TOI: H02I Individual Health - Accident Only Sub-TOI: H02I.000 Health - Accident Only Application for Accidental Death Policy/UAIN-TAP(03)

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1 TOI: H02I Individual Healh - Acciden Only Sub-TOI: H02I.000 Healh - Acciden Only Produc Name: Projec Name/Number: / Filing a a Glance Company: Unied American Insurance Company Produc Name: Applicaion for Accidenal Deah SERFF Tr Num: AMLC Sae: Arkansas Policy TOI: H02I Individual Healh - Acciden Only SERFF Saus: Closed-Approved- Sae Tr Num: Closed Sub-TOI: H02I.000 Healh - Acciden Only Co Tr Num: Sae Saus: Approved-Closed Filing Type: Form Reviewer(s): Rosalind Minor Auhor: Linda Newell Disposiion Dae: 06/02/2011 Dae Submied: 05/19/2011 Disposiion Saus: Approved- Closed Implemenaion Dae Requesed: On Approval Implemenaion Dae: Sae Filing Descripion: General Informaion Projec Name: Saus of Filing in Domicile: Pending Projec Number: Dae Approved in Domicile: Requesed Filing Mode: Review & Approval Domicile Saus Commens: Explanaion for Combinaion/Oher: Marke Type: Individual Submission Type: New Submission Individual Marke Type: Overall Rae Impac: Filing Saus Changed: 06/02/2011 Sae Saus Changed: 06/02/2011 Deemer Dae: Creaed By: Linda Newell Submied By: Linda Newell Corresponding Filing Tracking Number: Filing Descripion: We are submiing form for your review and approval. The capioned form is being submied as a new filing and will no replace any previously approved form. The form does no conain any unusual or unorhodox provisions or wording. The readabiliy score is shown on he enclosed readabiliy cerificaion form. This applicaion will be used wih our individual Accidenal Deah Insurance Policy form UAINADP which was approved on May 12, 2011, SERFF racking number AMLC This coverage will be agen sold. Company and Conac PDF Pipeline for SERFF Tracking Number AMLC Generaed 06/02/ :08 PM

2 TOI: H02I Individual Healh - Acciden Only Sub-TOI: H02I.000 Healh - Acciden Only Produc Name: Projec Name/Number: / Filing Conac Informaion Linda Newell, Compliance Analys 3700 S. Sonebridge Drive [Phone] McKinney, TX [FAX] Filing Company Informaion Unied American Insurance Company CoCode: Sae of Domicile: Nebraska P.O. Box 8080 Group Code: 290 Company Type: Life and Healh McKinney, TX Group Name: Libery Naional Sae ID Number: (972) ex. [Phone] FEIN Number: Filing Fees Fee Required? Yes Fee Amoun: $50.00 Realiaory? No Fee Explanaion: Nebraska, our sae of domicile, does no charge a filing fee. One applicaion form a $ Per Company: No COMPANY AMOUNT DATE PROCESSED TRANSACTION # Unied American Insurance Company $ /19/ PDF Pipeline for SERFF Tracking Number AMLC Generaed 06/02/ :08 PM

3 TOI: H02I Individual Healh - Acciden Only Sub-TOI: H02I.000 Healh - Acciden Only Produc Name: Projec Name/Number: Correspondence Summary / Disposiions Saus Creaed By Creaed On Dae Submied Approved- Closed Rosalind Minor 06/02/ /02/2011 PDF Pipeline for SERFF Tracking Number AMLC Generaed 06/02/ :08 PM

4 TOI: H02I Individual Healh - Acciden Only Sub-TOI: H02I.000 Healh - Acciden Only Produc Name: Projec Name/Number: Disposiion / Disposiion Dae: 06/02/2011 Implemenaion Dae: Saus: Approved-Closed Commen: Rae daa does NOT apply o filing. PDF Pipeline for SERFF Tracking Number AMLC Generaed 06/02/ :08 PM

5 TOI: H02I Individual Healh - Acciden Only Sub-TOI: H02I.000 Healh - Acciden Only Produc Name: Projec Name/Number: / Schedule Schedule Iem Schedule Iem Saus Public Access Supporing Documen Flesch Cerificaion Approved-Closed Yes Supporing Documen Applicaion Approved-Closed Yes Supporing Documen Healh - Acuarial Jusificaion Approved-Closed Yes Supporing Documen Ouline of Coverage Approved-Closed Yes Form Approved-Closed Yes PDF Pipeline for SERFF Tracking Number AMLC Generaed 06/02/ :08 PM

6 TOI: H02I Individual Healh - Acciden Only Sub-TOI: H02I.000 Healh - Acciden Only Produc Name: Projec Name/Number: Form Schedule / Lead Form Number: Schedule Form Form Type Form Name Acion Acion Specific Readabiliy Aachmen Iem Saus Number Daa Approved- UAIN- Applicaion/ Applicaion for Iniial UAIN- Closed 06/02/2011 TAP(03) Enrollmen Form Accidenal Deah Policy TAP(03).pdf PDF Pipeline for SERFF Tracking Number AMLC Generaed 06/02/ :08 PM

7 UNITED AMERICAN INSURANCE COMPANY A LEGAL RESERVE STOCK COMPANY * Adminisraive Office: McKinney, Texas Benefi Amoun $3,000 ($3,000 spouse, $1,000 each child) Proposed Insured/Applican Annual Mode of Premium Mode of Premium Paymen Send Premium Noices Auomaic Paymen Plan Day (01-28) of he Monh o Draf Bank Accoun Address Ciy Age Las Birhday Home Phone No. - - Work Phone No. - - Beneficiary Name Sae (mm-dd-yyyy) - - Zip Code Address of Proposed Insured/Applican Relaionship Sex Male Female Spouse (mm-dd-yyyy) - - Child 1 Child 2 (mm-dd-yyyy) - - Child 3 (mm-dd-yyyy) - - (mm-dd-yyyy) - - (Applicaion Condinued) 44244

8 UNITED AMERICAN INSURANCE COMPANY A LEGAL RESERVE STOCK COMPANY * Adminisraive Office: McKinney, Texas Child 4 (mm-dd-yyyy) - - Child 5 (mm-dd-yyyy) - - Child 6 (mm-dd-yyyy) - - Is he insurance applied for inended o replace or change any coverage now in force wih his or any oher company? If "Yes," comply wih he applicaion Replacemen Regulaion or Rule. Yes No This policy is no o be used o replace oher coverage. DECLARATION AND AUTHORIZATION I hereby declare ha he saemens recorded above are rue and complee o he bes of my knowledge and belief wih respec o any proposed insured. I agree ha: (1) no policy will be binding upon he Company unless upon is dae of issue and delivery each proposed insured is alive; (2) no agen has auhoriy o accep risks or make or change conracs or waive he Company's righs or requiremens. I undersand and agree ha he Company reserves he righ during he firs year he policy is in force, o resric beneficiaries o designaions accepable o he Company. Excep wih respec o a minor child of mine, his applicaion is made wih he knowledge and consen of he proposed insured. Any person who knowingly presens a false or fraudulen claim for paymen of a loss or benefi or knowingly presens false informaion in an applicaion for insurance is guily of a crime and may be subjec o fines and confinemen in prison. Dae Applicaion Signed (mm-dd-yyyy) - - Sae Agen's Signaure Signed Proposed Insured Agen No. Signed Prin Firs 5 Leers of Agen's Applican (If oher han he Proposed Insured) lasnameagen's SEND POLICY Name: TO: Agen Insured The Policy will be sen o insured unless oherwise insruced

9 TOI: H02I Individual Healh - Acciden Only Sub-TOI: H02I.000 Healh - Acciden Only Produc Name: Projec Name/Number: / Supporing Documen Schedules Iem Saus: Saus Dae: Saisfied - Iem: Flesch Cerificaion Approved-Closed 06/02/2011 Commens: Aachmen: AR flesch.pdf Iem Saus: Saus Dae: Saisfied - Iem: Applicaion Approved-Closed 06/02/2011 Commens: See Forms Schedule ab. Iem Saus: Saus Dae: Bypassed - Iem: Healh - Acuarial Jusificaion Approved-Closed 06/02/2011 Bypass Reason: N/A Commens: Iem Saus: Saus Dae: Bypassed - Iem: Ouline of Coverage Approved-Closed 06/02/2011 Bypass Reason: N/A Commens: PDF Pipeline for SERFF Tracking Number AMLC Generaed 06/02/ :08 PM

10 ARKANSAS CERTIFICATION This is o cerify ha he aached Policy Form Applicaion for Accidenal Deah Policy has achieved a Flesch Reading Ease Score of and complies wih he requiremens of Arkansas Sa. Ann. SS hrough , cied as he Life and Disabiliy Insurance Policy Language Simplificaion Ac. Michael J. Gaisbauer, Vice Presiden SUPPLEMENTAL FORMS SCORE FORM S-1351(3) 5/82

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