Application for Life Insurance

11, Employer andtime employed 12. Annual Income 13. Plan Name
VWivoc Wii ROT rate
14. a, Death Benefit Option (UL on b Definitions ma Insurance Test (Appties to E/UL only. GPT must be selected if policy is not a MEC.)

15. Face Amount $ 16. Additional Benefits and Amounts

17. Premium Information

| anu ies a, 26
b, Planned Periodic Premium $i

c. Cash with Application Go

18, Primary Benoficiary. Re

19. Aaa ed el Rela jonstip, eager S.S#
7 Fedher-

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Part 2 - General information and Health Questions for Proposed Primary Insured
20. Please list any life or disability insurance you currently have (include amount, company name and year of issue). If none, check this box:

21, Are you actively at work full time (30 hours per week) and able to perform all of your regular duties? -....
22. Have you ever been declined or rated for life or disability insurance or offered a rated policy?........--
23. Do you plan to replace or change insurance or annuities if this insurance is ISSUed? reer err eeenrnee
24, Within the past 6 months have you applied for or do you [ess ary calorie aaa) ia ile or dsl nase?
25. Have you received or applied for disability compensation? ---- anes
26, Do you participate in aviation activities other than as a fare paying passenger? tt ‘Yes! on form 8003) sree
27. Do you participate in sky diving, scuba diving, hang gliding, ar peliye meer racing, rodeos or any-avocation generely
considered dangerous? (if'Yes’ complete form 8003) ~ sesvnnenensannsnenseenseugustmnanonneennereeecnceeravmuenannnaneneseeorgpgeeet POS Os0 8
28. Do you intend to travel or reside outside of the U.S.A. > (tt Yes," damnit hit 8003) ~
29. Have there been any bankruptcy proceedings against you within the last seven years? seovnannannes anaes negeeresentrecnannter
30. Have you had any moving traffic violations in the last 3 years or a suspended license or DUI in the last 5 ee
31. Have you ever been convicted of a felony or misdemeanor? -
32. Have you used any tobacco or nicotine products within the last 12 months? (if Yes’, indicate type and amount}

gaia of Personal Physician

Reason? !
i | 35. Are you currently taking any medication? (if Yes’, list ype, dose and frequency in the Remarks section)
36. In the last ten years have you been diagnosed, treated, taken medication for, or know of having any indication of any.
a. Heart Disease or Disorder or Chest Pains ----- j. Lung Disease or Asthma
b. Blood or Circulatory Disorder (excluding ue k, Epilepsy, Stroke, Alzheimer’s or Brain Disorder --
status) wadbibueelWinewbacediey Weedenbiendiee |. Arthritis, Joint, Back or Bone Disorder cree
c. Alcohol or Drug Abuse ---..--.... seste m. Gastro-Intestinal or Digestive Disorder.
d. Diabetes or High Blood Sugar. ve n. Kidney, Prostate or Urinary Disorder —-
e. Cancer, Polyps or Tumors ae 0, Any other Disease or Disorder not specified
f. Depression or Psychiatric Disorder .---------- p. Any family history of heart disease, cancer, diabetes!
g. Eye, Ear, Nose or Throat Disorder. — Huntington's disease, or polycystic kidney disease? .-
h. Hepatitis or Liver Disorder --- ~ q. Have you had X-rays, EKGs or other diagnostic test
i. High Blood Pressure or Elevated Chaledene: {excluding tests fOr HIV)? -----cc-ccesessersesreentersni cies
8121CA(0305} Life Insurance Company of The Southwest Page 1

| Administrative Office: One National Life Drive « Montpalier, VT 05604 « Tel: 800 732-8939 Cat. No. 46483
Home Office: 1300 West Mockingbird Lane » Dallas, TX 75247-4921

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