Best Doctors: BENEFICIARY DESIGNATION FOR PAYMENT OF VESTED COMMISSIONS Pursuant to terms and conditions of the Agent's Agreement dated 1 hereuy designate ihe following Natural Person/Trust to receive vested commission paymerts*, i any, payable after my death. | understand that this designation is not effective until received and ‘approved by Best Doctors insurance Limited. | further understand that once approved payments wil be made in the ‘manner set forth under the terms and conditions of my Agent Agreement. NATURAL PERSON Thereby designate as my beneficiary to receive 100% of my vested commission payments: Name’ Passport or Social Securty No Relationship: DOB Adress: Furthermore, in the event my designated beneficiary is deceased at the time of my death, | hereby designate as my contingent beneficiary to receive 100% of my vested commission payments: Name; Passport or Social Security No Relationship. OB. Address: ‘TRUST hereby designate the folowing Trust to receive 100%of my vested commission payments Name of Trust Date of Trust Agreement Tax ID Number Agent Signature: Date: IMPORTANT: Wate my sine in is document | uertnd there can al ke one desied bene to recive 100% of ou vested commission payments Best Dect In Best Door Insane ited or any oft flats ae ure ode your omission between mule benefits To deine eferert eres’ ineasel receive conmssion fom leer cores, Imust sme ane fom fresh coreaet. Furthermore, understand, none of teins rmell shor unite my desthortheTrustromed above atin esstnce atte tine of my det then opments of vst enews shal be pilin seconoce wih the aplesle au. Sexe nus aml egtons may pio 9 tstameray tors of enews emissions uses fom. Please keep this form with your Best Doctors Agent Agreement. Bezausethe egal regrets of some jstons may vo 25s tothe pope exeeuton of is fom, revraton ofthis fom orthe impor fh fom your este, we reconmend tht you consul wth your lea disor before sang “This fom shoud be sued upon te dest of te grt Please suka he cg sgned fom and 2 cere copy ofthe death crite Best Dts Ine, Ager Series 5201 BlueLagoon Dive, 3:Floy Miami FL, 3325.