I agree that: (1) the statement and answers given in this application are true, and correctly recorded to the best of my knowledge and belief; (2) this application will be part of the contract for which I apply; (3) the policy is a one year contract that is guaranteed renewable in accordance with the terms of the policy; (4) I understand that this policy must remain in force for a 12-month period and that premiums are due for the entire 12 month period; (5) I understand that this policy will be renewed on each policy anniversary date for a new 12-month period unless given written notification to Opticare of Utah to terminate the policy 60 days prior to the policy renewal date. I will notify the insurer if any statements or answers given in this application change prior to policy deliver; and (6) I have received the outline of coverage.

I herby authorize Opticare of Utah to withdraw premium payments from the financial institution and account named above under section 4 of this application. I understand that this authorization will remain in effect until the financial institution has received and has had reasonable time to act on a written request from me to terminate this agreement. I understand that I can stop a withdraw by notifying the financial institution at least three business days before the withdraw is made. In the event of a withdraw error, I must promptly notify the financial institution to preserve any rights I may have. I understand that I may direct my billing inquiries to Opticare of Utah, 1901 West Parkway Blvd, Salt Lake City Utah 84119.

Any person who knowingly presents a false of fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. The policy provides vision benefits only. Review your policy carefully.