Common use of Allot Clause in Contracts

Allot. 19. Amount paid $208.00 [ ] None (Must be "None" if either 17a or 17b is answered "Yes".) ----------------------------------------------------------------------------------------------------------------------------------- 20. Is a medical examination to be made on Yes No a. the proposed Insured?.......................................................................................... [ ] [X] b. spouse (if proposed for coverage)? ............................................................................ [ ] [ ] ----------------------------------------------------------------------------------------------------------------------------------- 21. If 20a or 20b is "Yes", is it agreed that no insurance will take effect on anyone proposed for coverage until Yes No the person(s) indicated in 20 have been examined, even if 19 shows that an amount has been paid? ................. [ ] [ ] ----------------------------------------------------------------------------------------------------------------------------------- 22. Changes made by the Company ----------------------------------------------------------------------------------------------------------------------------------- XXX 00000-00 Page 1 (Continued on page 2)

Allot. 19. Amount paid $208.00 468.00 [ ] None (Must be "None" if either 17a or 17b is answered "Yes".) - ----------------------------------------------------------------------------------------------------------------------------------- 20. Is a medical examination to be made on Yes No a. the proposed Insured?.......................................................................................... ............................................... Yes [ ] No [X] b. spouse (if proposed for coverage)? ............................................................................ ................................. Yes [ ] [ No [X] - ----------------------------------------------------------------------------------------------------------------------------------- 21. If 20a or 20b is "Yes", is it agreed that no insurance will take effect on anyone proposed for coverage until Yes No the person(s) indicated in 20 have been examined, even if 19 shows that an amount has been paid? ................. [ ] [ ] - ----------------------------------------------------------------------------------------------------------------------------------- 22. Changes made by the Company Company. - ----------------------------------------------------------------------------------------------------------------------------------- XXX 00000ORD 84376-00 82 Page 1 (Continued on page 2Contixxxx xx xxxx 0)

Allot. 1916. Amount paid $208.00 $ [ ] None (Must be "None" if either 17a 14a or 17b b is answered "Yes".) ----------------------------------------------------------------------------------------------------------------------------------- 2017. Is a medical examination to be made on on: Yes No a. the proposed Insured?.......................................................................................... ? ......................................................................................... [ ] [X[ ] b. spouse (if proposed for coverage)? ............................................................................ [ ] [ ] ----------------------------------------------------------------------------------------------------------------------------------- 2118. If 20a 17a or 20b b is "Yes", is it agreed that no insurance will take effect on anyone proposed for coverage until Yes No the person(s) indicated in 20 17 have been examined, even if 19 16 shows that an amount has been paid? ................. [ ] [ ] ----------------------------------------------------------------------------------------------------------------------------------- 22. Changes made by the Company ----------------------------------------------------------------------------------------------------------------------------------- XXX 00000ORD 84376-00 86 Page 1 (Continued on page 2)

Allot. 1916. Amount paid $208.00 $ [ ] None (Must be "None" if either 17a 14a or 17b b is answered "Yes".) ----------------------------------------------------------------------------------------------------------------------------------- 2017. Is a medical examination to be made on on: Yes No a. the proposed Insured?.......................................................................................... ? ......................................................................................... [ ] [X[ ] b. spouse (if proposed for coverage)? ............................................................................ [ ] [ ] ----------------------------------------------------------------------------------------------------------------------------------- 2118. If 20a 17a or 20b b is "Yes", is it agreed that no insurance will take effect on anyone proposed for coverage until Yes No the person(s) indicated in 20 17 have been examined, even if 19 16 shows that an amount has been paid? ................. [ ] [ ] ----------------------------------------------------------------------------------------------------------------------------------- 22. Changes made by the Company ----------------------------------------------------------------------------------------------------------------------------------- XXX 00000-00 Page 1 (Continued on page 2)) II-120

Allot. 1916. Amount paid $208.00 $ [ ] None (Must be "None" if either 17a 14a or 17b b is answered "Yes".) ----------------------------------------------------------------------------------------------------------------------------------- 2017. Is a medical examination to be made on on: Yes No a. the proposed Insured?.......................................................................................... ? ......................................................................................... [ ] [X[ ] b. spouse (if proposed for coverage)? ............................................................................ [ ] [ ] ----------------------------------------------------------------------------------------------------------------------------------- 2118. If 20a 17a or 20b b is "Yes", is it agreed that no insurance will take effect on anyone proposed for coverage until Yes No the person(s) indicated in 20 17 have been examined, even if 19 16 shows that an amount has been paid? ................. [ ] [ ] ----------------------------------------------------------------------------------------------------------------------------------- 22. Changes made by the Company ----------------------------------------------------------------------------------------------------------------------------------- XXX 00000-00 Page 1 (Continued on page 2)) II-84