TEXAS ENSURE, INC.

YOU ARE ELECTING TO DO A TANDEM SKYDIVE.

THIS IS JUST A REQUEST TO DESIGNATE A BENEFICIARY IN CASE A COVERED ACCIDENTAL DEATH OCCURS AT A COVERED DROP ZONE DURING A COVERED EVENT.  IT DOES NOT GUARANTEE THE DROP ZONE HAS A VALID POLICY.

BY SUBMITTING THIS FORM, IT IS A RECORD OF DESIGNATION PROVIDED AS A RECORD IN CASE A LOSS OF LIFE OCCURS DURING A COVERED TANDEM JUMP.

$250,000 ACCIDENTAL DEATH BENEFIT ONLY

Coverage provided by Insured Drop Zones:

While tandem jumping from the time the person leaves the door of the plane to until the person lands.

Designation of Beneficiary

Complete the following to designate a beneficiary.

I want to designate as my beneficiary to whom loss of life benefits are payable at: