I, the undersigned, hereby authorize the agent named above, if any, and/or the underwriting department of the insurance company named above to collect credit-related and other information about me from the following types of oranizations:

• Credit Bureaus
• Other organizations providing personal or privileged information

I understandthis information will be used for the purpose of making underwriting decisions in connection with the insurance for which I have applied, sought reinstatement or requested a change in benefits. These decisions may include determinations to grant or deny me coverage and/or the rates I will be charged.

I understand that this temporary authorization will expire as soon as one of the following occurs;

• The above-named company makes the underwriting decision(s) in question, or
• One year elapses after the date I sign this authorization

APPLICANT/NAMED INSURED'S SIGNATURE                     DATE