LOA Agent Contracting:

Agent Questionaire (2 Pages)

Assignment of Commissions

Kroll Form

Application for Fraternal Membership(Please include a 30.00 Check for Membership)

Advance Commission Repayment Agreement (2 Pages)

Please check the appointment fee schedule for any Resident andNon- Resident fees that are required. Make check payable to UCT and mailto:

Please Fax all required documents to :

The Financial Marketplace, Inc.1410 Piedmont DriveLexington, NC 27292

Fax: 866.454.1008

THE ORDER OF

UNITED COMMERCIAL TRAVELERS OF AMERICA632 NORTH PARK STREET, P.O. BOX 158019 COLUMBUS, OHIO 43215-8619

(614)228-3276 • TOLL-FREE: (BOO) 849-0123 - FAX: (614)228-1898 • www.uct.oig

Dear Prospective Agent:

Thank you for your interest in becoming an agent with The Order Of United CommercialTravelers of America (UCT), We are a fraternal benefit society offering our membersvarious insurance products and other benefits since 1888, whose members are from allwalks of life and number nearly 80,000 across the United States and Canada.

We offer many attractive products including Medicare supplement plans, Medicare PartD, Life insurance plans (whole life, single premium whole life, and final expense), SinglePremium Juvenile Term life insurance and Annuity products. We have includedinformation on these plans in the folder.

Also, since it is required that you become a member to sell our products, we have aspecial membership product just for you, Membership and Accident Coverage Protection(MAC). Please take a moment to read over the MAC brochure and learn the valuablebenefits offered under this plan.

Listed below is an outline of what we require to become a licensed agent with us, and allpaperwork is included in this folder. Please review all of the material and feel free to call(800) 848-1124 ext. 128, with any questions you may have.

* AGENT QUESTIONNAIRE Sign and complete the Agent Questionnaire

* SALES AGREEMENT Sign and complete Page 4 of both copies of yourGeneral Agent Sales Agreement or the Assignmentof Commissions form. Also, sign the BusinessAssociate Addendum to the General Agent SalesAgreement.

COMMISSIONSCHEDULES

MEMBERSHIPAPPLICATION - MBR-91

COPY OF YOURCURRENT LICENSE

AUTHORIZATION FORA BACKGROUNDCHECK

Commission Schedules should remain attached toboth copies of the General Agent Sales Agreement.Please make copies for your records.

You must be a fraternal member of UCT to sell theproducts. If you are ages 18-70, complete thisapplication and return with your check for $35. Overage 70, complete form Frat-05 and return with acheck for $30.

Please send a copy of your current license with acheck for your appointment fee, if applicable. Seeattached fee schedule.

A Background Release Authorization form is requiredby the following states: AL, FL, GA, KY, MS, OK, PA,SC.UT.WV.andWY.

LICENSING AND CONTRACTING FEESAS OF JULY 20, 2004

STATEALARAZCACOCTDE

" FLGAIAIDINILKSKYLAMAMDMEMlMNMOMSMTNCNCNDNENVNYOHOKORPASCSDTNTXUTVAWA\AflWVWY

RES APPT FEES$30.00$0.00$0.00

$24.00$0.00

$45.00$25.00$62.10$20.00$20.00$0.00$0.00$0.00$5.00

$40.00$20.00$75.00$0.00

$30,00$5.00

$10.00$0.00

$10.00$0.00

$20.00$10.00$10.00$20.00$15.00$0.00

$20.00$40.00$0.00

$15.00$0.00

$10.00$15.00$10.00$0.00

$14.00$20.00$7.00

$25.00$15.00

NON-RES FEES$30.00$0.00$0.00

$24.00$0.00

$45.00$25.00$62.10$20.00$20.00$0.00$0.00$0.00$5.00

$50.00$20.00$75.00$0.00

$70.00$5,00

$10.00$0.00

$10.00$0.00

$20.00$10.00$10.00$20.00$15.00,$0.00

$20.00$40.00$0.00

$15.00$0.00

$20.00$15.00$10.00$0.00

$14.00$20.00

$24.M$25.00$15.00

LifeHealth

BACKGROUND CHECKS ARE REQUIRED IN:

AL, FL, GA, KY, MS, OK, PA, SC, UT, WV, WY

^gent Questionnaire

TRAVELERSOF AMERICA

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DhdMdud nPartnenWpOatpocneName: corporate IRS Na«

SendTe; OBu^nsa DBBsMenea {DonotobtrovtateadcfeaoBuneHAddrBsi end street OTPXJ. BOX: ictty: ajumv; janaTelapfwneMo,

RananceAotelPBacnaSlreeforP.O7BoK County: state: gp: Area Coon and Taepnane NO,:

cay: coumy: store: weo code end iwepnone NO,

county: ap; «ea cocw ana lenpnone rax

HOVB you ever Been cflnvtetea of qfetofiy? QYea

HavByouavBTbeencofMcredafanitedameanon aVes Qlw { Yes, pieasocwpiain:

iwre of Birth (MonttVDav/Yea);

MarWShKuc OMantod HOIvapced

aDre a Accident and Health UcenwNo, 3. Store oUte QAecMentanciHaanh uoenseNo.

aADddantandHeattti license ra 4, Store DAcddentondHflOttfi toenieNO.

tr you wtih to apply fornofHBftlentappoWment lit flw stc^s and (ncfude the approprtale fees tnd/orfcims:

hawvouevwtBenterniwtedbyanmMticecornpaniyi1 a yes TP^TpieaweJpaSr

rnrdalrAagatitfyoudtaata^ DYss ONo

iromoninMoncgcompcny? .ONo

MneRmn-1 Rev. T/05

How many years have youheld an Insurance license?

Do you cany Errors and Omissions Insurance? cp?esIf "Yes," none of carter:

Policy No,:

Provide the fotowhg Information regarding al current and past appointments with life or health Insurance companies:KAMI OF COMPANY: |ADO«SSOf HOMIOFHCfc | FROM: (MO/W.) j IO:(MO^YR) jOtCTOCONTACH

oYes

a Yes QNo

Have you ever been or are you currently bound by any employment agreement non-compete agreement or non-solicitation agreement theteims of which (1) restrict where or to whom you may sefl Insinancepoteles or, (2) restrict yowabllfy to sell UCTpoHctes? aYes

rTYes7nptease explain:

years in the Insurance Industry:

PRODUCTION RECORD

UfePremium

UfeVolume

HealthPremium

GroupPremium

«OWU^CAU^WAAGWCTrasw««HI««100A«eB|c¥

wsoNJT01™ ^Wr

Total number of producing agents or brokers In your agency? JHow many wffl be appointed wflhUCT?

Rafir Credit Reporting Act DisclosureAn hvesljgafive consider rep^

acquainted wtti you. TWs hquiry includes information as to ywir character,a written lequest v in a reasonable perkxi of time to receto

Tolhebestoriir/laiowIe .allofliealxnelsnMrec ^a^of any of my contecte wtti rther insurance companies.YOfiSKNATURE: DATE:

ESTif

HOTA Fraternal Benefit IP E O P L E H E L P I N G P E O P L E

THE ORDER OF

UNITEDCOMMERCIALTRAVELERSOF AMERICA

Assignment of CommissionHome Office: www.uctorg632 N. Park Street, P.O. Box 159019, Columbus, OH 43215-8619(614) 228-3276 • Toll-free: (800) 848-1124 • Fax: (614) 228-0483

Canadian Office:901 Centre Street North, Room 300, Calgary, AB T2E 2P6(403) 277-0745 • Toll-free: (800) 267-2371 • Fax: (403) 277-6662

For valuable consideration, receipt of which is acknowledged, the Assignor,Name

C,l(lrlC IHnae \J

hereby assigns toTax ID No. Name

(hereinafter called "Assignee") all rights, title and interest to commissions on all policies due or to become due, from UnitedCommercial Travelers, its subsidiaries, affiliates or successors (hereinafter called the "Company") under the Assignor's

Agency Agreement with Company dated 20. provided, however, that suchcommissions shall be subject to all the terms and provisions of said contract including the right of the Company to withholdand use such commissions to offset any indebtedness of the Assignor or Assignee to the Company.

Assignor hereby directs the Company to pay the aforesaid commissions to the Assignee and releases the Company from anyand all liability whatsoever to the Assignor by reason of payment of such commissions hereto. This assignment will becomeeffective on the date accepted and approved by the Company.

Assignor hereby acknowledges that no other assignment or order exists in connection with the commissions described above.

Dated on. ,20Assignor Signature

Tax ID No Print Name

Acceptance of AssigneeAssignee hereby accepts assignment of the above-described commissions and agrees to be bound by the terms andconditions of the above-referenced contract as they affect the above-described commissions.

Dated on .20

Tax ID No, Print Name

Consent to AssignmentThe Company hereby consents to the above assignment of commissions subject to the terms, provisions and conditionsstated or referred to herein, but assumes no responsibility or obligation as to the validity or sufficiency thereof.

Accepted this. . day of. _,20_

Company

By:Name and Title

JfcoffThe Risk Consulting CompanyKnu Background Am*ric*, lac. NOTICE/AUTHORIZATION AND RELEASE FOR THE PROCUREMENT

OF A CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT(PLEASE PRINT OR TYPE)

i, the undersigned consumer, do hereby authorize United Commercial Travelers of America (UCTi. by and through Its Independentcontractor, KROLL BACKGROUND AMERICA, INC. ("KBA"), to procure a consumer report and/or investigative consumer report on me.

These above-mentioned reports may include, but are not limited to, information as to my character and general reputation, discernedthrough employment and education verifications; personal references; personal interviews; my personal credit history (If applicable to theposition) based on reports from any credit bureau; my driving history, including any traffic citations; a social security number verification;present and/or former addresses; criminal and civil history/records; or any other public record.

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report ofwhich I am the subject upon my written request to KBA, if such Is made within a reasonable time after the date hereof. I also understandthat I may receive a written summary of my rights under 15 U.S.C. § 1681et. sea.

1 further authorize any person, business entity or governmental agency who may have information relevant to the above to disclose thesame to UCT, by and through KBA, including, but not limited to, any and all courts, public agendas, law enforcement agencies and creditbureaus, regardless of whether such person, business entity or governmental agency compiled the Information itself or received ft fromother sources.

I hereby release UCT, KBA and any and all persons, business entities and governmental agencies, whether public or private, from anyand ail liability, claims and/or demands, by me, my heirs or others making such claim or demand on my behalf, for providing a consumerreport and/or investigative consumer report hereby authorized.

I understand that this Authorization/Release form shall remain in effect for the duration of my employment with said Company.Additionally, I give UCT permission to Investigate any incidents of workplace misconduct, including but not limited to; sexual harassment,of which I have been accused for which I am alleged to have been Involved during my employment Further, I certify that the informationcontained on this Authorization/Release form is true and correct and that my application or employment may be terminated based on anyfalse, omitted, altered or fraudulent Information.

Signature:. Date:

Printed Name:First Middle Last

Other Names Used (Alias, maiden, nickn

Current Address:

Former Address:

Former Address:

Street /P.O. Box

Street /P.O. Box

Street /P.O. Box

iame, etc):

CHy

City

City

Date Used:

State

State

State

Zip Code

Zip Code

ZfpCode

County

County

County

Date Lived

Date Lived

Date Lived

Sodal Security Number _ ; _ Daytime Telephone Number ( )

Driver's License Number _. _ State of Issuance: _ Date of Birth*: __ - Gender*:

• Have you ever been sanctioned or had your licenses suspended or revoked by any regulatory agency? Yes No.* Are you currently under any Investigation or pending charge? Yes __ No.

PROFESSIONAJL LICENSE (S) OR CERTIFICATION (SI LICENSE OR CERTIFICATION # (SI STATE (S) ISSUED

* TTUs information will enable as to property Identify you In the event we find adverse Information during (be course of oar background search,

O2003 Kroli Background America, Inc., All Rights Reserved

UCTA Fraternal Benefit Sodety

H E L P I N G P E O P L E

THE ORDER OF

UNITEDCOMMERCIALTRAVELERSOF AMERICA

PROPOSED MEMBER INFORMATION Please PrintName of council Applicant will belong to:

Council City:

Council No.:

Application for Fraternal MembershipU.S. Residente send to: 632 N. Park St., P.O. Box 159019, Columbus, OH 43215-W1CCanadian Residents send to: 901 Centre St. N., Room 3DO, Calgary, AB T2E 2P<5

THIS SECTION TO BE COMPLETED BY SPONSORING MEMBER

This is to certify that I am acquainted with the applicant and hereby recommend theapplicant for membership.

State/Prov.:

MembeFDues(S18Min.) + S12"Member Fee' = Total Due:

Full Name of Applicant {First. Middle, Last):

j _.^K. .

Street Address:

?tate/Prov.: Postal Code:

Area Code and Phone No.: Dote of Birth: Soc. Sec. No./Can. I.D. No.:

E-mail Address:

Sponsor's Signature:

Date (M/D/Y): Sponsor's Membership No.:

Print Sponsor Name:

Street Addr

City: Stafe/Prdv.-lPostal Code:

THIS SECTION TO BE COMPLETED BY COUNCIL SECRETARYCouncil Action:

Approved DisapprovedDale (M/D/Y):

Secretary's Signature:

Applicant's Signature: Date (M/D/Y):Please enroll me for membership in The Order of United CommercialTravelers of America (UCT). I understand UCT 4s a fraternal benefitsociety and agree to abide by the Society's Constitution and Bylaws.

FM-05Illlllllllllllllllllllllllllll

' 3 0 2 1 0 '

Printed 8/05

BENEFITS AND DISCOUNTS

UCT was founded on a need for security and friendship. In keeping with its motto of"People Helping People'the organization makes availablea number of benefitsanddiscounts to members and their families:

• UCT Foundation Benefit (disaster relief) - This fund is designed to giveimmediate assistance to members in the event of a major disaster-relatedemergency such as a fire, flood or tornado. Members may receive moneyimmediately to purchase needed food, clothing and shelter. This benefit coversthe member's primary residence only.

• Widows' and Orphans' Benefit - This benefit may provide supplementalincome to needy families of deceased members. Widows and widowers who donot have sufficient resources to meet necessary living expenses may receiveassistance. Also, an allowance for each child under 18 years of age may begranted. These benefits are given in strict confidence.

• Fraternal Benevolent Benefit - This benefit may provide financial assistancetoUCTmemt)eFSv*obea)mepQrrnarwrtJyphysical(yormentally incapacitated.In case of need, this benefit will supplement income. There may also be anallowance for each child under 18 years of age and an additional sum for adependant spouse.

• UCT Canadian Drug Program - Through this mail order program, UCTmembers may save 30-75percent off typical U.S. prescription costs by orderingprescription medication from a licensed Canadian pharmacy. Depending onannual prescriptiori requirements, this may equate to hundreds orthousands ofdollars worth of savings per year.

• PreMriptionCaKlSawngs-U.S.membersmayremedJcafion by using UCTs Prescription Plan Plus drug card at participating localpharmacies.

• Car Rental Discounts -Wrier) traveling, UCT members may receive discountswith Hertz, Alamo and Avis throughout the United States and Canada.

• Buckeye Moving and Storage Discount - Members may receive discountsand credits on packing and moving costs throughout the U.S. and Canadathrough Buckeye Moving and Storage, an agent for Mayflower Transit, one ofthe most respected moving companies in the business.

• Club USA Theme Park Discounts - Members may save money with thismembership to Club USA, the official discount program of Sea Work), BuschGardens and other Anheuser-Busch Theme Parks. Club USA discounts areavailablefree of charge toUCT members andprovide substantial savings atSeaWorld (California, Florida, Texas), Busch Gardens (Florida, Virginia), AdventureIsland (Florida), Water Country USA (Virginia), Six Flags Over Georgia andSesame Place (Pennsylvania) parks.

• Choice Hotels Discount - Members may save 20 percent off applicable ratesat thousands of Sleep, Comfort, Quality, Clarion, Econo Lodge and Rodewayinns, hotels and suites throughout the United States and Canada.

• TD Insurance Home and Auto Discount-Canadian members are eligible toreceive preferred rates for botti homeandauto insurance through TD InsuranceHome ar«IAuto,ourinsurance partner. Thfediscount enables members to enjoysomedihemanybenefitsMTTJ Insurance HwrieandAirtooffers:cornpetitiverates, outsiarKlirigdientcare.additionaicffsrountsforsafetyKior^ous behavior,no-interest payment options and fast claims settlements.

• Esso Discount - Through this program, Canadian members with businessvehicles may receive up to a 3 percent discount on gasoline with a minimummonthly purchase.

' Please note that some discount programs require an additional fee.

ADVANCE COMMISSION REPAYMENT AGREEMENT

This Advance Commission Repayment Agreement (the "Agreement") is entered into thisday of , 200___, and supplements and amends a certain Sales Agreement enteredinto by and between ("Selling Agent") and The Order of UnitedCommercial Travelers of America ("UCT").

The purpose of this Agreement is set forth the terms pursuant to which UCT will pay Selling Agentadvance commissions and to evidence Selling Agent's promise to repay UCT the advancecommissions. - • • • -

}

1. The Company agrees to make weekly interest bearing (9% per annum) commission advances {Ito the Selling Agent on Medicare Supplement policies written through the Selling Agent'soffice and processed as paid for on the Company's records. Provided that the method ofpayment is either EFT or automated bank draft. Advance commissions will not be paid forother methods of premium payments. Advance commissions will not be paid on MedicareSupplement policies issued to persons under the age of 64-1/2 at the time of issuance.

These commission advances shall be made against the first year commissions due or tobecome due to the Selling Agent from such policies under the terms of the Basic Contract.The Selling Agent hereby agrees that commissions, when earned, shall be applied by theCompany to reduce indebtedness created by the advances including interest thereon. The 1subparagraphs below describe the manner in which these commission advances will becomputed and how earned commissions will be applied against such indebtedness,

A. The Gross weekly Commission Advances will be the sum of the cash advanced foreach such policy processed as paid for during the week as computed from theschedule below:

PREMIUM MODE - COMMISSION ADVANCEii

Monthly - 9 months of commissions applicable to the monthly payment

B. From the Gross weekly Commission Advance so computed, the Company will:

(i) Deduct for any policy processed as lapsed, canceled or not taken during theweek the amount previously advanced to the Selling Agent on the portion ofthe first year premiums which will not be paid except through reinstatement

- j

(ii) Add back, for any policy which is reinstated during the same week, theamount of advance commissions, if any, which were charged back when thepolicy lapsed. I

i

C. The result obtained from the computations in A and B above, when aggregated, shallconstitute the weekly cash advance. The weekly cash advance will be aggregated and

(H0249145.4 )

D.

paid with other commissions due to the Selling Agent. If the computation results in anegative amount, then such negative amount shall be carried forward to the nextweek-

All delivery requirements must be met and the first mode of premium paid in orderfor a policy to be processed as paid for. Agency checks and cashier's checks are notacceptable.

2. The Selling Agent understands and agrees that the amount by which the weekly commissionadvances received by the Selling Agent exceed the earned commissions against which suchadvances were made constitute an indebtedness to the Company. Such indebtedness shall besubject to an interest rate of 9% per annum calculated monthly. This interest expensecalculation will be the sum of the beginning and ending monthly debit balance, divided bytwo, multiplied by the applicable interest rate.

3. The gross weekly commission advances will be offset against earned commissions andbeginning with the effective issue month until fully recovered.

4. The Company may at any time offset the debit balances created by advances made under thisAgreement against any commissions or other compensation due Selling Agent from theCompany on any policies issued by Company. The Selling Agent grants Company a securityinterest in all commissions and compensation due Selling Agent from the Company andauthorizes the Company to perfect its security interest.

5. The Company may elect to discontinue paying advance commissions upon 10 days writtennotice to the Selling Agent, which notice shall be delivered personally or mailed. TheCompany or the Selling Agent may, by notice delivered personally or mailed, one to theother, terminate this Agreement upon 30 days written notice independent of the BasicContract. Upon termination of this Agreement, the debit balances created by advances madeunder this Agreement shall be immediately due and owing and shall be repaid in full by theSelling Agent. The Company may amend this Agreement at time by like notice.

In Witness Whereof, the parties have executed this Agreement on the day and year set forth above.

SELLING AGENT:

[Signature]

[Print Name]

UCT:The Order of United Commercial Travelers ofAmerica, Inc.By:.

Approved By(Home Office Use Only)

[Print Name]:

(HOM9I4S.4 ]