Common use of First Name Listed Below Will Clause in Contracts

First Name Listed Below Will. Be The Servicing Producer ------------------------------------------------------------------------------------------------------------------------------------ Phone Fax Servicing Producer Comm. Producer Name Number E-Mail Address Number Office # Code % ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Broker Dealer Name__________________________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ REMARKS - IDENTIFY QUESTION AND GIVE DETAILS ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ AP2001-PRPT Page 12 00-00000-00 05/2001 Pacific Life Insurance Company Life Insurance Division - Client Services Department 000 Xxxxxxx Xxxxxx Xxxxx . Newport Beach, CA 92660 (000) 000-0000 [LOGO OF PACIFIC LIFE] DISCLOSURE NOTICE DETACH AND LEAVE WITH PROPOSED INSURED(S) This brief description of our underwriting process is designed to help you to understand how an application for life insurance is handled, the types and sources of information we may collect about you, the circumstances under which we may disclose that information to others and your right, or your authorized representative's right, to learn the nature and substance of that information upon written request. The purpose of the underwriting process is to make sure you qualify for life insurance under the rules of Pacific Life Insurance Company (PL), and assuming you do, establish the proper premium charge for that insurance. The goal of the underwriting process is to have the cost of insurance distributed equitably among all policyowners, so that each individual pays his or her fair share. To determine your insurability, we must consider such factors as your medical history, physical condition, occupation and hazardous avocations. We get this information from various sources. Application and Medical Records - Your application, including the medical history, is the primary source of information in the evaluation process. In addition, we may ask you to take a physical examination or other special test such as an electrocardiogram. We may also ask for a report from your doctor or hospital, another insurance company, or the Medical Information Bureau, Inc. When we do so, we will use the Authorization Of The Proposed Insured(s) To Obtain Information that you signed. Medical Information Bureau, Inc. (MIB) - is a non-profit corporation, which operates an information exchange on behalf of member life insurance companies. As a member company, we will ask the MIB if it has a record concerning you. If you previously applied to a member company for insurance, MIB may have information about you in its file. The purpose of the MIB is to protect member companies and their policyowners from those who would conceal significant facts relevant to their insurability. The information, which is obtained from MIB, may be used only as an alert to the possible need for further independent investigation. It cannot be used as a basis to make a final underwriting decision. Information regarding your insurability will be treated as confidential. PL, its subsidiaries or its reinsurer(s) may, however, make a brief report to the MIB. If you later apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, upon request, will supply the company with the information it may have about you in its file. PL, its subsidiaries or its reinsurer(s) may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. At your request, or your authorized representatives request, the MIB will arrange disclosure of any information it may have about you in its file. If you question the accuracy of information on file, you may contact the MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the information office of MIB, Inc. is Post Office Xxx 000, Xxxxx Xxxxxxx, Xxxxxx, Xxxxxxxxxxxxx 00000. Their telephone number is (000) 000-0000. Investigative Consumer Report - As part of our underwriting procedure, we may request an investigative consumer report from a consumer reporting agency. A consumer report confirms and supplements the information on your application pertaining to employment and residence verification, smoking habits, marital status, occupation, hazardous avocations and general health. This report may also cover information concerning your general reputation, personal characteristics and mode of living, (except as may be related directly or indirectly to your sexual orientation) including drug and alcohol use, motor vehicle driving record and any criminal activity. This information may be obtained through personal interviews with you, your family, friends, neighbors and business associates. If a report is required and you wish to be personally interviewed, please let us know and we will notify the consumer reporting agency. The information contained in the report may be retained by the consumer reporting agency and subsequently disclosed to other companies to the extent permitted by the Fair Credit Reporting Act. Investigative consumer reports are held in strict confidence and used only to evaluate your application on a fair and equitable basis. You have a right to inspect and obtain a copy of the report from the consumer reporting agency. DISCLOSURE TO OTHERS Personal information obtained about you during the underwriting process is confidential and will not be disclosed to other persons or organizations without your written authorization except to the extent necessary for the conduct of our business. Examples of situations where we may share information about you are as follows: . The Producer may retain a copy of your application. . If reinsurance is required, the reinsurance company would have access to our application file. . We may release information to another life insurance company to whom you have applied for life or health insurance or to whom you have submitted a claim for benefits, if you have authorized it to obtain such information. . As stated earlier, we may report information to the Medical Information Bureau, Inc. . We will disclose information to government regulatory officials, law enforcement authorities and others where required by law. DISCLOSURE TO YOU In general, you have a right to learn the nature and substance of any personal information about you in our file upon written request. Whenever an adverse underwriting decision is made, we will notify you of the reason(s) for the decision and the source of the information upon which our action is based. Medical record information, however, will normally be given only to a licensed physician of your choice. Please refer to the section on MIB, Inc., for that organization's disclosure procedure. Should you feel that any information we have is inaccurate or incomplete, please write to: Manager, Risk Selection Department, PL Insurance Company, 000 Xxxxxxx Xxxxxx Xxxxx, Xxxxxxx Xxxxx, Xxxxxxxxxx 00000. Your comments will be carefully considered and corrections made where justified. We hope this Notice will help you to understand how we obtain and use personal information in the underwriting process, and the ways you can learn about this information. We are concerned with insuring privacy as well as lives, and the collection, use and disclosure of personal information is limited to those specified in this Notice. AP2001-DISC Page 13 15-23217-00 05/2001 TIA PACIFIC LIFE INSURANCE COMPANY Life Insurance Division - Client Services Department [LOGO OF PACIFIC LIFE] 000 Xxxxxxx Xxxxxx Xxxxx . Newport Beach, CA 92660 (000) 000-0000 TEMPORARY INSURANCE AGREEMENT (TIA) - LIFE This TIA provides a limited amount of life insurance coverage, for a limited period of time, subject to the Terms and Conditions shown below. Advance payment in the amount of $________ is made in connection with either a request for determination of probable underwriting class or an application for life insurance (each referred to below as "Request/Application") on: _______________________________________________________________________________ ________________________________________________ Name of Proposed Insured(s) Request/Application No.

First Name Listed Below Will. Be The Servicing Producer ------------------------------------------------------------------------------------------------------------------------------------ Phone Fax Servicing Producer Comm. Producer Name Number E-Mail Address Number Office # Code % ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Broker Dealer Name__________________________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ REMARKS - IDENTIFY QUESTION AND GIVE DETAILS ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ AP2001-PRPT Page 12 00-00000-00 05/2001 Pacific Life Insurance Company Life Insurance Division - Client Services Department 000 Xxxxxxx Xxxxxx Xxxxx . Newport Beach, CA 92660 (000) 000-0000 [LOGO OF PACIFIC LIFE] DISCLOSURE NOTICE DETACH AND LEAVE WITH PROPOSED INSURED(S) This brief description of our underwriting process is designed to help you to understand how an application for life insurance is handled, the types and sources of information we may collect about you, the circumstances under which we may disclose that information to others and your right, or your authorized representative's right, to learn the nature and substance of that information upon written request. The purpose of the underwriting process is to make sure you qualify for life insurance under the rules of Pacific Life Insurance Company (PL), and assuming you do, establish the proper premium charge for that insurance. The goal of the underwriting process is to have the cost of insurance distributed equitably among all policyowners, so that each individual pays his or her fair share. To determine your insurability, we must consider such factors as your medical history, physical condition, occupation and hazardous avocations. We get this information from various sources. Application and Medical Records - Your application, including the medical history, is the primary source of information in the evaluation process. In addition, we may ask you to take a physical examination or other special test such as an electrocardiogram. We may also ask for a report from your doctor or hospital, another insurance company, or the Medical Information Bureau, Inc. When we do so, we will use the Authorization Of The Proposed Insured(s) To Obtain Information that you signed. Medical Information Bureau, Inc. (MIB) - is a non-profit corporation, which operates an information exchange on behalf of member life insurance companies. As a member company, we will ask the MIB if it has a record concerning you. If you previously applied to a member company for insurance, MIB may have information about you in its file. The purpose of the MIB is to protect member companies and their policyowners from those who would conceal significant facts relevant to their insurability. The information, which is obtained from MIB, may be used only as an alert to the possible need for further independent investigation. It cannot be used as a basis to make a final underwriting decision. Information regarding your insurability will be treated as confidential. PL, its subsidiaries or its reinsurer(s) may, however, make a brief report to the MIB. If you later apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, upon request, will supply the company with the information it may have about you in its file. PL, its subsidiaries or its reinsurer(s) may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. At your request, or your authorized representatives request, the MIB will arrange disclosure of any information it may have about you in its file. If you question the accuracy of information on file, you may contact the MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the information office of MIB, Inc. is Post Office Xxx 000, Xxxxx Xxxxxxx, Xxxxxx, Xxxxxxxxxxxxx 00000. Their telephone number is (000) 000-0000. Investigative Consumer Report - As part of our underwriting procedure, we may request an investigative consumer report from a consumer reporting agency. A consumer report confirms and supplements the information on your application pertaining to employment and residence verification, smoking habits, marital status, occupation, hazardous avocations and general health. This report may also cover information concerning your general reputation, personal characteristics and mode of living, (except as may be related directly or indirectly to your sexual orientation) including drug and alcohol use, motor vehicle driving record and any criminal activity. This information may be obtained through personal interviews with you, your family, friends, neighbors and business associates. If a report is required and you wish to be personally interviewed, please let us know and we will notify the consumer reporting agency. The information contained in the report may be retained by the consumer reporting agency and subsequently disclosed to other companies to the extent permitted by the Fair Credit Reporting Act. Investigative consumer reports are held in strict confidence and used only to evaluate your application on a fair and equitable basis. You have a right to inspect and obtain a copy of the report from the consumer reporting agency. DISCLOSURE TO OTHERS Personal information obtained about you during the underwriting process is confidential and will not be disclosed to other persons or organizations without your written authorization except to the extent necessary for the conduct of our business. Examples of situations where we may share information about you are as follows: . The Producer may retain a copy of your application. . If reinsurance is required, the reinsurance company would have access to our application file. . We may release information to another life insurance company to whom you have applied for life or health insurance or to whom you have submitted a claim for benefits, if you have authorized it to obtain such information. . As stated earlier, we may report information to the Medical Information Bureau, Inc. . We will disclose information to government regulatory officials, law enforcement authorities and others where required by law. DISCLOSURE TO YOU In general, you have a right to learn the nature and substance of any personal information about you in our file upon written request. Whenever an adverse underwriting decision is made, we will notify you of the reason(s) for the decision and the source of the information upon which our action is based. Medical record information, however, will normally be given only to a licensed physician of your choice. Please refer to the section on MIB, Inc., for that organization's disclosure procedure. Should you feel that any information we have is inaccurate or incomplete, please write to: Manager, Risk Selection Department, PL Insurance Company, 000 Xxxxxxx Xxxxxx Xxxxx, Xxxxxxx Xxxxx, Xxxxxxxxxx 00000. Your comments will be carefully considered and corrections made where justified. We hope this Notice will help you to understand how we obtain and use personal information in the underwriting process, and the ways you can learn about this information. We are concerned with insuring privacy as well as lives, and the collection, use and disclosure of personal information is limited to those specified in this Notice. AP2001-DISC Page 13 15-23217-00 05/2001 TIA PACIFIC LIFE INSURANCE COMPANY Life Insurance Division - Client Services Department [LOGO OF PACIFIC LIFE] 000 Xxxxxxx Xxxxxx Xxxxx . Newport Beach, CA 92660 (000) 000-0000 TEMPORARY INSURANCE AGREEMENT (TIA) - LIFE This TIA provides a limited amount of life insurance coverage, for a limited period of time, subject to the Terms and Conditions shown below. Advance payment in the amount of $________ is made in connection with either a request for determination of probable underwriting class or an application for life insurance (each referred to below as "Request/Application") on: _______________________________________________________________________________ ________________________________________________ Name of Proposed Insured(s) Request/Application No.:

First Name Listed Below Will. Be The Servicing Producer ------------------------------------------------------------------------------------------------------------------------------------ Phone Fax Servicing Producer Comm. Producer Name Number E-Mail Address Number Office # Code % ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Broker Dealer Name__________________________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ REMARKS - IDENTIFY QUESTION AND GIVE DETAILS ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ AP2001-PRPT Page 12 00-00000-00 05/2001 Pacific Life Insurance Company Life Insurance Division - Client Services Department 000 Xxxxxxx Xxxxxx Xxxxx . Newport BeachXxxxxxx Xxxxx, CA 92660 XX 00000 (000) 000-0000 [LOGO OF PACIFIC LIFE] DISCLOSURE NOTICE DETACH AND LEAVE WITH PROPOSED INSURED(S) This brief description of our underwriting process is designed to help you to understand how an application for life insurance is handled, the types and sources of information we may collect about you, the circumstances under which we may disclose that information to others and your right, or your authorized representative's right, to learn the nature and substance of that information upon written request. The purpose of the underwriting process is to make sure you qualify for life insurance under the rules of Pacific Life Insurance Company (PL), and assuming you do, establish the proper premium charge for that insurance. The goal of the underwriting process is to have the cost of insurance distributed equitably among all policyowners, so that each individual pays his or her fair share. To determine your insurability, we must consider such factors as your medical history, physical condition, occupation and hazardous avocations. We get this information from various sources. Application and Medical Records - Your application, including the medical history, is the primary source of information in the evaluation process. In addition, we may ask you to take a physical examination or other special test such as an electrocardiogram. We may also ask for a report from your doctor or hospital, another insurance company, or the Medical Information Bureau, Inc. When we do so, we will use the Authorization Of The Proposed Insured(s) To Obtain Information that you signed. Medical Information Bureau, Inc. (MIB) - is a non-profit corporation, which operates an information exchange on behalf of member life insurance companies. As a member company, we will ask the MIB if it has a record concerning you. If you previously applied to a member company for insurance, MIB may have information about you in its file. The purpose of the MIB is to protect member companies and their policyowners from those who would conceal significant facts relevant to their insurability. The information, which is obtained from MIB, may be used only as an alert to the possible need for further independent investigation. It cannot be used as a basis to make a final underwriting decision. Information regarding your insurability will be treated as confidential. PL, its subsidiaries or its reinsurer(s) may, however, make a brief report to the MIB. If you later apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, upon request, will supply the company with the information it may have about you in its file. PL, its subsidiaries or its reinsurer(s) may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. At your request, or your authorized representatives request, the MIB will arrange disclosure of any information it may have about you in its file. If you question the accuracy of information on file, you may contact the MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the information office of MIB, Inc. is Post Office Xxxxxx Xxx 000, Xxxxx Xxxxxxx, Xxxxxx, Xxxxxxxxxxxxx 00000. Their telephone number is (000) 000-0000. Investigative Consumer Report - As part of our underwriting procedure, we may request an investigative consumer report from a consumer reporting agency. A consumer report confirms and supplements the information on your application pertaining to employment and residence verification, smoking habits, marital status, occupation, hazardous avocations and general health. This report may also cover information concerning your general reputation, personal characteristics and mode of living, (except as may be related directly or indirectly to your sexual orientation) including drug and alcohol use, motor vehicle driving record and any criminal activity. This information may be obtained through personal interviews with you, your family, friends, neighbors and business associates. If a report is required and you wish to be personally interviewed, please let us know and we will notify the consumer reporting agency. The information contained in the report may be retained by the consumer reporting agency and subsequently disclosed to other companies to the extent permitted by the Fair Credit Reporting Act. Investigative consumer reports are held in strict confidence and used only to evaluate your application on a fair and equitable basis. You have a right to inspect and obtain a copy of the report from the consumer reporting agency. DISCLOSURE TO OTHERS Personal information obtained about you during the underwriting process is confidential and will not be disclosed to other persons or organizations without your written authorization except to the extent necessary for the conduct of our business. Examples of situations where we may share information about you are as follows: . The Producer may retain a copy of your application. . If reinsurance is required, the reinsurance company would have access to our application file. . We may release information to another life insurance company to whom you have applied for life or health insurance or to whom you have submitted a claim for benefits, if you have authorized it to obtain such information. . As stated earlier, we may report information to the Medical Information Bureau, Inc. . We will disclose information to government regulatory officials, law enforcement authorities and others where required by law. DISCLOSURE TO YOU In general, you have a right to learn the nature and substance of any personal information about you in our file upon written request. Whenever an adverse underwriting decision is made, we will notify you of the reason(s) for the decision and the source of the information upon which our action is based. Medical record information, however, will normally be given only to a licensed physician of your choice. Please refer to the section on MIB, Inc., for that organization's disclosure procedure. Should you feel that any information we have is inaccurate or incomplete, please write to: Manager, Risk Selection Department, PL Insurance Company, 000 Xxxxxxx Xxxxxx Xxxxx, Xxxxxxx Xxxxx, Xxxxxxxxxx 00000. Your comments will be carefully considered and corrections made where justified. We hope this Notice will help you to understand how we obtain and use personal information in the underwriting process, and the ways you can learn about this information. We are concerned with insuring privacy as well as lives, and the collection, use and disclosure of personal information is limited to those specified in this Notice. AP2001-DISC Page 13 15-23217-00 05/2001 TIA PACIFIC LIFE INSURANCE COMPANY Life Insurance Division - Client Services Department [LOGO OF PACIFIC LIFE] 000 Xxxxxxx Xxxxxx Xxxxx . Newport BeachXxxxxxx Xxxxx, CA 92660 XX 00000 (000) 000-0000 TEMPORARY INSURANCE AGREEMENT (TIA) - LIFE This TIA provides a limited amount of life insurance coverage, for a limited period of time, subject to the Terms and Conditions shown below. Advance payment in the amount of $________ is made in connection with either a request for determination of probable underwriting class or an application for life insurance (each referred to below as "Request/Application") on: _______________________________________________________________________________ ________________________________________________ Name of Proposed Insured(s) Request/Application No.