Part 96, page 25

Transcript

The scan is the source; the transcript is machine-generated from it.

INSTRUCTIONS PRESS HARD FOR GOOD COPIES Please Print (Use Ballpoint Pen) LEAVE FORM INTACT (Your copy will be returned after processing)

Name (First) MACK (Init.) H (Last) EASTERBROOK Group Policyholder: Kans Lu[guess: re] Corporation Date of Birth: Mo 7 / Da 04 / Yr 36 Sex: [X] Male [ ] Female Social Sec. No.: 557-46-8529 Spouse Date of Birth: Mo 11 / 08 / 36 [ ] Single [X] Married [X] Widow(er) or Divorced Eligible Children? [X] Yes [ ] No Do you wish to insure eligible dependents? [X] Yes [ ] No

Beneficiary—Fill in only when group life or accidental death benefits are provided. (Relationship)

Unless otherwise provided herein, if two or more beneficiaries are named, the proceeds shall be paid in equal share(s) to the named beneficiaries surviving the insured.

I request to be insured. If the group insurance plan that contributions be made by me, I authorize my employer to deduct them from my pay.

Date Signed: 11 / 30 / 73 Signature of Employee or Member: [signature] Occupation: Pattern Shop man

THE BANKERS LIFE (logo) GP12000 - 1 Group Enrollment Card

Bankers Life to Complete Account No. I.D. No. Eff. Date: ___ Life Insurance Med. Code Income Benefit Code 1 Code 2 Code 3 b6 Code 4 Code 5 b7C

Amount: $3.50 [ ] (1) Mo [ ] (2) Mo [ ] (3) Yr Bankers Life Company

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(INA logo) LIFE INSURANCE COMPANY OF NORTH AMERICA BENEFICIARY FORM

Complete this block each time this card is used. Please PRINT LEGIBLY

Insured's Name: MACK H. EASTERBROOK Insured's Address: P.O. Box 950 Beaverton ORE. Name of Policyholder: KANSBURG. Corp. Policy No. or renewal: [illegible]

BENEFICIARY DESIGNATION

Complete and sign this block if you wish to name or change your beneficiary.

I hereby designate the following beneficiary with respect to indemnity for loss of life, revoking any previous beneficiary designation with respect to the above identified policy. (Show given name and relationship to Insured. If more than one beneficiary, state how each should share):

[blank field]

Signature: [signature] Date: 11/20/73

LG-6860 PRINTED IN U.S.A.

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DB Cooper-42923

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b6 b7C