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40 <br />*� Supplemental Information: To Be Completed by Highmark Life Agent/Broker <br />Please be sure the Policyholder clearly understands the change requested and any change in premium rates. <br />'`- Unilenvrititi <br />L.' V -W ntfn ter' un g ra�� 1ec� t s. <br />Are there any changes to rates, lives, and/or volume created by this requested amendment? v Yes _ No <br />If yes, complete the following information and attach census showing age, sex, and insurance amounts for persons to be added or <br />dropped. <br />Life Dep. Life AD&D STD LTD Other <br />Quoted Rates <br />Approximate Volume Increase <br />(Decrease) <br />Lives Increase (Decrease) _ <br />Proposal prepared by _ Home Office _ Field Office _ None Prepared _ Other: <br />Is any Evidence Of Insurability required on the effective date? _ Yes _ No If yes, attach forms. <br />sImportantNotices/Revised Certifiestes <br />Important Notices will be prepared for most changes. New certificates will be provided if the amendment reduces benefits or if we <br />decide that the changes are so substantial, complex, or numerous that a new certificate is warranted. <br />Commissions,:'r.Y <br />Does this amendment involve a change of broker? _ Yes _ No <br />Change of Commission Scale?_ Yes _ No If yes, please provide name of broker, address and Commission Scale. <br />Name: <br />Address: <br />City: State Zip Code <br />Commission Scale: <br />,::.Hartford Home Office.Maiting Instructions <br />Do you want the completed amendment mailed to the Policyholder from the Home Office? _ Yes _ No If yes, a <br />copy will be mailed to the broker's office. <br />i ' Comments „ ;; <br />