CA-41 °0ther Insured Rider (Uteri ❑App5cants Waiver of Premium Rider (Faye) H. Marital Status (2<terried El Single 0 Divorced 0 Widowed IS. 00B I Ffagtrthplace corgaVywf It US Social Security elTaz ID It US Dtiveis License tia.30 62151 State i\-)1/4/ Expirsoan Dot /•QP4ii If rant type of povemmestiss