Pre-purchase Contract page 3         Page 3 of 3        Back

____ Annuity contract

Beneficiary Name: ____________________________________________________

Address: ____________________________________________________________

____________________________________________________________________

Annuity #:___________________________________________________________

Annuity Name: _____________________________

Description of Contract: _______________________________________________

    Buyer(s) may cancel the prepaid contract, whether revocable or irrevocable, whether cash,   insurance or annuity funded, at anytime prior to performance of the contract by the Seller.

   Should Buyer(s) cancel this contract funded by life insurance or by annuity, Buyer(s) may suffer a surrender penalty.

     Seller shall furnish to the Buyer(s) the merchandise and services as set forth above at the     contract price regardless of the cost of the merchandise and services at the death of the Contract Beneficiary.

       NOTICE: This contract is irrevocable and if you choose to transfer this contract to a substitute provider, the entire amount of the contract will be transferred and you may have to pay more to obtain 100% of the services for in the original contract.

     Upon cancellation of the contract prior to and after the death of the contract beneficiary, the insurance, annuity contract, and/or trust proceeds shall be disposed of as follows:

        If Buyer stops making payments Seller will retain 15% of all monies paid to it by the Buyer as of the date of the last payment.  If Buyer cancels this contract 100% of the money paid in by the buyer will be transferred to another casket provider chosen by the Buyer.

8. The Arkansas Insurance Department regulates the sale of prepaid funeral benefits contracts.  For further information or questions regarding the regulations of this contract please contract the Arkansas Insurance Department, Pre-Need, Little Rock, Arkansas 72204

Telephone: (501) 686-2900.

IN WITNESS WHEREOF the parties have hereunto set their hands and seals this _______ day of ____________, 20___.

Seller: _________________________________________________

Buyer(s) _______________________________________________

                _______________________________________________