
	 	Typhus and Ricketsiosis
	17

	 	Rabies
	 	Other Infective or Parasitic Diseases
	17

	 	Rat-bite Fever
	 	Other Infective or Parasitic Diseases
	54

	 	Raynaud’s syndrome
	 	Arteries, Arterioles, Capillaries
	22

	 	Rectal Cancer
	 	Cancer — Rectum, Recto Sigmoid
	72

	 	Rectal prolapse
	 	Other Digestive Diseases
	22

	 	Recto sigmoid Cancer
	 	Cancer — Rectum, Recto Sigmoid
	72

	 	Rectovaginal fistula
	 	Other Digestive Diseases
	22

	 	Rectum Cancer
	 	Cancer — Rectum, Recto Sigmoid
	70

	 	Recurrent hepatitis
	 	Cirrhosis of Liver
	47

	 	Refsum’s disease
	 	Other Nervous System
	69

	 	Regional enteritis
	 	Gastgro-enteritis, Colitis
	17

	 	Reiter’s disease
	 	Other Infective or Parasitic Diseases
	74

	 	Renal abscess
	 	Kidney Infections
	77

	 	Renal artery embolism
	 	Other Genito-Urinary
	77

	 	Renal artery hemorrhage
	 	Other Genito-Urinary
	77

	 	Renal artery thrombosis
	 	Other Genito-Urinary
	54

	 	Renal atherosclerosis
	 	Arteries, Arterioles, Capillaries
	31

	 	Renal Cell Cancer
	 	Cancer — Other
	38

	 	Renal diabetes
	 	Nutritional, Metabolic & Immunity Disorders
	77

	 	Renal disease
	 	Other Genito-Urinary
	77

	 	Renal Failure
	 	Other Genito-Urinary
	38

	 	Renal glycosuria
	 	Nutritional, Metabolic & Immunity Disorders
	77

	 	Renal infarction
	 	Other Genito-Urinary
	77

	 	Renal insufficiency
	 	Other Genito-Urinary
	77

	 	Renal ischemia
	 	Other Genito-Urinary
	73

	 	Renal osteodystrophy
	 	Nephritis, Renal Scleroris

45

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	73

	 	Renal sclerosis
	 	Nephritis, Renal Scleroris
	51

	 	Renal sclerosis with hypertension
	 	Hypertensive Disease
	75

	 	Renal stone
	 	Urinary System Infections
	54

	 	Rendu-Osler-Weber disease
	 	Arteries, Arterioles, Capillaries
	38

	 	Respiratory acidosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Respiratory alkalosis
	 	Nutritional, Metabolic & Immunity Disorders
	87

	 	Respiratory arrest
	 	Unknown Causes & Ill-Defined Causes
	63

	 	Respiratory failure
	 	Other Respiratory
	54

	 	Respiratory granulomatosis
	 	Arteries, Arterioles, Capillaries
	1

	 	Respiratory Tuberculosis
	 	Tuberculosis — Respiratory System
	33

	 	Reticulosarcoma
	 	Lymphosarcoma, Etc
	33

	 	Reticulus cell sarcoma
	 	Lymphosarcoma, Etc
	47

	 	Retinal Ischemia
	 	Other Nervous System
	31

	 	Retroperitoneum Cancer
	 	Cancer — Other
	47

	 	Reye’s Syndrome
	 	Other Nervous System
	81

	 	Rhabdomyolysis
	 	Other Skin & Musculoskeletal Diseases
	30

	 	Rhabdomyosarcoma
	 	Cancer — Bone, Cartilage
	49

	 	Rheumatic aortic insufficiency
	 	Rheumatic Heart Disease
	49

	 	Rheumatic aortic stenosis
	 	Rheumatic Heart Disease
	48

	 	Rheumatic chorea
	 	Rheumatic Fever
	49

	 	Rheumatic endocarditis
	 	Rheumatic Heart Disease
	48

	 	Rheumatic Fever
	 	Rheumatic Fever
	49

	 	Rheumatic Heart Disease
	 	Rheumatic Heart Disease
	49

	 	Rheumatic mitral insufficiency
	 	Rheumatic Heart Disease
	49

	 	Rheumatic myocarditis
	 	Rheumatic Heart Disease
	49

	 	Rheumatic pericarditis
	 	Rheumatic Heart Disease
	49

	 	Rheumatic Tricuspid Valve Insufficiency
	 	Rheumatic Heart Disease
	81

	 	Rheumatoid arthritis
	 	Other Skin & Musculoskeletal Diseases
	81

	 	Rheumatoid carditis
	 	Other Skin & Musculoskeletal Diseases
	17

	 	Rhinoscleroma
	 	Other Infective or Parasitic Diseases
	30

	 	Rhomdbomyosarcoma
	 	Cancer — Bone, Cartilage
	38

	 	Riboflavin deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Rickets
	 	Nutritional, Metabolic & Immunity Disorders
	15

	 	Ricketsiosis
	 	Typhus and Ricketsiosis
	15

	 	Rickettsialpox
	 	Typhus and Ricketsiosis
	36

	 	Riedel’s Thyroiditis
	 	Thyrotoxicosis
	52

	 	Right bundle branch hemiblock
	 	Other Heart Disease
	82

	 	Riley-Day syndrome
	 	Congenital Anomalies
	81

	 	Ritter’s disease
	 	Other Skin & Musculoskeletal Diseases
	15

	 	Rocky Mountain spotted fever
	 	Typhus and Ricketsiosis
	38

	 	Rotor’s syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Rubella
	 	Other Infective or Parasitic Diseases
	14

	 	Rubeola
	 	Measles
	54

	 	Rupture of artery
	 	Arteries, Arterioles, Capillaries
	72

	 	Rupture of bile duct
	 	Other Digestive Diseases
	77

	 	Rupture of bladder
	 	Other Genito-Urinary
	52

	 	Rupture of chordae tendineae
	 	Other Heart Disease
	77

	 	Rupture of diverticulum — bladder
	 	Other Genito-Urinary
	69

	 	Rupture of diverticulum — intestine
	 	Gastgro-enteritis, Colitis
	52

	 	Rupture of papillary muscle
	 	Other Heart Disease
	52

	 	Rupture of pulmonary vessel
	 	Other Heart Disease
	53

	 	Ruptured blood vessel in brain
	 	Cerebrovascular Diseases
	38

	 	Saccharopinuria
	 	Nutritional, Metabolic & Immunity Disorders
	54

	 	Saddle embolus
	 	Arteries, Arterioles, Capillaries
	18

	 	Salivary gland Cancer
	 	Cancer — Mouth, Throat, Pharynx
	72

	 	Salivary Gland Diseases
	 	Other Digestive Diseases
	5

	 	Salmonella Infections
	 	Intestinal Infections — Other

46

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	5

	 	Salmonella septicemia
	 	Intestinal Infections — Other
	38

	 	Sanfilippo’s syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	52

	 	Sarcoidosis — cardiac
	 	Other Heart Disease
	63

	 	Sarcoidosis — Lung
	 	Other Respiratory
	38

	 	Sarcosinemia
	 	Nutritional, Metabolic & Immunity Disorders
	6

	 	Scarlet Fever
	 	Scarlet Fever & Strep Throat
	38

	 	Scheie’s syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	47

	 	Schilder’s disease
	 	Other Nervous System
	17

	 	Schistosomiasis
	 	Other Infective or Parasitic Diseases
	41

	 	Schizophrenic disorders
	 	Mental, Drugs, Alcohol
	81

	 	Scleroderma
	 	Other Skin & Musculoskeletal Diseases
	80

	 	Sclerosinmg osteomyelitis of Garre
	 	Osteomyelitis, periostitis
	39

	 	Scorbutic anemia
	 	Anemia, Thalassemia
	67

	 	Scrotal hernia
	 	Intestinal Obstruction, Hernia
	77

	 	Scrotal Infection
	 	Other Genito-Urinary
	38

	 	Scurvy
	 	Nutritional, Metabolic & Immunity Disorders
	57

	 	Segmental pneumonia
	 	Pneumonia
	45

	 	Seizure Disorder
	 	Epilepsy
	97

	 	Self-Inflicted Injury
	 	Suicide
	85

	 	Senescence
	 	Senility
	54

	 	Senile arteritis
	 	Arteries, Arterioles, Capillaries
	85

	 	Senile asthenia
	 	Senility
	85

	 	Senile debility
	 	Senility
	54

	 	Senile endarteritis
	 	Arteries, Arterioles, Capillaries
	85

	 	Senile exhaustion
	 	Senility
	85

	 	Senility
	 	Senility
	47

	 	Sensory neuropathy — heriditary
	 	Other Nervous System
	7

	 	Sepsis
	 	Septicemia
	52

	 	Septic endocarditis
	 	Other Heart Disease
	52

	 	septic myocarditis
	 	Other Heart Disease
	61

	 	Septic pleurisy
	 	Emphysema
	63

	 	Septic tonsillitis
	 	Other Respiratory
	7

	 	Septicemia
	 	Septicemia
	80

	 	Sequestrum of bone
	 	Osteomyelitis, periostitis
	61

	 	Seropurulent pleurisy
	 	Emphysema
	33

	 	Sezary’s disease
	 	Lymphosarcoma, Etc
	5

	 	Shigellosis
	 	Intestinal Infections — Other
	47

	 	Shy-Drager syndrome
	 	Other Nervous System
	81

	 	Sicca syndrome
	 	Other Skin & Musculoskeletal Diseases
	39

	 	Sickle-cell anemia
	 	Anemia, Thalassemia
	39

	 	Sickle-cell thalassemia
	 	Anemia, Thalassemia
	52

	 	Sinoatrial block
	 	Other Heart Disease
	52

	 	Sinoauricular block
	 	Other Heart Disease
	63

	 	Sinusitis
	 	Other Respiratory
	31

	 	Sipple’s Syndrom
	 	Cancer — Other
	81

	 	Sjogren’s disease
	 	Other Skin & Musculoskeletal Diseases
	29

	 	Skin Cancer
	 	Cancer — Skin, Melanoma
	79

	 	Skin Infection
	 	Skin Infections
	69

	 	Small Bowel Ischemia
	 	Gastgro-enteritis, Colitis
	21

	 	Small Intestine Cancer
	 	Cancer — Colon, Cecum, Sigmoid
	17

	 	Smallpox
	 	Other Infective or Parasitic Diseases
	93

	 	Smoke Inhalation — Accidental
	 	Accidental Fires
	60

	 	Smokers Cough
	 	Bronchitis
	53

	 	Spasm of cerebral arteries
	 	Cerebrovascular Diseases
	63

	 	Spasmodic rhinorrhea
	 	Other Respiratory
	47

	 	Spielmeyer-Vogt disease
	 	Other Nervous System
	82

	 	Spina Bifida
	 	Congenital Anomalies

47

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	47

	 	Spinal Cord Infarction
	 	Other Nervous System
	47

	 	Spinal Cord Ischemia
	 	Other Nervous System
	47

	 	Spinal muscular atrophy
	 	Other Nervous System
	47

	 	Spinocerebellar disease
	 	Other Nervous System
	17

	 	Spirillary fever
	 	Other Infective or Parasitic Diseases
	31

	 	Spleen Cancer
	 	Cancer — Other
	39

	 	Spleen Infarction
	 	Anemia, Thalassemia
	83

	 	Splenomegaly — Bengal
	 	Birth Injuries
	39

	 	Splenomegaly — Chronic
	 	Anemia, Thalassemia
	39

	 	Splenomegaly — Cirrhotic
	 	Anemia, Thalassemia
	83

	 	Splenomegaly — Congenital
	 	Birth Injuries
	39

	 	Splenomegaly — Congestive
	 	Anemia, Thalassemia
	39

	 	Splenomegaly — Congestive
	 	Anemia, Thalassemia
	83

	 	Splenomegaly — Cryptogenic
	 	Birth Injuries
	39

	 	Splenomegaly — Neutropenic
	 	Anemia, Thalassemia
	39

	 	Splenomegaly — Siderotic
	 	Anemia, Thalassemia
	17

	 	Splenomegaly — Syphilitic
	 	Other Infective or Parasitic Diseases
	17

	 	Splenomegaly — Tropical
	 	Other Infective or Parasitic Diseases
	81

	 	Spontaneous fracture
	 	Other Skin & Musculoskeletal Diseases
	55

	 	Spontaneous hemorrhage
	 	Veins, Other Circulatory
	75

	 	Staghorn calculus
	 	Urinary System Infections
	5

	 	Staphylococcal food poisoning
	 	Intestinal Infections — Other
	43

	 	Staphylococcal meningitis
	 	Meningitis
	52

	 	Staphylococcal myocarditis
	 	Other Heart Disease
	62

	 	Staphylococcal pleurisy
	 	Pleurisy
	7

	 	Staphylococcal septicemia
	 	Septicemia
	63

	 	Staphylococcal tonsillitis
	 	Other Respiratory
	72

	 	Stenosis of bile duct
	 	Other Digestive Diseases
	72

	 	Stenosis of esophagus
	 	Other Digestive Diseases
	67

	 	Stenosis of intestine or colon
	 	Intestinal Obstruction, Hernia
	20

	 	Stomach Cancer
	 	Cancer — Stomach
	64

	 	Stomach ulcer
	 	Ulcer, Gastric Hemorrhage
	39

	 	Stomatocytosis
	 	Anemia, Thalassemia
	67

	 	Strangulated Inguinal hernia
	 	Intestinal Obstruction, Hernia
	17

	 	Streptobacillary fever
	 	Other Infective or Parasitic Diseases
	6

	 	Streptococal Sore Throat
	 	Scarlet Fever & Strep Throat
	43

	 	Streptococcal meningitis
	 	Meningitis
	62

	 	Streptococcal pleurisy
	 	Pleurisy
	7

	 	Streptococcal septicemia
	 	Septicemia
	64

	 	Stress ulcer
	 	Ulcer, Gastric Hemorrhage
	72

	 	Stricture of anus
	 	Other Digestive Diseases
	54

	 	Stricture of artery
	 	Arteries, Arterioles, Capillaries
	72

	 	Stricture of bile duct
	 	Other Digestive Diseases
	67

	 	Stricture of intestine or colon
	 	Intestinal Obstruction, Hernia
	53

	 	Stroke
	 	Cerebrovascular Diseases
	53

	 	Stroke — Basal Ganglia
	 	Cerebrovascular Diseases
	36

	 	Struma lymphomatosa
	 	Thyrotoxicosis
	53

	 	Subarachnoid hemorrhage
	 	Cerebrovascular Diseases
	53

	 	Subclavian steal syndrome
	 	Cerebrovascular Diseases
	53

	 	Subdural hematoma
	 	Cerebrovascular Diseases
	53

	 	Subdural hemorrhage
	 	Cerebrovascular Diseases
	50

	 	Subendocardial infarction
	 	Ischemic & Coronary Heart Disease
	50

	 	Subendocardial ischemia
	 	Ischemic & Coronary Heart Disease
	23

	 	Subglottis Cancer
	 	Cancer — Larynx
	87

	 	Sudden Death
	 	Unknown Causes & Ill-Defined Causes
	81

	 	Sudeck’s atrophy
	 	Other Skin & Musculoskeletal Diseases
	97

	 	Suicide
	 	Suicide

48

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	47

	 	Sulfatid lipidosis
	 	Other Nervous System
	81

	 	Sunburn
	 	Other Skin & Musculoskeletal Diseases
	55

	 	Suppurative phlebitis
	 	Veins, Other Circulatory
	23

	 	Supraglottis Cancer
	 	Cancer — Larynx
	37

	 	Suprarenal Infarction
	 	Diabetes Mellitus — Endocrine Disorders
	30

	 	Synovial Sarcoma
	 	Cancer — Bone, Cartilage
	3

	 	Syphilis
	 	Syphilis
	3

	 	Syphilitic aortitis
	 	Syphilis
	3

	 	Syphilitic encephalitis
	 	Syphilis
	3

	 	Syphilitic endocarditis
	 	Syphilis
	3

	 	Syphilitic meningitis
	 	Syphilis
	3

	 	Syphilitic Parkinsonism
	 	Syphilis
	3

	 	Syphilitic Retrobulbar neuritis
	 	Syphilis
	47

	 	Syringobulbia
	 	Other Nervous System
	47

	 	Syringomyelia
	 	Other Nervous System
	81

	 	Systemic lups erythematosus
	 	Other Skin & Musculoskeletal Diseases
	81

	 	Systemic sclerosis
	 	Other Skin & Musculoskeletal Diseases
	3

	 	Tabes dorsalis
	 	Syphilis
	52

	 	Tachycardia
	 	Other Heart Disease
	54

	 	Takayasu’s disease
	 	Arteries, Arterioles, Capillaries
	47

	 	Tay-Sachs disease
	 	Other Nervous System
	69

	 	Terminal Hemorrhagic enteropathy
	 	Gastgro-enteritis, Colitis
	54

	 	Termporal arteritis
	 	Arteries, Arterioles, Capillaries
	99

	 	Terrorism
	 	War
	31

	 	Testicular Cancer
	 	Cancer — Other
	31

	 	Testis Cancer
	 	Cancer — Other
	77

	 	Testis Infarction
	 	Other Genito-Urinary
	11

	 	Tetanus
	 	Tetanus
	39

	 	Thalassemia
	 	Anemia, Thalassemia
	62

	 	Thickening of pleura
	 	Pleurisy
	54

	 	Thoracic aneurysm
	 	Arteries, Arterioles, Capillaries
	54

	 	Thromboangiitis obliterans
	 	Arteries, Arterioles, Capillaries
	32

	 	Thrombocytic leukemia
	 	Leukemia
	55

	 	Thrombophlebitis
	 	Veins, Other Circulatory
	55

	 	Thrombophlebitis migrans
	 	Veins, Other Circulatory
	55

	 	Thrombophlebitis of breast
	 	Veins, Other Circulatory
	55

	 	Thrombosis
	 	Veins, Other Circulatory
	55

	 	Thrombosis
	 	Veins, Other Circulatory
	53

	 	Thrombosis of basilar artery
	 	Cerebrovascular Diseases
	53

	 	Thrombosis of carotid artery
	 	Cerebrovascular Diseases
	69

	 	Thrombosis of mesenteric artery
	 	Gastgro-enteritis, Colitis
	47

	 	Thrombosis of Spinal cord
	 	Other Nervous System
	53

	 	Thrombosis of vertebral artery
	 	Cerebrovascular Diseases
	54

	 	Thrombotic infarction
	 	Arteries, Arterioles, Capillaries
	55

	 	Thrombotic Infarction
	 	Veins, Other Circulatory
	54

	 	Thrombotic microangiopathy
	 	Arteries, Arterioles, Capillaries
	54

	 	Thrombotic thrombocytopenic purpura
	 	Arteries, Arterioles, Capillaries
	38

	 	Thymic hypoplasia
	 	Nutritional, Metabolic & Immunity Disorders
	24

	 	Thymus Cancer
	 	Cancer — Lung, Trachea
	37

	 	Thymus gland disorders
	 	Diabetes Mellitus — Endocrine Disorders
	36

	 	Thyroid Hemorrhage
	 	Thyrotoxicosis
	36

	 	Thyroid Infarction
	 	Thyrotoxicosis
	36

	 	Thyroiditis
	 	Thyrotoxicosis
	36

	 	Thyrotoxicosis
	 	Thyrotoxicosis
	33

	 	TIAs
	 	Lymphosarcoma, Etc
	15

	 	Tick Fever
	 	Typhus and Ricketsiosis
	15

	 	Tick-borne rickettsioses
	 	Typhus and Ricketsiosis

49

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	13

	 	Tick-borne viral encephalitis
	 	Encephalitis
	18

	 	Tongue Cancer
	 	Cancer — Mouth, Throat, Pharynx
	18

	 	Tonsil Cancer
	 	Cancer — Mouth, Throat, Pharynx
	63

	 	Tonsillitis
	 	Other Respiratory
	36

	 	Toxic Diffuse Goiter
	 	Thyrotoxicosis
	47

	 	Toxic encephalopathy
	 	Other Nervous System
	81

	 	Toxic epidermal necrolysis
	 	Other Skin & Musculoskeletal Diseases
	69

	 	Toxic gastoenteritis
	 	Gastgro-enteritis, Colitis
	69

	 	Toxic megacolon
	 	Gastgro-enteritis, Colitis
	52

	 	Toxic myocarditis
	 	Other Heart Disease
	47

	 	Toxic myoneural disorder
	 	Other Nervous System
	36

	 	Toxic uninodular goiter
	 	Thyrotoxicosis
	17

	 	Toxoplasmosis
	 	Other Infective or Parasitic Diseases
	24

	 	Trachea Cancer
	 	Cancer — Lung, Trachea
	1

	 	Tracheal tuberculosis
	 	Tuberculosis — Respiratory System
	63

	 	Tracheitis
	 	Other Respiratory
	60

	 	Tracheobronchitis
	 	Bronchitis
	17

	 	Trachoma
	 	Other Infective or Parasitic Diseases
	53

	 	Transient cerebral ischemia
	 	Cerebrovascular Diseases
	17

	 	Trichinosis
	 	Other Infective or Parasitic Diseases
	17

	 	Trichomoniasis
	 	Other Infective or Parasitic Diseases
	50

	 	Tricuspid valve disorders
	 	Ischemic & Coronary Heart Disease
	52

	 	Trifascicular block
	 	Other Heart Disease
	38

	 	Triglyceride storage disease
	 	Nutritional, Metabolic & Immunity Disorders
	77

	 	Trigonitis
	 	Other Genito-Urinary
	82

	 	Trisomy 13, 21, 22, D1, 18, E3, G
	 	Congenital Anomalies
	63

	 	Tropical eosinophilia
	 	Other Respiratory
	17

	 	Tropical pyomyositis
	 	Other Infective or Parasitic Diseases
	17

	 	Tropical Splenomegaly
	 	Other Infective or Parasitic Diseases
	72

	 	Tropical sprue
	 	Other Digestive Diseases
	72

	 	Tropical steatorrhea
	 	Other Digestive Diseases
	17

	 	Trypanosomiasis
	 	Other Infective or Parasitic Diseases
	2

	 	Tuberculosis — Nonrespiratory
	 	Tuberculosis — Nonrespiratory
	1

	 	Tuberculosis — Respiratory System
	 	Tuberculosis — Respiratory System
	2

	 	Tuberculosis of bones and joints
	 	Tuberculosis — Nonrespiratory
	2

	 	Tuberculosis of genitourinary system
	 	Tuberculosis — Nonrespiratory
	1

	 	Tuberculosis of intrathoracic lymph nodes
	 	Tuberculosis — Respiratory System
	2

	 	Tuberculous encephalitis
	 	Tuberculosis — Nonrespiratory
	2

	 	Tuberculous of brain or spinal cord
	 	Tuberculosis — Nonrespiratory
	2

	 	Tuberculous peritonitis
	 	Tuberculosis — Nonrespiratory
	1

	 	Tuberculous pleurisy
	 	Tuberculosis — Respiratory System
	1

	 	Tuberculous pneumonia
	 	Tuberculosis — Respiratory System
	1

	 	Tuberculous pneumothorax
	 	Tuberculosis — Respiratory System
	2

	 	Tubercuous oophoritis
	 	Tuberculosis — Nonrespiratory
	73

	 	Tubular necrosis
	 	Nephritis, Renal Scleroris
	17

	 	Tularemia
	 	Other Infective or Parasitic Diseases
	4

	 	Typhoid
	 	Typhoid
	15

	 	Typhus and Ricketsiosis
	 	Typhus and Ricketsiosis
	38

	 	Tyrosinosis
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Tyrosinuria
	 	Nutritional, Metabolic & Immunity Disorders
	64

	 	Ulcer
	 	Ulcer, Gastric Hemorrhage
	54

	 	Ulcer of artery
	 	Arteries, Arterioles, Capillaries
	72

	 	Ulcer of esophagus
	 	Other Digestive Diseases
	72

	 	Ulcer or rectum or anus
	 	Other Digestive Diseases
	63

	 	Ulcerative tonsillitis
	 	Other Respiratory
	81

	 	Ulcers — Decubitis
	 	Other Skin & Musculoskeletal Diseases
	67

	 	Umbilical hernia
	 	Intestinal Obstruction, Hernia

50

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	87

	 	Unattended death
	 	Unknown Causes & Ill-Defined Causes
	87

	 	Unknown
	 	Unknown Causes & Ill-Defined Causes
	47

	 	Unverricht-Lundborg disease
	 	Other Nervous System
	72

	 	Upper Gastrointestinal bleeding
	 	Other Digestive Diseases
	24

	 	Upper Respiratory Cancer
	 	Cancer — Lung, Trachea
	73

	 	Uremia
	 	Nephritis, Renal Scleroris
	87

	 	Uremia
	 	Unknown Causes & Ill-Defined Causes
	51

	 	Uremic hypertension
	 	Hypertensive Disease
	31

	 	Ureter Cancer
	 	Cancer — Other
	77

	 	Ureteral fistula
	 	Other Genito-Urinary
	74

	 	Ureteritis cystica
	 	Kidney Infections
	31

	 	Urethra Cancer
	 	Cancer — Other
	77

	 	Urethral abscess
	 	Other Genito-Urinary
	77

	 	Urethral caruncle
	 	Other Genito-Urinary
	77

	 	Urethral diverticulum
	 	Other Genito-Urinary
	77

	 	Urethral granuloma
	 	Other Genito-Urinary
	77

	 	Urethral stricture
	 	Other Genito-Urinary
	77

	 	Urethritis
	 	Other Genito-Urinary
	77

	 	Urethrotrigonitis
	 	Other Genito-Urinary
	77

	 	Urethrovesical fistula
	 	Other Genito-Urinary
	38

	 	Uric Acid nephrolithiasis
	 	Nutritional, Metabolic & Immunity Disorders
	75

	 	Urinary bladder stone
	 	Urinary System Infections
	75

	 	Urinary calculus
	 	Urinary System Infections
	77

	 	Urinary obstruction
	 	Other Genito-Urinary
	75

	 	Urinary System Infection
	 	Urinary System Infections
	77

	 	Urinary Tract infection
	 	Other Genito-Urinary
	77

	 	Urinoma
	 	Other Genito-Urinary
	77

	 	Urosepsis
	 	Other Genito-Urinary
	27

	 	Uterine Cancer
	 	Cancer — Other Uterine
	77

	 	UTI
	 	Other Genito-Urinary
	31

	 	Vagina Cancer
	 	Cancer — Other
	50

	 	Valvular heart disease
	 	Ischemic & Coronary Heart Disease
	55

	 	Varicose veins
	 	Veins, Other Circulatory
	54

	 	Vascular degeneration
	 	Arteries, Arterioles, Capillaries
	69

	 	Vascular insufficiency of intestine
	 	Gastgro-enteritis, Colitis
	47

	 	Vascular myelopathies
	 	Other Nervous System
	55

	 	Vein inflammation
	 	Veins, Other Circulatory
	17

	 	Venereal disease
	 	Other Infective or Parasitic Diseases
	55

	 	Venofibrosis
	 	Veins, Other Circulatory
	55

	 	Venous insufficiency
	 	Veins, Other Circulatory
	63

	 	Ventilation pneumonitis
	 	Other Respiratory
	67

	 	Ventral hernia
	 	Intestinal Obstruction, Hernia
	52

	 	Ventricular cardiac arrhythmia
	 	Other Heart Disease
	52

	 	Ventricular failure
	 	Other Heart Disease
	52

	 	Ventricular fibrillation
	 	Other Heart Disease
	52

	 	Ventricular flutter
	 	Other Heart Disease
	53

	 	Ventricular hemorrhage
	 	Cerebrovascular Diseases
	52

	 	Ventricular hypertrophy
	 	Other Heart Disease
	53

	 	Vertebral Artery Ischemia
	 	Cerebrovascular Diseases
	53

	 	Vertebral artery syndrome
	 	Cerebrovascular Diseases
	30

	 	Vertebral Cancer
	 	Cancer — Bone, Cartilage
	81

	 	Vertebral collapse
	 	Other Skin & Musculoskeletal Diseases
	77

	 	Vesicocolic fistula
	 	Other Genito-Urinary
	77

	 	Vesicocutaneous fistula
	 	Other Genito-Urinary
	77

	 	Vesicoenteric fistula
	 	Other Genito-Urinary
	77

	 	Vesicoperineal fistula
	 	Other Genito-Urinary
	77

	 	Vesicorectal fistula
	 	Other Genito-Urinary

51

 

Benefit Payments Procedure Manual

Ordinary Life Claims

	 	 	 	 	 
	77

	 	Vesicoureteral reflux
	 	Other Genito-Urinary
	17

	 	Vincent’s angina
	 	Other Infective or Parasitic Diseases
	17

	 	Viral conjunctivitis
	 	Other Infective or Parasitic Diseases
	17

	 	Viral hepatitis
	 	Other Infective or Parasitic Diseases
	17

	 	Viral hepatitis A
	 	Other Infective or Parasitic Diseases
	17

	 	Viral hepatitis B
	 	Other Infective or Parasitic Diseases
	57

	 	Viral pneumonia
	 	Pneumonia
	57

	 	Viral pneumonitis
	 	Pneumonia
	63

	 	Viral tonsillitis
	 	Other Respiratory
	77

	 	Viral URTI (Urinary Tract Infection)
	 	Other Genito-Urinary
	38

	 	Vitamin A deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Vitamin B deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Vitamin B12 deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Vitamin B6 deficiency syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Vitamin Deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	31

	 	Vocal Cord Cancer
	 	Cancer — Other
	47

	 	Vogt’s Disease
	 	Other Nervous System
	38

	 	Volume Depletion
	 	Nutritional, Metabolic & Immunity Disorders
	67

	 	Volvulus
	 	Intestinal Obstruction, Hernia
	38

	 	von Gierke’s disease
	 	Nutritional, Metabolic & Immunity Disorders
	31

	 	Vulva Cancer
	 	Cancer — Other
	38

	 	Waardenburg syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Waldenstrom’s hypergammaglobulinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Waldenstrom’s macroglobulinemia
	 	Nutritional, Metabolic & Immunity Disorders
	99

	 	War
	 	War
	87

	 	Wasting disease
	 	Unknown Causes & Ill-Defined Causes
	10

	 	Waterhouse-Friderichsen syndrome
	 	Meningococcal Infection
	52

	 	Weak heart
	 	Other Heart Disease
	54

	 	Wegeber’s granulomatosis
	 	Arteries, Arterioles, Capillaries
	54

	 	Wegener’s syndrome
	 	Arteries, Arterioles, Capillaries
	47

	 	Werdnig-Hoffmann disease
	 	Other Nervous System
	37

	 	Wermer’s syndrome
	 	Diabetes Mellitus — Endocrine Disorders
	41

	 	Wernicke-Korsakoff syndrome
	 	Mental, Drugs, Alcohol
	17

	 	Whipple’s disease
	 	Other Infective or Parasitic Diseases
	9

	 	Whooping Cough
	 	Whooping Cough
	38

	 	WIlson’s Disease
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Wiskott-Aldrich syndrome
	 	Nutritional, Metabolic & Immunity Disorders
	63

	 	Woakes’ syndrome
	 	Other Respiratory
	52

	 	Wolff-Parkinson-White syndrome
	 	Other Heart Disease
	38

	 	Wolman’s disease
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Xanthinuria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Xanthoma tuberosum
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Xerophthalmia due to Vitamin A deficiency
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	X-Linked agammaglobulinemia
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Xylosuria
	 	Nutritional, Metabolic & Immunity Disorders
	38

	 	Xylulosuria
	 	Nutritional, Metabolic & Immunity Disorders
	17

	 	Yaws
	 	Other Infective or Parasitic Diseases
	72

	 	Yellow atrophy of liver
	 	Other Digestive Diseases

52

 

Exhibit D

REINSURANCE PREMIUMS

	D.1  	 	Life
	 
	 	 	Plans covered under this Agreement will be reinsured on a YRT basis. Reinsurance premiums will be based on the following
percentage of the attached 2001 Select and Ultimate Valuation Basic Table, Male, Smoker Composite, Age Last Birthday.

	 	 	 	 	 	 	 	 	 	 	 	 	 
	Plan(s)/Rider(s)	 	Class	 	Duration 1	 	Duration 2 on
	Modified
	 	Aggregate	 	 	0	%	 	 	110	%
	Whole Life
	 	 	 	 	 	 	 	 	 	 	 	 

	D.2  	 	Age Basis
	 
	 	 	Age Last
	 
	D.3  	 	Policy Fees
	 
	 	 	IHLIC will not participate in any policy fees.
	 
	D.4  	 	Recapture Period
	 
	 	 	Number of years:       20
	 
	D.5  	 	Substandard Ratings
	 
	 	 	Premiums will be based on the standard rate increased by an extra 25% per table of assessed rating.
Allowances are the same as those for standard life coverage.
	 
	D.6  	 	Flat Extras
	 
	 	 	The total premium remitted to IHLIC will include the flat extra premium minus the allowances shown below.

	 	 	 	 	 	 	 	 	 
	Type of Flat Extra Premium	 	First Year	 	Renewal
	Temporary (1-5 years)
	 	 	90	%	 	 	90	%
	Permanent (6 years & greater)
	 	 	25	%	 	 	90	%

 

 

Exhibit E

SELF-ADMINISTERED REPORTING

	E.1  	 	The Ceding Company, through the Administrator, will self-administer all reinsurance
reporting. The Ceding Company, through the Administrator, will send IHLIC the reports listed
below at the frequency specified.
	 
	 	 	Transaction Reports [monthly]

	 	1.	 	New Business
	 
	 	2.	 	First Year – Other than New Business
	 
	 	3.	 	Renewal Year
	 
	 	4.	 	Changes and Terminations
	 
	 	5.	 	Accounting Information

	 	 	Periodic Reports

	 	6.	 	Statutory Reserve Information (quarterly)
	 
	 	7.	 	Policy Exhibit Information (monthly)
	 
	 	8.	 	Inforce (monthly)

	 	 	A brief description of the data requirements follows below.
	 
	 	 	Transaction Reports
	 
	 	 	The Ceding Company, through the Administrator, agrees to provide the following policy data
in each report as outlined in Exhibits F, G and H, and as referenced below:

	 	1.	 	New Business
	 
	 	 	 	This report will include new issues only, the first time the policy is reported to
IHLIC. Automatic and Facultative business will be identified separately.
	 
	 	2.	 	First Year – Other than New Business
	 
	 	 	 	This report will include policies previously reported on the new business detail and
still in their first duration, or policies involved in first year premium
adjustments.
	 
	 	3.	 	Renewal Year
	 
	 	 	 	All policies with renewal dates within the Accounting Period will be listed.

 

 

Exhibit E

(continued)

	 	4.	 	Changes and Terminations
	 
	 	 	 	Policies affected by a change during the current reporting period will be included
in this report. Type of change or termination activity must be clearly identified
for each policy.
	 
	 	 	 	The Ceding Company, through the Administrator, will identify the following
transactions either by separate listing or unique transaction codes: Terminations,
Reinstatements, Changes, Conversions, and Replacements. For Conversions and
Replacements, the Ceding Company, through the Administrator, will report the
original policy date, as well as the current policy date.
	 
	 	5.	 	Accounting Information
	 
	 	 	 	Premiums and allowances will be summarized for Life coverages, Benefits, and Riders
by the following categories: Automatic and Facultative, First Year and Renewals.

	 	 	Periodic Reports

	 	6.	 	Statutory Reserve Information
	 
	 	 	 	Statutory reserves will be summarized for Life coverages, Benefits and Riders. The
Ceding Company, through the Administrator, will specify the reserve basis used.
	 
	 	7.	 	Policy Exhibit Information
	 
	 	 	 	This is a summary of transactions during the current period and on a year-to-date
basis, reporting the number of policies and reinsured amount.
	 
	 	8.	 	Inforce
	 
	 	 	 	This is a detailed report of each policy in force.

 

 

Exhibit F

LIST OF RISKS REINSURED

The “List of Risks Reinsured,” showing all renewing policies, should be prepared and submitted
monthly, quarterly, or annually according to the terms of the Agreement. At least once a year at
the end of each year, a list must be submitted by the Ceding Company to IHLIC including ALL
risks reinsured under this Agreement. Premiums due should be included only for the period being
reported. The information required to be shown on such lists is set out below.

	 	 	 	 	 	 	 	 	 
	 	 	A.	 	Policy number
	 
	 	 	 	 	 	 	 	 
	 	 	B.	 	Name of insured (minimum is surname and first initial; prefer to have first name and
middle initial as well.)
	 
	 	 	 	 	 	 	 	 
	 	 	C.	 	Sex
	 
	 	 	 	 	 	 	 	 
	 	 	D.	 	Date of birth (month, day, year)
	 
	 	 	 	 	 	 	 	 
	 	 	E.	 	Issue age
	 
	 	 	 	 	 	 	 	 
	*	 	F.	 	Attained age
	 
	 	 	 	 	 	 	 	 
	 	 	G.	 	Policy date (month, day, year) or date of increase/decrease in specified amount
	 
	 	 	 	 	 	 	 	 
	 	 	H.	 	Transaction code (in force)
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	1.	 	 	First year, newly reported (i.e., new business)
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	2.	 	 	First year, previously reported (i.e., renewal business in first policy year)
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	3.	 	 	Renewal
	 
	 	 	 	 	 	 	 	 
	 	 	I.	 	Substandard rating (table, mortality percentage, flat extra amount and duration. Show
multiple of standard for ADB or WPD.)
	 
	 	 	 	 	 	 	 	 
	 	 	J.	 	Plan or plan code (if more than one plan is covered by the Agreement)
	 
	 	 	 	 	 	 	 	 
	 	 	K.	 	Underwriting class (smoker, nonsmoker, preferred, etc.)
	 
	 	 	 	 	 	 	 	 
	 	 	L.	 	Specified amount issued (life, ADB, WPD)
	 
	 	 	 	 	 	 	 	 
	 	 	M.	 	Death benefit option (i.e., cash value included in or in addition to the
specified amount)
	 
	 	 	 	 	 	 	 	 
	*	 	N.	 	Current death benefit (under original policy)
	 
	 	 	 	 	 	 	 	 
	 	 	O.	 	Proportion reinsured this policy (where applicable)
	 
	 	 	 	 	 	 	 	 
	 	 	P.	 	Amount reinsured
	 
	 	 	 	 	 	 	 	 
	 	 	Q.	 	Current reinsurance amount at risk
	 
	 	 	 	 	 	 	 	 
	 	 	R.	 	Reinsurance premium (life, ADB, WPD)
	 
	 	 	 	 	 	 	 	 
	*	 	S.	 	Net cash amount due IHLIC (life, ADB, WPD)
	 
	 	 	 	 	 	 	 	 
	*	 	T.	 	Automatic or facultative
	 
	 	 	 	 	 	 	 	 
	*	 	U.	 	Currency code if not U.S. currency

 

			
	*	 	Desirable but not required

 

 

Exhibit F

(continued)

There should be separate subtotals for all items listed below. Each subtotal should include:

	 	 	 
	Policy count

	 	(life—separately for new business, renewals, and combined)
	Reinsurance amount at risk

	 	(separately for new business, renewals, and combined)
	Reinsurance premium

	 	(separately for new business, renewals, and combined)
	Reinsurance commission

	 	(separately for new business, renewals, and combined)
	Net amount due IHLIC

	 	(separately for new business, renewals, and combined)

The various policy details including reinsurance amount at risk and proportion reinsured shown on
the “List of Risks Reinsured” should correspond to the in force after any changes reported
concurrently on the “List of Amendments.” We need a grand total each reporting period for policy
count in force and reinsurance amount at risk in force (separately for new business, renewals, and
combined). A separate total of ADB in force is needed. This need not be separated into new
business and renewals.

A grand total of reinsurance premium and net amount due IHLIC, including all in force and
amendments, should be shown (separately for first year, renewals, and combined categories).
Separate totals should be provided for life, ADB, and WPD. This may be shown on the “List of Risks
Reinsured” or may be included in a separate summary.

Where premiums for more than one period are being reported on a single list, the basic
identification (policy number, name of insured, sex, date of birth, age, and policy date) need be
shown only one time on the first line for the policy. Subsequent lines should each relate to a
different period and the period involved should be indicated.

Although an increase or decrease in the specified amount will not, as a rule, result in the
issuance of a new policy, the amount of such increase or decrease should be reported separately
from the base specified amount so that differences in premium rates can be reflected. For example,
the amount of increase in specified amount might involve a substandard rating that differs from the
rating for the base specified amount. In any such case, it might be a good idea to assign a
separate policy number suffix.

Any significant deviations from these reporting guidelines must be agreed to by IHLIC.

 

 

Exhibit G

LIST OF AMENDMENTS

Each “List of Amendments” (monthly, quarterly, or annual) should show details for each policy for
which any transaction (see codes 4–12 below) occurred which has an effect on either the reinsurance
amount at risk or reinsurance premium. The basic policy details to be shown include the following:

	 	 	 	 	 	 	 	 	 
	 	 	a.	 	Policy number
	 
	 	 	 	 	 	 	 	 
	 	 	b.	 	Name of insured
	 
	 	 	 	 	 	 	 	 
	*	 	c.	 	Date of birth
	 
	 	 	 	 	 	 	 	 
	 	 	d.	 	Transaction code (changes to in force)
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	4.	 	 	Termination without value
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	5.	 	 	Policy not placed (NTO)
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	6.	 	 	Surrender (full or partial)
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	7.	 	 	Reinstatement
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	8.	 	 	Increase in specified amount
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	9.	 	 	Decrease in specified amount
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	10.	 	 	Conversion or change of plan (e.g., Option A to Option B)
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	11.	 	 	Death
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	12.	 	 	Other (Please describe.)
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	Under item 12, we would like you to describe any other amendments such as partial
recapture, full recapture, table rating reduction, etc,
	 
	 	 	 	 	 	 	 	 
	 	 	e.	 	Effective date of transaction
	 
	 	 	 	 	 	 	 	 
	 	 	f.	 	Net increase or decrease in reinsurance amount at risk from the reinsurance amount at risk
last reported to IHLIC before the change
	 
	 	 	 	 	 	 	 	 
	 	 	g.	 	Reinsurance premium adjustment (separately for first year/renewal)
	 
	 	 	 	 	 	 	 	 
	 	 	h.	 	Net adjustment due IHLIC (separately for first year/renewal)
	 
	 	 	 	 	 	 	 	 
	 	 	i.	 	Currency code if not U.S. currency
	 
	 	 	 	 	 	 	 	 
	 	 	Subtotals of policy count and reinsurance amount at risk should be provided for each transaction
code where the transaction is such that the life policy count in force is altered by the
transaction. For items g and h only grand totals are required (separately for first
year/renewal/combined).
	 
	 	 	 	 	 	 	 	 
	 	 	The premium adjustments should include adjustments up to the current reporting period
(e.g., month, quarter). Premiums for the current reporting period should appear on the “List of
Risks Reinsured.”
	 
	 	 	 	 	 	 	 	 
	 	 	It is not necessary to adhere strictly to the set of transaction codes shown above as long as the
amendments are clearly identified and appropriate subtotals and totals can be provided.

 

			
	*	 	Desirable but not required

 

 

Exhibit H

	IN-FORCE SUMMARY FORM

	SELF-ADMINISTERED LIFE REINSURANCE

	Summary Report

	For the Period   through  

	| |
Investors Heritage Life Insurance Company
Account
Company Name            Number
——  —
Treaty ID:
—
Plan ID:
—
Prepared By            Date            Phone
—

	| |

	I. Policy Exhibit Summary (Life Reinsurance Only)

	Number of            Amount of
Policies            Reinsurance
A. In Force As Of Last Report
B. New Paid Reinsurance Ceded
C. NTO
D. Reinstatements
E. Administrative New Business (Conversions, Etc.)
F. Lapses
G. Recaptures
H. Surrenders (Coinsurance Only)
I. Death
J. Expiries
K. Administrative Lapses
L. Increase/Decrease            XXXXXX
M. In Force As Of Current Report
N. ADB In Force As of Current Report            XXXXXX
==================================== =========

	II. Accounting Summary

	Net Due
Category            Premiums            Commissions            Other* IHLIC-Life
First Year            Renewal Year            First Year            Renewal Year
Life
WP
ADB
Total
=====

	* If more than one category is included (e.g., surrender benefits,
dividends), please show details on the reverse side

	of this form. RADF61

	Exhibit I Application for Facultative Reinsurance

	| | |
LIFE            WPD            ADB
——  -—  —
Previous In Force
Previous Retained
Issued This Policy
Retained This Policy
Reinsured Amount
—

	| | |

	Inforce Policies:
—
Policy Number            Issue Amount            Retained Amount
——  ——  —

	Comments

	Policy            Amount
Year            Age            At Risk
====== === =======

	FACULTATIVE-AUTOMATIC SUBMISSION Investors Heritage Life Insurance Company

	Ceding Co.: ORIGINAL-ADDITIONAL-MIB Inquiry Only P. O. Box 717, Frankfort, KY 40602
Address: Telephone: (502) 223-2361
Underwriter’s Name: DATE: Fax: (502) 875-7084
Underwriting Area:

	Insured’s Name (Lst, Fst, M) Policy Number: Original Pol No.:
Date of Birth: Issue Age: Sex: Policy Date: Original Pol Date:
Birth State: Birth Country: Reins Eff Date: Original Iss Age:
Reside State: Reside Country: Continuation: Duration:

	Occupation: Policy Certificate ID:
——  ——  —
Second Insured’s Name:
——  ——  —
Date of Birth: Issue Age: Sex:
——  —

	Plan Name: Smoker Code:
——  ——  —
Rider Name: Smoker Code:
——  ——  —

	Life Rates:
——  ——  —
Reserve Basis:
——  ——  —

	Benefit 1: Ben 1 Rating:
——  ——  —
Benefit 2: Ben 2 Rating:
——  ——  —
Benefit 3: Ben 3 Rating:
——  ——  —
Benefit 4: Ben 4 Rating:
——  ——  —
Benefit 5: Ben 5 Rating:
——  ——  —

	Flat Extra 1: Flat Ex 1 Dur:
Flat Extra 2: Flat Ex 2 Dur:

	Submission Type:Fac            Auto
——  ——  —
Original Submission Date:
——  —
Offer Accepted Date:
——  ——  —
Withdrawal Date:
——  ——  —

	Submitted File Includes:
========================
Application            X-Ray
——  —
Medical Examination            Other Medical Underwriting Data
——  —
Blood Profile            Inspection Report
——  —
Heart Chart            Additional Inspection Report
——  —
Attending Physician’s Report            Aviation Questionnaire
——  —
Microscopic Urinalysis            Other Non-medical Data
——  —
Electrocardiogram
=================

	Circle Withdrawal Reason:

	1. Underwriting Not Complete
2. Policy Not Delivered
3. All Within Our Retention
4. Placed With Automatic Reinsurer
5. Placed With Another Reinsurer:

	a) Rating b) Requirements c) Quicker Response

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00126-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00126-of-00352.parquet"}]]