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We will be happy to provide you with a free quote on any of our insurance products. "Make Sure All Information Has Been Entered Before Sending Email" (Automated System Does Not Send Incomplete Emails) • Name (First & Last):   • Gender:   Select Gender ------------------------------- Male Female Unisex • Date of Birth:     (00-00-0000) • Type of Insurance:   Select Insurance Type --------------------------- Term Life Whole Life Universal Life --------------------------- Long Term Care Short Term Disability Long Term Disability — Answer if Term Life Was Selected — • Years of Coverage Desired:   Select Number of Years ------------------------------- 10 Years 15 Years 20 Years 25 Years 30 Years — Answer if Term Life, Whole Life or Universal Life Was Selected — • Amount of Coverage Desired:   Select Amount of Coverage ------------------------------- $100,000 - $199,000 $200,000 - $299,000 $300,000 - $399,000 $400,000 - $499,000 $500,000 - $599,000 $600,000 - $699,000 $700,000 - $799,000 $800,000 - $899,000 $900,000 - $999,000 $1,000,000 - $1,249,000 $1,250,000 - $1,499,000 $1,500,000 - $1,749,000 $1,750,000 - $2,000,000 — Answer if Short-Term or Long-Term Disability Was Selected — • Waiting Period Desired:   Select Waiting Period ------------------------------- 2 Months 3 Months 6 Months 12 Months • Monthly Income Benefit Desired:       Maximum: 60% of Earned Income Select Monthly Benefit ------------------------------- $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 $4,500 $5,000 $5,500 $6,000 $6,500 $7,000 $7,500 $8,000 $8,500 $9,000 $9,500 $10,000 $10,500 $11,000 $11,500 $12,000 $12,500 $13,000 $13,500 $14,000 $14,500 $15,000 • Current Health Condition:   Excellent Good Fair Poor • Height:   Select Feet ------------- 4 Ft. 5 Ft. 6 Ft. 7 Ft.     Select Inches ------------- 0 In. 1 In. 2 In. 3 In. 4 In. 5 In. 6 In. 7 In. 8 In. 9 In. 10 In. 11 In. • Weight:     (200 lb) • Smoked Within Last 2 Years:   Yes No • Other Tabacco Use Last 2 Years:   Yes No • Email Address:   • Phone Number:     (000) 000-0000 • Please Explain Reason for Coverage •

Ron Knowles and Chad Rodriguez offers securities through Centaurus Financial, Inc. who is a member of FINRA and SIPC. Supervisory office: 540 Fort Evans Road, NE, Suite 200, Leesburg, VA 20176 (800) 880-4234. Please be advised that Safe Money Management, LLC and Centaurus Financial, Inc. are not affiliated. This is not an offer to sell securities. A proposal can only be submitted to a client after the proper delivery of a prospectus and the client's suitability has been reviewed and determined. Information relating to securities is only intended for use by individuals that reside in Louisiana.

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