Supplemental Good Health Statement

IMPORTANT:
This supplementary proposal form should be completed to the best of your knowledge and belief, and all material facts (see
below*) should be disclosed. Failure to do so may nullify cover under any policy or certificate issued.

* A material fact is one that is likely to influence acceptance or assessment of the proposal. You should consult us if you are in
any doubt as to what constitutes a material fact.

If you consider that the answer to any question in the proposal form requires expert knowledge which you do not have, please
indicate this in your answer.

A specimen copy of the policy wording is available on request.

A. CONSENT FOR USE OF PERSONAL INFORMATION (Does not apply to residents of the UK)
Enrollment under this group plan may require that you provide us with sensitive personal information about you and your enrolling
dependents. In accordance with the privacy policy posted on our website, we will require your consent and the consent of those dependents
you are applying for to process this request for insurance coverage.

Once enrolled, we will require your continued consent to administer your plan and this will include pre-authorization of medical services, claims
administration, appeals, and plan renewal (if applicable).

Our privacy policy provides information concerning the use and disclosure of your personal information including your rights under this policy.
This privacy policy is in compliance with GBG’s data protection policies and those of the European Union (EU) General Data Protection
Regulation (GDPR). Throughout the year the terms of the privacy policy may be updated. You can find the most recent version at our website
http://gbg.com/#/AboutGBG/PrivacyPolicy.

Your personal information, including special category or sensitive personal information such as medical and health details which you supply to
the insurer may be used in many ways including, but not limited to: processing and underwriting your application for insurance, deciding
whether an offer of insurance coverage can be made and on what terms, administering your policy and handling claims, and detecting and
preventing fraudulent activity. Other GBG affiliates and third parties who provide services to the insurer could use your information in the same
manner and further detail in respect of the transfer of your data to third parties is contained in the privacy policy.

By ticking the box “I CONSENT”, you consent to the use and disclosure of your healthcare information in accordance with our privacy policy. If
you do not consent to the use and disclosure of your healthcare information GBG will not be able to evaluate your request and therefore will
not be able to provide you with insurance cover. The following enrollment form should only be completed if you are willing to provide consent.

Primary Applicant Signature: Printed Name: Carlos Ernesto Guzman Pirela

✔ I CONSENT Date: March 4th 1968

Spouse Signature:
Printed Name: Camila GuzmanChirinos
(If dependent spouse applying for coverage)
✔ I CONSENT Date: April 13th 2008

Child Signature:
Printed Name: Flavia Guzman Chirinos
(Dependent children age 16 or older if applying for coverage)

✔ I CONSENT Date: May 14th 2009

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B. APPLICATION INFORMATION

Last Name: Guzman Pirela First Name: Carlos Middle Initial: E

Since making your last Proposal, have you changed your occupation or residence? Yes ✔ No If yes, what are new details?

Have you suffered from any illness or accident or consulted a doctor for any purpose? Yes ✔ No
If so, state details including dates, period of disability, name and address of the doctor and reason for consultation and whether you have now
completely recovered?

Are there any additional facts affecting the proposed assurance which should be disclosed?
no

What is your present annual salary? (Not applicable for Medical Insurance): $30,0000
C. DECLARATION

I declare that the above statements are true and complete, and that, apart from the matters declared above, I am in good health and ordinarily
enjoy good health. I consent to Underwriters seeking medical information from any doctor who at any time has attended me concerning
anything which affects my physical or mental health. I also consent to Underwriters for seeking information from any insurance office to which a
proposal has been made for insurance on my life and I authorize the giving of such information. I agree that this proposal shall form the basis of
the basis of the contract should the assurance be affected.

Applicant Signature: Date: 05/15/2021

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