American Skandia American Skandia Life Assurance Corporation
Where To Invest { } Application for Life Insurance
1. Proposed Insured Section (Please Print) 2. Proposed Second Insured (Complete if Applicable)
Full Name Full Name
Address Address
Date of Birth State/Place of Birth Date of Birth State/Place of Birth
Tax I. D. No. Tax I. D. No.
Sex Male Female Sex Male Female
Driver's License No. State Driver's License No. State
Relationship to Proposed Insured
3. Owner (if other than Proposed Insured) 4. Premium Information
Name Estimated Premium $
Address Estimated Face Amount $
Method of Payment:
Telephone Number Cash $ CD Transfer $
Relationship to Proposed Insured(s) Mutual Fund Transfer $ Life Insurance Exchange $
Tax I. D. No. Other $
Sex Male Female Date of Birth
5. Beneficiary Designation (The Owner reserves the right to change the Beneficiaries unless otherwise indicated in
Special Instructions
Primary Beneficiary Contingent Beneficiary
Name Relationship to Proposed Insured Name Relationship to Proposed Insured
------------------------ -----% ------------------------------ -----%
----------------------- -----% ------------------------------ -----%
6. Questions for Proposed Insured(s)
A. Will the insurance applied for replace any other life insurance or
annuities on the life/lives of the insured(s)? Yes No (If
yes, provide company, Policy #, individual insured, amount and attach
the required
replacement forms.)
Proposed Insured Proposed Second Insured
B. Within the last 12 months have you
used any tobacco products? Yes No Yes No
C. Within the past 10 years have you been
treated for or been told you have the
following: cancer, heart disease or stroke? Yes No Yes No
D. Have you been diagnosed with or treated by a member of the medical
profession for an immune deficiency disorder, the Acquired immune
Deficiency Syndrome (AIDS) or AIDS
Related Complex (ARC)? Yes No Yes No
E. Are you under the age of 20 or over
the age of 80? Yes No Yes No
If question C, D, or E is answered yes by Proposed Insured, then premium cannot
be taken with this Application and the Temporary Life Insurance Agreement cannot
be completed. Has a Temporary Insurance Agreement been completed?
Yes No
A representative will contact you for an interview to help determine your
eligibility for this coverage.
Proposed Insured Proposed Second Insured
Best Time: __________ Best Day: _____________ Best Time: ________ Best Day: ________
Most convenient place to call: Business Home Most convenient place to call:
Business Home
Home phone ( ) ______________________ Home phone ( ) _________________________
Business phone ( ) ____________________ Business phone ( ) _______________________
7. Suitability
To be completed by the Owner
a. Do you believe that this Policy will meet your insurance needs and
financial objectives? Yes No
b. Do you understand that the Death Benefit, the Account Value and Cash
Value may increase or decrease depending on the investment experience of the
sub-accounts? Yes No
c. Do you understand that the initial premium may be allocated to the Money
Market Account until the Right to Cancel period expires? Yes No
d. Did you receive a copy of the product prospectus for the Policy?
Yes No
8. Special Instructions
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9. Declarations, Authorizations and Signatures
I declare and agree that: (1) All statements and answers made in all parts of
this Application are full, complete and true to the best of my knowledge and
belief, (2) This Application, any amendments to it, any Application Supplement
and any related medical examinations will become a part of the Policy and are
the basis for any insurance issued on this Application; (3) No agent or medical
examiner may accept risks or make or change any contract, or waive or change any
of American Skandia Life Assurance Corporation's rights or requirements; (4)
Unless otherwise provided in the Temporary Life Insurance Agreement, any Policy
issued based on this Application will not take effect unless each Proposed
Insured is alive and in the same condition of health as described in this
Application and any Application Supplement when the Policy is delivered to the
Owner and the full premium is paid.
I certify under penalty of perjury if allowed by law that my Tax Identification
Number is correct.
I authorize any physician, medical practitioner, hospital, clinic, other medical
or medically-related facility, insuring or reinsuring company, the Medical
Information Bureau, Inc., consumer reporting agency, or employer having
information available as to diagnosis, treatment and prognosis with respect to
any physical or mental condition and/or treatment of me and any other
non-medical information about me to give the Company and/or its legal
representative any and all such information.
I understand that the policy has an Accelerated Death Benefit which will affect
the values therein.
I understand that the information obtained by use of this Authorization will be
used by the Company to determine my eligibility for insurance. Any information
obtained will not be released by the Company to any person or organization
except to reinsuring companies, the Medical Information Bureau, Inc., or other
persons or organizations performing business or legal services in connection
with this Application, claim, or as may otherwise be required by law, lawfully
required, or as I may authorize.
I understand that I have a right to receive a copy of this Authorization, that a
copy of this Authorization will be valid as the original and that this
Authorization will be valid for two and one half years (30 months) from the date
shown below.
I have received the Notice of Insurance Information Practices and Notice
Regarding Medical Information Bureau.
I consent to a consumer report containing personal or credit information or both
that may be requested in connection with this Application.
The Owner agrees to be bound by all statements, answers and agreements made by
the Proposed Insured and any Proposed Second Insured.
Signed at _____________________________, on ________________ _________ _______
(city) (state) (month) (day) (year)
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Signature of Proposed Insured Signature of Proposed Second Insured, if
applicable
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Signature of Owner Signature of Licensed Agent/
(if other than insured) Registered Representative
(if other than insured)
NOTE: If the Owner is an entity, full name to be shown and to be signed by
an authorized individual with title shown.
10. Amendments to the Application (Home office use only)
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11. Representative's Certification
Estimated annual income, net worth of Proposed Insured (both Proposed Insureds
on last survivor applications):
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I CERTIFY:
1. to the best of my knowledge, the insurance applied for will
will not (CHECK ONE) replace any life insurance or annuity on the life of
any Proposed Insured;
2. to the best of my knowledge there is nothing that may adversely affect
the insurability of any person proposed for insurance except as stated in this
Application;
3. that I asked each question separately; the answers were recorded as
given; and, they are complete and accurate to the best of my knowledge and
belief;
4. that I am a NASD Registered Representative;
5. that I have reviewed the purchase of this insurance Policy as to
suitability.
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Signature of Licensed Agent/ Date
Registered Representative
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Agent's Name (Print) Agent Number Location
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Phone Number Fax Number Agency Broker/Dealer
DETACH THIS NOTICE AND GIVE IT TO THE PROPOSED INSURED
12. Notice of Insurance Information Practices
As part of our procedure for processing your application, an
investigative consumer report may be prepared. Information is obtained through
personal interviews with your neighbors, friends, or others with whom you are
acquainted. Questions will be asked as to your character, general reputation,
personal characteristics, personal financial information and mode of living. You
have the right to send a written request within a reasonable period of time to
receive additional detailed information about the nature and scope of this
investigation. You have the right to access this information upon written
request. You may request correction, amendment or deletion of any information
which you believe to be inaccurate.
As part of your application for insurance you may receive a telephone
call from an authorized person. This person's responsibility is to review and
clarify information you provided on your application and ask some additional
questions which will aid in considering your application. The information is
considered confidential and will only be used to assess your eligibility for
insurance.
Whenever possible, calls will be made at your convenience and to the telephone
number you have provided.
Address any questions you have regarding this notice to: American Skandia
Life Assurance Corporation, P.O. Box 290698, Wethersfield, CT 06129-0698
13. Notice Regarding Medical Information Bureau
Information regarding your insurability will be treated as confidential.
American Skandia Life Assurance Corporation, or its reinsurers, may, however,
make a brief report thereon to the Medical Information Bureau Inc., a non-profit
membership organization of life insurance companies, which operates an
information exchange on behalf of its members. If you apply to another Bureau
member company for life or health insurance coverage, or a claim for benefits is
submitted to such a company, the Bureau, upon request, will supply such company
with the information it may have in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. If you question the accuracy of
information in the Bureau's file, you may contact the Bureau and seek a
correction in accordance with the procedures set forth in the federal Fair
Credit Reporting Act. The address of the Bureau's information office is: Post
Office Box 105, Essex Station, Boston, Massachusetts 02112, Telephone: (617)
426-3660.
American Skandia Life Assurance Corporation, or its reinsurers, may also release
information in its file to other life insurance companies to whom you may apply
for life or health insurance, or to whom a claim for benefits may be submitted.