Allstate Life Insurance Company of New York, Home Office: Hauppauge, NY
       P.O. Box 82656, Lincoln, NE 68501-2656 FAX: 1-866-525-5433
            Proposed Insured’s Name (First, Middle, Last)                                          Policy Number (If assigned) Date of Birth (MM/DD/YYYY)

       1. Check all of the activities you engage in:
          K Hikes, treks, trails or scrambles, non-techical climbs, no special equipment required
          K Climbing Towers                K Rappelling              K Rock Climbing                          K Mountain Climbing                 K Ice Climbing
          K Other (describe):
       2. How long have you engaged in the activities indicated above?
       3. Have you engaged in any of these activities in the past two years?                                                                      K Yes K No
          If “yes”, details:
       4. Do you intend to engage in any of these activities in the next two years?                                                               K Yes K No
          If “yes”, details:
       5. Do you have any formal training or hold licenses or certifications?                                                                     K Yes K No
          If “yes”, details:
       6. Do you belong to any clubs or sanctioning organizations?                                                                                K Yes K No
          If “yes”, details:
       7. Do you participate for money or compensation?                                                                                           K Yes K No
       8. Do you engage or plan to engage in climbs alone, at night, in winter or off-season?                                                     K Yes K No
          If “yes”, details:
       9. In what counties, states or provinces do you climb?
       10. What mountains or other formations/structures do you climb?
       11. Average duration of climb?                                             12. Maximum duration of climb?
       13. Have you ever climbed to over 14,000 feet elevation, or do you plan to do so?                                                          K Yes K No
           If “yes”, details:
       14. Maximum altitude climbed to date:                                      15. Maximum altitude planned in next two years:
       16. Do any of your climbs require guides or altitude acclimatization, or are they considered expedition climbs?                            K Yes K No
           If “yes”, details:
       17. Please indicate the equipment you use:
         K Altimeter           K Ascenders (jumars)              K Belay Anchors            K Cams, Camalots,           K Chocks &                 K Climbing
                                                                                                 SLCDs                       Nuts, Hexes               Harness
             K Crampons                 K Etriers or Web Ladders K Headlights or            K Helmet                    K Ice Axe/Adze             K Ice Screws
             K Mountaineering K Oxygen Tanks                     K Perlon Ropes &           K Portaledge                K Radio                    K Snow Picket
                  Boots                                             Carabiners
             K Stoppers                 K Other
       I declare that the answers and statements given above are full and correct to the best of my knowledge and belief. I agree that this Questionnaire
       is part of my application and will become part of the policy applied for, if issued.

              Signed at (City, State)                                                         Date (MM/DD/YYYY)

              Signature of Proposed Insured                                                   Signature of Owner if other than Proposed Insured

       FIC384CQNY                                                                                                                     SKU# FIC384CQNY (11/09)

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