Birthdate: January February March April May June July August September October November December / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985

Sex:    Male Female

Used Tobacco in Past 2 years:    Yes No

Health Rating: Preferred Plus Preferred Standard Plus Standard

Coverage Amount:  $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 $300,000 $325,000 $350,000 $375,000 $400,000 $425,000 $450,000 $475,000 $500,000 $600,000 $650,000 $700,000 $750,000 $800,000 $850,000 $900,000 $950,000 $1,000,000 $1,100,000 $1,200,000 $1,250,000 $1,300,000 $1,400,000 $1,500,000 $1,750,000 $2,000,000 $2,250,000 $2,500,000 $3,000,000 $3,500,000 $4,000,000 $5,000,000

Level Term Period: 1 Year Level Term 5 Year Level Term 10 Year Level Term 15 Year Level Term 20 Year Level Term 25 Year Level Term 30 Year Level Term 35 Year Level Term 40 Year Level Term To Age 65 To Age 70 To Age 75 To Age 80 To Age 85 To Age 90 To Age 95 To Age 100 To Age 105 To Age 110 Other Term 10 Year Return of Premium 15 Year Return of Premium 20 Year Return of Premium 25 Year Return of Premium 30 Year Return of Premium To age 65 Return of Premium To age 70 Return of Premium To age 75 Return of Premium Other Return of Premium To Age 121 Level (No Lapse U/L) To Age 121 Level - Pay to 100 To Age 121 Level - Pay to 65 To Age 121 Level - 20 Pay To Age 121 Level - 10 Pay To Age 121 Level - Single Pay

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