CAUTION: Any person who knowingly and with intent to injure, defraud or decieve any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

CAUTION: EMPLOYEE must complete sections 1 - 18.

NOTE: Eligible class of employees - all active full-time employees of the sponsoring employer who are under age of 70.

I hereby apply to Life Insurance Company of North America (LINA), a Cigna Company, for Disability Salary Continuation Insurance. I understand that my coverage will take effect (if actively at work) on the day following the end of the payroll period in which the first payroll deduction is made. I also certify that I am an Employee of the Sponsoring Employer in an Eligible Class (as specified above), and authorize my Employer to deduct from my earnings an amount sufficient to pay the premium for this insurance , including Age Band changes. I hereby acknowledge that I have received the outline of coverage (brochure) describing insurance for which I am now applying.

Enter the characters shown in the image.