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11 anyques rens h ac ion' o rs oim were answered "yes`, please provide an explanation using the additional space below. Refer to the specific question number, and give details including names where appropriate. It additional space is needed, use a separate sheot of paper, and refer to the question number. Be sure to sign, date and have it witnessed. Question No. Explanation Insurance to be Issued: "N" for non contributory or "C" for contributory. If "C" Indicate % of employee contribution.. Employee: I Life % I Dental C °F loo I Vision % I STD % I LTD % Dependent: i Life 1) Agent Name: Duncan Chalmers, CLU Code: Guardian. Agency: Code; Agent Sheet City State Zip Code For file insurance only: To the best of your knowledge, will this insurance roplace any existing life insurance or annuity? c Yes = No Agent Signature: Soc. Sec. # License # Tax ID # -12) Agent Name: °/T Code: — Guardian Agency: Code: Agent Address: Street City stale 25p Code For life insurance only: To the best of your knowledge, will this insurance replace any existing life insurance or annuity? Yes t No Agent Signature: Sec. Sec. # License fl Tax ID # Sales Sales Representative Code SECTION V I AGREEMENT Request for participation In A Certain Trust Agreement The undersigned Planholder engaged primarily in the industry described in Section I, hereby requests that it be approved as a partiCipant in the Trust ,slablished by other Planholders engaged in the same industry for the purpose of purchasing insurance for the benefit of their employees and equesis inclusion as a participant under the Group Insurance Plan(s) issued to the Trustee for the plan(s) of insurance shown in Sr cljon Ill. 2onditfone of Agreement I is understood that no individual shall become insured while not actively at work on a full-time basis, and only full-time employees shall be eligible. - ull-time employee means one who regularly works at least the number of hours in the normal work week established by this Planholder (but nol ass than 30 hours per week) at his Planholder's place of business. It is further understood that no agent has power on behalf of the Guardian. Life •asurance Co. of America to make or modify any request or application for insurance, or to bind said Insurance Company by making any promise or epresentation or by giving or receiving any information. It is further understood that no insurance will be effective until the pian is accepted in wrifing V the Insurance Company. No contract of insurance is to be implied in any way on the basis of the completion and submission of the specifications ,hown on both sides of this form. Any person who knowingly and with intent to injure. defraud or deceive any insurer files a statement of claim or an application containing any false, ncomplete or misleading information is guilty of a felony of the third degree". have reviewed the stalemeMs. made by me on this application. and they are Irue and complete. Signature and Title of Officer,. 'artier or Proprietor. Date-, 5/25/99 Fran B. Adams', Vicb Chairman 'rint Name of Officer, Partner it Proprietor ,ignature of Witness ly and Slate Where Signed: ---j+{Lacjt,_j Date:�l s/rr