Name of Organization _________________________________________________________
Your Name ____________________________________	Male   Female	Soc. Sec. No. ___________________

Residence Address ____________________________________________________________________________________

STREET

_________________________________________________________________Phone Number______________________

CITY                         STATE                         ZIP

This address is my   Business      Home      Both

Occupation (Specialty) ____________________

Beneficiary________________________

Relationship________________

I WOULD LIKE TO APPLY FOR DISABILITY INSURANCE. Indicate the monthly benefit desired: (in $100 increments) $_______________

Are you now working at least 30 hours per week with your present employer?       Yes       No

My annual income for the 12 months immediately preceeding the date of this application is: $__________________________

I wish to pay premiums: Annually    Semi–Annually

Indicate waiting period:    30 Day      60 Day      90 Day      180 Day      365 Day

Indicate Benefit Period: _________________________________ Principal Sum: $_________________________________

HEALTH SECTION (Must be completed in full prior to any underwriting consideration)

1.	Have you ever had or been treated for: (Circle specific disorders experienced)
	a.	Heart trouble or murmur, chest pain, rheumatic fever, elevated blood pressure, stroke?	Yes	No
	b.	Injury, pain or disorder of neck or back? Sciatica? Any disabling injury?	Yes	No
	c.	Arthritis, gout, bursitis or rheumatism?	Yes	No
	d.	Dizziness, epilepsy, convulsions, recurrent headaches, glaucoma, cataract, or other disorder of the eyes or ears?	Yes	No
	e.	Disease or disorder of rectum or anus, Varicose veins, or other vascular disorder?	Yes	No
	f.	Diabetes? Sugar, albumin, or pus in urine? Thyroid or other glandular disorder?	Yes	No
	g.	Duodenal or stomach ulcer, or other disorder of stomach, liver, gall bladder? Colitis, diverticulitis, or other disorder of small or large intestine?	Yes	No
	h.	Prostrate disorder? Kidney stone or colic, nephritis, nephrosis, or other kidney disorders? Urinary infection?	Yes	No
	i.	Menstrual, uterine, or ovarian disorder, disorder of the breast?	Yes	No
	j.	Bronchitis, emphysema, pleurisy, difficult breathing, blood spitting, or other disorder of lung or nose?	Yes	No
	k.	Cancer or other tumor? Deformity or loss of limb? Congenital defect?	Yes	No
	l.	Mental or emotional problems requiring help of a physician or psychologist?	Yes	No
	m.	A surgical operation? A surgical operation advised but not performed?	Yes	No
2.	Have you ever had treatment by, or consultation with any hospital, institution, physician or practitioner within the past 5 years?		Yes	No

If you answered “Yes” to questions 1a–m or 2, please explain fully in the chart below. Should you require additional space please use separate sheet of paper, sign and date it, and attach it to this form.

Ques. # Condition Date Occurred Duration Degree of Recovery Names & Addresses of Physicians, Hospitals or Clinic Consulted

What other Disability Insurance do you have? (Give Full Details)

Insurance Company Amount of Monthly Benefit Accident How Long Are Benefits Payable? Sickness

Are you replacing any current disability coverage you have?       Yes      No

DECLARATION OF MEMBER GIVING STATEMENT OF INSURABILITY
1.   To the best of my knowledge and belief, all statements made on this application are true and complete.
2.   I understand that my application for insurance will be accepted or declined on the basis of these statements.

AUTHORIZATION AND DECLARATION OF PERSON GIVING STATEMENT OF INSURABILITY

I authorize the sources stated on the MIB Disclosure to give to Security of American General Life Insurance Company of Pennsylvania (AGPA), or any consumer reporting agency acting on its behalf, information about me. Such information will pertain to my employment, other insurance coverage, and medical care, advice, treatment for supplies for any physical or mental condition. Authorized sources are: any physician or medical professional, any hospital, clinic, or other medical care institution; any insurer, the Medical Information Bureau; any consumer reporting agency; any employer. I understand that this information will be used by AGPA to determine eligibility for insurance. I understand that I may revoke this authorization at any time. I agree that such revocation will not affect any action which AGPA has taken in reliance on the authorization. I understand that this authorization will not be valid after 30 months, if not revoked earlier. I know that I have the right to receive a copy of this authorization if I request one. I agree that a photocopy of this authorization is as valid as the original.

FRAUD STATEMENT

Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Signed at	________________________________________	on	__________________________________________________
by______	____________________________________________________________________________________________

Date

____________________________________

Signature of Agent

_____________________________________________

Form S–10511–1                                  underwritten by: American General Life Insurance Company of Pennsylvania