Gallagher Actuarial Services
                    SIMPLIFIED BENEFIT VALUATION APPLICATION
 Applicant Name:
          Telephone:                              
 Mailing Address:                          
 email address:
        (Report will be emailed to this address!)
 Case Reference:
 Participant Information:
        Plan Name:
        Name:                                   
        Date of Birth:  ___/___/___             Sex (check one):__ Male__ Female
        Health (check one):__ Healthy      ("Healthy" assumed if not completed.)
                           __ Disabled 
                           __ Disabled receiving Social Security
                                  Nature of Disability:_________________
 Spouse/Beneficiary Information:
        Name:                                   
        Date of Birth:  ___/___/___             Sex (check one):__ Male__ Female
        Health (check one):__ Healthy      ("Healthy" assumed if not completed.)
                           __ Disabled 
                           __ Disabled receiving Social Security
                                  Nature of Disability:_________________
 Benefit Definition:
        Amount of Periodic Payment:  $_________ per (check one):  __Month __Year
        Date of First Payment (complete one):
                           __in pay status, started:  ___/___/___
                           __first future payment date:  ___/___/___
        Form of Payment (check one and complete as necessary):
                (Single Life assumed if not completed.)
                __  Single Life of Participant
                __  Life of Participant with ___ payments guaranteed
                     (must be consistent with above Frequency!)
                        (Certain and Continuous Form)
                __  Life of Participant with ___% continuation to surviving
                     Spouse/Beneficiary(Contingent Annuitant or 
                        Qualified Joint and Survivor Form)
                __  Joint Life of Participant and Spouse/Beneficiary with 
                    ___% continuation to survivor (common Joint and Survivor)
                __  Period Certain only:  ___ payments
                __  Other (describe fully):_______________________________
        Effect of Inflation (check one and complete as necessary):
         (No automatic cost of living adjustments assumed if not completed.)
                __  Plan does not provide for cost of living changes
                __  Plan provisions include automatic annual post-retirement
                     cost of living adjustments based on:
                          __ CPI changes  __ other basis:__________
 Requested Valuation Date: ___/___/___(Last day of current month assumed if no entry.)
 Applicant Signature:_____________________________________________ Date:  ___/___/___
 Send completed Application, with check for current fee of $50.00 to:
 Michael E. Gallagher
 Gallagher Actuarial Services, P.O. Box 297, Sebago, ME  04029-0297
 Tel:  (207) 650-6405                                          
 Please complete all items! Unsigned or incomplete Applications may be returned!
 One Benefit per Application Only!                             05/23