Page 12 - Customer-Booklet_Texas
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7. YOUR TOTAL ANNUAL PREMIUM (at time of Application)
The modal premiums for the coverage(s) outlined above are: $______________
Lump Sum Cancer Insurance Policy $______________
Lump Sum Heart and Stroke Rider $______________
Hospital and Intensive Care Unit Indemnity Benefit Rider $______________
Hospital Indemnity Benefit Rider $______________
Intensive Care Unit Indemnity Benefit Rider $______________
Return of Premium Rider
TOTAL $______________
8. VOLUNTARY ARBITRATION PROVISION - Your Policy contains a Voluntary Arbitration Provision which may
affect Your rights. Please read Your Policy and all attached Riders carefully.
LY-LSC-OC-B-FL 10 10/13
The modal premiums for the coverage(s) outlined above are: $______________
Lump Sum Cancer Insurance Policy $______________
Lump Sum Heart and Stroke Rider $______________
Hospital and Intensive Care Unit Indemnity Benefit Rider $______________
Hospital Indemnity Benefit Rider $______________
Intensive Care Unit Indemnity Benefit Rider $______________
Return of Premium Rider
TOTAL $______________
8. VOLUNTARY ARBITRATION PROVISION - Your Policy contains a Voluntary Arbitration Provision which may
affect Your rights. Please read Your Policy and all attached Riders carefully.
LY-LSC-OC-B-FL 10 10/13
