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APPLICATION FOR LIFE INSURANCE * UNITED AMERICAN INSURANCE COMPANY A LEGAL RESERVE STOCK CO. * ADMINISTRATIVE OFFICE: MCKINNEY, TX 75070 NORTH DAKOTA Primary Insured First Name Last Name SS # M.I.
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. . . . . Insurance Company Primary Insured. . . . . . . . , Life Insurance Company. 2,000,000 ,, Premium. , . . . , Life. . 2,000,000 , AGE 19 to 23 4 0 0 0 0 0 0 0 0 1 13 23 24 4 0 5 14 22 24 5 0 5 22 24 13 0 10 21 20 12 2 3 21 20 28 3 1 7 22 20 38 1 0 14 22 18 42 0 2 20 19 24 25 25 19 22 1 1 26 19 22 25 22 24 18 22 0 1 24 20 18 26 22 22 19 21 1 0 22 16 25 33 27 26 20 25 1 1 15 21 18 32 27 26 20 25 22 12 1 4 32 17 28 22 22 19 25 0 0 20 22 21 35 28 21 24 31 0 1 18 21 17 31 28 21 24 23 16 1 4 28 16 30 35 20 21 23 11 1 4 31 18 35 33 19 20 22 9 4 22 22 42 28 19 22 21 10 32 19 35 38 13 19 21 8 24 19 36 27 18 22 18 6 31 18 36 38 9 19 21 4 21 16 37 27 17 21 17 4 21 15 38 26 16 21 15 3 21 12 39 26 15 21 12 2 20 11 39 24 16 20 11 2 20 9 39 23 16 19 9 2 20 8 39 22 16 18 8 1 21 8 39 21 16 17 8 0 21 0 38 20 15 17 7 0 20 0 36 19 15 16 6 0 20 0 35 18 14 14 5 0 20 0 32 18 14 13 5 0 20 0 31 17 13 12 5 0 19 0 31 16 13 11 5 0 19 0 30 16 12 11 5 0 19 0 28 15 10 10 4 0 19 0 26 13 10 9 4 0 18 0 24 12 10 8 4 0 18 0 22 11 10 7 3 0 17 0 21 10 9 5 0 18 0 20 10 9 4 0 17 0 19 9 8 5 0 17 0 18 9 8 4 0 17 0 17 8 8 3 0 16 0 16 8 8 4 0 15 0 15 8 7 5 0 15 0 14 8 6 5 0 14 0 13 8 6 6 0 14 0 12 8 6 6 0 14 0 10 7 4 0 14 0 9 7 4 0 14 0 8 8 2 0 14 0 6 7 2 0 13. . . , . , , , , 4. 4. 4. , . 4.

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