Date of Birth

State --Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Gender --Select One-- Male Female

Tobacco Use --Select One-- Have Used in the Last 12 Months Do Not Use Tobacco

Marital Status --Select One-- Married Single

Premium Amount --Select One-- Enter Specific Amount $250,000.00 $275,000.00 $300,000.00 $325,000.00 $350,000.00 $375,000.00 $400,000.00 $425,000.00 $450,000.00 $475,000.00 $500,000.00 $550,000.00 $600,000.00 $650,000.00 $700,000.00 $750,000.00 $800,000.00 $850,000.00 $900,000.00 $950,000.00 $1,000,000.00 $1,100,000.00 $1,200,000.00 $1,300,000.00 $1,400,000.00 $1,500,000.00 $1,600,000.00 $1,700,000.00

Premium Years --Select One-- 1 2 3 4 5

LTC Option --Select One-- Fixed Growth 5% Level Market Growth

Benefit Duration Months --Select One-- 48 72