<html> <head> <title>Rule 20:06:06:0A Sample Application Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:06:0A"> <META NAME="Description" Content="Administrative Rules 20:06:06:0A Sample Application Form."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <title>CHAPTER 20:06:21</title> <style> <!-- /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:12.0pt; font-family:"Times New Roman","serif";} p.MsoFooter, li.MsoFooter, div.MsoFooter {margin:0in; margin-bottom:.0001pt; font-size:12.0pt; font-family:"Times New Roman","serif";} p {margin-right:0in; margin-left:0in; font-size:12.0pt; font-family:"Times New Roman","serif";} /* Page Definitions */ @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt;} div.WordSection1 {page:WordSection1;} @page WordSection2 {size:8.5in 11.0in; margin:49.7pt 1.4in 49.7pt .8in;} div.WordSection2 {page:WordSection2;} @page WordSection3 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt;} div.WordSection3 {page:WordSection3;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>SAMPLE APPLICATION FORM</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Chapter 20:06:06</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>APPENDIX A</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>SEE: &#167;&nbsp;20:06:06:11</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b><span style='font-weight:bold'>Source:</span></b> 32 SDR 203, effective June 5, 2006.</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman">&nbsp;</font></p> </div> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <div class=WordSection2> <p align=center style='text-align:center'><a name="OLE_LINK1"><b><font size=3 face=Arial><span style='font-size:12.0pt;font-family:"Arial","sans-serif"; font-weight:bold'>APPENDIX A</span></font></b></a></p> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width="109%" style='border-collapse:collapse'> <tr height=43 style='height:32.6pt'> <td width="19%" height=43 valign=top style='width:19.4%;border:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:32.6pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Insured Debtor </span></font></p> </td> <td width="30%" colspan=6 height=43 valign=bottom style='width:30.6%; border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:32.6pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>John Doe&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Box 555</span> </font></p> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Anywhere, USA 55555</span></font></p> </td> <td width="12%" colspan=2 height=43 valign=top style='width:12.92%; border:solid windowtext 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt; height:32.6pt'> <p class=MsoNormal align=center style='text-align:center'><font size=2 face=Arial><span style='font-size:10.0pt;font-family:"Arial","sans-serif"'>Date of Birth&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></p> </td> <td width="14%" colspan=3 height=43 valign=top style='width:14.32%; border:solid windowtext 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt; height:32.6pt'> <p class=MsoNormal align=center style='text-align:center'><font size=2 face=Arial><span style='font-size:10.0pt;font-family:"Arial","sans-serif"'>Age&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></p> </td> <td width="22%" nowrap colspan=6 height=43 valign=top style='width:22.76%; border-top:solid windowtext 1.0pt;border-left:none;border-bottom:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:32.6pt'> <p class=MsoNormal align=center style='text-align:center'><font size=2 face=Arial><span style='font-size:10.0pt;font-family:"Arial","sans-serif"'>Certificate Number&nbsp;&nbsp;&nbsp; </span></font></p> </td> <td style='height:32.6pt;border:none' width=0 height=43></td> </tr> <tr height=17 style='height:12.75pt'> <td width="50%" nowrap colspan=7 height=17 valign=bottom style='width:50.0%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:none; border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Joint Insured Debtor</span></font></p> </td> <td width="12%" nowrap colspan=2 height=17 valign=bottom style='width:12.92%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=3 height=17 valign=bottom style='width:14.32%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="22%" colspan=6 height=17 style='width:22.76%;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=51 style='height:38.25pt'> <td width="19%" height=51 valign=top style='width:19.4%;border:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:38.25pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Creditor (Beneficiary)&nbsp;&nbsp; (Name and Address)</span></font></p> </td> <td width="43%" colspan=8 height=51 valign=top style='width:43.52%; border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:38.25pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>ABC Bank&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;555 AVENUE&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Anywhere, USA 55555&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></p> </td> <td width="37%" nowrap colspan=9 height=51 valign=top style='width:37.08%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:38.25pt'> <p class=MsoNormal align=center style='text-align:center'><font size=2 face=Arial><span style='font-size:10.0pt;font-family:"Arial","sans-serif"'>Creditors Insurance Account No</span></font></p> </td> <td style='height:38.25pt;border:none' width=0 height=51></td> </tr> <tr height=34 style='height:25.5pt'> <td width="34%" colspan=3 height=34 valign=top style='width:34.62%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt; border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:25.5pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Assignee&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Name and Address)</span></font></p> </td> <td width="28%" nowrap colspan=6 height=34 valign=top style='width:28.3%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:25.5pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Monthly Payment</span></font></p> </td> <td width="37%" nowrap colspan=9 height=34 valign=top style='width:37.08%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:25.5pt'> <p class=MsoNormal align=center style='text-align:center'><font size=2 face=Arial><span style='font-size:10.0pt;font-family:"Arial","sans-serif"'>Annual Simple Interest Rate</span></font></p> </td> <td style='height:25.5pt;border:none' width=0 height=34></td> </tr> <tr height=17 style='height:12.75pt'> <td width="62%" colspan=9 height=17 valign=top style='width:62.92%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt; border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Second Beneficiary</span></font></p> </td> <td width="37%" nowrap colspan=9 height=17 valign=bottom style='width:37.08%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Relationship</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="34%" colspan=3 height=17 valign=top style='width:34.62%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:none; border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>EFFECTIVE DATE</span></font></p> </td> <td width="28%" nowrap colspan=6 height=17 valign=bottom style='width:28.3%; border:none;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>EXPIRY DATE</span></font></p> </td> <td width="37%" nowrap colspan=9 height=17 valign=bottom style='width:37.08%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Days to 1st Payment</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="62%" colspan=9 height=17 valign=top style='width:62.92%; border:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>COVERAGES</span></font></p> </td> <td width="14%" colspan=2 rowspan=2 style='width:14.18%;border-top:none; border-left:none;border-bottom:solid black 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>INITIAL AMOUNT OF INSURANCE</span></font></p> </td> <td width="11%" nowrap colspan=3 rowspan=2 style='width:11.52%;border-top: none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>PREMIUMS</span></font></p> </td> <td width="11%" colspan=4 rowspan=2 style='width:11.38%;border-top:none; border-left:none;border-bottom:solid black 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>TERM IN MONTHS</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap colspan=2 height=17 valign=bottom style='width:19.72%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp; Gross&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; or</span></font></p> </td> <td width="16%" nowrap colspan=2 height=17 valign=bottom style='width:16.24%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp;&nbsp; NET</span></font></p> </td> <td width="13%" nowrap colspan=2 height=17 valign=bottom style='width:13.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp; W. Dism</span></font></p> </td> <td width="13%" nowrap colspan=3 height=17 valign=bottom style='width:13.58%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp; W/O Dism</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap colspan=2 height=17 valign=bottom style='width:19.72%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp; Decreasing Term</span></font></p> </td> <td width="16%" nowrap colspan=2 height=17 valign=bottom style='width:16.24%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="26%" nowrap colspan=5 height=17 valign=bottom style='width:26.96%; border:none;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp; Periodic Decreasing Term</span></font></p> </td> <td width="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.18%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 28,615.00 </span></font></p> </td> <td width="11%" nowrap colspan=3 height=17 valign=bottom style='width:11.52%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> <td width="11%" nowrap colspan=4 height=17 valign=bottom style='width:11.38%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>59</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap colspan=2 height=17 valign=bottom style='width:19.72%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp; Jt. Decreasing Term</span></font></p> </td> <td width="16%" nowrap colspan=2 height=17 valign=bottom style='width:16.24%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="26%" nowrap colspan=5 height=17 valign=bottom style='width:26.96%; border:none;border-right:solid black 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp; Jt. Periodic Decreasing Term</span></font></p> </td> <td width="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.18%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=3 height=17 valign=bottom style='width:11.52%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=4 height=17 valign=bottom style='width:11.38%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap colspan=2 height=17 valign=bottom style='width:19.72%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp; Level Term</span></font></p> </td> <td width="16%" nowrap colspan=2 height=17 valign=bottom style='width:16.24%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.18%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp; Jt. Level Term</span></font></p> </td> <td width="11%" nowrap height=17 valign=bottom style='width:11.78%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal style='margin-right:21.65pt'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.18%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 22,352.47 </span></font></p> </td> <td width="11%" nowrap colspan=3 height=17 valign=bottom style='width:11.52%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> <td width="11%" nowrap colspan=4 height=17 valign=bottom style='width:11.38%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>60</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=18 style='height:13.5pt'> <td width="19%" nowrap colspan=2 height=18 valign=bottom style='width:19.72%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal align=right style='text-align:right'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>59</span></font></p> </td> <td width="16%" nowrap colspan=2 height=18 valign=bottom style='width:16.24%; padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Payments of&nbsp; $</span></font></p> </td> <td width="15%" nowrap colspan=4 height=18 valign=bottom style='width:15.18%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:13.5pt'> <p class=MsoNormal align=center style='text-align:center'><u><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>$485.00 </span></font></u></p> </td> <td width="11%" nowrap height=18 valign=bottom style='width:11.78%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:13.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=2 height=18 valign=bottom style='width:14.18%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 28,615.00 </span></font></p> </td> <td width="11%" nowrap colspan=3 height=18 valign=bottom style='width:11.52%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> <td width="11%" nowrap colspan=4 height=18 valign=bottom style='width:11.38%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>59</span></font></p> </td> <td style='height:13.5pt;border:none' width=0 height=18></td> </tr> <tr height=34 style='height:25.5pt'> <td width="19%" nowrap colspan=2 height=34 valign=bottom style='width:19.72%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:25.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="16%" nowrap colspan=2 height=34 valign=bottom style='width:16.24%; padding:0in 5.4pt 0in 5.4pt;height:25.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Final Payment of $</span></font></p> </td> <td width="15%" nowrap colspan=4 height=34 valign=bottom style='width:15.18%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:25.5pt'> <p class=MsoNormal align=center style='text-align:center'><u><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>$22,352.47 </span></font></u></p> </td> <td width="11%" nowrap height=34 valign=bottom style='width:11.78%; padding:0in 5.4pt 0in 5.4pt;height:25.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" colspan=2 rowspan=5 style='width:14.18%;border-top:none; border-left:solid windowtext 1.0pt;border-bottom:solid black 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:25.5pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&nbsp;[$485.00&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Monthly Disability Benefit] </span></font></p> </td> <td width="11%" nowrap colspan=3 rowspan=5 style='width:11.52%;border-top: none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:25.5pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&nbsp;$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> <td width="11%" colspan=4 rowspan=5 style='width:11.38%;border-top:none; border-left:none;border-bottom:solid black 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:25.5pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>PREMIUM &#8592;TOTAL</span></font></p> </td> <td style='height:25.5pt;border:none' width=0 height=34></td> </tr> <tr height=17 style='height:12.75pt'> <td width="62%" nowrap colspan=9 height=17 valign=bottom style='width:62.92%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp;&nbsp; Disability Coverage&nbsp;&nbsp;&nbsp; (Insured Debtor Only)</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=17 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="12%" nowrap colspan=2 height=17 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="50%" nowrap colspan=7 height=17 valign=bottom style='width:50.0%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>WAITING PERIOD&nbsp;&nbsp;&nbsp;&nbsp; ELIMINATION PERIOD</span></font></p> </td> <td width="12%" nowrap colspan=2 height=17 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp;&nbsp; 7 Days</span></font></p> </td> <td width="15%" nowrap colspan=2 height=17 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Retrospective</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>0 Days</span></font></p> </td> <td width="12%" nowrap colspan=2 height=17 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp;&nbsp; 14 Days</span></font></p> </td> <td width="15%" nowrap colspan=2 height=17 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Retroactive</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>0 Days</span></font></p> </td> <td width="12%" colspan=2 rowspan=4 valign=top style='width:12.92%; border:solid windowtext 1.0pt;border-bottom:none;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>Maximum Monthly Disability (per debtor)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></p> </td> <td width="14%" colspan=2 rowspan=4 valign=top style='width:14.18%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>Maximum Monthly Disability (per debtor)</span></font></p> </td> <td width="11%" colspan=3 rowspan=4 valign=top style='width:11.52%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>Maximum Term</span></font></p> </td> <td width="11%" colspan=4 rowspan=6 style='width:11.38%;border-top:none; border-left:none;border-bottom:solid black 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><b><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"; font-weight:bold'>&nbsp;Maximum Issue Age <u>65</u> Inclusive</span></font></b></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &#9633;&nbsp;&nbsp;&nbsp;&nbsp; 30 Days</span></font></p> </td> <td width="15%" nowrap colspan=2 height=17 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Retroactive</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>0 Days</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&#9633;&nbsp;&nbsp;&nbsp;&nbsp; 14 Days</span></font></p> </td> <td width="15%" nowrap colspan=2 height=17 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Non-Retro</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>14 Days</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &#9633;&nbsp;&nbsp;&nbsp;&nbsp; 30 Days</span></font></p> </td> <td width="15%" nowrap colspan=2 height=17 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Non-Retro</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>30 Days</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=17 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="12%" colspan=2 rowspan=2 valign=top style='width:12.92%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:solid black 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>$1000.00 (Ages 18-65)</span></font></p> </td> <td width="14%" colspan=2 rowspan=2 valign=top style='width:14.18%; border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right: solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>$100,000.00 (Ages 18-65)</span></font></p> </td> <td width="11%" colspan=3 rowspan=2 valign=top style='width:11.52%; border-top:none;border-left:none;border-bottom:solid black 1.0pt;border-right: solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>120 Months</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=18 style='height:13.5pt'> <td width="19%" nowrap height=18 valign=bottom style='width:19.4%;border-top: none;border-left:solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=18 valign=bottom style='width:15.22%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:13.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=4 height=18 valign=bottom style='width:15.38%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:13.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:13.5pt;border:none' width=0 height=18></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=17 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="12%" nowrap colspan=2 height=17 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.18%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=3 height=17 valign=bottom style='width:11.52%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=4 height=17 valign=bottom style='width:11.38%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="34%" nowrap colspan=3 height=17 valign=bottom style='width:34.62%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Application for Insurance</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="12%" nowrap colspan=2 height=17 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.18%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=3 height=17 valign=bottom style='width:11.52%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=4 height=17 valign=bottom style='width:11.38%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=17 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="12%" nowrap colspan=2 height=17 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.18%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=3 height=17 valign=bottom style='width:11.52%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=4 height=17 valign=bottom style='width:11.38%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=24 style='height:.25in'> <td width="50%" nowrap colspan=7 height=24 valign=bottom style='width:50.0%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:.25in'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>ABC ASSURANCE COMPANY</span></font></p> </td> <td width="12%" nowrap colspan=2 height=24 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:.25in'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=2 height=24 valign=bottom style='width:14.18%; padding:0in 5.4pt 0in 5.4pt;height:.25in'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>(Called We)</span></font></p> </td> <td width="22%" nowrap colspan=7 height=24 valign=bottom style='width:22.9%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:.25in'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Anywhere, USA 55555-5555</span></font></p> </td> <td style='height:.25in;border:none' width=0 height=24></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=17 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="12%" nowrap colspan=2 height=17 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.18%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="12%" nowrap colspan=5 height=17 valign=bottom style='width:12.54%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="10%" nowrap colspan=2 height=17 valign=bottom style='width:10.36%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=34 style='height:25.5pt'> <td width="100%" colspan=18 height=34 valign=bottom style='width:100.0%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:25.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>I am indebted to the above named Creditor for the above sum and for the security of payment of said debt. I hereby apply for credit insurance covering the amount of said debt as indicated above</span></font></p> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:25.5pt;border:none' width=0 height=34></td> </tr> <tr height=17 style='height:12.75pt'> <td width="100%" colspan=18 height=17 valign=bottom style='width:100.0%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>I represent that the answers on this application are true and complete to the best of my knowledge and belief. They are the basis on which insurance requested by me may be issued.</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=17 style='height:12.75pt'> <td width="100%" colspan=18 height=17 valign=bottom style='width:100.0%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=20 style='height:15.0pt'> <td width="19%" nowrap height=20 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.0pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>Insured</span></font></p> </td> <td width="15%" nowrap colspan=2 height=20 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:15.0pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>Debtor</span></font></p> </td> <td width="15%" nowrap colspan=4 height=20 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:15.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="13%" nowrap colspan=3 height=20 valign=bottom style='width:13.62%; padding:0in 5.4pt 0in 5.4pt;height:15.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=3 height=20 valign=bottom style='width:14.12%; padding:0in 5.4pt 0in 5.4pt;height:15.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=2 height=20 valign=bottom style='width:11.14%; padding:0in 5.4pt 0in 5.4pt;height:15.0pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>Joint Insured</span></font></p> </td> <td width="11%" nowrap colspan=3 height=20 valign=bottom style='width:11.14%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.0pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>Debtor</span></font></p> </td> <td style='height:15.0pt;border:none' width=0 height=20></td> </tr> <tr height=20 style='height:15.0pt'> <td width="19%" nowrap height=20 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.0pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>Yes</span></font></p> </td> <td width="15%" nowrap colspan=2 height=20 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:15.0pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>No</span></font></p> </td> <td width="15%" nowrap colspan=4 height=20 valign=bottom style='width:15.38%; padding:0in 5.4pt 0in 5.4pt;height:15.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="13%" nowrap colspan=3 height=20 valign=bottom style='width:13.62%; padding:0in 5.4pt 0in 5.4pt;height:15.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=3 height=20 valign=bottom style='width:14.12%; padding:0in 5.4pt 0in 5.4pt;height:15.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=2 height=20 valign=bottom style='width:11.14%; padding:0in 5.4pt 0in 5.4pt;height:15.0pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>Yes</span></font></p> </td> <td width="11%" nowrap colspan=3 height=20 valign=bottom style='width:11.14%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.0pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>No</span></font></p> </td> <td style='height:15.0pt;border:none' width=0 height=20></td> </tr> <tr height=21 style='height:15.75pt'> <td width="19%" nowrap height=21 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=21 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="43%" nowrap colspan=10 height=21 valign=bottom style='width:43.12%; padding:0in 5.4pt 0in 5.4pt;height:15.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>1. Are you under age 66?</span></font></p> </td> <td width="11%" nowrap colspan=2 height=21 valign=bottom style='width:11.14%; padding:0in 5.4pt 0in 5.4pt;height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="11%" nowrap colspan=3 height=21 valign=bottom style='width:11.14%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td style='height:15.75pt;border:none' width=0 height=21></td> </tr> <tr height=41 style='height:30.75pt'> <td width="19%" nowrap height=41 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:30.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=41 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:30.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="43%" colspan=10 height=41 valign=bottom style='width:43.12%; padding:0in 5.4pt 0in 5.4pt;height:30.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>2. Are you in good health as far as you know and believe?</span></font></p> </td> <td width="11%" nowrap colspan=2 height=41 valign=bottom style='width:11.14%; padding:0in 5.4pt 0in 5.4pt;height:30.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="11%" nowrap colspan=3 height=41 valign=bottom style='width:11.14%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:30.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td style='height:30.75pt;border:none' width=0 height=41></td> </tr> <tr height=47 style='height:35.25pt'> <td width="19%" nowrap height=47 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:35.25pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=47 valign=bottom style='width:15.22%; padding:0in 5.4pt 0in 5.4pt;height:35.25pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="43%" colspan=10 height=47 valign=bottom style='width:43.12%; padding:0in 5.4pt 0in 5.4pt;height:35.25pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>3. Are you actively and gainfully employed for wage or profit on a full time basis</span></font></p> </td> <td width="22%" nowrap colspan=5 height=47 valign=bottom style='width:22.26%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:35.25pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>N/A</span></font></p> </td> <td style='height:35.25pt;border:none' width=0 height=47></td> </tr> <tr height=21 style='height:15.75pt'> <td width="19%" nowrap height=21 valign=bottom style='width:19.4%;border-top: none;border-left:solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=21 valign=bottom style='width:15.22%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="15%" nowrap colspan=4 height=21 valign=bottom style='width:15.38%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="13%" nowrap colspan=3 height=21 valign=bottom style='width:13.62%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=3 height=21 valign=bottom style='width:14.12%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=2 height=21 valign=bottom style='width:11.14%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="11%" nowrap colspan=3 height=21 valign=bottom style='width:11.14%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:15.75pt;border:none' width=0 height=21></td> </tr> <tr height=21 style='height:15.75pt'> <td width="19%" nowrap height=21 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="15%" nowrap colspan=2 height=21 valign=bottom style='width:15.22%; border:none;padding:0in 5.4pt 0in 5.4pt;height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="43%" colspan=10 height=21 valign=bottom style='width:43.12%; border:none;padding:0in 5.4pt 0in 5.4pt;height:15.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>4. During the past 5 years have you been treated for, or been told you had, any of the following conditions (Please Circle) High Blood Pressure; Heart Disease; Cancer or Tumor; Diabetes; Stroke; Disease of Liver or Kidney; Alcoholism; Drug Addiction; any Brain, Nervous System or Mental/Neurological Disorder; Acquired Immune Deficiency Syndrome (AIDS).</span></font></p> </td> <td width="11%" nowrap colspan=2 height=21 valign=bottom style='width:11.14%; border:none;padding:0in 5.4pt 0in 5.4pt;height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td width="11%" nowrap colspan=3 height=21 valign=bottom style='width:11.14%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:15.75pt'> <p class=MsoNormal align=center style='text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>&#9633;</span></font></p> </td> <td style='height:15.75pt;border:none' width=0 height=21></td> </tr> <tr height=17 style='height:12.75pt'> <td width="100%" colspan=18 rowspan=2 valign=bottom style='width:100.0%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>I understand that if the aforesaid representations are false and untrue, the Insurance Company's Liability shall be limited to the return of the premium paid for said coverage (subject to the 2-year incontestability provision).</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=21 style='height:15.75pt'> <td style='height:15.75pt;border:none' width=0 height=21></td> </tr> <tr height=15 style='height:11.5pt'> <td width="100%" colspan=18 rowspan=2 valign=bottom style='width:100.0%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:11.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>I further understand that the insurance prepaid for is not compulsory, nor a condition precedent to any loan or credit transaction. I certify that I have been given the option to purchase such credit insurance from any insurer or agent of my choice. I freely chose the insurer and agent to whom this application is made. I declare that I have read or had read to me this statement before signing.</span></font></p> </td> <td style='height:11.5pt;border:none' width=0 height=15></td> </tr> <tr height=51 style='height:38.25pt'> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'> <td style='height:38.25pt;border:none' width=0 height=51></td> </span></font> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="17%" nowrap colspan=4 height=17 valign=bottom style='width:17.04%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="13%" nowrap colspan=2 height=17 valign=bottom style='width:13.56%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="13%" nowrap colspan=3 height=17 valign=bottom style='width:13.62%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=3 height=17 valign=bottom style='width:14.12%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="12%" nowrap colspan=4 height=17 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="9%" nowrap height=17 valign=bottom style='width:9.34%;border:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=18 style='height:13.5pt'> <td width="36%" nowrap colspan=5 height=18 valign=bottom style='width:36.44%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Date</span></font></p> </td> <td width="63%" nowrap colspan=13 height=18 valign=bottom style='width:63.56%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Signature of Insured Debtor</span></font></p> </td> <td style='height:13.5pt;border:none' width=0 height=18></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="17%" nowrap colspan=4 height=17 valign=bottom style='width:17.04%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="13%" nowrap colspan=2 height=17 valign=bottom style='width:13.56%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="13%" nowrap colspan=3 height=17 valign=bottom style='width:13.62%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=3 height=17 valign=bottom style='width:14.12%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="12%" nowrap colspan=4 height=17 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="9%" nowrap height=17 valign=bottom style='width:9.34%;border:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=18 style='height:13.5pt'> <td width="36%" nowrap colspan=5 height=18 valign=bottom style='width:36.44%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Witness</span></font></p> </td> <td width="63%" nowrap colspan=13 height=18 valign=bottom style='width:63.56%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>Signature of Joint Insured Debtor</span></font></p> </td> <td style='height:13.5pt;border:none' width=0 height=18></td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.4%;border: none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="17%" nowrap colspan=4 height=17 valign=bottom style='width:17.04%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="13%" nowrap colspan=2 height=17 valign=bottom style='width:13.56%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="13%" nowrap colspan=3 height=17 valign=bottom style='width:13.62%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="14%" nowrap colspan=3 height=17 valign=bottom style='width:14.12%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="12%" nowrap colspan=4 height=17 valign=bottom style='width:12.92%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="9%" nowrap height=17 valign=bottom style='width:9.34%;border:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=2 face=Arial><span style='font-size:10.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td style='height:12.75pt;border:none' width=0 height=17></td> </tr> <tr height=18 style='height:13.5pt'> <td width="100%" nowrap colspan=18 height=18 valign=bottom style='width:100.0%; border:solid windowtext 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt; height:13.5pt'> <p class=MsoNormal align=center style='text-align:center'><font size=2 face=Arial><span style='font-size:10.0pt;font-family:"Arial","sans-serif"'>Upon Acceptance by the Insurer, the insurance shall become effective as of the effective date shown above.</span></font></p> </td> <td style='height:13.5pt;border:none' width=0 height=18></td> </tr> <tr height=0> <td width=159 style='border:none'></td> <td width=3 style='border:none'></td> <td width=122 style='border:none'></td> <td width=11 style='border:none'></td> <td width=4 style='border:none'></td> <td width=106 style='border:none'></td> <td width=5 style='border:none'></td> <td width=9 style='border:none'></td> <td width=97 style='border:none'></td> <td width=6 style='border:none'></td> <td width=110 style='border:none'></td> <td width=1 style='border:none'></td> <td width=4 style='border:none'></td> <td width=89 style='border:none'></td> <td width=2 style='border:none'></td> <td width=6 style='border:none'></td> <td width=8 style='border:none'></td> <td width=77 style='border:none'></td> <td style='border:none' width=0><p class='MsoNormal'>&nbsp;</td> </tr> </table> <p><b><font size=2 face="Times New Roman"><span style='font-size:10.0pt; font-weight:bold'>&nbsp;</span></font></b></p> </div> <b><font size=2 face="Times New Roman"><span style='font-size:10.0pt; font-family:"Times New Roman","serif";font-weight:bold'><br clear=all style='page-break-before:always'> </span></font></b> <div class=WordSection3> <p><b><font size=2 face="Times New Roman"><span style='font-size:10.0pt; font-weight:bold'>&nbsp;</span></font></b></p> </div> </body> </html>