DESIGNATION OF BENEFICIARYAND MODE OF SETTLEMENT …

1 PROTECTIVE LIFE INSURANCE COMPANY, BIRMINGHAM, ALABAMA. DESIGNATION OF beneficiary AND MODE OF SETTLEMENT . Provisions applicable to the proceeds of Policy(ies) Number on the life of The undersigned hereby requests that the aforesaid proceeds (or portion of the proceeds) of the said Policy or Policies be paid upon receipt of due proof of the Insured's death to the beneficiaries and in the manner as follows: SECTION I: DESIGNATION OF beneficiary . Class Name Relationship Date of Birth Primary beneficiary : Contingent beneficiary : Final beneficiary : (In one sum). SECTION II: MODE OF SETTLEMENT .

2 (Please X appropriate blocks for Mode of SETTLEMENT elected.). A. SETTLEMENT with Primary beneficiary . The proceeds shall be paid the Primary beneficiary , if surviving the Insured, in the following manner: In one sum Option (1), Installments for years. Option (2), Life Income, years certain. Option (3), Retained at interest Option (4), Installments of $ each until proceeds exhausted. If Option (3) or (4) has been elected, Automatically change on Permit Primary beneficiary to change within months after Insured's death to Option for the proceeds then remaining unpaid. Interest or installment payments to be made: Annually Semi-annually Quarterly Monthly Right of Primary beneficiary to commute or withdraw: None Unlimited Limited as follows B.

3 SETTLEMENT with Contingent beneficiary . Upon the death of the Primary beneficiary while entitled to receive under Options (1), (2), or (4), the remaining installments under Option (1) or (4), or for the remaining years certain under Option (2), will be continued to the Contingent beneficiary . Upon the death of the Primary beneficiary while entitled to receive under Option (3), interest payments will be continued to and at the end of the above designated period the proceeds will be paid to the Contingent beneficiary . Provided, however, that in any event the proceeds will be paid in one sum to the Contingent beneficiary upon the death of the Primary beneficiary if SETTLEMENT in one sum is elected below.

4 F-788-R. If the Primary beneficiary dies before the Insured, the proceeds shall be paid the Contingent beneficiary , if surviving the Insured, in the following manner: In one sum Option (1), Installments for years. Option (2), Life Income, years certain. Option (3), Retained at interest Option (4), Installments of $ each until proceeds exhausted. If Option (3) or (4) has been elected, Automatically change on Permit Contingent beneficiary to change within months after Insured's death to Option for the proceeds then remaining unpaid. Interest or installment payments to be made: Annually Semi-annually Quarterly Monthly Right of Contingent beneficiary to commute or withdraw: None Unlimited Limited as follows C.

5 SETTLEMENT with Final beneficiary . Upon the death of the last to die of the Insured, the Primary beneficiary and the Contingent beneficiary , the proceeds, if any, shall be paid in one sum to the Final beneficiary , if a Final beneficiary be designated and is then living, otherwise to the executors or administrators of the last to die of the Insured, the Primary and the Contingent beneficiary , except that if the Insured is not the Owner of the policy, and no beneficiary survives the Insured, such payment shall be made to the Owner. D. Children of Insured as beneficiary . If a child (or children) of the Insured is beneficiary , the provisions for distribution to the children of a deceased child by representation contained in Section III, paragraph 4 shall be effective.

6 E. Power of Appointment in Primary beneficiary . If the Primary beneficiary in this DESIGNATION is the spouse of the Insured, the Power of Appointment provision con- tained in Section III, Paragraph 5 shall be effective with respect to such DESIGNATION . F. Additional Provisions. (Any provisions applicable under this paragraph shall supersede any conflicting provisions set forth herein): G. Incorporation of Other Provisions. The provisions of Section III attached to this instrument form a part of this DESIGNATION of beneficiary and Mode of SETTLEMENT as fully as if set out in full at this point; and the term DESIGNATION .

7 As used in Sections I, II, and III hereof, refers to this DESIGNATION of beneficiary and Mode of SETTLEMENT , including Section III. The Company is requested to amend the policies referred to in this DESIGNATION by making this DESIGNATION a part of each policy contract referred to in this DESIGNATION . It is agreed that payments under this DESIGNATION shall be subject to all the terms and conditions appearing in the said policies, except in the case of a conflict between the provisions of a policy and the provisions of this DESIGNATION , in which event the provisions of this DESIGNATION shall prevail.

8 If there is a provision in said policy requiring that it accompany any request for change of beneficiary and that such change shall not take effect until endorsed by the Company on the policy, such provision is hereby modified, and the beneficiary may be changed pursuant to this written request, which change will be effected by recordation by the Company at its Home Office without endorsement on the policy, and when so recorded shall take effect as of the date of this request, but subject to any payment made or action taken by the Company before such recordation. Upon approval by the Company at its Home Office an acknowledgement of this request is to be returned for attach- ment to the policy.

9 EXECUTED AT _____this _____day of _____, 19____. (City) (State) (Month). WITNESS: _____ _____. Insured, Owner or Applicant Address: _____. PROTECTIVE LIFE INSURANCE COMPANY agrees that the policy or policies described in this DESIGNATION are amended by making such DESIGNATION a part of each policy contract applicable thereto. EXECUTED at Birmingham, Alabama, this _____. PROTECTIVE LIFE INSURANCE COMPANY. _____. Registrar Secretary SECTION III: GENERAL PROVISIONS. The provisions of this Section III are incorporated in and made a part of each DESIGNATION of beneficiary and Mode of SETTLEMENT to which this Section III is attached, in like manner as if set out in full in the body of each such DESIGNATION .

10 References in this Section III to this DESIGNATION refer to each DESIGNATION to which this Section III is attached, sepa- rately and severally. 1. Rights Retained: Any previous DESIGNATION of beneficiary and Mode of SETTLEMENT under any of the above described policies is hereby revoked and the beneficiary thereof is hereby changed and SETTLEMENT elected in accordance with this DESIGNATION , except that if this DESIGNATION applies to a portion of the proceeds of any of said policies, it shall constitute a revocation and change of beneficiary and SETTLEMENT election only with respect to such portion of the proceeds.