Common use of THE AGENT OR LEAVE THE PAYEE BLANK Clause in Contracts

THE AGENT OR LEAVE THE PAYEE BLANK. If the question below is answered yes or left blank with respect to a Proposed Insured, no representative of the Company is authorized to accept money, and NO COVERAGE will take effect under this Agreement with respect to such Proposed Insured. Within the past 90 days, has the Proposed Insured been admitted to a hospital or other medical facility, been advised to be admitted or had surgery performed or recommended?  Yes  No This Agreement provides a Limited Amount of Life Insurance protection for a Limited Period of time, subject to the terms of this Agreement, in consideration of advance payment in the amount of $ Application dated (MM/DD/YYYY) / / made on the life of in connection with the MoneyGuard® / / / Name of Proposed Insured: (First) (Middle) (Last) (Suffix) Method of Payment (Check One)  Check  Electronic Funds Transfer (Attach completed EFT Authorization Form) Terms and Conditions AMOUNT OF COVERAGE - $500,000 MAXIMUM FOR ALL APPLICATIONS OR AGREEMENTS If money has been accepted by the Company as advance payment for an application for Life Insurance and death of a Proposed Insured occurs while this Agreement is in effect, the Company will pay to the beneficiary designated in the Application, or to the estate of the proposed insured if no beneficiary has been designated, the lesser of a) the amount of all death benefits applied for in the Application(s) with respect to said Proposed Insured, or b) $500,000. This total benefit limit applies to all insurance applied for under this and any current Company Tickets or Applications to the Company and any other Temporary Life Insurance Agreements. Temporary Long-Term Care coverage is not available under this Agreement. DATE COVERAGE BEGINS Coverage under this Agreement will begin on the date of this Agreement but only if the MoneyGuard® Application(s) has been completed on the same date or not more than 10 days prior to the date of this Agreement.

THE AGENT OR LEAVE THE PAYEE BLANK. If the question below is answered yes or left blank with respect to a Proposed Insured, no representative of the Company is authorized to accept money, and NO COVERAGE will take effect under this Agreement with respect to such Proposed Insured. Within the past 90 days, has the Proposed Insured been admitted to a hospital or other medical facility, been advised to be admitted or had surgery performed or recommended?  Yes  No This Agreement provides a Limited Amount of Life Insurance protection for a Limited Period of time, subject to the terms of this Agreement, in consideration of advance payment in the amount of $ Application dated (MM/DD/YYYY) / / made on the life of in connection with the MoneyGuard® / / / Ticket dated made on the life of . Name of Proposed Insured: (First) (Middle) (Last) (Suffix) Method of Payment (Check One)  Check  Electronic Funds Transfer (Attach completed EFT Authorization Form) Terms and Conditions Insured TERMS AND CONDITIONS AMOUNT OF COVERAGE - $500,000 MAXIMUM FOR ALL APPLICATIONS OR AGREEMENTS If money has been accepted by the Company as advance payment for an application for Life Insurance and death of a Proposed Insured occurs while this Agreement is in effect, the Company will pay to the beneficiary designated in the Application, or to the estate of the proposed insured if no beneficiary has been designated, the lesser of a) the amount of all death benefits applied for in the Application(sTicket(s) with respect to said Proposed Insured, or b) $500,000. This total benefit limit applies to all insurance applied for under this and any current Company Tickets or Applications to the Company and any other Temporary Life Insurance Agreements. Temporary Long-Term Care coverage is not available under this Agreement. DATE COVERAGE BEGINS Coverage under this Agreement will begin on the date of this Agreement but only if the MoneyGuard® Application(sTicket(s) has been completed on the same date or not more than 10 days prior to the date of this Agreement.

THE AGENT OR LEAVE THE PAYEE BLANK. If the question below is answered yes or left blank with respect to a Proposed Insured, no representative of the Company is authorized to accept money, and NO COVERAGE will take effect under this Agreement with respect to such Proposed Insured. (If the agent/company accepts the application and initial premium, the coverage that was applied for will be deemed to be in effect until the applicant has been notified of an adverse underwriting decision and premium has been refunded.) Within the past 90 days, has the Proposed Insured been admitted to a hospital or other medical facility, been advised to be admitted or had surgery performed or recommended?  Yes  No This Agreement provides a Limited Amount of Life Insurance protection for a Limited Period of time, subject to the terms of this Agreement, in consideration of advance payment in the amount of $ Application dated (MM/DD/YYYY) / / made on the life of in connection with the MoneyGuard® / / / Name of Proposed Insured: (First) (Middle) (Last) (Suffix) Method of Payment (Check One)  Check  Electronic Funds Transfer (Attach completed EFT Authorization Form) Terms and Conditions AMOUNT OF COVERAGE - $500,000 MAXIMUM FOR ALL APPLICATIONS OR AGREEMENTS If money has been accepted by the Company as advance payment for an application for Life Insurance and death of a Proposed Insured occurs while this Agreement is in effect, the Company will pay to the beneficiary designated in the Application, or to the estate of the proposed insured if no beneficiary has been designated, the lesser of a) the amount of all death benefits applied for in the Application(s) with respect to said Proposed Insured, or b) $500,000. This total benefit limit applies to all insurance applied for under this and any current Company Tickets or Applications to the Company and any other Temporary Life Insurance Agreements. Temporary Long-Term Care coverage is not available under this Agreement. DATE COVERAGE BEGINS Coverage under this Agreement will begin on the date of the Application and initial premium. DATE COVERAGE TERMINATES Coverage under this Agreement but only if will terminate automatically on the MoneyGuard® Application(s) date the applicant has been completed on the same date or not more than 10 days prior to the date notified of this Agreementan underwriting decision and premium has been returned.

THE AGENT OR LEAVE THE PAYEE BLANK. If the question below is answered yes or left blank with respect to a Proposed Insured, no representative of the Company is authorized to accept money, and NO COVERAGE will take effect under this Agreement with respect to such Proposed Insured. Within the past 90 days, has the Proposed Insured been admitted to a hospital or other medical facility, been advised by a licensed member of the medical profession consulted by the applicant to be admitted or had surgery performed or recommended?  Yes  No This Agreement provides a Limited Amount of Life Insurance protection for a Limited Period of time, subject to the terms of this Agreement, in consideration of advance payment in the amount of $ Application dated (MM/DD/YYYY) / / made on the life of in connection with the MoneyGuard® / / / Name of Proposed Insured: (First) (Middle) (Last) (Suffix) Method of Payment (Check One)  Check  Electronic Funds Transfer (Attach completed EFT Authorization Form) Terms and Conditions AMOUNT OF COVERAGE - $500,000 MAXIMUM FOR ALL APPLICATIONS OR AGREEMENTS If money has been accepted by the Company as advance payment for an application for Life Insurance and death of a Proposed Insured occurs while this Agreement is in effect, the Company will pay to the beneficiary designated in the Application, or to the estate of the proposed insured if no beneficiary has been designated, the lesser of a) the amount of all death benefits applied for in the Application(s) with respect to said Proposed Insured, or b) $500,000. This total benefit limit applies to all insurance applied for under this and any current Company Tickets or Applications to the Company and any other Temporary Life Insurance Agreements. Temporary Long-Term Care coverage is not available under this Agreement. DATE COVERAGE BEGINS Coverage under this Agreement will begin on the date of this Agreement but only if the MoneyGuard® Application(s) has been completed on the same date or not more than 10 days prior to the date of this Agreement.