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State of Residence Alabama Arizona Arkansas California Colorado Connecticut Florida Georgia Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Your Date of Birth Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 Your Gender Male Female Tobacco or Nicotine Use None Cigarettes Cigar or Pipe Chew or Snuff Nicotine Patch Nicotine Gum  (in last year) Health Class Preferred Plus Preferred Standard Plus Standard Guaranteed Coverage Amount $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 $550,000 $600,000 $650,000 $700,000 $750,000 $800,000 $850,000 $900,000 $950,000 $1,000,000 $1,100,000 $1,200,000 $1,300,000 $1,400,000 $1,500,000 $1,600,000 $1,700,000 $1,800,000 $1,900,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Guaranteed Term 1 Years 5 Years 10 Years 15 Years 20 Years 25 Years 30 Years

The following agent license numbers are provided for G. Peck Moxley as required by state law: CA agent #0B28285 LA agent #140199
MN agent #IN-20025704 UT agent #85975 MA agent #1745274