Proposed Insured

Name

Address

Telephone No.

Fax No.

E-Mail:

Date of Birth:

Citizenship:

Sex:

Proposed Policy owner (if different)

Name

Address

Telephone No.

Fax No.

E-Mail:

Reason for insurance (check applicable box):

Personal/Family Protection

Inheritance tax

Private Residential Loan

Keyman

Commercial Loan

Occupation:

Nature of Business or Occupation

Rank and duties if a member of the Armed Forces

Do your duties involve you in any way (other than clerical) with:

The licensed trade or entertainment industry?

Yes

No

Working at heights, offshore, aviation (other than scheduled flights), diving or the fishing or mining industries, work requiring special safety precautions or any other activity which may be regarded as hazardous?

Yes

No

If yes, give full details:

Does your job require a license, eg driving?

Yes

No

Policy Details

Term:            Years

Principal Sum $

Desired Effective Date:

Total Principal Sum under existing life insurance policies (please circle appropriate box):

$0 to $100,000.

$100,001 to $250,000

$250,001 to $500,000

$500,001 to $750,000

Over $750,001

Are you currently purchasing or intending to purchase any other life insurance or have you done so within the last 12 months?

Yes

No

If yes, please provide details of companies, dates and amounts of insurance:

Personal Details:

Doctor who currently holds your medical records:

Name

Address

Telephone No.

Fax No.

E-Mail

If you have changed doctors within the last 3 months, please provide the following information regarding your previous doctor:

Name

Address

Telephone No.

Fax No.

E-Mail

Height:

Weight:

Provide details to all “Yes” answers.

Yes

No

1.  Have you ever had an application for health or life insurance voided, declined,     canceled, rescinded or modified (including medical exclusion riders)?

2.  In the last 12 months, have you used tobacco in any form?

3.  In the last 12 months, have you experienced a weight change of 15 pounds or more?

4.  In the last 5 years, have you had any indication, diagnosis or treatment of an alcohol or drug dependency, problem or abuse or any alcohol or drug related arrest?

5.  In the last 5 years, have you consumed alcoholic beverages in excess of 14 drinks per week?

6.  Are you pregnant?

7.  Do you read, write, speak and understand English?  If no, what is your primary language?_________________________

8.  In the last 12 months, have you taken medication or received medical advice or treatment of any kind?

Within the last 10 years, have you had any indication, signs, symptoms, diagnosis or treatment of any disease or disorder of:

9.  Gallbladder?

10. Pancreas or liver?

11. Joints or spine?

12. Kidney?

13. Eyes, ears or nose?

14. Mouth, throat or jaw?

Within the last 10 years, have you had any indication, signs, symptoms, diagnosis or treatment of:

15. High blood pressure?

16. Chest pain?

17. Headaches?

18. Paralysis?

19. Arthritis?

20. Convulsions or epilepsy?

21. Elevated cholesterol?

22. Sexually transmitted disease?

23. Cancer?

24. Diabetes or sugar in the blood or urine?

25. Stroke?

26. Acquired Immune Deficiency Syndrome (AIDS) or any HIV-related disease or illness?

27. Tumor, cyst, polyp, lump or growth of any kind?

Within the last 10 years, have you:

28. Had a complicated pregnancy or delivery?

29. Tested positive for antibodies to the HIV virus?

30. Been hospital confined, had surgery or discussed surgery?

31. Consulted a mental health professional?

Within the last 10 years, have you had any indications, signs, symptoms, diagnosis or treatment of any disease, disorder, or abnormality of the:

32. Heart or circulatory system?

33. Nervous system?

34. Digestive system?

35. Muscular or skeletal system?

36. Respiratory system?

37. Male or female reproductive system?

38. Urinary system?

39. Thyroid, breast or other glands?

40. Within the last 10 years, have you had any signs, indication, symptoms, diagnosis or treatment of any other disorder, disease, injury or adverse finding or had any adverse or abnormal test results?

For any question answered “Yes”, plesas provide details of the condition including:  treatment dates, name, address and telephone number of the treating physician, diagnosis, prognosis and present course of treatment.  Attach additional pages if necessary.  Additional information may be required.

Have either of your parents or any brothers or sisters died from or suffered from heart disease, stroke, diabetes, cancer or a nervous disorder”

Yes

No

If yes, provide details including relationship and age at time, and state if death resulted:

Beneficiary (if other than Policy owner):

Name

Relationship to Applicant:

Address

Telephone No.

Fax No.

E-Mail:

Contingent Beneficiary:

Name

Relationship to Applicant:

Address

Telephone No.

Fax No.

E-Mail:

Declaration/Application:

I hereby apply for membership in the Atlas/International Citizen Group Insurance Trust, Hamilton, Bermuda, and for the insurance provided by Certain Underwriters at Lloyds, London.  I have personally completed this Application.  I represent that the answers and statements on this Application are true, complete and correctly recorded.  I understand that any misrepresentation contained herein will void my insurance and all claims will be forfeited.  I understand that no coverage is effective until I am notified in writing by MultiNational Underwriters, Inc. I understand that if this Application is not accepted, the sole obligation of the MultiNational Underwriters, Inc.is to return the premium to me.  The undersigned authorizes any doctor, medical practitioner, hospital, clinic, health facility, pharmacy, government agency, insurance agency, insurance company, group policyholder or insurance or benefit administrator or any other entity having information as to the care, advice, treatment, diagnosis or physical or mental condition of any family member listed on this Application to release said information to MultiNational Underwriters, Inc.

Signature of Applicant:

Date of Signature:

Signature of Policy owner (if different):

Date of Signature: