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Please complete a Designation of Beneficiary Form if you are the only person on this form or if all insureds are minors.
NB: The monthly premium payable for the Primary Insured is based on the issue age and the selected coverage limit, maximum age of entry is 59 years. The premium amount payable for each coverage amount applied for remains the same for that coverage amount throughout the lifetime of the certificate for the Primary Insured, subject to any changes arising from annual premium rate reviews.
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