<p> American Income Life Insurance Company P.O. Box 2608 Waco, TX 76797 254-751-8600 www.ailife.com</p><p>ARREST QUESTIONNAIRE (For Arrests other than DWI’s)</p><p>Applicant’s Name ______</p><p>Policy Number ______</p><p>Date of arrest?______Place (City, ST)?______</p><p>Description of incident that led to arrest?______</p><p>______</p><p>Charge?______</p><p>Was this a Felony?______or a Misdemeanor?______</p><p>Were you convicted?______Date of conviction?______</p><p>Length of Sentence?______</p><p>Any time served in jail?______How long?______</p><p>Any time served in prison?______How long?______</p><p>Paroled?______Date?______How long?______</p><p>Probation?______Date Began?______How long?______</p><p>Paid fine?______Amount of fine?______</p><p>Any other arrests other than DWI?______(if yes, complete a separate Arrest Questionnaire for each arrest)</p><p>Note: Information regarding arrests for DWI’s should be provided on an Alcohol Use Questionnaire. </p><p>X______X______(Proposed Insured's Signature) (Date) </p><p>X ______(Agent’s Signature)</p><p>FORM AG-2195 201</p>