APPLICATION FOR INSURANCE - United American

1 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. Term (18-63)Whole Life (18-63)10 Yr. Term (18-63)Whole Life (18-63)$10,000$ 5,000 Life Face Amount$, Premium$.

2 $,$,.Additional Premium Included$10,000$7,500$6,000$5,000$4,000$ 3,000$2,500$2,000 LOUISIANAI nitials ofPrimary InsuredAPPLICATION FOR INSURANCE * United American INSURANCE COMPANYA LEGAL RESERVE STOCK COMPANY * ADMINISTRATIVE OFFICE: MCKINNEY, TEXAS15210 PRIMARY INSUREDA ddressChild 2 First NametAgeWeight(lbs.)MaleFemaleHeight(ft. in.)Last 2 Primary Insured's OccupationBeneficiary for Spouse will be Primary Insured unless notice is given to United American INSURANCE Company's Home (ft. in.)Weight(lbs.)MaleFemaleLast NameSS #----Date of Birth(mm-dd-yyyy)Birth StateOccupationHeight(ft. in.) 1 First NametHeight(ft. in.) First NametYesNoI, the agent, have personallyseen this of Birth(mm-dd-yyyy)BirthStateAgeWeight(lbs .)

3 Last NameI, the agent, have personallyseen this , the agent, have personallyseen this AddressChild 3 First (ft. in.)Beneficiary RelationshipPrimary Insured's BeneficiaryWeight(lbs.)Last NameWeight(lbs.)Last Name( APPLICATION Continued)YesNoI, the agent, have personallyseen this of Birth(mm-dd-yyyy)AgeYesNoI, the agent, have personallyseen this of Birth(mm-dd-yyyy)--Date of Birth(mm-dd-yyyy)MGAPB(17)LOUISIANAI nitials ofPrimary InsuredAPPLICATION FOR INSURANCE * United American INSURANCE COMPANYA LEGAL RESERVE STOCK COMPANY * ADMINISTRATIVE OFFICE: MCKINNEY, TEXAS15210( APPLICATION Continued)Pg 3 INSUREDYES/NOSPOUSEYES/NOCHILD 1 YES/NOCHILD 2 YES/NOCHILD 3 YES/NOIf Optional Life coverage is chosen, please answer the following THE ANSWER TO QUESTION 1 IS "YES" THEN CONTINUE.

4 IF THE ANSWER IS"NO" THE PROPOSED INSURED IS NOT ELIGIBLE FOR (17)LOUISIANAI nitials ofPrimary Insured4. During the last three (3) years, has any proposed insured ever had:a. a disease or disorder of the heart or circulatory system includingheart attack or stroke; high blood pressure?b. a disease or disorder of the eye, ear, nose, throat, lung, breastor generative organs?c. a disease or disorder of the rectum, kidney, prostate, stomach,intestine, gall bladder, urinary bladder, liver, connective tissue,Lupus, collagen disease, pancreas, pituitary or adrenal gland?d. a disease or disorder of the brain (including retardation, dementia orAlzheimer s), mental or nervous system (including seizures orconvulsions), back or spine, paralysis or arthritis?

5 E. cancer, tumor, diabetes, blood disorders including anemia orspleen disorder?f. had his/her driver s license suspended or revoked because of a movingviolation or been arrested for driving under the influence of alcoholor drugs?g. received treatment for alcohol abuse or been advised by a physicianto reduce alcohol consumption?h. used or received treatment or consultation for heroin, cocaine orother similar agent or narcotic drug?5. During the past five (5) years, has any proposed insured had any medical or surgical advice, treatment or operations or been advised to have medical tests or surgery that has not yet been performed, or is awaiting medicaltest results?

6 7. Does any proposed insured participate in any hazardous sports or avocations?No benefits will be provided for loss due to such During the past two (2) years, has any proposed insured:a. had a cesarean section, miscarriage or serious complications of aprevious pregnancy?b. been hospitalized 3 or more times?8. Does any proposed insured have any existing (or pending APPLICATION for)health INSURANCE ?If yes, list coverage type _____9. Will the INSURANCE being applied for replace or change any existinghealth INSURANCE ?10. Have you received an outline of coverage ?11. Has any proposed insured used tobacco in any form within the past 12 months?12. Will the life INSURANCE being applied for replace or change any existinglife INSURANCE ?

7 1. Does each proposed insured have a Major Medical Policy or other comprehensive health coverage in force (or pending APPLICATION )? Please list company, policy number and effective date (if available): Has any proposed insured ever been treated for, diagnosed, or tested positive ashaving Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex(ARC), or ever tested positive for antibodies for the AIDS (HIV) virus?2. During the past three (3) months, except for minor illness of one (1) weekor less or pregnancy, has any illness, injury or health related problemprohibited any proposed insured from working full time at his/her regularoccupation or performing the normal activities of a person of the same age?

8 APPLICATION FOR INSURANCE * United American INSURANCE COMPANYA LEGAL RESERVE STOCK COMPANY * ADMINISTRATIVE OFFICE: MCKINNEY, TEXAS15210 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 ofmy knowledge and belief, true and complete. I agree the policy shall not be effective unless it has actually been issued. No agent may change this policy or waive any of HEREBY AUTHORIZE the MIB, Inc., any INSURANCE company, hospital, physician or other practitioner having any information available as to my diagnosis, treatment and prognosiswith respect to any physical or mental condition and/or treatment, to disclose such information to United American INSURANCE Company for the purpose of determining myeligibility for INSURANCE and eligibility for benefits under this policy.

9 I understand that I or an authorized representative may request a copy of this authorization. Information forconsumers about MIB, Inc., may be obtained on its website at Any person who knowingly presents a false or fraudulent claim for payment of a loss, a benefit, or knowingly presents false information in an APPLICATION for INSURANCE is guilty of acrime and may be subject to fines and confinement in 's SignatureAgent NamePrint First 5 Letters of Agent's Last NamePg 4If any proposed insured answered "Yes" to any of questions 4 - 7, provide details below for each "Yes" answer.* In column below list "I " for Insured, "S" for Spouse, "C1" for Child 1, "C2" for Child 2 and "C3" for Child of Doctors & Hospitals*StateDate APPLICATION Signed(mm-dd-yyyy)--Primary InsuredSignedSignedApplicant (If other than the Primary Insured)To the best of your knowledge as writing agent, isthe INSURANCE applied for intended to replace anyexisting INSURANCE ?

10 YesNo (The Policy will be sent to Insured unless otherwise instructed.)AgentInsuredSEND POLICY TO:"Automatic" Payment Plan / Bank DraftPlease TAPE personalized VOIDED CHECK NOT STAPLEBest time to call:8 AM - NoonNoon - 6 PM6 PM - 9 PM"AUTOMATIC" PAYMENT PLAN / BANK DRAFT AUTHORIZATION: I authorize you to pay and charge to my account, checks or electronic debits drawn on myaccount by and payable to the order of United American INSURANCE Company. This authorization is to remain in effect until revoked by me. All premiums andnon- INSURANCE charges may be automatically withdrawn from my account on MONTHLY mode, unless a different mode has been selected on the Holder's Signature (as it appears on financial institution records)-Home Phone Number()-Work Phone Number()MGAPB(17)LOUISIANAI nitials ofPrimary InsuredAPPLICATION FOR INSURANCE * United American INSURANCE COMPANYA LEGAL RESERVE STOCK COMPANY * ADMINISTRATIVE OFFICE: MCKINNEY, TEXAS15210