GROUP QUOTE REQUEST FORM

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="039285a1erlcgo.png"> <div> <FONT SIZE="5" COLOR="#FFCC66" FACE="Arial" ><B>LIFE, DISABILITY, MEDICAL, MEDIGAP, DENTAL, LTCI and ANNUITIES </B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="LIFE, DISABILITY, MEDICAL, MEDIGAP, DENT"><U><B>home</B></U></A></div> <div>                                                   </div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="038d2c00dkelyh.png"> <div> W. Forrest Veal, CLU</div> <div> P. O. Box 700222</div> <div> Dallas, TX 75370</div> <div> 972 250 6516</div> <div> 1 888 845 8325</div> <div> Fax 1 775 542 0808</div> <div> E-mail - vealbs@juno.com</div> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>GROUP QUOTE REQUEST FORM</I></div> <div> <B>Print a copy to complete and Fax to:</B></div> <bR> <div> <B>VEAL BENEFIT SERVICES INC.                 FAX NO: 1 775 542 0808</B></div> <bR> <div> <B>COMPANY AND EMPLOYEE DATA FOR GROUP QUOTE</B></div> <bR> <div> Employer __________________________________________________</div> <div> Address ___________________________________________________</div> <div> City, State, ZIP ______________________________________________</div> <div> Tel. No. ________________________Fax No. _____________________</div> <div> Nature of Business ______________________________SIC__________</div> <div> Current Plan - HMO __________________PPO Network _____________</div> <div> Contact Name ______________________________________________</div> <bR> <div> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="645" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 ><NOBR><div> <B>EE/name-code</B></div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div> <B>Age/DOB & Sex</B></div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div> <B>Deps - S/C/S&C</B></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="121"><div>    <B>Home ZIP</B></div> </tD> <tD VALIGN=TOP><NOBR><div>    <B>Comments</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="121"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="121" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="121"><IMG BORDER="0" 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ALIGN="bottom" WIDTH="121" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="121"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="121" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="121"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="121" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="121"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="121" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="121"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="121" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="121"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="121" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="121"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="121" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="121"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="121" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP WIDTH="121"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="121" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> <B>Quote - Life/AD&D___ LTD___ Medical___ Dental ___ Critical Illness ___</B></div> <div> <B>If quote includes LTD, provide employee job title and monthly pay in comments column.</B></div> <div> <B>Note in comments, the reason for any employee not being actively at work.</B></div> <div> <B>This information will help in obtaining the best possible rate for your group.</B></div> <bR> <div> <B>EMPDATA.001</B></div> </td> </tr></table></body>