PART A - GENERAL INFORMATION:

Company Code___________________________________________________________

Company Name___________________________________________________________

Creditor Name____________________________________________________________

This deviation request form must be completed separately for each plan of credit life or credit disability insurance written by the creditor or group of creditors requesting the deviation. Experience of accounts may be combined only within the same plan of benefits and class of business. If experience of accounts is combined, attach a list of those included.

Based on the Experience Period commencing _____________________ and ending ___________________.

(month/day/year) (month/day/year)

Class of Business:

(1) ( ) Credit Unions

(2) ( ) Commercial Banks and Savings and Loan Associations

(3) ( ) Finance Companies

(4) ( ) Motor Vehicle Dealers

(5) ( ) Other Sales Finance

(6) ( ) Production Credit Association Bank Agricultural Loans

(7) ( ) All Others

Plan of Benefits: ( ) Credit Life, Death Benefits Only

( ) Credit Disability

_____ days

_____ RETRO _____ NON RETRO

[13.18.2.31 NMAC - Rp, 13.18.2.31 NMAC, 3/11/2025]