<html> <head> <title>Rule 20:06:06:0B Sample Application Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:06:0B"> <META NAME="Description" Content="Administrative Rules 20:06:06:0B 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 1.4in 49.7pt .8in;} 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='margin-right:.65pt;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 B</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='margin-right:-.05in;text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>APPENDIX B</span></font></b></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width="109%" style='border-collapse:collapse'> <tr height=45 style='height:33.5pt'> <td width="21%" colspan=3 height=45 valign=top style='width:21.4%;border: solid windowtext 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt; height:33.5pt'> <p class=MsoNormal><font size=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>Insured Debtor </span></font></p> </td> <td width="28%" colspan=4 height=45 valign=bottom style='width:28.0%; 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:33.5pt'> <p class=MsoNormal><font size=3 face=Arial><span style='font-size:12.0pt; 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;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&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&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&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</span></font></p> </td> <td width="12%" colspan=4 height=45 valign=top style='width:12.64%; border:solid windowtext 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt; height:33.5pt'> <p class=MsoNormal align=center style='text-align:center'><font size=3 face=Arial><span style='font-size:12.0pt;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="11%" colspan=2 height=45 valign=top style='width:11.56%; border:solid windowtext 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt; height:33.5pt'> <p class=MsoNormal align=center style='text-align:center'><font size=3 face=Arial><span style='font-size:12.0pt;font-family:"Arial","sans-serif"'>Age&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></p> </td> <td width="26%" nowrap colspan=10 height=45 valign=top style='width:26.4%; 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:33.5pt'> <p class=MsoNormal align=center style='margin-right:37.1pt;text-align:center'><font size=3 face=Arial><span style='font-size:12.0pt;font-family:"Arial","sans-serif"'>Certificate Number&nbsp;&nbsp;&nbsp; </span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="49%" nowrap colspan=7 height=17 valign=bottom style='width:49.4%; 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=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>Joint Insured Debtor</span></font></p> </td> <td width="12%" nowrap colspan=4 height=17 valign=bottom style='width:12.64%; 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 width="11%" nowrap colspan=2 height=17 valign=bottom style='width:11.56%; 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 width="26%" colspan=10 height=17 style='width:26.4%;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> </tr> <tr height=51 style='height:38.25pt'> <td width="21%" colspan=3 height=51 valign=top style='width:21.4%;border: solid windowtext 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt; height:38.25pt'> <p class=MsoNormal><font size=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>Creditor (Beneficiary)&nbsp;&nbsp; (Name and Address)</span></font></p> </td> <td width="40%" colspan=8 height=51 valign=top style='width:40.62%; 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=3 face=Arial><span style='font-size:12.0pt; 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=12 height=51 valign=top style='width:37.96%; border:solid windowtext 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt; height:38.25pt'> <p class=MsoNormal align=center style='text-align:center'><font size=3 face=Arial><span style='font-size:12.0pt;font-family:"Arial","sans-serif"'>Creditors Insurance Account No</span></font></p> </td> </tr> <tr height=34 style='height:25.5pt'> <td width="34%" colspan=4 height=34 valign=top style='width:34.3%;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=3 face=Arial><span style='font-size:12.0pt; 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="27%" nowrap colspan=7 height=34 valign=top style='width:27.72%; 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=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>Monthly Payment</span></font></p> </td> <td width="37%" nowrap colspan=12 height=34 valign=top style='width:37.96%; 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=3 face=Arial><span style='font-size:12.0pt;font-family:"Arial","sans-serif"'>Annual Simple Interest Rate</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="62%" colspan=11 height=17 valign=top style='width:62.04%; 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=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>Second Beneficiary</span></font></p> </td> <td width="37%" nowrap colspan=12 height=17 valign=bottom style='width:37.96%; 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=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>Relationship</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="34%" colspan=4 height=17 valign=top style='width:34.3%;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=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>EFFECTIVE DATE</span></font></p> </td> <td width="27%" nowrap colspan=7 height=17 valign=bottom style='width:27.72%; border:none;border-right:solid black 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"'>EXPIRY DATE</span></font></p> </td> <td width="37%" nowrap colspan=12 height=17 valign=bottom style='width:37.96%; 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=3 face=Arial><span style='font-size:12.0pt; font-family:"Arial","sans-serif"'>Days to 1st Payment</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="62%" colspan=11 height=17 valign=top style='width:62.04%; 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="13%" colspan=4 rowspan=2 style='width:13.3%;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="12%" nowrap colspan=4 rowspan=2 style='width:12.28%;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="12%" colspan=4 rowspan=2 style='width:12.38%;border:solid windowtext 1.0pt; border-left: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"'>TERM IN MONTHS</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.6%;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; Gross&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; or</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.88%; 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 height=17 valign=bottom style='width:13.46%; 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; W. Dism</span></font></p> </td> <td width="13%" nowrap colspan=5 height=17 valign=bottom style='width:13.12%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.6%;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; Decreasing Term</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.88%; 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=6 height=17 valign=bottom style='width:26.58%; 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;&nbsp; Periodic Decreasing Term</span></font></p> </td> <td width="13%" nowrap colspan=4 height=17 valign=bottom style='width:13.3%; 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;$&nbsp;&nbsp; 5,400.00 </span></font></p> </td> <td width="12%" nowrap colspan=4 height=17 valign=bottom style='width:12.28%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> <td width="12%" nowrap colspan=4 height=17 valign=bottom style='width:12.38%; 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='margin-right:-.9pt;text-align:center'><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'>36</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.6%;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; Jt. Decreasing Term</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.88%; 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=6 height=17 valign=bottom style='width:26.58%; 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;&nbsp; Jt. Periodic Decreasing Term</span></font></p> </td> <td width="13%" nowrap colspan=4 height=17 valign=bottom style='width:13.3%; 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="12%" nowrap colspan=4 height=17 valign=bottom style='width:12.28%; 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="12%" nowrap colspan=4 height=17 valign=bottom style='width:12.38%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="19%" nowrap height=17 valign=bottom style='width:19.6%;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; Level Term</span></font></p> </td> <td width="15%" nowrap colspan=4 height=17 valign=bottom style='width:15.88%; 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=3 height=17 valign=bottom style='width:15.92%; 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"'>&#9633;&nbsp;&nbsp;&nbsp;&nbsp; Jt. Level Term</span></font></p> </td> <td width="10%" nowrap colspan=3 height=17 valign=bottom style='width:10.64%; 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 width="13%" nowrap colspan=4 height=17 valign=bottom style='width:13.3%; 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;$ 11,197.00 </span></font></p> </td> <td width="12%" nowrap colspan=4 height=17 valign=bottom style='width:12.28%; 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;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> <td width="12%" nowrap colspan=4 height=17 valign=bottom style='width:12.38%; 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"'>36</span></font></p> </td> </tr> <tr height=18 style='height:13.5pt'> <td width="19%" nowrap height=18 valign=bottom style='width:19.6%;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"'>35</span></font></p> </td> <td width="15%" nowrap colspan=4 height=18 valign=bottom style='width:15.88%; 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=3 height=18 valign=bottom style='width:15.92%; 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"'>$150.00 </span></font></u></p> </td> <td width="10%" nowrap colspan=3 height=18 valign=bottom style='width:10.64%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:13.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> <td width="13%" nowrap colspan=4 height=18 valign=bottom style='width:13.3%; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:13.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;$&nbsp;&nbsp; 5,400.00 </span></font></p> </td> <td width="12%" nowrap colspan=4 height=18 valign=bottom style='width:12.28%; 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;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> <td width="12%" nowrap colspan=4 height=18 valign=bottom style='width:12.38%; 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"'>36</span></font></p> </td> </tr> <tr height=34 style='height:25.5pt'> <td width="19%" nowrap height=34 valign=bottom style='width:19.6%;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="15%" nowrap colspan=4 height=34 valign=bottom style='width:15.88%; 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=3 height=34 valign=bottom style='width:15.92%; 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"'>$11,347.51 </span></font></u></p> </td> <td width="10%" nowrap colspan=3 height=34 valign=bottom style='width:10.64%; 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="13%" colspan=4 rowspan=5 style='width:13.3%;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;[$150.00&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Monthly Disability Benefit] </span></font></p> </td> <td width="12%" nowrap colspan=4 rowspan=5 style='width:12.28%;border-top: none;border-left:none;border-bottom:solid black 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:25.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> <td width="12%" colspan=4 rowspan=5 style='width:12.38%;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: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&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &#8592;TOTAL</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="62%" nowrap colspan=11 height=17 valign=bottom style='width:62.04%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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:14.62%; 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="13%" nowrap colspan=5 height=17 valign=bottom style='width:13.12%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="34%" nowrap colspan=4 height=17 valign=bottom style='width:34.3%; 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="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.62%; 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="13%" nowrap colspan=5 height=17 valign=bottom style='width:13.12%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.62%; 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="13%" nowrap colspan=5 height=17 valign=bottom style='width:13.12%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.62%; 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="13%" colspan=5 rowspan=4 valign=top style='width:13.12%; 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="13%" colspan=4 rowspan=4 valign=top style='width:13.3%;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="12%" colspan=4 rowspan=4 valign=top style='width:12.28%; 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="12%" colspan=4 rowspan=6 style='width:12.38%;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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.62%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.62%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.62%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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:14.62%; 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="13%" colspan=5 rowspan=2 valign=top style='width:13.12%; 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="13%" colspan=4 rowspan=2 valign=top style='width:13.3%;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="12%" colspan=4 rowspan=2 valign=top style='width:12.28%; 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> </tr> <tr height=18 style='height:13.5pt'> <td width="21%" nowrap colspan=3 height=18 valign=bottom style='width:21.4%; 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="12%" nowrap height=18 valign=bottom style='width:12.9%;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="14%" nowrap colspan=2 height=18 valign=bottom style='width:14.62%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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:14.62%; 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="13%" nowrap colspan=5 height=17 valign=bottom style='width:13.12%; 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="13%" nowrap colspan=4 height=17 valign=bottom style='width:13.3%; 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=4 height=17 valign=bottom style='width:12.28%; 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="9%" nowrap colspan=3 height=17 valign=bottom style='width:9.58%; 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="2%" nowrap height=17 valign=bottom style='width:2.78%;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> </tr> <tr height=17 style='height:12.75pt'> <td width="97%" colspan=22 rowspan=2 valign=bottom style='width:97.2%; 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"'>DEATH CLAIM STATEMENT- INSTRUCTIONS: Creditor Policyholder should complete the statement below and return with the following documents: 1. Certified copy of the Death Certificate showing cause of death; 2. Copy of the conditional sales contract or note covered by the Insurance; 3. Copy of the Policy or Certificate Issued to the deceased. This completed form, together with the documents specified above, should be sent to:</span></font></p> </td> <td width="2%" nowrap height=17 valign=bottom style='width:2.78%;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> </tr> <tr height=29 style='height:21.75pt'> <td width="2%" nowrap height=29 valign=bottom style='width:2.78%;border:none; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:21.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="97%" nowrap colspan=22 height=17 valign=bottom style='width:97.2%; 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"'>ABC ASSURANCE COMPANY&nbsp;&nbsp;&nbsp;&nbsp; Insurance Division, 555 Boulevard, Anywhere, USA, 55555-555</span></font></p> </td> <td width="2%" nowrap height=17 valign=bottom style='width:2.78%;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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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:14.62%; 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:11.38%; 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="13%" nowrap colspan=4 height=17 valign=bottom style='width:13.3%; 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="13%" nowrap colspan=5 height=17 valign=bottom style='width:13.94%; 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="9%" nowrap colspan=4 height=17 valign=bottom style='width:9.66%; 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="2%" nowrap height=17 valign=bottom style='width:2.78%;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> </tr> <tr height=17 style='height:12.75pt'> <td width="97%" nowrap colspan=22 height=17 valign=bottom style='width:97.2%; 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"'>1. Name of Insured</span></font></p> </td> <td width="2%" nowrap height=17 valign=bottom style='width:2.78%;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> </tr> <tr height=17 style='height:12.75pt'> <td width="48%" colspan=6 height=17 valign=bottom style='width:48.92%; 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:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>2. Certificate No. (or individual Policy No.)</span></font></p> </td> <td width="12%" colspan=4 height=17 valign=bottom style='width:12.24%; border:none;border-bottom: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"'>Date of Loan</span></font></p> </td> <td width="13%" colspan=4 height=17 valign=bottom style='width:13.22%; border:none;border-bottom: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="10%" colspan=3 height=17 valign=bottom style='width:10.6%; border:none;border-bottom: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"'>for Term of </span></font></p> </td> <td width="12%" colspan=5 height=17 valign=bottom style='width:12.22%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:12.75pt'> <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"'>Mos.</span></font></p> </td> <td width="2%" nowrap height=17 valign=bottom style='width:2.78%;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> </tr> <tr height=17 style='height:12.75pt'> <td width="20%" nowrap colspan=2 height=17 valign=bottom style='width:20.46%; 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"'>3& & & & & & & & & & & & & </span></font></p> </td> <td width="13%" colspan=2 height=17 valign=bottom style='width:13.84%; 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"'>Original Amount Insured</span></font></p> </td> <td width="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.62%; 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"'>& & & & & & & & & & & .</span></font></p> </td> <td width="12%" colspan=4 height=17 valign=bottom style='width:12.24%; border:none;border-bottom: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;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> <td width="13%" colspan=4 height=17 valign=bottom style='width:13.22%; 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="10%" colspan=3 height=17 valign=bottom style='width:10.6%; padding:0in 5.4pt 0in 5.4pt;height:12.75pt'> <p class=MsoNormal style='margin-left:1.35pt'><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=5 height=17 valign=bottom style='width:12.22%; 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="2%" nowrap height=17 valign=bottom style='width:2.78%;border:solid windowtext 1.0pt; border-left:none;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> </tr> <tr height=17 style='height:12.75pt'> <td width="20%" nowrap colspan=2 height=17 valign=bottom style='width:20.46%; border-top:solid windowtext 1.0pt;border-left:solid windowtext 1.0pt; border-bottom:none;border-right:none;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"'>4& & & & & & & & & & & & & </span></font></p> </td> <td width="13%" colspan=2 height=17 valign=bottom style='width:13.84%; border:none;border-top: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"'>Less Amount Paid</span></font></p> </td> <td width="14%" nowrap colspan=2 height=17 valign=bottom style='width:14.62%; border:none;border-top: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"'>& & & & & & & & & & & .</span></font></p> </td> <td width="12%" colspan=4 height=17 valign=bottom style='width:12.24%; border:none;border-bottom: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;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> <td width="38%" colspan=13 rowspan=4 style='width:38.82%;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: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> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</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> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>To comply with certain State Laws, our payoff to a creditor may be for the net amount due (Gross amount less unearned interest and/or advance payments). Please advise us of this amount. Any remaining balance is payable to the second beneficiary if named, otherwise to the Debtors Estate.</span></font></p> </td> </tr> <tr height=34 style='height:25.5pt'> <td width="20%" nowrap colspan=2 height=34 valign=bottom style='width:20.46%; border-top:solid windowtext 1.0pt;border-left:solid windowtext 1.0pt; border-bottom:none;border-right:none;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"'>5& & & & & & & & & & & & & </span></font></p> </td> <td width="13%" colspan=2 height=34 valign=bottom style='width:13.84%; border:none;border-top: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"'>Less Unearned Interest</span></font></p> </td> <td width="14%" nowrap colspan=2 height=34 valign=bottom style='width:14.62%; border:none;border-top: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"'>& & & & & & .& & & & </span></font></p> </td> <td width="12%" colspan=4 height=34 valign=bottom style='width:12.24%; border:none;border-bottom: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;$&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> </tr> <tr height=68 style='height:51.0pt'> <td width="20%" nowrap colspan=2 height=68 valign=bottom style='width:20.46%; border:solid windowtext 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt; height:51.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>6& & & & & & & & & & & & & </span></font></p> </td> <td width="13%" colspan=2 height=68 valign=bottom style='width:13.84%; border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:51.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Less Unearned A &amp; H Premium&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Life Premium Earned)</span></font></p> </td> <td width="14%" nowrap colspan=2 height=68 valign=bottom style='width:14.62%; border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:51.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>& & & & & & & & & & & </span></font></p> </td> <td width="12%" colspan=4 height=68 valign=bottom style='width:12.24%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:51.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;$&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; -&nbsp;&nbsp; </span></font></p> </td> </tr> <tr height=41 style='height:30.75pt'> <td width="20%" nowrap colspan=2 height=41 valign=bottom style='width:20.46%; border-top:none;border-left:solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:30.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>7& & & & & & & & & & & & & </span></font></p> </td> <td width="13%" colspan=2 height=41 valign=bottom style='width:13.84%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:30.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Balance Due</span></font></p> </td> <td width="14%" nowrap colspan=2 height=41 valign=bottom style='width:14.62%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:30.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>& & & & & & & & & & & </span></font></p> </td> <td width="12%" colspan=4 height=41 valign=bottom style='width:12.24%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:30.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;$&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> </tr> <tr height=47 style='height:35.25pt'> <td width="20%" nowrap colspan=2 height=47 valign=bottom style='width:20.46%; 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:35.25pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>8& & & & & & & & & & & & & .</span></font></p> </td> <td width="28%" colspan=4 height=47 valign=bottom style='width:28.46%; border:none;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"'>Number of Monthly Payments in Default at Death</span></font></p> </td> <td width="12%" colspan=4 height=47 valign=bottom style='width:12.24%; border:none;border-bottom:solid windowtext 1.0pt;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"'>&nbsp;</span></font></p> </td> <td width="12%" colspan=3 height=47 valign=bottom style='width:12.42%; border:none;border-bottom:solid windowtext 1.0pt;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"'>&nbsp;</span></font></p> </td> <td width="13%" colspan=5 height=47 valign=bottom style='width:13.94%; border:none;border-bottom:solid windowtext 1.0pt;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"'>&nbsp;</span></font></p> </td> <td width="3%" colspan=2 height=47 valign=bottom style='width:3.88%; border:none;border-bottom:solid windowtext 1.0pt;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"'>&nbsp;</span></font></p> </td> <td width="8%" nowrap colspan=3 height=47 valign=bottom style='width:8.58%; 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:35.25pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> </tr> <tr height=35 style='height:26.25pt'> <td width="20%" nowrap colspan=2 height=35 valign=bottom style='width:20.46%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:26.25pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>9& & & & & & & & & & & & & .</span></font></p> </td> <td width="40%" colspan=8 height=35 valign=bottom style='width:40.7%; border:none;border-top:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:26.25pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Creditor Policyholder's Name</span></font></p> </td> <td width="30%" colspan=10 height=35 valign=bottom style='width:30.24%; border:none;padding:0in 5.4pt 0in 5.4pt;height:26.25pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&quot;Insurance Account No.&quot;</span></font></p> </td> <td width="8%" nowrap colspan=3 height=35 valign=bottom style='width:8.58%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:26.25pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="49%" nowrap colspan=7 height=17 valign=bottom style='width:49.4%; 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:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Street Address</span></font></p> </td> <td width="11%" colspan=3 height=17 valign=bottom style='width:11.76%; border:none;border-bottom: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"'>City</span></font></p> </td> <td width="12%" colspan=3 height=17 valign=bottom style='width:12.42%; border:none;border-bottom: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"'>State</span></font></p> </td> <td width="13%" nowrap colspan=5 height=17 valign=bottom style='width:13.94%; 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"'>Zip Code</span></font></p> </td> <td width="3%" nowrap colspan=2 height=17 valign=bottom style='width:3.88%; 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="8%" nowrap colspan=3 height=17 valign=bottom style='width:8.58%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="91%" nowrap colspan=20 height=17 valign=bottom style='width:91.42%; 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"'>I hereby certify that the above answers are complete and true, and the balance due is the amount in line 7.</span></font></p> </td> <td width="8%" nowrap colspan=3 height=17 valign=bottom style='width:8.58%; 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"'>&nbsp;</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="34%" nowrap colspan=4 height=17 valign=bottom style='width:34.3%; 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:12.75pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>Date:</span></font></p> </td> <td width="26%" colspan=5 height=17 valign=bottom style='width:26.0%; border:none;border-bottom: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"'>By:</span></font></p> </td> <td width="31%" colspan=11 height=17 valign=bottom style='width:31.1%; border:none;border-bottom: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"'>Title:</span></font></p> </td> <td width="8%" nowrap colspan=3 height=17 valign=bottom style='width:8.58%; 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> </tr> <tr height=20 style='height:15.0pt'> <td width="21%" nowrap colspan=3 height=20 valign=bottom style='width:21.4%; border:none;border-left:solid windowtext 1.0pt;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="12%" nowrap height=20 valign=bottom style='width:12.9%;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="15%" colspan=3 height=20 valign=bottom style='width:15.1%; 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="10%" colspan=2 height=20 valign=bottom style='width:10.9%; 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%" colspan=4 height=20 valign=bottom style='width:13.3%; 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=5 height=20 valign=bottom style='width:13.94%; 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="3%" nowrap colspan=2 height=20 valign=bottom style='width:3.88%; 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="8%" nowrap colspan=3 height=20 valign=bottom style='width:8.58%; border:none;border-right:solid windowtext 1.0pt;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> </tr> <tr height=21 style='height:15.75pt'> <td width="49%" nowrap colspan=7 height=21 valign=bottom style='width:49.4%; 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><b><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif";font-weight:bold'>PREMIUM REFUND RECEIPT SCHEDULE</span></font></b></p> </td> <td width="42%" colspan=13 height=21 valign=bottom style='width:42.02%; 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"'>Send to: P.O. Box 555 Anywhere, USA 55555-555</span></font></p> </td> <td width="8%" nowrap colspan=3 height=21 valign=bottom style='width:8.58%; border:none;border-right: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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" colspan=3 height=17 valign=bottom style='width:21.4%; 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: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%" height=17 valign=bottom style='width:12.9%;border:none; border-bottom: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"'>MO.</span></font></p> </td> <td width="15%" colspan=3 height=17 valign=bottom style='width:15.1%; border:none;border-bottom: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"'>DAY</span></font><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'> </span></font></p> </td> <td width="10%" colspan=2 height=17 valign=bottom style='width:10.9%; border:none;border-bottom: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"'>YEAR</span></font></p> </td> <td width="11%" colspan=3 height=17 valign=bottom style='width:11.4%; border:none;border-bottom: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 width="8%" colspan=4 height=17 valign=bottom style='width:8.84%; border:none;border-bottom: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"'>LIFE</span></font><font size=1 face=Arial><span style='font-size:8.0pt;font-family:"Arial","sans-serif"'> </span></font></p> </td> <td width="10%" colspan=4 height=17 valign=bottom style='width:10.86%; border:none;border-bottom: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"'>DISABILITY</span></font></p> </td> <td width="8%" colspan=3 height=17 valign=bottom style='width:8.58%; border:solid windowtext 1.0pt;border-left:none;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"'>TOTAL</span></font></p> </td> </tr> <tr height=34 style='height:25.5pt'> <td width="21%" colspan=3 height=34 valign=bottom style='width:21.4%; 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"'>DATE OF CANCELLATION</span></font></p> </td> <td width="12%" height=34 valign=bottom style='width:12.9%;border:none; border-bottom: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="15%" colspan=3 height=34 valign=bottom style='width:15.1%; border:none;border-bottom: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="10%" colspan=2 height=34 valign=bottom style='width:10.9%; border:none;border-bottom: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="11%" colspan=3 height=34 valign=bottom style='width:11.4%; border:none;border-bottom: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"'>PERCENT UNEARNED</span></font></p> </td> <td width="8%" colspan=4 height=34 valign=bottom style='width:8.84%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:25.5pt'> <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"'>%</span></font></p> </td> <td width="10%" colspan=4 height=34 valign=bottom style='width:10.86%; border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:25.5pt'> <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"'>%</span></font></p> </td> <td width="8%" colspan=3 height=34 valign=bottom style='width:8.58%; border: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"'>&nbsp;</span></font></p> </td> </tr> <tr height=2 style='height:1.5pt'> <td width="21%" colspan=3 height=2 valign=bottom style='width:21.4%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:1.5pt'> <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="12%" height=2 valign=bottom style='width:12.9%;padding:0in 5.4pt 0in 5.4pt; height:1.5pt'> <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%" colspan=3 height=2 valign=bottom style='width:15.1%; padding:0in 5.4pt 0in 5.4pt;height:1.5pt'> <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="10%" colspan=2 height=2 valign=bottom style='width:10.9%; padding:0in 5.4pt 0in 5.4pt;height:1.5pt'> <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="11%" colspan=3 height=2 valign=bottom style='width:11.4%; padding:0in 5.4pt 0in 5.4pt;height:1.5pt'> <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="8%" colspan=4 height=2 valign=bottom style='width:8.84%; padding:0in 5.4pt 0in 5.4pt;height:1.5pt'> <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="10%" colspan=4 height=2 valign=bottom style='width:10.86%; padding:0in 5.4pt 0in 5.4pt;height:1.5pt'> <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="8%" colspan=3 height=2 valign=bottom style='width:8.58%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:1.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> </tr> <tr height=52 style='height:39.0pt'> <td width="21%" colspan=3 height=52 valign=bottom style='width:21.4%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:39.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>POLICY CERTIFICATE WAS IN FORCE</span></font></p> </td> <td width="12%" height=52 valign=bottom style='width:12.9%;padding:0in 5.4pt 0in 5.4pt; height:39.0pt'> <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="15%" colspan=3 height=52 valign=bottom style='width:15.1%; padding:0in 5.4pt 0in 5.4pt;height:39.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>MONTHS</span></font></p> </td> <td width="10%" colspan=2 height=52 valign=bottom style='width:10.9%; padding:0in 5.4pt 0in 5.4pt;height:39.0pt'> <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%" colspan=3 height=52 valign=bottom style='width:11.4%; padding:0in 5.4pt 0in 5.4pt;height:39.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>AMOUNT OF REFUND</span></font></p> </td> <td width="8%" colspan=4 height=52 valign=bottom style='width:8.84%; border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:39.0pt'> <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"'>%</span></font></p> </td> <td width="10%" colspan=4 height=52 valign=bottom style='width:10.86%; border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:none;padding:0in 5.4pt 0in 5.4pt;height:39.0pt'> <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"'>%</span></font></p> </td> <td width="8%" colspan=3 height=52 valign=bottom style='width:8.58%; 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:39.0pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> </tr> <tr height=54 style='height:40.5pt'> <td width="91%" colspan=20 height=54 valign=bottom style='width:91.42%; border:none;border-left:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:40.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>I understand, hereby request cancellation of the above numbered certificate or policy as of 12:00 noon, Standard Time, as of the date of cancellation shown above. I hereby acknowledge receipt of the amount of refund shown above as a full refund of the unearned portion of the premium and hereby release ABC Company from all further liability under said certificate (s) or policy(ies)) as the case may be</span></font></p> </td> <td width="8%" nowrap colspan=3 height=54 valign=bottom style='width:8.58%; border:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt; height:40.5pt'> <p class=MsoNormal><font size=1 face=Arial><span style='font-size:8.0pt; font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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=3 height=17 valign=bottom style='width:15.1%; 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:10.9%; 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="13%" nowrap colspan=4 height=17 valign=bottom style='width:13.3%; 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="13%" nowrap colspan=5 height=17 valign=bottom style='width:13.94%; 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="3%" nowrap colspan=2 height=17 valign=bottom style='width:3.88%; 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="8%" nowrap colspan=3 height=17 valign=bottom style='width:8.58%; 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"'>&nbsp;</span></font></p> </td> </tr> <tr height=18 style='height:13.5pt'> <td width="21%" nowrap colspan=3 height=18 valign=bottom style='width:21.4%; 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="12%" nowrap height=18 valign=bottom style='width:12.9%;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=3 height=18 valign=bottom style='width:15.1%; 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="24%" nowrap colspan=6 height=18 valign=bottom style='width:24.2%; 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"'>Date</span></font></p> </td> <td width="26%" nowrap colspan=10 height=18 valign=bottom style='width:26.4%; 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"'>&nbsp;</span></font></p> </td> </tr> <tr height=17 style='height:12.75pt'> <td width="49%" nowrap colspan=7 height=17 valign=bottom style='width:49.4%; border:none;border-left: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"'>AGENT OR WITNESS</span></font></p> </td> <td width="10%" nowrap colspan=2 height=17 valign=bottom style='width:10.9%; 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="13%" nowrap colspan=4 height=17 valign=bottom style='width:13.3%; 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="21%" nowrap colspan=8 height=17 valign=bottom style='width:21.26%; 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"'>SIGNATURE OF INSURED</span></font></p> </td> <td width="5%" nowrap colspan=2 height=17 valign=bottom style='width:5.16%; 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> </tr> <tr height=17 style='height:12.75pt'> <td width="21%" nowrap colspan=3 height=17 valign=bottom style='width:21.4%; 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="12%" nowrap height=17 valign=bottom style='width:12.9%;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=3 height=17 valign=bottom style='width:15.1%; 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:10.9%; 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="13%" nowrap colspan=4 height=17 valign=bottom style='width:13.3%; 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="13%" nowrap colspan=5 height=17 valign=bottom style='width:13.94%; 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="7%" nowrap colspan=3 height=17 valign=bottom style='width:7.32%; 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="5%" nowrap colspan=2 height=17 valign=bottom style='width:5.16%; 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> </tr> <tr height=18 style='height:13.5pt'> <td width="49%" nowrap colspan=7 height=18 valign=bottom style='width:49.4%; 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"'>Name of Creditor</span></font></p> </td> <td width="50%" nowrap colspan=16 height=18 valign=bottom style='width:50.6%; 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"'>Address</span></font></p> </td> </tr> <tr height=0> <td width=160 style='border:none'></td> <td width=7 style='border:none'></td> <td width=6 style='border:none'></td> <td width=104 style='border:none'></td> <td width=11 style='border:none'></td> <td width=127 style='border:none'></td> <td width=3 style='border:none'></td> <td width=15 style='border:none'></td> <td width=72 style='border:none'></td> <td width=6 style='border:none'></td> <td width=6 style='border:none'></td> <td width=78 style='border:none'></td> <td width=15 style='border:none'></td> <td width=6 style='border:none'></td> <td width=7 style='border:none'></td> <td width=41 style='border:none'></td> <td width=36 style='border:none'></td> <td width=20 style='border:none'></td> <td width=1 style='border:none'></td> <td width=29 style='border:none'></td> <td width=27 style='border:none'></td> <td width=18 style='border:none'></td> <td width=22 style='border:none'></td> </tr> </table> <p class=MsoNormal><font face=Arial><span style='font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font face=Arial><span style='font-family:"Arial","sans-serif"'>&nbsp;</span></font></p> </div> <font size=3 face=Arial><span style='font-size:12.0pt;font-family:"Arial","sans-serif"'><br clear=all style='page-break-before:always'> </span></font> <div class=WordSection3> <p class=MsoNormal><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html>