STATE OF                       )
COUNTY OF                      )

________________________________________________________, hereinafter called “Deponent” , being
duly sworn, deposes and says:

1. Deponent is of legal age, resides at ______________________________________________________
   ______________________________________, and is entitled to the possession and is the legal
   beneficial owner of the following stock certificate:

    North Coast Life Insurance Company Stock Certificate No. ____________ for ____________ shares of
    common stock, issued in the name of ______________________________________________________.

2. The original stock certificate was acquired by Deponent on or about (date) ________________________
   and was lost, stolen, seized or destroyed on or about (date) _____________________________, under
   the following circumstances: (Please advise where the original was kept and who had access to it, when
   and by whom the loss was discovered, when and where the original was last seen, and what measures
   have been taken to recover the original.) ___________________________________________________

3. The original (was) (was not ) endorsed. If the stock certificate was endorsed, describe the exact manner
   of its endorsement, including the name and address of the endorsee. If the endorsement was by separate
   instrument (such as a stock power), please so state.

4. Deponent has made or has caused to be made, a diligent search for the original, and has been unable to
   find or recover it. Deponent has not sold, assigned, pledged, transferred, deposited under any agreement,
   or hypothecated the original or any interest therein or (except as may be stated in the foregoing
   paragraph) signed any power of attorney or other authorization respecting same which is now
   outstanding and in force, or otherwise disposed of same; and (except as stated above) no person, firm,
   corporation, agency or government other than the Deponent has asserted any right, title, claim, equity
   or interest in, to or respecting the said original or the proceeds thereof.

5. This Affidavit of Loss and Agreement of Indemnity is made for the purpose of inducing North Coast Life
   Insurance Company to refuse to recognize any person other than deponent as the owner of the original
   and Deponent requests North Coast Life Insurance Company to refuse to recognize any person other than
   Deponent as the owner of the original and Deponent requests North Coast Life to refuse to make any
   payment, transfer, registration, delivery or exchange called for by the original to any person other than
   Deponent and to refuse to take any other action pursuant to the request or demand of any person other
   than Deponent and to issue a new stock certificate in North Coast Life Insurance Company in lieu of the
Affidavit of Loss and Indemnity Agreement
Page 2

6. If Deponent should find or recover the original, Deponent will immediately surrender the same to North
   Coast Life for cancellation without requiring any consideration therefor.

7. Deponent agrees, in consideration of compliance with the foregoing request, to indemnify and hold
   harmless North Coast Life and any person, firm or corporation now or hereafter acting as its transfer
   agent or in any other capacity, and also any successors in any such capacities, from and against any and
   all liability, loss damage and expense in connection with or arising out of compliance with the request
   of Deponent herein set forth, and further agrees to furnish to the above-described persons without any
   expense to them, a bond of indemnity in case this Affidavit of Loss should at any time for any reason
   in the opinion of such persons not afford them sufficient protection.

Signed, sealed and delivered by Deponent this __________ day of _____________________, 20 _________.


Subscribed and sworn to before me this _________ day of ________________________, 20 ____________.

                                                 Notary Public in and for the State of ___________________
                                                 residing at ______________________________________.

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