Case 2:10-cv-09198-JVS-RNB Document 408-3 Filed 03/18/13 Page 2 of4 Page ID #:18182

QUESTIONNAIRE

INSTRUCTIONS

You are receiving this questionnaire because you have been identified as someone who may have purchased an indexed universal life insurance policy issued by Life Insurance Company of the Southwest (“LSW”’). Please complete the enclosed questionnaire and return it to the address indicated below by , 2013. [

QUESTIONS

If you believe that you purchased an indexed universal life insurance policy issued by LSW, please respond to the following questions. You may use additional sheets if necessary.

1. What is your name and current mailing address? NAME: ADDRESS: CITY/STATE/ZIP:

2. Did you purchase a SecurePlus Provider or SecurePlus Paragon life insurance policy issued by LSW? (circle one)

YES NO I DON’T KNOW

(If your answer to Question #1 is “No,” you need not respond to the remainder of this questionnaire. Please sign at the bottom and return it to the address indicated below)

2 What is the policy number of your SecurePlus Provider or SecurePlus Paragon policy? (beginning with “LS”)

4. Was your SecurePlus Provider or SecurePlus Paragon policy issued on or after September 24, 2006? YES NO I DON’T KNOW a Was your SecurePlus Provider or SecurePlus Paragon policy issued on or after September 24, 2007? YES NO I DON’T KNOW 1 QUESTIONS? CALL 1-800-XXX-XXXX OR VISIT WWW. .COM

ACTIVEUS 105540852v.1

Case 2:10-cv-09198-JVS-RNB Document 408-3 Filed 03/18/13 Page 3of4 Page!D

#:18183 6. Do you still own your SecurePlus Provider or SecurePlus Paragon policy? YES NO I DON’T KNOW 7. What documents were you shown or provided with regarding your SecurePlus Provider or

SecurePlus Paragon policy before you applied for your policy? (list all that apply)

Please include photocopies of all documents listed above in response to Question No. 7, and any other documents that you believe bear upon what you were told before you applied for your policy. If copies of these documents are no longer available to you, please indicate who else may have copies of them:

8. Did you receive a Policy Illustration before you applied for your SecurePlus Provider or SecurePlus Paragon policy?

YES NO I DON’T KNOW

(If your answer to Question #5 is “No,” you need not respond to the remainder of this questionnaire. Please sign at the bottom and return it to the address indicated below)

9. Did any illustration you received before you applied for your policy include the phrase “One Policy Fee”?

YES NO I DON’T KNOW 10. Did any illustration you received before you applied for your policy include pages entitled

“Policy Charges and Expenses” or pages containing the year-by-year amounts of charges and fees associated with your policy (other than the Monthly Administrative Charge)?

YES NO I DON’T KNOW 2 QUESTIONS? CALL 1-800-XXX-XXXX OR VISIT WWW. .COM

ACTIVEUS 105540852v.1

Case 2:10-cv-09198-JVS-RNB Document 408-3 Filed 03/18/13 Page 4of4 Page ID #:18184

SIGNATURE

Please sign and date where indicated, and return to Walker v. LSW Questionnaires, P.O. Box ___, . To ensure that your questionnaire is considered, you must complete and return it by

_____I75 days from date of mailing].

I swear or affirm that I have answered the questions above to the best of my recollection.

Name Date

3 QUESTIONS? CALL 1-800-XXX-XXXX OR VISIT WWW. .COM ACTIVEUS 105540852v.1