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UE MPANY wv ass Holl | 02L.v706350 | weowr | PART | — APPLIG e roroseo wsuneo bel we SECTION I") Name Bithdale Age Sex Girh Place © Boda) Soe No The fog oR, GET Tn a] roped | Wells Re] | |() Have you used any form of tobacco in the lst 3 years? (Type IL ives ‘ge SECTION I Pian of insurance Face Amount _ f Paley Dnvestors Select |s 490,000 | Modal i Mode of Payment 22h | Death Benett Option? Continuation of UL Premium? ADB? APL? faivpiot Premium? | [gor u. ony es, For (Non-UL On| [INGHLUL Ony) | | (Xone ‘or "Two = Yes ives 4 1 Aéetional Riders - - eee | ‘On Base Inst rime Term Rider (UL only) ‘] | - ‘D Aceltional Insured Rider amouns 150,000 | | | ; ‘On Other Persorys) (3 Addtonal Insured Rider .eeeososse ciseeses sosnssse «+ Complete Spoof] Vion Page 2 | | [Goma Rider tor One Two units Tote — A | [O Caretaker (Long Term Care—UL only) Other t |, [O Satekeeper (Catastrophic Iliness—UL only) Other. | [s,s le surance poy bong kinded by a quaifiedretrerent plan pursuant oe incidental insurance proviso [Tova Whe | SECTION Ill Name of Applicant (Owner I Other Than Propased Insured Relationship Socal a Tad Ne S Apeant | | SuMe | Cad iti | ag Owned caress pBagspe endings & Techie € oe | e| || SECTION WV Pama SS bivonsnp ‘Aaeross | Boatcay PMike Wi husband stella Weasas Contingent + 4 ons LEY Va landhag Aom Sister Li Os guardan fF Tanner Jacob wells UI oie | PART | CONTINUED (Page 2) i SECTION V | more than one aollional awed, check here CI and complete Seajon V of aur applcaion } aaa Name T"Bieseta, Age Sex Binh Place { | insured | ieee Height Sules | Spouse Employer's Name and Address. =I | | —— 1 i 1 z ADB? Fors ! [1A] Bo you curvonly smoke egaretes, or have yox-artdted mem nthe act 12 MOTEL | | [(6} Have you usec any form of obacco iniae Et 9 Yours? [Kind Fes i | Beneficiary —_ | | [Pamavy. elauorship | Contingent z | SECTI ‘Gniy children, siop-chidren and-adopted chidten underage 18. ino i aster ! oni . : I eat ‘Name = Age See Biindans Bir He i | Bo C a" | | tneurea | Under | i his _ P| } | Rider cor | | - ~ \ SECTION Vili -EsCereonal and business ife nourance,annully, and long fer care coverage. “none, so ste) Existing ‘Proposed insureds) Life Amount Plan Company Fol 8 _ ADB Amdant| [Year tssued | , insurance = Qu Wells Beo,z0 [ULE [Ailstctc (3397995) f (haa | { T | i I _ il | { { I I ll | | {8} Wil this policy, i issued, replace or chande insurance or annuitas in tis or any company? Yes No | if {VY6S, cls which polis Isted above are fo be replaced oF chatiged and fofaw state reguations Aacafwunt boing | i ‘epiaced SOC Ba | SECTION Vit Questions apply to all proposad incureds, Provide Goals "VES" anaversin Sesion TT ' Aagtonal [ais any oer mane apteain poring? _ | 8 ld any appleston for nsurance deci 8d, a fod, or etsed for esate es Who] | i ton | L@!8d any applcston for nswance decined,pesipored, rated, mode, dtorrensiatemanth id Ye | Siigaton, —|{1c) Ever been convicted of a felony? —_ _— Yes fENo | {0} In the last 3 years TT | ||” (Had or more moving wae voltors, had iver’ leense suspended o revoked, i i or more than 2 auto accidents? "Yes" DLA) | (21 Flown as a plot, co-poor crew member ofan arcrat? | | _(9] Panteipatodn sky or scuba diving, hang acing or racing? | |. (_ Has ved inne USA {or less than 3 years of wil vavel out ofthe USA mnie nen 2 years? | 1 * | {G]} Hes anyone to be considered been advsad they need to have an exam or ab test ] | ‘or ths surance? yes, prowce name below) ak | SECTIONAX, A t r | Remarks, TT Wed ae