________ ___, 2012

Attn: Authorized Inspector UCPB General Insurance Co. Inc. Account Manager Financial Intermediaries Dept. Subject: Inspection of (state account here) Dear Sir/ Madam: This is to authorize your inspector to conduct an inspection on the above captioned account at the below described time and date: Address: ________________________________________________ ________________________________________________ Date: Time: ______________ ______________

Contact Person (if any): ________________ Phone Number: ____________________ This authority to inspect is issued pursuant to the completion of underwriting requirements for the insurance of the above captioned account Thank you very much.

Name/Owner Position/Owner Company