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" ;Sex: ;,! " ;Race: ;,! " ;Country/State   ofResidence: ;,! " ;Educational   Attainment:#^DC\XX#XX\^DC ?,! " ?Anticipated   RetirementAge: = ,! " =#^DC\X#^DC  = ,!    = = ,!A!"  = = ,!A""  = = ,!A#"  = ? ,!A$"  ?1'%A%"    1#^ߊ \  ##^DC\ \^ߊ #\^DC f  XX  fII.FAMILYMEMBERS/CLAIMANTS#XXX X ##XX # i( *  d ddd dd edd eK dd"d  XhX&hX&, dd ,K ,d ,d ,&d +  + Y-*Y- +XXB` : !&h6x<>@Bh,p!#B@@< < 6< Name = ,!yM,"  =Relationshiptothe - Decedent: = ,!yM."  =@@^DateofBirth = ,!yM0"  =ResideWith 1 Decedent? = ,!yM2"  =AmountofChild 3 Support,ifapplicable 6,!yM4"  6#X #Fh,p!#` : !&h6x<>@B)F  '5 ' '6 ' '7" ' '8" ' '9" ' '): ' '); ' ')<" ' ')=" ' ')>" ' ']? ' ']@ ' ']A" ' ']B" ' ']C" ' 'D ' 'E ' 'F" ' 'G" ' 'H" ' 'II ' 'IJ ' 'IK" ' 'IL" ' 'IM" ' '}N ' '}O ' '}P" ' '}Q" '"}R"  "# #XX.XE XX XX X.XEIII.EMPLOYMENT/EARNINGSHISTORYU _#  1       ]1S * d d dd K d d &d  hX&hX&, dd ,'dd ,dd ,dd ,'d ,dd +  +E! UE!  + f X X#.  f# .Employer: 4#!!} V3 4 +!} W + +!} X + +!} Y + +!} Z + 4#!} [ 4Position: 4#!=#"\3 4 +=#"] + +=#"^ + +=#"_ + +=#"` + -#=#"a -#XAX #&^%XXAYear:#XAX%&^# XXA#. U# . * &%d" *#XAX #&^%XXA GrossEarnings: #XAX%&^##.XE XXXA[#XAX X.XE XXA 9/!&]%g" 9 #XAX b#&^%XXAGrossEarnings: #XAX%&^# XXA#. C# . 6,!&]%j" 6 #XAX 6#&^%XXAGrossEarnings: #XAX%&^##.XE XXXAx#XAX X.XE XXA * &]%m" * #XAX #&^%XXAGrossEarnings: #XAX%&^# XXA#. l# . 6,!&]%p" 6 #XAX P#&^%XXACombinedGross %$r Earnings: #XAX%&^ ##.XE XXXA#XAX X.XE XXA I?&]%s" 4@19974@I1997 ND3A('t" 4@1997 4@ RNЈ 3)A('uUR R3Ј 3)A('vUR R3Ј 3)A('wUR R3Ј 3)A('xUR R3Ј OEA('yUR 8@19988@O1998 ND3)(z" 8@1998 8@ RNЈ 3))({UR R3Ј 3))(|UR R3Ј 3))(}UR R3Ј 3))(~UR R3Ј OE)(UR <@1999<@O1999 ND3a+5*" <@1999 <@ RNЈ 3)a+5*UR R3Ј 3)a+5*UR R3Ј 3)a+5*UR R3Ј 3)a+5*UR R3Ј OEa+5*UR @@2000@@O2000 ND3,+" @@2000 @@ RNЈ 3),+UR R3Ј 3),+UR R3Ј 3),+UR R3Ј 3),+UR R3Ј OE,+UR D@2001D@O2001 ND3.U-" D@2001 D@ RNЈ 3).U-UR R3Ј 3).U-UR R3Ј 3).U-UR R3Ј 3).U-UR R3Ј(.U-UR  (#XAX  ##.XE XXXA #<h,p!#h,p!#<XX X.XE3XX@$ $ Z#XX3(#XX WRONGFULDEATHWORKSHEET #XX7)#Ԁ(pg.2) ,   #.XE XXX(# XX X.XEIV.COMPANYPAIDFRINGEBENEFITS  #.XE XX X)#XAX X.XE XXA *dd dd 'dd 'dd dd 'd 'dd  hX&hX&,Ld ,K +  # *# '  ' Pleasecheck Yesifthedecedentsmostrecentemployermade D contributionstowardsanyofthefollowingfringebenefits: 9/!@  91'%@ "  19h, p!#h,p!#9 Y(03 "3"  9h, !#h, p!#9  3-2  A  .3  0    RetirementandSavingsPlanPayments: Q("("#3(Yes)3-[.݌h < X&X& Ќ        1.0 DefinedBenefitPensionPlanContributions! ._Q""#_______h <  X& X& ! !"g"  gK00  0X&X&2  2  .3  0 X&X&  401KandSimilar! .EQ""#_______gK0x0݌d 8  X& X& Ќ  "g"  g10  0X&X&2  3  .3  0 X&X&  ProfitSharing! .CQ""#_______g11݌` 4  X& X& Ќ  "g"  g20  0X&X&2  4  .3  0 X&X&  StockBonus,EmployeeStockOwnershipPlans! .&&`Q""#_______g22݌\0  X& X& Ќ  "g"  g40  0X&X&2  5  .3  0 X&X&  OtherRetirementPlan! .JQ""#_______g434݌X, X& X& Ќ  "3"    3E52  B  .3  0    MedicalandMedicallyRelatedBenefitPayments: 3E5~5݌P$X&X& Ќ  "g"  gM60  0X&X&2  1  .3  0 X&X&  HealthInsuranceCoverage! .NQ""#_______gM6z6݌L  X& X& Ќ  "g"  g70  0X&X&2  2  .3  0 X&X&  DentalInsuranceCoverage! .NQ""#_______g77݌H X& X& Ќ  "g"  g80  0X&X&2  3  .3  0 X&X&  VisionCareCoverage! .rrIQ""#_______g88݌D X& X& Ќ  "g"  g:0  0X&X&2  4  .3  0 X&X&  PrescriptionDrugCoverage! .ffOQ""#_______g:2:݌@ X& X& Ќ  "3"    3I;2  C  .3  0    MiscellaneousBenefitPrograms:3I;;݌8 X&X& Ќ  "g"  gA<0  0X&X&2  1  .3  0 X&X&  EmployeeEducationExpenditures(tuition,etc.)! .NNdQ""#_______gA<n<݌4 X& X& Ќ  "g"  g=0  0X&X&2  2  .3  0 X&X&  Other(PleaseSpecify)__________________________! .eQ""#_______g==݌0 X& X& Ќ   f   XX  fV.DECEDENTSPERSONALCONSUMPTIONEXPENDITURES ( 9h, !#h, !#9#XAXX X>## XXA ?#  ! ! c(ƽ00Y"3"      3@2ƽ  A  .3  0    Ifpossible,pleaseprovideyourbestestimateoftheweekly/monthly/annual(pleasecircle   one)spendingbythedecedentfor:3@@݌ !X&X& Ќ          򀀀 󀀀 !" "e"  eB0  0X&X&0X&X&2ƽ  1  .3  0 X&X&  Food! . 9$Q&"&"#򀀀eB C݌" # X& X& Ќ  "e"  e+D0  0X&X&0X&X&2ƽ  2  .3  0 X&X&  Clothing! . =򀀀 @ % e+DXD݌#!$ X& X& Ќ  "e"  esE0  0X&X&0X&X&2ƽ  3  .3  0 X&X&  Transportation! .C򀀀esEE݌$"% X& X& Ќ  "e"  eF0  0X&X&0X&X&2ƽ  4  .3  0 X&X&  Medical/HealthCare! .H򀀀 @ % eFF݌%#& X& X& Ќ  "e"  eH0  0X&X&0X&X&2ƽ  5  .3  0 X&X&  Recreation/Entertainment! .M򀀀 @ % eH5H݌ &$' X& X& Ќ  "e"  e`I0  0X&X&0X&X&2ƽ  6  .3  0 X&X&  Misc./Other! .@򀀀 @ % e`II݌'%( X& X& Ќ  @JJiOR )'*    0  B. 0X&X&Ifyouhavenofinancialrecordsorareotherwiseunabletoestimatethedecedentss *), personalspending,wouldyouconsiderhis/herspendinghabits,giventheamountof +*- familyincomeandthenumberoffamilymembers,tobe(checkone):,+.X&X&         򀀀 󀀀3(Yes) -,/ ! !"e"  e6M0  0X&X&0X&X&2ƽ  1  .3  0 X&X&  Average! . <򀀀 @ % e6McM݌.-0 X& X& Ќ  "e"  e}N0  0X&X&0X&X&2ƽ  2  .3  0 X&X&  AboveAverage! .66B򀀀 @ % e}NN݌/.1 X& X& Ќ  "e"  eO0  0X&X&0X&X&2ƽ  3  .3  0 X&X&  BelowAverage! .22B򀀀 @ % eOO݌0/2 X& X& Ќ  9h,p!#h, !#9 3@  Z#3uQ# WRONGFULDEATHWORKSHEET (pg.3) , # VQ# f   XX  fVI.LOSSOFHOUSEHOLD/CHILDCARESERVICES#XAXX X)R## XXAHR#     Ӏ# R#Asaresultofthedeathofanindividual,thesurvivingfamilymemberssustainalossoftheirservicesinand  Ѐaroundthehome.   S*\wddLd LK hX&hX&,d ,K +  '  ' Surveydatasuggestthattheaveragepersonspendsthefollowingtimeperforming d8 servicesinandaroundthehome: ` 4  ̀Malesonaveragespend15hoursperweek X ,  ЀFemalesonaveragespend40hoursperweek T (   Givenyourknowledge,wouldyouconsiderthedecedenttobeaverage?Yes___*No___ L  *If No,pleasecompletethefollowing: 9/!H  9Estimated P $  TimeSpent L  PerWeek1'%H"  19h, p!#h,p!#99h, !#h, p!#9 Y(00c"3"    3\X2  A  .3  0    Housekeeping/Cooking(vacuuming,dusting,laundry,cooking)! .cQ\!\!#_______hrs.3\XX݌pDX&X& Ќ  "3"    3Y2  B  .3  0    Shopping/GoodsBuying(groceries,clothing,householdsupplies)! .gQ\!\!#_______hrs.3YY݌h<X&X& Ќ  "3"    3Z2  C  .3  0    RepairandMaintenance(home,auto,boat,yardwork)! ...\Q\!\!#_______hrs.3Z/[݌`4X&X& Ќ  "3"    3:\2  D  .3  0    Miscellaneous(billpaying,taxpreparation,etc.)! .ZQ\!\!#_______hrs.3:\s\݌X,X&X& Ќ  "3"    3|]2  E  .3  0    Child/DependentCare(supervising,chauffeuring,etc.)! .66^Q\!\!#_______hrs.3|]]݌P$ X&X& Ќ   f   XX  fVII.INSURANCEBENEFITS# f X X^##   f^# H"    9h, !#h, !#9  # t_#Asasurvivingfamilymember,haveyoureceivedanyfinancialpaymentsfromprivateoremployerfunded 8 $ lifeinsurance;oranyotherdeathbenefitprogram(suchasfrompensionfundsorunioninsuranceprograms)! 4% checkone: 0& _! ! j(h80Y  No_____Yes_____* (!( a_  *If Yes,pleaselistthesourceandamountofinsurancebenefitsreceived,aswellasthenameofan  #!* insurancecompanyorbenefitproviderrepresentativewhocanbecontactedconcerningthespecifictermsunder $"+ whichthislifeinsuranceorrelateddeathbenefitwascreated. %#, *m ndwdd K \hX&hX&, dd , dd ,dd ," d +  * '%.'% R*SourceofInsurance t'H&/ Benefit/NameofInsurer 3)p(D'0"R R3AmountofInsurance t'H&1 BenefitYouReceive 3)p(D'2"R R3ContactPersonat t'H&3 InsuranceCompany 3)p(D'4"R R3TelephoneNumberfor t'H&5 ContactPerson(p(D'6"R (b*p qdd dd dd dd " d " m nhX&hX&, dd , dd ,dd ," d +  * *\)7*\) R*Ј 3)*)8UR R3Ј 3)*)9UR R3Ј 3)*):UR R3Ј 3)*);UR R3Ј 3)|,P+<UR R3Ј 3)|,P+=UR R3Ј 3)|,P+>UR R3Ј 3)|,P+?UR R3Ј 3) .,@UR R3Ј 3) .,AUR R3Ј 3) .,BUR R3Ј( .,CUR  (