Exhibit 10(d)
American
|General
|Financial Group
Part A Single Insured
Life Insurance Application
[_] American General Life Insurance Company, Houston, TX
[_] The Old Line Life Insurance Company of America, Milwaukee, WI
[_] All American Life Insurance Company, Springfield, IL
[_] The Franklin Life Insurance Company, Springfield, IL
[_] The American Franklin Life Insurance Company, Springfield, IL
Members of American General Financial Group. American General
Financial Group is a marketing name for American General
Corporation and its subsidiaries.
In this application, the "Company" refers to the insurance company
whose name is checked above.
The insurance company checked above is solely responsible for the
obligation and payment of benefits under any policy that it may
issue. No other company shown is responsible for such obligations
or payments.
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Personal Information
Proposed Name Social Security #
insured ----------------------------- -----------------------------------
Address Zip
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Home phone # Work phone #
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E-mail address
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Sex: [_] male [_] female
Birthplace (city, state, country)
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Date of birth Drivers license # State
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U.S. citizen: [_] yes [_] no
If no, date of entry Type of visa
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Employer
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Occupation and duties Income:
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Tobacco use
Have you ever used any form of tobacco or
nicotine products? [_] yes [_] no
Date of last use
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Type of tobacco or nicotine products
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Product Information
Product name
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(If a variable product, complete appropriate supplement.)
Amount applied for $
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Reason for insurance (If more space is needed, use "Remarks"
section.)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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Business Does the proposed insured have an ownership interest
coverage in the business? [_] yes [_] no
If yes, what is proposed insured's percentage
(Complete only of ownership? %
if applying -----------------------
for business If buy-sell, stock redemption, or key person insurance,
coverage) will all partners or key people be covered? [_] yes [_] no
Describe any special circumstances.
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Riders [_] Waiver of premium
[_] Waiver of monthly deduction
[_] Waiver of monthly guarantee premium
[_] Accidental death benefit $
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[_] Other rider(s)
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Dividend options For participating policy only
[_] Cash [_] Premium reduction [_] Paid-up additions
[_] Deposit earning interest [_] Other (explain)
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Death benefit For universal life only
options [_] Level [_] Increasing
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AGLC 0033-99
Page 1
Beneficiary Primary
Name Relationship % share
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Name Relationship % share
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Contingent
Name Relationship % share
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Name Relationship % share
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Complete if beneficiary is a trust.
Exact name of trust
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Trust ID # Date of trust
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Current trustee(s)
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Other life Indicate life insurance policies or annuities in force or
insurance or pending for the proposed insured.
annuities Type: i = individual, b = business, g = group,
p = pending life insurance or annuity
Policy Insurance Type Year of Amount Replacement*
number company issue
[_] Check if none ------------- -------------- ----------- ------------ $__________ [_] yes [_] no
------------- -------------- ----------- ------------ $__________ [_] yes [_] no
------------- -------------- ----------- ------------ $__________ [_] yes [_] no
------------- -------------- ----------- ------------ $__________ [_] yes [_] no
* Replacement means that the insurance being applied for
may replace, change, or use any monetary value of any
existing or pending life insurance policy or annuity. If
replacement may be involved, complete and submit
replacement-related forms.
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Owner [_] Primary proposed insured [_] Someone other than
[_] Trust a proposed insured or
trust
Complete if owner is a trust.
Exact name of trust
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Trust ID # Date of trust
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Current trustee(s)
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Complete if someone other than a proposed insured or
trust is the owner.
Name Home phone #
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Address City, State Zip
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Social Security or Tax ID # Date of birth
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Relationship to proposed insured
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Premium payment [_] Single premium: $ [_] Modal premium: $ [_] Additional initial premium: $
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Frequency of modal premium
[_] Annual [_] Semi-annual [_] Quarterly [_] Monthly Amount submitted with application $
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Method
[_] Direct billing [_] Automatic bank draft
[_] List bill: number
[_] Other
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Premium payor
Complete if other than owner.
Name Social Security #
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Address
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Zip Home phone #
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Remarks -----------------------------------------------------------
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AGLC 0033-99 Page 2
Your Signature
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Authorization to obtain and disclose information and declaration
I hereby give my consent to any of the entities listed below to give to the
Company or its legal representative, all information they have pertaining to:
my medical consultations, treatments, or surgeries; hospital confinements,
which concern my physical and mental condition; my use of drugs or alcohol; or
any other non-medical information. Non-medical information could include items
such as: personal finances; habits; hazardous avocations; motor vehicle or court
records; or foreign travel, etc. The list of entities for which I give my
consent to provide the information above is as follows: any physical or medical
practitioner; any hospital, clinic or other health care facility; any insurance
or reinsurance company; any consumer reporting agency or insurance support
organization; my employer; or the Medical Information Bureau (MIB).
I understand the information obtained will be used by the Company to
determine eligibility for insurance and eligibility for benefits under an
existing policy. The Company may disclose such information and any
information developed during its evaluation of my application to: its
reinsurers; MIB; other insurance companies; other persons or organizations
performing business or legal services in connection with my application or
claim; me; any physician designated by me; or any person or entity required
to receive such information by law or as I may further consent.
I, as well as any person authorized to act on my behalf, may upon written
request, obtain a copy of this consent from the Company.
This consent will be valid for 30 months from the date of this application. I
agree that a photocopy of this consent will be as valid as the original. I
authorize the Company to obtain an investigative consumer report on me. I
understand that I may: request to be interviewed in connection with the
preparation of the report; and receive, upon written request, a copy of such
report.
[_] Check if you wish to be interviewed.
I have read the above statements or they have been read to me. The above
statements are true and complete to the best of my knowledge and belief. I
understand that this application: (1) will consist of Part A, Part B, and, if
applicable, Part C and related forms; and (2) shall be the basis for any
policy issued on this application. I understand that any misrepresentation
contained in this application and relied on by the Company may be used to:
reduce or deny a claim or void the policy, if it is within its contestable
period and if such misrepresentation materially affects the acceptance of the
risk. Except as may be provided in a Limited Temporary Life Insurance
Agreement (LTLIA) for which all eligibility requirements are met, I
understand and agree that no insurance will be in effect pursuant to this
application, or under any policy issued by the Company, unless or until: the
policy has been delivered and accepted; the full first modal premium for the
issued policy has been paid; and there has been no change in the health of
any proposed insured that would change the answers to any questions in the
application.
I understand and agree that no agent is authorized to: accept risks or pass
upon insurability; make or modify contracts; or waive any of the Company's
rights or requirements.
I have received a copy of the Notice to Proposed Insured regarding Fair
Credit Reporting Act; the MIB; Insurance information practices; and telephone
interview information.
Limited Temporary Life Insurance - If eligible, I have received and accepted
the LTLIA. Temporary insurance is available only if: the full first modal
premium is submitted with this application and only "no" answers have been
given by proposed insured to the "Health and Age" questions in the LTLIA.
Under penalties of perjury, I certify: that the number shown on this
application is my correct Social Security or Tax ID number; and that I am
not subject to backup withholding under Section 3406(a)(1)(C) of the
Internal Revenue Code. The Internal Revenue Service does not require my
consent to any provision of this document other than the certifications
required to avoid backup withholding.
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Signatures X Owner Date
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Signed at (city, state)
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X Witness Date
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X Proposed insured Date
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(If under age 15, signature of parent or guardian)
If the Company needs to contact the proposed insured,
when would be the best time to call?
Time Day of the week
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Date Phone number
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I certify that I have truthfully and accurately recorded on
the Part A application the information supplied by the
proposed insured.
Agent name (please print)
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Agent # State license #
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X Agent Date
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AGLC 0033-99 Page 3
Agent's Report
Number of years you have known proposed insured
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Have you scheduled a medical exam, inspection report,
blood profile, urinalysis, or APS? [_] yes [_] no
If yes, please provide name of examiner, clinic, date, and
the type of report ordered.
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Statements
Did you personally see the proposed insured on the date of
this application, ask each question, and accurately record
the answers yourself? [_] yes [_] no
If no, please provide details in the "Remarks" section below.
Do you have any information that indicates that the proposed
insured may replace, change, or use any monetary value of any
existing or pending life insurance policy or annuity with any
company in connection with the purchase of insurance?
[_] yes [_] no If yes, please provide details in the
"Remarks" section below and attach all replacement-related forms.
Are you aware of any information that would adversely affect any
proposed insured's eligibility, acceptability, or insurability?
[_] yes [_] no If yes, please provide details in the
"Remarks" section below, and do not provide limited temporary
life insurance.
Did you provide client with LTLIA? [_] yes [_] no
Has the proposed insured or the owner submitted an application
for coverage with any of the American General life insurance
companies within the last 30 days? [_] yes [_] no
If proposed insured is a child, what amount of insurance
is in force on the father $___________ and/or mother $________?
Are you related by blood or marriage to the proposed insured?
[_] yes [_] no (If yes, relationship)________________________
Remarks (Please include information on any split dollar,
collateral assignment, etc.)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
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Commission Please list servicing agent first.
Agent(s) to receive commission Agency number Agent number Percent of commission
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X Writing agent Date
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Social Security or Tax ID # Phone #
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Primary appointing company
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Client #
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If applicable:
Broker-Dealer(s)
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Contact person Processing center
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Phone # Fax #
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If other than writing agent, send policy/delivery requirements to:
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AGLC 0033-99 AR
Limited Temporary Life Insurance Agreement
[_] American General Life Insurance Company, Houston, TX
[_] The Old Line Life Insurance Company of America, Milwaukee, WI
[_] All American Life Insurance Company, Springfield, IL
[_] The Franklin Life Insurance Company, Springfield, IL
[_] The American Franklin Life Insurance Company, Springfield, IL
In this application, the "Company" refers to the insurance
company whose name is checked above.
The insurance company checked above is solely responsible for the
obligation and payment of benefits under any policy that it may
issue. No other company shown is responsible for such obligations
or payments.
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Health and If the proposed insured answers "yes" to either Proposed
Age questions question, temporary insurance is not available, insured
this agreement will be void, and any payment
submitted will be refunded.
During the last two years, have you had a heart
attack, stroke, cancer, diabetes, or disorder of
the immune system; or have you been confined in
a hospital or other health care facility or been
advised to have any diagnostic test or surgery
not yet performed? [_] yes [_] no
Are you age 71 or above? [_] yes [_] no
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Premium payment
Received $ Date
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All premium checks must be made payable to the Company.
Do not make check payable to the agent or leave payee blank.
Note: Agent does not have the authority to accept a premium
(including automatic bank draft check, salary savings,
or government allotment) with this application if the conditions
in "Authorization to obtain and disclose information and
declaration" cannot be met or if any part of the
"Health and Age questions" have been answered "yes" by the
proposed insured, answered falsely, or left blank.
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Conditions 1. The first modal premium must be paid with Part A of the
of temporary application.
life
insurance 2. The answer to both of the above "Health and Age questions" must
be "no".
3. Upon receiving proof of the death of the proposed insured
during the period covered by this agreement, the total
amount that will be paid by the Company pursuant to this and
any other limited temporary life insurance agreements covering
the proposed insured will be the lesser of:
. the plan amount the proposed insured applied for;
or
. $500,000 plus the amount of any premium paid for
coverage in excess of $500,000.
The Company will pay this sum to the beneficiary named in the
application. If death is due to suicide, payment will be
limited to the amount of premium paid.
4. Coverage under this agreement will begin on the date
the later of the following events have been completed:
. this Limited Temporary Life Insurance Agreement
(LTLIA) has been signed by the proposed insured; or
. all required medical examinations have been taken.
5. Coverage under this agreement will end on the earliest of the
following dates:
. the date the policy as applied for is delivered
and accepted;
. the date the Company declines the application;
. the date the Company states the application will not be
considered on a prepaid basis;
. 60 days from the date coverage begins under this agreement;
or
. the date the Company issues a policy other than as applied
for.
6. The prepayment for this temporary insurance will be:
. applied to the first premium due if the policy is issued as
applied for; or
. refunded if the Company declines the application or if the
owner does not accept the policy; or
. applied to the first premium if a policy is issued other than
as applied for and is accepted.
7. Any misrepresentation contained in this agreement and relied on
by the Company may be used to deny a claim on or void this
agreement.
No changes may be made in the terms and conditions of this
agreement. No statement that tries to make such a change will
bind the Company.
X Owner Date
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Signed at (city, state)
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X Witness Date
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X Proposed insured Date
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(If under age 15, signature of parent or guardian)
I certify that I have truthfully and accurately recorded
on the LTLIA the information supplied by the proposed insured.
Agent name (please print)
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Agent # State license #
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X Agent Date
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AGLC 0033-99 TIA
Bank Draft Information
[_] American General Life Insurance Company, Houston, TX
[_] The Old Line Life Insurance Company of America, Milwaukee, WI
[_] All American Life Insurance Company, Springfield, IL
[_] The Franklin Life Insurance Company, Springfield, IL
[_] The American Franklin Life Insurance Company, Springfield, IL
The company checked above will withdraw the premiums from
the specified account. This company will be referred to hereafter
as the "Company." "You," "your," "I," and "me" refer to the
accountholder whose name appears below.
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How automatic bank draft works
Automatic bank draft is a debit service that offers a convenient way to pay
life insurance premiums. The Company will collect the life insurance premiums
from your bank account electronically - you do not need to write checks or mail
in any payments. Premium withdrawals will appear on your bank statement,
and your statements will be your receipt for payment of your premium.
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Automatic bank draft agreement
I authorize the Company to electronically withdraw money from my account at
(name of bank) ___________________________________________________________
(bank address)____________________________________________________________
(Type of account [_] Checking [_] Savings)
for the payment of premiums and other charges on the insurance policy. I
authorize the Company to continue to make these withdrawals if there is a
conversion, renewal, or other change in the policy. I will compensate the
Company for any loss, claim, or liability caused by these withdrawals and
will not hold the Company responsible for any such loss, claim, or liability.
This authorization will not affect the terms of the policy. If the premiums
are not paid within the grace period allowed, the policy may lapse, and it
will be subject to any applicable nonforfeiture provision. Authorizing this
automatic payment plan does not put the insurance policy into effect.
This authorization may be retracted by me or the Company at any time for any
reason by giving written notice. The Company may retract the authorization
immediately, without giving me written notice, if any debt is not paid by the
bank stated above for any reason.
Name of proposed insured
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Premium amount $
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Frequency: [_] annual [_] semi-annual [_] quarterly [_] monthly
Preferred withdrawal date
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[_] Please debit my account for all outstanding premiums due.
X Signature of accountholder
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Print name
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Please attach voided check.
AGLC 0033-99 BDI
Detach this page and leave it with the proposed insured.
Notice To The Proposed Insured
You have applied for life insurance with one of the following companies:
American General Life Insurance Company, The Old Line Life Insurance Company
of America, All American Life Insurance Company, The Franklin Life
Insurance Company, or The American Franklin Life Insurance Company. "Company"
refers to the company with which you have applied for insurance. This
notice is provided on behalf of that company.
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Fair Credit Reporting Act
Pursuant to the Federal Fair Credit Reporting Act, as amended (15 U.S.C.
1681d), notice is hereby given that, as a component of our underwriting
process relating to your application for life insurance, the Company may
request an investigative consumer report that may include information about
your character, general reputation, personal characteristics, and mode of
living.
This information may be obtained through personal interviews with your
neighbors, friends, associates, and others with whom you are acquainted or who
may have knowledge concerning any such items of information. You have a right to
request in writing, within a reasonable period of time after receiving this
notice, a complete and accurate disclosure of the nature and scope of the
investigation the Company requests. You should direct this written request to
the Company at:
P. O. Box 1931
Houston, TX 77251-1931
Upon receipt of such a request, the Company will respond by mail within five
business days.
To make it easier to use its products and services, the Company may share
information about you with its affiliates beyond the 30 month period
described in "Authorization to Obtain and Disclose Information and
Declaration." You should notify the Company in writing at the address above
if you do not want the Company to share this information with its affiliates.
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Medical Information Bureau
The designated insurer or its reinsurers may make a brief report regarding
your insurability to the Medical Information Bureau (MIB), a non-profit
membership organization of life insurance companies, that operates an
information exchange on behalf of its members. If you apply to another
MIB-member company for life or health insurance or a claim for benefits is
submitted to such a company, the MIB will supply such company with the
information they have about you.
At your request, the MIB will disclose any information it has in your file.
If you question the accuracy of information in the MIB's file, you may seek a
correction in accordance with the procedures set forth in the Federal Fair
Credit Reporting Act. The address and phone number of the MIB's information
office are:
P. O. Box 105
Essex Station
Boston, Massachusetts 01112
(617) 426-3660
The designated insurer, or its reinsurer, 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.
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Insurance information practices
To issue an insurance policy, we need to obtain information
about you. Some of that information will come from you, and some will come
from other sources. This information may in certain circumstances be
disclosed to third parties without your specific authorization as permitted
by law.
You have the right to access and correct this information, except information
that relates to a claim or a civil or criminal proceeding.
Upon your written request, the Company will provide you with a more detailed
written notice explaining the types of information that may be collected, the
types of sources and investigative techniques that may be used, the types of
disclosures that may be made and the circumstances under which they may be
made without your authorization, a description of your rights to access and
correct information, and the role of insurance support organizations with
regard to your information.
If you desire additional information on Insurance Information Practices you
should direct your requests to the Company at:
P. O. Box 1931
Houston, TX 77251-1931
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Telephone interview information
To help process your application as soon as possible, the Company may have
one of its representatives call you by telephone, at your convenience,
and obtain additional underwriting information.
AGLC 0033-99 NPI