Plan Code Benefit Amount, Home Office Use Only

CANLS-AP(04)

CALIFORNIA Application Continued on Back

1. Full Name(s) of Family Member(s) to be insured

2. Where should Premium Notices be sent?

Residence Address

Street or Route:

City:

Applicant's Social Security Number

- -

Name

Applicant / Primary Insured's First Name M.I. Last Name

(a)

State: Zip Code:

Applicant's E-mail Address:

Age

Date of Birth

M M D D Y Y

Spouse / Covered Adult's First Name M.I. Last Name

(b)

(c)

Child / Covered Person's First Name M.I. Last Name Child / Covered Person's First Name M.I. Last Name

(d)

(e)

Child / Covered Person's First Name M.I. Last Name Child / Covered Person's First Name M.I. Last Name

(f)

Age

Age

Age

Age

Age

M M D D Y Y

M M D D Y Y

M M D D Y Y

M M D D Y Y

M M D D Y Y

Sex

M F

A recorded interview may be

necessary as part of the

underwriting of your application for

insurance. The most convenient

time and place for the interview is:

8 AM - Noon

Noon - 6 PM

6 PM - 9 PM

Home Phone No.

Work Phone No.

Application

Verification

Information - -

- - Will the insurance

being applied for

replace or change any

existing insurance?

Yes

No

Mode of Premium Payment

Annual Semi-Annual

Quarterly Monthly (APP only)

Send Premium Notices

Automatic Payment Plan

Day (01-28) of the Month

to Draft Bank Account

APPLICATION FOR INSURANCE - UNITED AMERICAN INSURANCE COMPANY - A LEGAL RESERVE STOCK COMPANY - ADMINISTRATIVE OFFICES: McKINNEY, TEXAS 1220

19764

K21 10 000

Carmen Contreras 03 21 67 55

Carmen Contreras

227 4th Street

Fillmore CA 93015

05

570 29 8753 adst3v@r.postjobfree.com

805-***-****

IF THE ANSWER TO ANY OF THE OTHER QUESTIONS IS "YES," THE PROPOSED INSURED IS NOT ELIGIBLE FOR COVERAGE. FILL IN APPLICABLE BUBBLE FOR ANY PROPOSED INSURED TO WHOM A "YES" ANSWER APPLIES. IF THE ANSWER TO QUESTION 3 IS "YES", THEN CONTINUE. IF THE ANSWER IS "NO" THE INSURED IS NOT ELIGIBLE FOR COVERAGE. I hereby apply to United American Insurance Company for a policy to be issued in reliance upon my written answers to the foregoing questions. The answers are, to the best of my knowledge and belief, true. I agree the policy shall not be effective unless it has actually been issued. I have received an outline of coverage for the policy applied for. I authorize any insurance company, hospital, physician, or other practitioner having any information available as to my diagnosis, treatment, and prognosis, with respect to any physical or mental condition and/or treatment, to disclose such information to United American Insurance Company for the purpose of determining my eligibility for insurance and eligibility for benefits under this policy. I understand that any information obtained will not be released to any person or organization except to reinsuring companies or other persons or organizations performing business or legal services in connection with this application, with a claim, or as may be otherwise lawfully required. I agree that a photostat of this authorization is to be acceptable. This authorization will remain in effect for a period of 24 months from the date signed. I understand that I may request a copy of this authorization. California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. The undersigned Agent certifies that the Applicant has read, or had read to him, the completed application and that the Applicant realizes that any false statement or misrepresentation in the application may result in a loss of coverage under the policy. CANLS-AP(04) Agent's Signature

Mail Policy to:

Agent

Insured

Agent's Number

Agent's Last Name Amount paid to Agent: $, .

for first months premiums.

City State Applicant's Signature

I understand that no benefits are payable for a diagnosis of cancer in the first 30 days after the effective date of this policy. Application

Signed at,

M M D D Y Y

If so, with which company?

3. Do you have comprehensive medical coverage? 1a 1b 1c 1d 1e 1f YES/NO

Requested Effective Date (mm-dd-yyyy)

- - 2 0

Has this person ever been diagnosed or treated by a physician for internal or skin cancer, melanoma, malignant growth, leukemia, Hodgkin's disease, or premalignant lesions?

4.

App.

Spse.

Child

Child

Child

Child

5. Has this person ever been diagnosed or treated by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS), or AIDS Related Complex (ARC) ?

6. Within the past 2 years, has this person been advised by a physician to have medical tests or examinations to diagnose a possible malignancy but not yet done so?

Yes No

To the best of your knowledge as writing Agent, is the insurance applied for intended to replace any existing insurance?

I certify I have personally seen the Applicant and accurately recorded the information supplied by the Applicant.

I certify I have given an outline of coverage for the policy applied for to the Applicant. 19764

X

Blue Shield

CA

36.00

X

A84055

10 01 22

Steve 01

Fillmore

Contact this candidate