The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application

as Humana.

Medical and Life products insured by Humana Insurance Company

Dental products insured by HumanaDental Insurance Company

Individual Product Application Texas

Please print clearly in ink and answer all questions or indicate not applicable.
Date of Application_________________ Requested effective date________________ Effective date cannot be prior to the application date.
Is this Application for:
q New Business (1st time applicant) q Reinstatement (reapplication)
q Change/modication to existing Policy - Current Policy Number______________________ Reason_______________________

Primary Applicant Information - If child-only coverage is being requested, the youngest child is the Primary Applicant.
Last name First name M.I. Gender
Address City State Zip Code Height Weight
Birth Date Country/State of Birth Social Security Number
Home Phone Number Daytime Phone Number Drivers License Number
( ) ( )
Type of business or industry Occupation
Email address (If you are 18 years of age or older)
Policy owner information if other than Primary Applicant.

Family Information - Please complete only if your spouse and/or dependent children are applying for coverage.
Spouses type of business or industry Spouses occupation
Name and Middle Initial Birthdate Social Security Number Gender Height Weight Full-time student
(include last name if different (Y / N)
from Primary Applicant)
Spouse:
Child:
Child:
Child:
Child:

Parent or Guardian Information - Please complete this section if Primary Applicant is under 18 years of age.
Parent or Guardian Full Legal Name Relationship to Child(ren)
Parent or Guardians Social Security Number Email address

General Eligibility - Please answer for all individuals applying for coverage.
Within the past 10 years have you or any of your dependents been previously denied, rated or had health conditions excluded or ridered
from life, disability, annuity or health insurance coverage? q NO q YES If yes, please supply the following:
Name of person(s) Reason Date
Have you or any of your dependents applying for coverage spent more than 2 months outside of the U.S. in the last year or intend to spend
more than 2 months outside of the U.S. in the next year? q NO q YES
If yes, please provide details including location:
Are you or any of your dependents applying for coverage a U.S. citizen? q NO q YES
If not a U.S. citizen, have you or any of your dependents applying for coverage been a permanent legal resident of the U.S. for the
past 2 years? q NO q YES If yes, please attach a copy of your resident Green Card for each applicant.

TX-70132-IP TX-55555-IP 6/2005

Humana Insurance Company
HumanaDental Insurance Company
HumanaOne Individual Health Application Texas

Health Plan Options - Doctor ofce visit copay rider and $0 prescription drug deductible are not
available on the HSA High Deductible Health Plan.
Individual Health Plan HSA High Deductible Health Plan
$_________deductible $_________ deductible
q 100/70
Doctor ofce visit copay rider q NO q YES q 80/60
$0 Prescription Drug Deductible q NO q YES

Existing Health Coverage

Do you or any of your dependents currently have any group or individual health plan coverage? q NO q YES
If yes, please supply the following:
Name
Insurance Carrier Name Telephone Number
Policy Number or Group Number Effective Date Termination Date
Will the insurance coverage applied for be used to replace existing health coverage? q NO q YES
If yes, have you or any of your dependents had this existing health coverage within the last 18 months? q NO q YES
IMPORTANT:
It is important that you do not cancel any existing health coverage until you receive notication from US of your acceptance for coverage.
Options with Medical Coverage - If health coverage is approved, you may purchase the additional options below.

Dental Option
Product Selection: Do you or any of your dependents currently have any group or individual dental coverage? q NO q YES
q Traditional Preferred If yes, please supply the following:
Name
Insurance Carrier Name Telephone Number
Policy Number or Group Number Effective Date Termination Date
Will the insurance coverage applied for be used to replace existing dental coverage? q NO q YES
If yes, Have you or any of your dependents had this existing dental coverage within the last 18 months?
q NO q YES
$20,000 Term Life Rider
q Primary Applicant Beneciary_______________________________ q Spouse Beneciary____________________________

Billing Information
Who will be paying for this plan(s)?
Name Address
Telephone Number ( )

Initial Payment Options

Initial payment must total one months premium for each product selected. Agent/Producer payments are not accepted.
Please choose your preference for payment of 1st months premium.
q Credit Card q One time bank withdrawal

Subsequent Payment Options

Please indicate both billing preference and payment method.
q Monthly: q Automatic bank withdrawal q Direct Bill
q Quarterly (Direct Bill)
q Semi-Annual (Direct Bill)
Please complete automatic bank withdrawal information or credit card authorization section.
TX-70132-IH TX-55555-IH 6/2005
Humana Insurance Company/HumanaDental Insurance Company
Evidence of Health Status Texas
For this insurance to be issued, the following health questions must be answered fully and truthfully to the best of your knowledge and
your belief, and all of the health information (including routine physical exams) must be provided. If any of the answers are YES, please
provide complete details.
Please answer for you and any of your dependents applying for coverage
Have you or any of your dependents:
1. Had a positive home pregnancy test in the last 90 days, or are currently an expectant parent? q NO q YES
2. Is any male listed on this application expecting a child with anyone, whether or not the mother is listed on
the application? q NO q YES
3. Within the past 24 months been advised to have or had a check-up, consultation, electrocardiogram, x-ray,
lab tests, or other diagnostic tests? q NO q YES
4. Within the past 24 months had any surgery or been advised to have surgery, which has not yet been
completed, including surgery performed by a dentist or oral surgeon? q NO q YES
5. Within the past 10 years had cosmetic or reconstructive surgery, a prosthesis, monitoring device, pace
maker, valve or joint replacement, implant, or internal xation (i.e. pins, plates, screws, etc.)? q NO q YES
6. Within the past 10 years had any signs or symptoms of chronic fatigue, fever, loss of appetite, oral thrush,
recurrent infections or weight loss with no known cause? q NO q YES
7. Within the past 10 years have you or any dependent been diagnosed by a physician as having acquired
immunodeciency syndrome (AIDS) or AIDS related complex? q NO q YES
In the past 10 years, have you or any dependents applying for coverage been treated for, had symptoms of, or been advised or
counseled that they have or may have had any of the following:
8. Respiratory Disorder Yes No 16. Brain or Nervous Disorder Yes No
a. Allergies, Asthma or Bronchitis q q a. Alzheimers, Dementia or Memory Loss q q
b. Emphysema, Pneumonia or Shortness of Breath q q b. Multiple Sclerosis or Paralysis q q
c. Sleep Apnea q q c. Cerebral Palsy or Parkinsons q q
d. Tuberculosis or Cystic Fibrosis q q d. Epilepsy or Seizures q q
9. Circulatory Disorder e. Headaches, Migraines or Dizziness/Syncope q q
a. Edema, Phlebitis or Varicose Veins q q 17. Emotional or Mental Disorder
b. Elevated Cholesterol or Triglycerides q q a. Anxiety or Depression q q
c. High Blood Pressure or Hypertension q q b. Attention Decit Disorder q q
d. Stroke or Transient Ischemic Attack (TIA) q q c. Eating Disorder q q
10. Heart Disorder d. Psychiatric or Psychological Counseling q q
a. Angina, Chest Pain or Heart Attack q q 18. Female Reproductive Disorder
b. Congenital Heart Disorder q q a. Disorder of the Breast or Abnormal Mammogram q q
c. Coronary Artery Disease or Congestive Heart Failure q q b. Menopausal Disorder q q
d. Heart Murmur, Mitral Valve Prolapse, q q c. Endometriosis, Infertility, Uterine Fibroids or q q
Valve Disorder or Irregular Heartbeat Pelvic Inammatory Disease
11. Digestive Disorder d. Complication of Pregnancy/Cesarean Section q q
a. Gastroesophageal Reux Disease (GERD), or Heartburnq q e. Sexually Transmitted Disease q q
b. Ulcer, Gastritis or Hernia q q f. Cervical, Ovarian, Uterine or Vaginal Disorder q q
c. Irritable Bowel Syndrome, Colitis or Crohns Disease q q g. Abnormal Pap Smear or Menstrual Disorder q q
d. Diverticulitis, Diverticulosis or Hemorrhoids, q q 19. Male Reproductive Disorder
Colon Polyps a. Penile, Prostate or Testicular Disorder q q
e. Cirrhosis or Hepatitis q q b. Sexually Transmitted Disease q q
f. Stomach, Liver, Pancreas, Spleen, Colon or q q c. Infertility or Sexual Dysfunction q q
Gallbladder Disorder 20. Blood, Gland, Endocrine, Pituitary or
12. Congenital or Development Disorder Lymph Node Disorder
a. Autism, Downs Syndrome or Mental Retardation q q a. Diabetes, High or Low Blood Sugar q q
b. Cleft Palate or Cleft Lip q q b. Anemia q q
c. Club Feet q q c. Obesity q q
d. Huntingtons Chorea q q d. Enlarged or Swollen Lymph Nodes q q
13. Cyst or Tumor e. Thyroid Gland or Glandular Disorder q q
a. Cancer, Carcinoma or Melanoma q q f. Blood, Endocrine, Pituitary or Lymph Node Disorder q q
b. Cyst, Growth, Lump, Mass or Tumor q q 21. Muscular Skeletal Disorder
c. Lupus q q a. Arthritis, Bursitis, Tendonitis or Gout q q
14. Eyes, Ears, Nose or Throat Condition b. Back or Spine Disorder q q
a. Disorder of the Ear, Ear Infections or Tubes In Earsq q c. Connective Tissue Disorder, Lupus q q
b. Hearing Loss or Cochlear Implants q q d. Fibromyalgia q q
c. Disorder of the Nose, Deviated Septum q q e. Temporomandibular Joint Syndrome (TMJ) q q
or Sinus Infection f. Bone, Joint, Muscular or Neuromuscular Disorder q q
d. Menieres, Labyrinthitis or Vertigo q q 22. Genitourinary Disorder
e. Disorder of the Throat, Tonsils or Adenoids q q a. Bladder disorder, Bladder Infection or Cystitis q q
f. Disorder of the Eyes, Blindness, Cataracts or Glaucoma q q b. Kidney Disorder or Kidney Stones q q
g. Speech Impairment q q 23. Been seen or consulted by any doctor, q q
15. Skin Conditions or any other person providing health
a. Acne or Rosacea q q care services for any other condition not
b. Eczema or Psoriasis q q listed on this application?
TX-70132-HS 9/2004 TX-55555-HS 6/2005
 Additional Health Question Information- To be completed if you or any dependent(s) answered YES to any question(s) in
the Evidence of Health Status section. If more space is needed, attach a separate sheet.
Each separate sheet must be signed and dated by the Primary Applicant, Dependent or Guardian, as applicable.

Person Treated:

Condition Question Number

Treatment Dates (past and future)

Last time seen by a doctor for this condition

Physician Name/Address

Person Treated:

Condition Question Number

Treatment Dates (past and future)

Last time seen by a doctor for this condition

Physician Name/Address

Medications
Have you or any of your dependents applying for coverage, taken any prescribed medications within the past 24 months? q NO q YES

If yes, please list all medications. You may use an additional sheet if necessary.

Family member Medication & dosage

Why was the medication prescribed Date prescribed

Date discontinued Physician Name Phone # Fax #

Physician address City State Zip code

Recreational Activity
Do you or any of your dependent(s) applying for coverage participate or plan to participate in any of the following activities:
Bungee jumping, private aviation, motorized vehicle racing, rock climbing, rodeo events, scuba diving or sky diving? q NO q YES
If yes:

Name of person What activities When

Lifestyle
Have you or your spouse to be insured used any type of tobacco product in the past 12 months? q NO q YES
If yes, check all that apply: q Primary Applicant q Spouse
How frequently do you use tobacco? How frequently do you use tobacco?
q More than one time per week q More than one time per week
q One time or less per week q One time or less per week

Have you or any of your dependents applying for coverage:

Been convicted for driving under the inuence in the past 5 years? q NO q YES
Used any illegal, controlled drugs or substances in the past 10 years? q NO q YES
Been diagnosed as chemically or alcohol dependent within the past 10 years? q NO q YES
If yes: Name of person When

TX-70132-HS 9/2004 TX-55555-HS 6/2005

Humana Insurance Company
HumanaDental Insurance Company

Payment Authorization Texas

Please complete this section if you have selected the automatic bank withdrawal or credit card payment options.

Automatic Bank Withdrawal Information

q I authorize Humana to draw premium payment from account
#______________ until this authorization is revoked by me.
Account Holders Name (please print)

Phone Number

Bank Name Address

Routing Number Account Number

Credit Card Options

q Visa q I authorize Humana to bill my VISA/Mastercard account

q Mastercard for the initial payment.
Authorized Amount: $________________

Card No.: Expiration Date (MO/YR): /

Cardholders Name:

Initial payment for each product applied for will be drafted separately against your account.

TX-70132-PA TX-55555-PA 6/2005

Medical and Life products insured by the Company Insurance Company
Dental products insured by HumanaDental Insurance Company
Agreement and Signature Texas
True and Complete Acknowledgment:
I understand, agree and represent:
I have read this document or it has been read to me.
The answers are, to the best of my knowledge and belief, true and complete.
I have received and reviewed any state or federal required disclosures.
Neither I nor my agent has the authority to waive a complete answer to any question, determine coverage or insurability, alter any
contract, or waive any of the Companys other rights and requirements.
This policy applied for is not an employer-sponsored group health plan and it does not comply with state or federal small employer
laws. I certify that I do not qualify for a group health plan or receive favorable tax treatment under federal or state law.
If this application for coverage is accepted, coverage will be effective on the date specied by the Company on the Policy. Acceptance
of premium and fees does not guarantee coverage.
To automatic withdrawal from my specied bank account for premium payment and administrative fees if selected under the
product section.
If I have selected the Pre-employment or College Graduate Health Plans to terminate coverage at the end of the reduced premium
period if I have obtained substantially similar health insurance coverage.
Premiums already paid will be refunded to me if a policy is not issued.
Any misrepresentation of material fact or omission contained herein relied on by the Company may be used to reduce or deny a claim
or void the contract within the contestable period if such misrepresentation of material fact or omission affects the
acceptance of the risk.
This document, together with any supplements, will form part of any contract and be the basis for any Policy issued.

Authorization
My dependents and I authorize any physician, medical or health care practitioner, hospital, clinic, veterans administration facility, other
medical or medically-related facility, third party administrator, Pharmacy Benet Manager, insurance, HMO or reinsuring company, the
Medical Information Bureau, Inc., employer or the Consumer Reporting Agency having information regarding myself and my dependents,
including information concerning, advice, diagnosis, treatment and care of the physical, psychiatric, mental or emotional conditions, drug,
substance or alcohol abuse, illness and copies of all hospital or medical records, non-public personal health information, and any other
non-medical information to share any and all such information with the Company, its reinsurer or its legal representatives, and its afliates.

My dependents and I understand and agree:

The information obtained by use of this authorization may be used by the Company to determine eligibility for coverage, eligibility for
benets under an existing policy, plan administration, and make claim determinations.
If you decide not to sign this authorization, we will decline to enroll you in a medical plan or to give you medical benets.
Any information obtained will not be released by the Company to any person or organization except to reinsuring companies, the
Medical Information Bureau, Inc. or other persons or organizations performing health care operations or business or legal services
in connection with any application, claim or as may be otherwise lawfully required, or as we may further authorize. If a Consumer
Reporting Agency is used, I (we) may request to be interviewed in connection with the preparation of the report and I (we) may request
a copy of the report.
Once personal and health (including medical, dental and pharmacy) information is disclosed pursuant to this authorization, it may be
redisclosed by the recipient and the information may not be protected by federal and state privacy requirements.
A copy of this authorization is available to me or my legal representative upon written request.
A photographic copy of this authorization shall be as valid as the original.
This authorization shall be valid for two years from the date shown below.
I have the right to revoke this authorization at any time:
To revoke this authorization, I must do so in writing and send my written revocation to Humanas Privacy Ofce.
The revocation will not apply to information that has already been released in response to this authorization.
The revocation may adversely affect my application, a claim or a pending insurance action.
The revocation will become effective after it is received by Humanas Privacy Ofce.
Any person who submits an application containing a false, incomplete or deceptive statement may be guilty of insurance fraud.

Primary Applicant or Legal Representative Signature:______________________________________________ Date_____________

(MM/DD/YYYY)
Name and Relationship of Legal Representative:_____________________________________________________________________

Spouse Signature:_________________________________________________________________________ Date_____________

(if covered dependent) (MM/DD/YYYY)
Payor Signature:___________________________________________________________________________ Date_____________
(if other than insured) (MM/DD/YYYY)
Child Signature:___________________________________________________________________________ Date_____________
(if over legal age and applying for dependent coverage) (MM/DD/YYYY)

TX-70132-AG 9/2004 TX-55555-AG 6/2005

Humana Insurance Company/Humana Dental Insurance Company

Agent/Broker/Producer Information Texas

1. Agent/Agency of Record (for commissions and correspondence):

Name (print) Tax ID/Social Security Number

Commission Split: q No q Yes If yes, percentage: (Total should equal 100%)

1. Writing Agent/Broker/Producer:

Name (print) Social Security Number

Commission Split: q No q Yes If yes, percentage: (Total should equal 100%)

2. Agent/Agency of Record (for split-commissions):

Name (print) Tax ID/Social Security Number

Percentage of Sales: q No q Yes If yes, percentage: (Total should equal 100%)

2. Writing Agent/Broker/Producer:

Name (print) Social Security Number

Percentage of Sales: q No q Yes If yes, percentage: (Total 100%)

Agent Replacement Question:

Will this policy replace or change any existing life insurance policy(s) annuity? q No q Yes

As the Writing Agent/Broker/Producer, I acknowledge that I am responsible to meet with the applicant submitting this application in order to

fully and accurately represent the terms and conditions of the plans and services of the offering or insuring entity, or one of its subsidiaries.

These provisions are available to me and the applicant in the Benet Summary document or other plan literature.

Writing Agents Signature:____________________________________________________________ Date:_______________________

Thank you for choosing HumanaOne.

TX-70132-AB TX-55555-AB 3/2004

Humana Insurance Company

HumanaOne Term Life Insurance Plan Texas

Term Life Plan for Primary Applicant

The amount of term life insurance I want is ______________. (Minimum selection is $25,000)

Term length: q 10 years q 15 years q 20 years

Primary Beneciary Relationship

Secondary Beneciary Relationship

Existing Life Coverage for Primary Applicant

Have any life insurance and/or annuity coverage currently in force? q NO q YES

Will the insurance coverage applied for be used to replace any existing life and/or annuity coverage? q NO q YES If yes:

Company Name Amount Policy Number

Term Life Plan for Spouse

The amount of term life insurance I want is ______________. (Minimum selection is $25,000)

Term length: q 10 years q 15 years q 20 years

Primary Beneciary Relationship

Secondary Beneciary Relationship

Existing Life Coverage for Spouse

Have any life insurance and/or annuity coverage currently in force? q NO q YES

Will the insurance coverage applied for be used to replace any existing life and/or annuity coverage? q NO q YES If yes:

Company Name Amount Policy Number

TX-70132-TL TX-55555-TL 6/2005

Paper Application
Frequently Asked Questions
Q. Where can I get a copy of the application?
A. Please contact your HumanaOne sales representative who will
be happy to provide all of the materials you will need to start
using the HumanaOne paper application. Once you receive the
application, please feel free to make as many copies as you need.
If you are not sure who your sales representative is, please view
the important number list for your state by visiting
www.humanaonehq.com.
Q. How do I submit the paper application to Humana?
A. Completed paper applications can be sent to Humana by fax to:
1-866-217-2122.
Humana is not accepting applications by mail at this time.
Q. How can I find out the status of a paper application once it
is submitted to Humana?
A. Just like the telephonic application, you can call the Agent
Service Center at 1-800-833-2572 to check on the status of your
paper applications.
Additionally, as an agent, you will receive regular e-mail updates
as your clients application progresses through the underwriting
process.
Q. How can I better ensure my applicant will be eligible for a
HumanaOne individual policy?
A. Humanas underwriting guidelines can be found in the Agent
Sales Guide, which is available at www.humanaonehq.com, or
through your HumanaOne sales representative.
You may also contact the Agent Service Center at 1-800-833-2572
for more information on determining if your client is eligible for
HumanaOne coverage.
Q. Who can I contact if I have questions while filling out the
paper application with my client?
A. Your HumanaOne sales representative would be happy to assist
you with any questions that you have while completing the
application.
Q. Do I need to keep a copy of the application after it is
submitted to Humana?
A. Yes. The length of time you need to keep a copy of an
application may vary based on your state, however, Humana asks
that you hold on to your application for a minimum of 90 days.
Q. Are there any additional forms that should be submitted
with the application?
A. Yes. Please contact your HumanaOne sales representative who
will be happy to provide all of the materials you will need to start
using the HumanaOne paper application, including additional
forms needed for a complete application.
If you have any questions on additional forms, please contact your
HumanaOne sales representative.
Q. What if my clients primary language is not English?
A. If your client speaks another language other than English,
please write the language that your applicant is most comfortable
speaking on the application. A translator will assist our
Underwriter when contacting your client to complete the
underwriting interview.
Q. Can a business account be used to pay for a HumanaOne
policy?
At this time Humana is only accepting payment from a personal
account, or a business that meets the following criteria:
Sole proprietorship (Except in Florida*)
No employees
Business may not be incorporated, LLC etc.
If the business fails to meet ANY of these criteria, it would not be
considered a valid form of payment for a HumanaOne policy.
Note: The HumanaOne Health Plan is not treated as a plan or
program for purposes of section 162 or 106 of the IRS code.
*The only form of payment accepted in Florida is from a personal
account.

Q. Will Humana contact my client during the application

process?
A. Yes. As part of Humanas underwriting process, an interview is
done with each applicant. The underwriter assigned to your
clients case will contact your client to complete this interview.

GN-46090-HH 3/05
TEXAS...... important / numbers
Tom Litchhult, Texas sales manager(713) 622-6639
tlitchhult@humana.com

Sean Morrison, Austin field rep(512) 338-2591

smorrison@humana.com

Shelly Sedberry, Houston field rep(713) 278-2516 or (800) 888-5727, x 22

ssedberry1@humana.com

Judy Jones, Houston field rep(713) 278-2516, x 18

jjones7@humana.com

Christine Candler, San Antonio/Corpus field rep(210) 617-1002

ccandler@humana.com

Mary Thole, Dallas/Forth Worth telesales(800) 833-6931, x5323

mthole@humana.com

Scott Shaw, SA/Corpus telesales(800) 833-6931, x 5032

sshaw@humana.com

Andy Davis, Houston telesales(800) 833-6931, x 5327

adavis@humana.com

Jon Johnson, Austin telesales(800) 833-6931, x 5324

adavis@humana.com

Elizabeth Escamilla, account coordinator(210) 615-3143

eescamilla@humana.com

Dan Mulkey, BenefitMall(800) 350-0500

dan.mulkey@benefitmall.com

Agent Service Center(800) 833-2572

Quoting Interactive Voice Response (IVR)(888) 226-0342

Submit a Paper Application via Fax: 1-866-217-2122

Application Team(800) 552-0758

Billing and Premium(800) 458-1354

Claims and Customer Service(800) 833-6917

Secured Logon Problems(800) 4HUMANA

Commission/Contracting Problems(800) 558-4444, x 8919

Additional
Forms and
Documents
Consent for Release of Personal & Health Information

Primary applicant and spouse: _______________________________________________

Dependents: _______________________________________________
Address: _______________________________________________
_______________________________________________
Policy Data Number (PDN): _______________________________________________

Purpose of the Authorization

By signing the form, you will authorize the disclosure and use of the protected health information described below for pre-
enrollment underwriting or risk-rating of health insurance coverage for you, or to determine your eligibility for enrollment or
benefits under a health plan.

If you decide not to sign this authorization, we will decline to enroll you in a medical plan or to give you medical benefits.

Information we will use and/or disclose

My dependents and I authorize any physician, medical or health care practitioner, hospital, clinic, veterans administration facility,
other medical or medically related facility, third party administrator, Pharmacy Benefit Manager, insurance, HMO or reinsuring
company, the Medical Information Bureau, Inc., employer or the Consumer Reporting Agency having information regarding
myself and my dependents, including information concerning, advice, diagnosis, treatment and care of the physical, psychiatric,
mental or emotional conditions, drug, substance or alcohol abuse, illness and copies of all hospital or medical records, non-public
personal health information, and any other non-medical information to share any and all such information with the Company, its
reinsurer or its legal representatives, and its affiliates.
The information obtained by use of this authorization may be used by the Company to determine eligibility for coverage,
eligibility for benefits under an existing policy, plan administration, and make claim determinations.
Any information obtained will not be released by the Company to any person or organization except to reinsuring companies, the
Medical Information Bureau, Inc., or other persons or organizations performing health care operations or business or legal
services in connection with any application, claim or as may be otherwise lawfully required, or as we may further authorize. If a
Consumer Reporting Agency is used, I (we) may request to be interviewed in connection with the preparation of the report and I
(we) may request a copy of the report.
Once personal and health (including medical, dental and pharmacy) information is disclosed pursuant to this authorization, it may
be redisclosed by the recipient and the information may not be protected by federal and state privacy requirements.

Expiration and revocation

A copy of this authorization is available to me or my legal representative upon written request. A photographic copy of this
authorization shall be as valid as the original.
This authorization shall be valid for two years from the date shown below. I have the right to revoke this authorization at any
time. To revoke this authorization:
I must do so in writing and send my written revocation to Humanas Privacy Office.
The revocation will not apply to information that has already been released in response to this authorization.
The revocation may adversely affect my application, a claim or a pending insurance action.
The revocation will become effective after it is received by Humanas Privacy Office.

Applicants signature Date

Parent or Legal Guardian must sign if the primary applicant is under age 18

Spouse's signature Date

Dependent(s) over age 18 Date

TEXAS NOTICE TO APPLICANT REGARDING
REPLACEMENT OF ACCIDENT AND
SICKNESS INSURANCE

Save a copy of this notice it may be important to you in the future!

According to your application, you intend to lapse or otherwise terminate existing

accident and sickness insurance and replace it with a policy to be issued by
Humana Insurance Company. For your own information and protection, you
should be aware of and seriously consider certain facts which may affect the
insurance protection available to you under the new policy.

(1) Health conditions which you may presently have may not be immediately or
fully covered under the new policy. This could result in a denial or delay of a
claim for benefits under the new policy, whereas a similar claim might have
been payable under your present policy.

(2) You may wish to secure the advice of your present insurer or its agent
regarding the proposed replacement of your present policy. This is not only
your right, but it is also in your best interests to make sure you understand all
the relevant factors involved in replacing your present coverage.

(3) If, after due consideration, you still wish to terminate your present policy and
replace it with new coverage, be certain to truthfully and completely answer all
questions on the application concerning your medical/health history. Failure to
include all material medical information on any application may provide a basis
for the company to deny any future claims and to refund your premium as
though your policy had never been in force. After the application has been
completed, and before you sign it, re-read it carefully to be certain that all
information has been properly recorded.

The above Notice of Applicant was delivered to me:

Applicants Name

Applicants Signature Date

TX-46013-HH 5/04
 Humana - Individual Product Segment
Underwriting Department
2 Riverwood Place
N19 W24133 Riverwood Drive
Suite #250
Waukesha WI 53188

NOTICE AND CONSENT FOR HIV RELATED TESTING FOR TEXAS APPLICANTS

To evaluate your insurability, the Insurer named above (the Insurer) has requested that you provide a sample of
your blood, oral fluid extracted from cheek and gum tissue, or urine for testing and analysis to determine the
presence of human immunodeficiency virus (HIV) antibodies. By signing and dating this form you agree that
this test may be done and that underwriting decisions will be based on the test result. A series of three tests will
be performed by a licensed laboratory through a medically accepted procedure.

Pre-Testing Consideration

Many public health organizations have recommended that before taking an HIV-related test a person seek coun-
seling to become informed concerning the implications of such a test. You may wish to consider counseling, at
your expense, prior to being tested.

Meaning of Positive Test Result

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 test result does not mean that you have AIDS
but that you are at significantly increased risk of developing problems with your immune system. The test for
HIV antibodies is very sensitive. Errors are rare, but they do occur. Your private physician, a public health
clinic, or an AIDS information organization in your city might provide you with further information on the
medical implications of a positive test.

Positive HIV antibody test results will adversely affect your application for insurance. This means that your
application may be declined, that an increased premium may be charged, or that other policy changes may
be necessary.

Confidentiality of Test Results

All test results are required to 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
responsibility to make underwriting decisions on behalf of the Insurer or to outside legal counsel who needs
such information to effectively represent the Insurer in regard to your application. The results may be disclosed
to a reinsurer, if the reinsurer is involved in the underwriting process. The test may be released to an insurance
medical information exchange under procedures that are designed to assure confidentiality, including the use of
general codes that also cover results of tests for other diseases or conditions not related to AIDS, or for the
preparation of statistical reports that do not disclose the identity of any particular person.

TX-46010-HH 10/03
 Notification of Test Results

If your test results are negative, no routine notification will be sent to you. If your test results are reported by
the laboratory to the Insurer as being positive, you will receive written notification of such results from a physi-
cian you have designated or, in the absence of such designation, from the Texas Department of Health. Because
a trained person should deliver that information so that you can understand clearly what the test result means,
please list your private physician so that the Insurer can have him or her tell you the test result and explain its
meaning.

Name of physician for reporting a possible positive test result:

______________________________________________________________________

Address: _______________________________________________________________

In the event the test is positive and you are denied coverage because of that fact and you request the reason for
denial, the insurer may require you to name a physician at that time in order to receive the information.

If the test indicates a positive result, but you do not designate a private physician, the test results will be provided
to you by a representative of the Texas Department of Health.

Consent

I have read and I understand this Notice and Consent for HIV-Related Blood Testing. I voluntarily consent to
the collection of a sample of blood, oral fluid extracted from cheek and gum tissue, or urine from me, the test-
ing of that sample, and the disclosure of the test results as described above. I have read the information on this
form about what a test result means.

I understand that I have the right to request and receive a copy of this authorization. A photocopy of this form
will be as valid as the original.

_____________________________________________ __________________________
Signature of Proposed Insured or Parent/Guardian Date Signed

_____________________________________________ __________________________
Name of Proposed Insured Address

TX-46010-HH 10/03
 DISCLOSURES

FAIR CREDIT REPORTING ACT AND PRIVACY ACT PRE-NOTIFICATION: Public Law
91-508 and state privacy acts require that Humana Insurance Company advise person(s) applying
for coverage that an investigative report may be made in connection with this application which
will provide applicable information concerning character and general reputation. I (we)
understand that this information may be obtained through a phone interview or personal interview
with the person (s) applying for coverage or other third parties. I (we) may request to be
interviewed in connection with the preparation of the report and I (we) may request a copy of the
report.

NOTICE OF INFORMATION PRACTICES: I (we) understand that in order to properly

underwrite insurance coverage, Humana Insurance Company must collect personal information
concerning the insurability of person(s) applying for coverage. Humana Insurance Company may
also contact other sources, including medical professionals and institutions, employer, and other
insurance companies. I (we) understand that I (we) have the right to be told about, and to see
(and receive a copy of) items of personal information about me (us) which may appear in my
(our) files. I (we) understand that I (we) have the right to seek correction, amendment, or deletion
of information I (we) believe to be inaccurate. If I (we) have questions or desire additional
information about the items disclosed above, I (we) understand that I (we) may write to Humana
Insurance Company, N19 W24133 Riverwood Drive, Suite 250, Waukesha, WI 53188.

Insured by Humana Insurance Company