I,__________________________, the Insured under your life insurance Policy No.________, hereby apply for (A.D.B., W.P.D., S.A.R., S.A.R.D.I) to supplement and form part of said life insurance policy, and hereby make the following statements:

1. (a) Present occupation: State in detail the nature of your duties         (b) Since when have you been so engaged?         (c) What was your former occupation? (a) (b) (c) 2. Have you ever proposed to insure against Accident or Sickness? If so, give name of Company or Companies   3. (a) Are you now insured or proposing to insure against Accident or Sickness? If so, in what Company or Companies, and for what amount?____________      (b) Is this Proposal for additional insurance against Accident? (a) (b) 4. Have you ever been declined or accepted on special terms for Life, Accident or Sickness Insurance, or has any Company ever cancelled or refused to renew your Policy, or desired to amend the conditions or benefits? If so, what Company or Companies, and when?_____________   5. (a) Have you ever received compensation or payment of benefits out of any accident or health insurance you had taken?______________ If so, by what company or companies? _______________   (b) How much weekly benefit payment did you receive and for how many weeks?   6. (a) Is your sight now impaired, or have you ever had any affliction of the eyes? If so, since when? _____________________     (b) Is you hearing impaired, or have you suffered any ear complaint, or any discharge from the ear? If so, since when? (a) (b) 7. (a) Have you ever suffered from Spitting of Blood, Consumption, Tuberculosis, any Chest Disease or Lung Infection, Gout, Erysipelas, Rheumatism, Heart or Brain Disease, Paralysis, Asthma, a Fit of any Kind, Cancer, Diabetes, Appendicitis, any Disease of the Stomach or Intestines, or from any nervous or recurring disease? If so, since when? ________________     (b) Have you any physical defect infirmity? If so, since when? (a) (b) 8. Give particulars of any Injury or Sickness for which you have received medical attention during the past five years.   9. For Women Only    (a) Have you been menstruating regularly? __________    (b) When did you have your last menstruation?______    (c) Are you pregnant? ______________________    (d) When was your last delivery? ______________ (a) (b) (c) (d) 10. Are there any circumstances connected with your occupation, health or habits of life, which render you specially liable to injury or sickness?If so, since when?   11. What is your present height?_____ft ____in. and weight? ______lbs.

I hereby agree that, this application shall supplement and form part of my original application which was the basis of the said life insurance.         I further agree that, if within two years from date of approval of this Application any of the foregoing declarations and representations is found to be untrue in any respect, the Company shall have the right to declare null and avoid any rider or certificate that it may have issued pursuant to said Application.         I attach herewith the said policy together with a remittance of P___________as deposit which may be applied to payment of the first premium upon approval of this application. Dated at___________ this____________day of _________, 19 _________

________________________________ (Customary signature of irrevocable beneficiary or co-insured) ____________________________ (Customary signature of Application)

(NOTE: This application must be countersigned by the irrevocable beneficiary.)