I hereby apply for and authorize the necessary salary deductions for the premium to pay for accident insurance under the terms of the above Master Policy as follows:

Your Full Name:__________________________________________________________ Birth Date:______________

Address:___________________________________ City:________________________  Zip Code:_____________

Occupation or Position:_________________________________  Social Security Number:______________________

Your beneficiary:_________________________    Relationship:________________________

Spouse's Occupation:______________________  

Amount of Principal Sum (i.e. benefit amount):$_________  Monthly Premium:$_______

Plan Selection (check one):     Employee only _____  Family Plan*_____                        Sex: Male_____  Female_____

*Employee applicant will be spouse's and dependent's beneficiary unless otherwise stated in writing.

Date of Employment or Membership=

_____  Declination--I have been given the opportunity to apply for this insurance, but I do not desire to participate.

Signature of Applicant:________________________________________________   Date of Application:_______________