Group Office:

Group Rep (R)

KANE	Current Date:	Proposed Effective Date:

Deadline:

General Agent:

HJM Group, Inc.	Producer/Broker: (R)

Broker of Record: Yes No
If not already licensed, the broker must be licensed in the state where the case will be sold before the application is signed.
Group Name: (R)

Current Lives (R):

Male Female
Location (City, State, Zip Code):

No. of Years in Business:

< 2 years

>2 Years
Describe the Nature of the Business:

SIC Code: (R)

Commission/Override (X) Standard (If other than Standard, call Sales Rep.)

Previous Period

(4)	Previous Period

(3)	Previous Period

(2)	Most Recent Period (1)
From
To	From
To	From
To	From
To
Paid Premium (O)*
Paid Claims (R)
Number of Lives (O)*
Rate(O)*
Statutory Benefits? (R)
If no, Benefit Description (R)
Carrier (O)

Data Elements Denoted (R) are required

Data Elements Denoted (O) are optional with the following restriction:

*Of Paid Premium, Number of Lives, and Rate, 2 out of three must be provided.

1

DBL Underwriting Requirements Form

BRENDAN KANE FAX 212-770-0053

Brendan.Kane@aig.com

4/04/02

DBL Underwriting Requirements form:

Customer

2002-09-03

Brendan W. Kane

AGC