DEPARTMENT OF LABOR AND REGULATION

1. (CalledWe) Anywhere, USA 55555-5555

   I am indebted to the above named Creditor for the above sum and for the security of payment of said debt. I hereby apply for credit insurance covering the amount of said debt as indicated above

   I represent that the answers on this application are true and complete to the best of my knowledge and belief. They are the basis on which insurance requested by me may be issued.

   Insured

   Debtor

   Joint Insured

   Debtor

   Yes

   No

   Yes

   No

   □

   □

   1. Are you under age 66?

   □

   □

   □

   □

   2. Are you in good health as far as you know and believe?

   □

   □

   □

   □

   3. Are you actively and gainfully employed for wage or profit on a full time basis

   N/A

   □

   □

   4. During the past 5 years have you been treated for, or been told you had, any of the following conditions (PleaseCircle) High Blood Pressure; Heart Disease; Cancer or Tumor; Diabetes; Stroke; Disease of Liver or Kidney; Alcoholism; Drug Addiction; any Brain, Nervous System or Mental/Neurological Disorder; Acquired Immune Deficiency Syndrome (AIDS).

   □

   □

   I understand that if the aforesaid representations are false and untrue, the Insurance Company's Liability shall be limited to the return of the premium paid for said coverage (subject to the 2-year incontestability provision).

   I further understand that the insurance prepaid for is not compulsory, nor a condition precedent to any loan or credit transaction. I certify that I have been given the option to purchase such credit insurance from any insurer or agent of my choice. I freely chose the insurer and agent to whom this application is made. I declare that I have read or had read to me this statement before signing.

   Date

   Signature of Insured Debtor

   Witness

   Signature of Joint Insured Debtor

   Upon Acceptance by the Insurer, the insurance shall become effective as of the effective date shown above.

DIVISION OF INSURANCE

SAMPLE APPLICATION FORM

Chapter 20:06:06

APPENDIX A

SEE: § 20:06:06:11

APPENDIX A

Insured Debtor

John Doe Box 555

Anywhere, USA 55555

Date of Birth

Age

Certificate Number

Joint Insured Debtor

Creditor (Beneficiary) (NameandAddress)

ABC Bank 555 AVENUE Anywhere, USA 55555

Creditors Insurance Account No

Assignee (NameandAddress)

Monthly Payment

Annual Simple Interest Rate

Second Beneficiary

Relationship

EFFECTIVE DATE

EXPIRY DATE

Days to 1st Payment

COVERAGES

INITIAL AMOUNT OF INSURANCE

PREMIUMS

TERM IN MONTHS

□ Gross or

□ NET

□ W. Dism

□ W/O Dism

□ Decreasing Term

□ Periodic Decreasing Term

$ 28,615.00

$ -

59

□ Jt. Decreasing Term

□ Jt. Periodic Decreasing Term

□ Level Term

□ Jt. Level Term

$ 22,352.47

$ -

60

59

Payments of $

$485.00

$ 28,615.00

$ -

59

Final Payment of $

$22,352.47

[$485.00 Monthly Disability Benefit]

$ -

PREMIUM ←TOTAL

□ Disability Coverage (InsuredDebtorOnly)

WAITING PERIOD ELIMINATION PERIOD

□ 7 Days

Retrospective

0 Days

□ 14 Days

Retroactive

0 Days

Maximum Monthly Disability (perdebtor)

Maximum Monthly Disability (perdebtor)

Maximum Term

Maximum Issue Age 65 Inclusive

□ 30 Days

Retroactive

0 Days

□ 14 Days

Non-Retro

14 Days

□ 30 Days

Non-Retro

30 Days

$1000.00 (Ages 18-65)

$100,000.00 (Ages 18-65)

120 Months

Application for Insurance

ABC ASSURANCE COMPANY

Source: 32 SDR 203, effective June 5, 2006.