Please read this form completely, before signing

The Check-O-Matic Payment Plan provides you with a safe, effective, and convenient method of paying your insurance premiums directly from your checking/money market or savings account. Special Instructions: This form is for Life Insurance Company of the Southwest products ONLY. Follow the instructions below and have the customer sign the form and return it to the Life Administrative office indicated below. For ALL requests, when completing this form: 1. List ALL policies/contracts to be included in the drafts and check the appropriate box for the type of payment involved. 2. Depositor MUST sign the form in two places, and the policyowner in one place, if different than the depositor. 3. Check the type of transaction in the appropriate box on Page 2 (i.e. New, Add, Bank Transfer, etc.) 4. Special requirements apply for accounts that exceed 19 characters. If your account exceeds 19 characters please call the 800 number provided below.

Check-O-Matic Authorization

Establish a new Check-O-Matic Payment Plan:

1. Select a draft date, or the date nearest the policy/contract issue day will automatically be selected. 2. Attach a deposit ticket or voided check and indicate what type of account, i.e. checking, savings or money market. 1. Indicate your existing Check-O-Matic Payment Plan number as it indicates in Establish. 1. 2. 3. 4. Indicate your existing Check-O-Matic Payment Plan number as it indicates in Establish. Indicate the effective date for the change in Bank Information. If all policies are not included in this change, please provide instructions. Attach a deposit ticket or voided check and indicate what type of account, i.e. checking, savings or money market.

Add Policies/Contracts to an existing Check-O-Matic Payment Plan. Change in Bank Information:

Important Information Regarding Conditions Pertaining To Your Payment Plan.

1. This plan may be terminated upon notice from the policyowner, depositor, or the depositors bank. Life Insurance Company of the Southwest may also terminate this plan at any time providing written notice to the policyowner and giving sufficient time for maintaining coverage. 2. Life Insurance Company of the Southwest offers drafts from Checking, Savings and Money Market Accounts. 3. While using this payment plan, premiums will be due at the reduced special monthly rate for Term and Whole Life

policies ONLY. 4. Please refer to your contract for any minimum premium requirements that apply to your policy. The minimum draft for a payment plan is $10.00 5. Returned items with the notation "Insufficient Funds" will automatically be deposited to your account twice before being returned to us as unpaid.
6. If you change your banking arrangements, at least ONE MONTHS ADVANCE NOTICE must be given to Life

Insurance Company of the Southwest. If this advance notice cannot be provided, sufficient funds should be left in your account to honor all charges until our records can be changed. Note: Failure to provide adequate notice may result in your bank assessing YOUR ACCOUNT return item fees or charges.

7. Once the Check-O-Matic Payment Plan is established, monthly deductions will occur on your selected draft date or shortly after to pay premiums due within that month. 8. Please be sure to record the monthly drafts to insure an accurate account balance. For service or questions, please contact your agent or Registered Representative, our local office, or call our toll free number: 1-800-732-8939, and a Home Office associate will be happy to assist you.

8028(0411) Cat. No. 45051

National Life Group is a trade name representing various affiliates, which offer a variety of financial service products.

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Centralized Mailing Address: One National Life Drive, Montpelier, VT 05604 | Home Office: Addison, TX | www.NationalLifeGroup.com

Please read this form completely, before signing

Please read the instructions on Page 1, and return this entire form. Checking account Savings account Money Market account Check TYPE of transaction: Bank Change Establish New COM Account* Add to Existing COM Account Change Account Number within Same Bank Policy Select Indicate all policies/contracts, Insureds/annuitants, and amount(s) affected:
Staple Voided Check/Deposit Slip Here

Check-O-Matic Authorization

Issue Draft Date: Date: 1-7 1st 8th 8 - 14 15th 15 - 21

Policy/Contract

Insured/Annuitant: (Give full name.)

Premium Amount If Applicable

22nd 22 - 31 Existing COM Payment Plan No.:

$ $ $ $ $

Effective Date of this Change:

(If applicable)

Agency No.: Special Instructions:

Date sent to AO:

First Year Annualization Authorized by:

I (we) request and authorize you to charge my (our) bank account, either by pre-authorized electronic fund transfer or other conventional means, for the purpose of paying premiums, or making deposits towards policies/contracts listed above (and/or attached), and agree to all terms and conditions as stated within the pages of this form.

**Depositors Signature: Depositors Mailing Address:

Date:

Owners Signature (if other than Depositor):

Date:

If a void check or deposit slip cannot be provided for the account information, please fill in the information below. Name of Bank: Name on Account:

**Depositors Signature:

Date:

Bank Transit No.

Customer Account No.

8028(0411)

National Life Group is a trade name representing various affiliates, which offer a variety of financial service products.

Page 2 of 2

Centralized Mailing Address: One National Life Drive, Montpelier, VT 05604 | Home Office: Addison, TX | www.NationalLifeGroup.com