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APPLICATION FOR INSURANCE * UNITED …

MGAPB(17)( APPLICATION Continued)Pg 1 Total Premium$,.Total Collected with APPLICATION $,.Requested Effective Date (mm-dd-yyyy)--2 0 Draft Day (01 to 28 only)Payment ModeMonthlyQuarterlySemi-AnnualAnnuallyP ayment TypeBank DraftDirectBASE PLANP rimary InsuredSpouseFoundation Signature Series Child 1 Child 2 Child 3 Child 4 Child 5 Child 6 Child 7 Child 8 Maximum Annual Benefit Premium$,.OPTIONAL RIDERH ospital Outpatient BenefitPrimary InsuredSpouseChild 1 Child 2 Child 3 Child 4 Child 5 Child 6 Child 7 Child 8 Premium$,.OPTIONAL LIFE INSURANCELifePrimary InsuredSpouseChild Term Rider10 Yr.

AGREEMENT: I hereby apply to United American Insurance Company for a policy to be issued in reliance on my written answers to all questions.The answers are, to the best of

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