DELAWARE - Corebridge Financial Life Insurance Authorizations

Underwriting Authorization

Form number AGLC200073-2019 Rev0422

American General Life Insurance Company
2727-A Allen Parkway, Houston, TX 77019
A member of Corebridge Financial, Inc.

The insurance company listed above (“Company”) is responsible for the obligation and payment of benefits under any policy that it may issue. No other company is responsible for such obligations or payments.

The purpose of this form is to obtain consent and authorization from the Proposed Insured to allow the Company to begin underwriting the application for life insurance.

I, the Proposed Insured, intend to apply for individual life insurance coverage offered by the Company checked above. For this reason, I immediately authorize any medical professional; any hospital, or clinic or health care facility; any pharmacy benefit manager or prescription database; any insurance or reinsurance company; any consumer reporting agency or insurance support organization; my employer; the Medical Information Bureau (MIB); or any accountant, attorney, financial advisor, court, government records custodian that has any records or knowledge of me or my physical or mental health or insurability, or that of any minor child for whom application for insurance is being made, not including information pertaining to HIV testing, to disclose and give to the Company, its legal representatives, its affiliated service companies, and its affiliated insurers all information in whatever form, including electronic records they have pertaining to: medical consultations; treatments; surgeries; hospital confinements for physical and/or mental conditions; use of drugs or alcohol; drug prescriptions; or any other information concerning me, or any minor child for whom application for insurance is being made. Other information may include, but is not limited to, items such as: personal finances including credit as permitted; habits; hazardous avocations; motor vehicle records from the Department of Motor Vehicles; court records; or foreign travel, etc. I understand this authorization may be revoked at any time, except to the extent action has been taken by the Company in reliance on this authorization, by sending a written request to the Company, Attn: Underwriting Department at P.O. Box 1931, Houston, TX 77251-1937.

I understand that the information obtained will be used by the Company to determine: (1) eligibility for insurance; (2) eligibility for benefits under an existing policy; and (3) verification of answers and statements on this authorization. I further authorize the Company to conduct a media or electronic search on me. Any information gathered during the evaluation of my application may be disclosed to: other insurers to whom I may apply for coverage; reinsurers; the MIB; other persons or organizations performing business or legal services in connection with my application or claim; me; any physician designated by me; or any person or entity required to receive such information by law or as I may further consent.

I, as well as any person authorized to act on my behalf, may, upon request, obtain a copy of this consent. I understand this consent may be revoked at any time by sending a written request to the Company, Attn: Underwriting Department at P.O. Box 1931, Houston, TX 77251-1931. This consent will be valid for the earlier of: (i) the date I, or any person authorized to act on my behalf, revoke or withdraw such authorization or consent; or (ii) 24 months from the date this form is signed or for such other period permitted by applicable state law where the policy is issued.

All statements and answers in this Underwriting Authorization Form are true to the best of my knowledge and belief. I understand that any misrepresentation contained in this agreement and relied on by the Company may be used to reduce or deny a claim or void the policy if: (1) such misrepresentation materially affects the acceptance of the risk; and (2) the policy is within its contestable period.

I agree that this Underwriting Authorization Form will become a part of my application for insurance.

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.

I consent to receive phone calls and text messages from the Company and/or a Third Party Administrator on behalf of Company, regarding products and services, at the phone number(s) above, including my mobile phone number if provided. I understand these calls and texts may be generated using an automated technology. I understand that consent is not required to make a purchase. Standard messaging and data rates apply for text messages.

I agree that a copy of the consent and electronic agreement will be as valid as the original.

Health Insurance Portability and Accountability Act (“HIPAA”) Authorization to Obtain and Disclose Information

Form number AGLC100633 Rev0222

I, the Insured/Proposed Insured above or the Insured/Proposed Insured’s Personal Representative acting on behalf of the Insured/Proposed Insured, hereby authorize all of the people and organizations listed below to give American General Life Insurance Company (“AGL”), The United States Life Insurance Company in the City of New York (“US Life”), and any affiliated company, (AGL, US Life and affiliated companies collectively the “Companies”), and their authorized representatives, including agents and insurance support organizations, (collectively, the “Recipient”), the following information:

any and all information relating to my health (except psychotherapy notes) and my insurance policies and claims, including, but not limited to, information relating to any medical consultations, treatments, or surgeries; hospital confinements for physical and mental conditions; use of drugs or alcohol; drug prescriptions; and communicable diseases including HIV or AIDS; and
information about me, including my name, address, telephone number, gender and date of birth.

I hereby authorize each of the following entities ("Providers") to provide the information outlined above:

any physician, nurse or medical practitioner or practitioner group;
any hospital, clinic, other health care facility, pharmacy, or pharmacy benefit manager;
any insurance or reinsurance company (including, but not limited to, the Recipient or any of the Companies (as defined above) which may have provided me with life, accident, health, and/or disability insurance coverage, or to which I may have applied for insurance coverage, but coverage was not issued);
any consumer reporting agency or insurance support organization;
my employer, group policy holder, or benefit plan administrator; and
the Medical Information Bureau (MIB).

I understand that the information obtained will be used by the Recipient to:

determine my eligibility for insurance;
underwrite my application for insurance;
determine my eligibility for benefits;
if a policy is issued, determine my eligibility for benefits and contestability of the policy; and
detect fraud or abuse or for compliance activities, which may include disclosure to MIB and participation in MIB's fraud prevention or fraud detection programs.

I hereby acknowledge that the Companies are subject to certain federal privacy regulations. I understand that information released to the Recipient will be used and disclosed as described in the Notice of Health Information Privacy Practices, but that upon disclosure to any person or organization that is not a health plan or health care provider, the information may no longer be protected by federal privacy regulations.

I understand that the Recipients requesting access to my (electronic or paper) medical records are acting as a patient authorized representative and will attempt to access my medical records in an efficient manner, including electronic interchange through a Health Information Exchange or directly through my Providers' electronic health record system.

I may revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization or other law allows the Recipient to contest a claim under the policy or to contest the policy itself, by sending a written request to: American General Life Companies Service Center, P.O. Box 9000, Amarillo, TX 79105-9000. I understand that my revocation of this authorization will not affect uses and disclosures of my health information by the Recipient for purposes of underwriting, claims administration and other matters associated with my application for insurance coverage and the administration of any policy issued as a result of that application.

I understand that the signing of this authorization is voluntary; however, if I do not sign the authorization, the Companies may not be able to obtain the information necessary to consider my application.

This authorization will be valid for 24 months. A copy of this authorization will be as valid as the original. I understand that I am entitled to receive a copy of this authorization.