03/30/2001 ALSC LIFE CLAIMLOSS =PORT- Allstate Life Insur..1ce Company 1 of 2 Loss Reported: 05/29/2001 4:43PM CLAIM #: 774-802-865 ° Handler: Dave Glodowski Loss Taker: Lorraine Conain Deceased: Jill Wells oo 266 University Drive Married Date of Death: 05/28/2001 4 Woodland Parks, CO 80863 Date of Birth: 09/10/1963 sv: Cause of Death: 24.0 Other Accident Policy Number: 798397993 Paid to Date: 04/27/2001 Face Amount: 100,000.00 Plan Code: D380 ULP92 Basic Reserve: 100,000.00 Effective Date: 06/07/1994 Primary Plan Code: DBO1 ADB Reserve: Policy Date: 09/27/1995 LOB: 1736 Other Reserve: 50,000.00 RO/State: 29 CO Premium Balance: 0.00 Agent Info: (29315) - ASPEN INSURANCE SER INC, - (719) 687-2744 Resources Riders Primary Insured Term Rider aneficiary: Mike Wells 266 University Drive ‘Woodland Parks, CO 80863 Phone: (719) 687-9462 SRaanaes 190m fy ad Beem |co-sPRincs;€0-80904 boadllen’ PLC poe Proceeds: Unknown Relationship: AOR - Dawn M Roberts 4007 v9) NO. Sn Coss Cents Tre SPSOIOT B P- Disabitty Claim vES/SOF Pilicy File Requested03/30/2001 ALSC LIFE CLAIMLOSS =PORT- Allstate Life Insura.1ce Company 2of2 CLAIM #: 774-802-865 Deceased: Jill Wells Loss Reported: 03/29/2001 4:43PM Handler: Dave Glodowski Loss Taker: Lorraine Connin Female 266 University Drive Married Date of Death: 03/28/2001 Woodland Parks, CO 80863 Date of rth: 08/10/1963 SSN: 494-80-3945 Cause of Death: 24.0 Other Accident Diary 3/29/01 4:52:28PM Reference LBL claim number 248 000 367. 3/29/01 4:55:44PM_ Loss reported to claim unit by LBL underwriter Mark Knuth (1-800-525-2799, 7404), LBL policy umber LV706350. The agent, Dawn M Roberts, faxed a letter to Mark notifying him of the insureds death which was reportedly due to an accidental gun shot. Therefore, the cause was coded as other accident (24.0). The policy was being underwritten atthe time ofthe insureds death, Per Mar, the Allstate policy was to be replaced by the LBL policy via 1035 Exchange. There is no change pending on the Allstate policy indicating the 1035 request has been received. 3/29/01 4:55:48PM Increased Reserve For Special Rider For ($750,000.00) 3/25/01 4:36:01PM_ Policy File: 798397993 Auto-Ordered From Central Files 3/30/01 8:56:55A Claim Reassigned From: Dever, Janet To: Dave Glodowski 3/80/01 9:30:51A Modified Reserve: RELEASED: GENERAL Bucket: OTHER Amount: $750,000.00 3/30/01 9°32:20A Modified Reserve: OPENED Bucket: OTHER Amount: $100,000.00 0/01 9:33:05 Corrected OTHER reserve amount, The Allstate policy has PITR for $100,000.00.