UNITED STATES - Social Security Insured Policy # [SSN]:

By the Will of: ___________________________________________
[PEO], PEO
Genuine American Principal Legacy Owner under SEAL of Life




I REVOKE the Underwriting of this Policy and All Insured Contracts attached to it.


SSN CARD (COPY)

Underwriting Revoked

Posted, Signed, Sealed and Dated on: ______________________