Authorization

This Authorization complies with the Health Insurance Portability and Accountability Act (“HIPAA”)

I hereby authorize all the entities listed below that have provided payments, treatments or services to me, or on my behalf, to disclose to The Savings Bank Mutual Life Insurance Company of Massachusetts (the “Company”) and its reinsurers, Producers, employees and representatives, including insurance support organizations, the following information: any and all information relating to my health 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 alcohol, drugs, and tobacco; drug prescriptions and communicable diseases, including Human Immunodeficiency Virus (HIV) and AIDS, and any other personal information about me.

I hereby authorize each of the following entities to provide the information outlined above:

• any physician or medical practitioner or health care professional;
• any hospital, laboratory, pharmacy, pharmacy benefit manager, clinic or other health care facility or provider;
• any insurance or reinsurance company;
• any consumer reporting agency or insurance support organization; and
• my employer, group policy holder, or benefit plan administrator

This information may be disclosed pursuant to this Authorization so that SBLI can use it to:

• determine my eligibility for insurance;
• underwrite my application and make risk rating, policy issuance and enrollment determinations;
• determine my eligibility for benefits under the Conditional Receipt Agreement;
• obtain reinsurance;
• if a policy is issued, administer coverage, administer claims and determine or fulfill responsibility for coverage and provision of benefits; and
• conduct other legally permissible activities that relate to any insurance coverage I have or have applied for with SBLI.

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 any physician, medical practitioner, health care provider, hospital, clinic or any other health care provider to release and disclose my entire medical record without restriction. I understand that my health care providers cannot refuse to provide treatment or payment for health care services if I refuse to sign this Authorization.

I authorize the Company and its reinsurers to release any information obtained by this Authorization to other insurers in which I have policies or to which I may apply or to which a claim for benefits may be submitted, to reinsurers, and to other persons or organizations performing legal or business services in connection with my application or claim.

I authorize MIB, Inc., and any MIB member insurer, to provide any medical or personal information that it has about me to the Company and its reinsurers or any MIB-authorized third-party administrator performing underwriting services on behalf of the Company. I also authorize the Company, its reinsurers or authorized third-party administrator, to make a brief report of my personal health information to MIB, Inc.

I authorize the Company to release to me, or to my physician, results that I may request of any medical or laboratory tests taken in connection with this application. In connection with a claim for benefits, this Authorization is valid no longer than the duration of the claim.

I also understand that failure to sign this Authorization statement, or subsequent revocation of this Authorization by me, may impair the ability of the Company to process my application or evaluate claims, and may be a basis for denying an application or claim for benefits.

I understand that any information that is disclosed pursuant to this Authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information.

By signing below I agree to the terms of this Authorization and acknowledge that I have read and understand it.

FOR MAINE and VERMONT APPLICANTS, this Authorization excludes the release of any information relating to previously administered test for HIV antibodies, T-Cell counts, AIDS or ARC, by the applicants family/regular/attending medical doctor/physician/practitioner or care giver or any other person or entity which may possess this information. This exclusion extends to any medical doctor, doctor of osteopathy, physician health care professional, hospital, clinic, medical facility, the Veterans Administration, employer, consumer, reporting agencies, other insurance companies, or anyone else with respect to previous test results. The applicant is not authorizing the Company to forward the results from any new test, requested of the applicant by the Company to an outside, non-affiliated company, nor to any entity not under specific contract with the Company to perform underwriting services.

I may revoke this Authorization in writing at any time, except to the extent that action has been taken in reliance of this Authorization or to the extent the Company has a legal right to contest a claim under an insurance policy or to contest the policy itself, by sending a written request to: The Savings Bank Mutual Life Insurance Company, P.O. Box 4048, Woburn, MA 01888.

This Authorization shall remain in force for the time limit, if any, permitted by applicable law in the state where the policy is delivered or issued for delivery, following the date of my signature below or for the duration of any claim for benefits. A copy of this Authorization is as valid as the original. I acknowledge that I have received a copy of this Authorization.