American Income Life Insurance Company

American Income Life Insurance Company P.O. Box 2608 Waco, TX 76797 254-751-8600 www.ailife.com

ARREST QUESTIONNAIRE (For Arrests other than DWI’s)

Applicant’s Name ______

Policy Number ______

Date of arrest?______Place (City, ST)?______

Description of incident that led to arrest?______

______

Charge?______

Was this a Felony?______or a Misdemeanor?______

Were you convicted?______Date of conviction?______

Length of Sentence?______

Any time served in jail?______How long?______

Any time served in prison?______How long?______

Paroled?______Date?______How long?______

Probation?______Date Began?______How long?______

Paid fine?______Amount of fine?______

Any other arrests other than DWI?______(if yes, complete a separate Arrest Questionnaire for each arrest)

Note: Information regarding arrests for DWI’s should be provided on an Alcohol Use Questionnaire.

X______X______(Proposed Insured's Signature) (Date)

X ______(Agent’s Signature)

FORM AG-2195 201