NATIONAL STATES INSURANCE COMPANY 1830 CRAIG PARK COURT, ST. LOUIS, MISSOURI (800)

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2 THE POLICY DESCRIBED IN THIS OUTLINE PROVIDES SUPPLEMENTAL COVERAGE ISSUED ONLY TO SUPPLEMENT INSURANCE ALREADY IN FORCE. NATIONAL STATES INSURANCE COMPANY 1830 CRAIG PARK COURT, ST. LOUIS, MISSOURI (800) THE POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. IF YOU ARE ELIGIBLE FOR MEDICARE, REVIEW THE POLICY THE GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH MEDICARE AVAILABLE FROM THE COMPANY. SUPPLEMENTAL COVERAGE REQUIRED OUTLINE OF COVERAGE FOR POLICY FORM MAS-1(06) Read Your Policy Carefully This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY! This policy is designed to supplement your existing hospital indemnity coverage. Coverage is provided for the benefits outlined below. The benefits described below may be limited by the Exceptions and Limitations provision. SPECIFIC BENEFITS ARE: DAILY HOSPITAL BENEFIT If you are confined in a hospital as a resident inpatient, because of injury or sickness, the policy pays at the rate of $ per day for each day you are confined up to a maximum of 10 days per Period of Care. ($100-$400) The maximum time for which this Hospital Confinement Benefit shall be payable is 365 days for all Periods of Care combined. OPTIONAL BENEFITS The following benefits are only applicable if you choose to purchase them for an additional premium at the time you apply for the policy. Dental, Vision and Hearing Care Expense Rider Form R-DVH-3(06) (Optional) If this Rider is purchased, benefits will be paid as follows: Covers services of all licensed dentists, including the cost of fillings, bridges, and dentures; visits to an Ophthalmologist or Optometrist for refraction, including the cost of eyeglasses or contact lenses; and the cost of initial hearing aids and repairs to initial hearing aids. A $100 deductible is applied in each calendar year and 80% of expenses after the deductible are covered. A maximum of $1,000 is payable under the Rider in each calendar year. Replacement or repair of existing dentures, bridges, eyeglasses, or contact lenses are not covered until this Rider has been in effect for over 12 months. Replacement of, or repair to, existing hearing aids is not covered by this Rider. EXCEPTIONS AND LIMITATIONS This policy does not cover loss resulting from: treatment, injury or sickness resulting from war or any act of war, whether war is declared or not; mental or nervous disorder without demonstrable organic disease; alcohol or drug abuse (unless the result of narcotics administered or prescribed by a doctor); dental treatment, except for injury; cosmetic surgery, except when necessary to restore normal bodily function or for reconstructive purposes incidental to or following surgery resulting from sickness or injury; being engaged in an illegal occupation; any type of care or service for which you have no legal obligation to pay in the absence of insurance (except Medicaid); any type of care or service covered under workers compensation or occupational disease law. PREEXISTING CONDITIONS Loss that is incurred within 6 months after the Policy Date and which results from a preexisting condition, is not covered. A preexisting condition is any condition that was diagnosed or treated by a doctor within 6 months prior to the Policy Date, or any condition which produced symptoms within 6 months prior to the Policy Date that would have caused an ordinarily prudent person to seek medical diagnosis or treatment. RENEWABLE CONDITIONS The policy is guaranteed renewable which means you have the right to continue the policy as long as you pay the premiums on time. The Company may increase premiums on all policies of this type in your state. The Company cannot raise premiums just on your policy because of a change in your health, or claims that you file. PREMIUMS Base Policy with Dental, Vision, Hearing Rider R-DVH-3(06) $ $ Annual Policy Fee $ $ Semi-Annual Total Initial Premium $ $ Quarterly $ Monthly Bank Draft or List Bill Date Agent s Printed Name Agent s Address & Phone Number Form OC-MAS-1(06) (TX)

3 MAS-1(06) Application to Policy No. National States Ins. Company 1. Applicant's Name (Print) Date of Birth Social Security No. Last First Initial Sex Mo. Day Year Age Home Office Use 1830 Craig Park Court, St. Louis, Missouri Effective Date Deferred Effective Date Requested: Address City State Zip Telephone No. Applicant's Address Employer's Name or Group/Association Name (if applicable) Sect. Dept. # Occupation HEALTH UNDERWRITING QUESTIONS In the past 18 months have you been medically treated or medically diagnosed for: cancer; heart attack; congestive heart failure; stroke; chronic kidney disease; chronic lung disease; chronic liver disease; any disorder requiring transplant; alcohol or drug abuse; any disease requiring amputation; any type of progressive terminal disease; or within the past 18 months have you been confined to a hospital; nursing home; or other medical facility? Yes No Have you ever been medically diagnosed as having or been treated for AIDS or ARC (AIDS Related Complex); or have you ever been advised by a medical professional that you have tested HIV positive? Yes No Please explain any "Yes" answers Does this Insurance replace any insurance you now have? Yes No (If "Yes", give details to include name(s) of company(ies), policy nos., types of coverage.) COVERAGE(S) APPLIED FOR PREMIUM MODE OF PAYMENT Daily Hospital Benefits: $100* $200 $400 (10 days) $ Monthly List Bill (5 or more) Dental, Vision, Hearing Rider R-DVH-3(06)... $ Monthly Bank Draft Total Premium... $ Quarterly Policy Fee (one time)... $ Semi-Annual Total Initial Premium...$ Annual *$100 Benefit not available under age 60 NOTICE: Any person who, with intent to defraud or knowing that he is facilitating a fraud against any insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. I agree that all answers above are true and complete to the best of my knowledge, and I understand that my eligibility for coverage will be determined based on my responses shown on this application. I understand the agent cannot waive any of the Company's rights or make any changes in the policy. I acknowledge receipt of: [ ] an outline of coverage [ ] "Guide to Health Insurance for People with Medicare" and "Notice that this is not a Medicare Supplement" (for applicants on Medicare). I understand that this policy has a 6 month waiting period for preexisting conditions and I have reviewed the definition of a preexisting condition contained in the outline of coverage. Signed at this day of 20. Amount paid $ for first months. I certify that I have truly and accurately recorded herein the information given by the Applicant. X X Agent's Signature Applicant's Signature Agent's Printed Name Branch Office # Pers. Code # Mail Policy to APPLICANT AGENT Form APP-MAS(GAC) (TX)

4 BANK PLAN AUTHORIZATION TO HONOR CHECKS DRAWN BY NATIONAL STATES INSURANCE COMPANY Name of Your Bank: Your Bank's Address: I hereby request the above named bank to honor checks drawn on me by the National States Insurance Company of St. Louis, Missouri, and to charge such checks against my account until further notice. I agree that there shall be no liability whatsoever on the bank's part for any reason whatsoever for payment of or failure to pay any such checks drawn on me. I understand that if for any reason these checks are not honored by my bank that the preauthorized check privilege will be automatically discontinued by National States and that it will be my responsibility to pay any premiums due directly to National States. I further understand that it is my responsibility to review my bank statement to be sure that pre-authorized checks have been properly submitted and honored. I would like my account drafted and I have enclosed a copy of a check bearing the account number to be drafted. (Annually, Semi-annually, Quarterly or Monthly) (Customer's Signature EXACTLY as it appears on Bank Records) (Date) IMPORTANT NOTICE TO AGENTS - Attach sample copy of Applicant's check. TO: The Bank named on the reverse side In order to induce you to comply with the request of your customer to provide the service authorized on the other side of this card, the National States Insurance Company of St. Louis, Missouri, undertakes and agrees: 1. To indemnify you and hold you harmless from any loss you may suffer as a consequence of your actions resulting from or in connection with the execution and issuance of any check, draft or order, whether or not genuine, purporting to be executed or issued by or on behalf of the undersigned company and received by you in the regular course of business for purpose of payment, including any costs or expenses reasonably incurred in connection herewith. 2. In the event that any such check, draft or order shall be dishonored, whether with or without cause, and whether intentionally or inadvertently, to indemnify you for any loss even though dishonor results in a forfeiture of the insurance. 3. To defend at our own cost and expense any action which might be brought by the depositor or any other person because of your actions taken pursuant to the foregoing requests, or in any manner arising by reason of your participation in the foregoing plan of premium collection. THE NATIONAL STATES INSURANCE COMPANY OF ST. LOUIS, MISSOURI Authorized in a Resolution adopted by the Board of Directors of the National States Insurance Company of St. Louis, Missouri, June 1, 1972 MAKE CHECKS PAYABLE TO: National States Insurance Company MAIL NEW BUSINESS TO: General Agent Center N 79th Pl - #100 Scottsdale, AZ 85260

5 National States Insurance Company Daily Hospital Benefit with Dental-Vision-Hearing Rider (NO Return of Premium Rider) Issue Age Bank Draft / List Bill Rates Quarterly Rates $27.55 List Bill Only $35.62 $86.92 List Bill Only $ List Bill Only List Bill Only List Bill Only List Bill Only List Bill Only List Bill Only $ $ Semi-Annual Rates Annual Rates Issue Age $ List Bill Only $ $ List Bill Only $ List Bill Only List Bill Only List Bill Only List Bill Only List Bill Only List Bill Only $ $ , Policy Fee: $20 payable once at the time of application. Not required in Kentucky & Michigan. Return of Premium not available in: AR, GA, IN, IA, MI, NE, OR, PA, SD, TN, TX, VA, WA & WI Form: MAS w/dvh