EXHIBIT 1.10(a)
AMERICAN GENERAL LIFE INSURANCE COMPANY
Home Office: Houston, Texas
APPLICATION FOR LIFE INSURANCE
1. Names of persons proposed for insurance:
First Name Middle Name Last Name Sex Relationship
Date of Birth Ins. Age Place of Birth Height Weight
A. Drivers Lic Num & State:_________________SS#___________________
B. Drivers Lic Num & State:_________________SS#___________________
C.
D.
For child or family benefits, list only children who are natural or legally
adopted children of the Primary Proposed Insured or Spouse and who actually
reside at the address of the Primary Proposed Insured.
2. Present Residence of Primary Proposed Insured
Address
City State ZIP
Telephone No. of Yrs.
3. OCCUPATION Proposed Insured A
Occupation Yrs.
Employer Name
Address
City__________________State______Zip______
Telephone
Proposed Insured B
Occupation Yrs.
Employer Name
Address
City__________________State______Zip______
Telephone
4. Has proposed insured A or B used tobacco in any form in the past 24 months?
Proposed Insured A Yes No Proposed Insured B Yes No
5. Plan of basic insurance: Amount
____________________ $______________
Planned Periodic Premium $______________
Lump Sum Payment $______________
Benefit Option: 1 - Level 2 - Increasing
Are you requesting Select Rates? Yes No
6. Additional benefits to be added Amount
Maturity Extension Rider - Death Benefit
Maturity Extension Rider - Accumulation Value
Terminal Illness Rider
Waiver of Premium/Waiver of Monthly Deduction
Waiver of Monthly Guarantee Premium
Accidental Death Benefit $______________
Spouse/Other Insured Rider $______________
FIB __________ Units CIB___________ Units
Additional Insurance Option $______________
Joint Insurance 4-Year Term $______________
First-to-die Term Rider $______________
Joint Term $______________
Joint ART A n B n $______________
Automatic Increase Rider ______________%
Return of Premium Death Benefit Option
Premium Assurance Rider
Other _____________ $______________
7. Premiums to be paid
Automatic Bank Check Direct
List Bill or Government Allotment List Bill #_______________
Company_______________________________________________
Annually Semi-Annually Quarterly
Amount paid with application $ _______________ or None
8. Beneficiary Designation Proposed Insured A
First_______________________________ Relationship_________________
Second______________________________ Relationship_________________
Trust Name__________________________ Date of Trust________________
Proposed Insured B
First_______________________________ Relationship_________________
Second______________________________ Relationship_________________
Trust Name__________________________ Date of Trust________________
9. Premium PAYOR
Name________________________________
Address______________________________
City___________________State_____ ZIP__________
Relationship to Primary Proposed Insured_________________________
Secondary Payor
Name_______________________________
Address____________________________
City____________________State_____ ZIP___________
10. Policyowner and taxpayEr identification number (must be completed)
Policyowner Name_________________________
Address_________________________________
City___________________State________ZIP__________
Social Security or Tax ID Number ___________________
Policyowner Date of Birth _______________
Insured Other Relationship
Contingent Owner Designation
Contingent Policyowner Name____________________________
Social Security or Tax ID Number _________________________________
(Contingent Policyowner designation becomes effective upon the
death of the Primary Owner)
11. INCLUDE AUTOMATIC PREMIUM LOAN IF AVAILABLE? Yes No
Home Office Endorsement Only. May not be used in any state where
prohibited.
Page 2
12. HAS ANY PERSON PROPOSED FOR INSURANCE DURING THE LAST 12 MONTHS
a. had a heart attack, stroke, cancer, diabetes, or disorder of the immune
system? Yes No
b. been confined to a hospital or other health care facility and/or been
advised to have any diagnostic test or surgery not yet performed?
Yes No
Temporary insurance is not available if there are any "yes" answers to question
number 12
13. REPLACEMENTS, EXCHANGES, CONVERSIONS
If this is a replacement, required state replacement forms and disclosures
must be used. If state does not require Policy Comparison Form, you must
attach AGL Replacement Comparison Guide (L8726).
a. List below all Life Insurance policies in force and applied for in all
companies.
(Use explanations section on pg. 3 if necessary.)
Proposed Proposed Company Year Coverage Amount Is Beneficiary Replace
Insured Insured Issued Life ADB Business or Yes No
A B Personal
Proposed Insured
A B-D
Yes No Yes No
b. Is this insurance intended to be a 1035 tax-free exchange?
c. Is this insurance intended to be a term conversion?
d. Will this insurance replace, change, or use the cash value of any existing
insurance policy or annuity?
PART 2. UNDERWRITING INFORMATION
Important: QUESTIONS 1 & 2 MUST BE ANSWERED EVEN IF A MEDICAL EXAM WILL BE
PROVIDED)
PROVIDE DETAILS TO ANY YES ANSWERS UNDER EXPLANATIONS ON PAGE 3
1. Has any Proposed Insured:
Proposed Insured
A B-D
Yes No Yes No
a. in the past 2 years flown in any type of aircraft or plan to fly in
the future, other than as a passenger? (If "Yes" complete Military &
Civilian Aviation Supplement.)
b. in the past 2 years participated or expect to participate in any
vehicle racing on land or water, bobsledding, scuba or skin diving,
skydiving or parachuting, ultralight aviation, or mountaineering?
(If "Yes" complete Avocation Questionnaire.)
c. during the past 90 days submitted an application for life insurance to
any other company or is any contemplated?
d. ever had a life insurance application modified, rated, declined,
postponed, withdrawn, canceled, or refused for renewal?
e. any intention of traveling or residing outside the United States or
Canada within the next 24 months?
f. during the past 3 years been refused a driver's license, had a moving
violation, or been involved in 1 or more accidents?
(If "Yes" give license number, issue state & details.)
g. ever used cocaine, barbiturates, heroin, or other narcotic drugs,
except as legally prescribed by a physician?
h. ever sought, received advice, counseling or treatment for the use of
alcohol, marijuana, barbiturates, or drugs including prescription
drugs?
2. Has any Proposed Insured ever been diagnosed or treated by any member of
the medical profession for Acquired Immune Deficiency Syndrome (AIDS)?
3. Has any Proposed Insured in the past 3 years ever had:
a. fainting spells, nervous disorder, convulsions or paralysis?
b. pain or discomfort in the chest, or shortness of breath?
c. disorder of the stomach, intestines, rectum or blood in the urine?
4. Has any Proposed Insured ever consulted a physician for or been diagnosed
or treated for:
Proposed Insured
A B-D
Yes No Yes No
a. mental disorder, epilepsy or stroke?
b. disease or disorder of the heart or blood vessels, heart attack, high
blood pressure, or rheumatic fever?
c. elevated cholesterol?
d. disease or disorder of the lungs, asthma, emphysema, or tuberculosis?
e. disease or disorder of stomach, intestines, rectum, liver, or gall
bladder?
f. disease or disorder of the kidney, bladder, or prostate gland?
g. sugar, albumin, blood, or pus in the urine?
h. cancer, tumor, syphilis, diabetes, gland or blood disorder, ulcer,
rupture, or disease or disorder of the breast or reproductive organs?
5. Has any Proposed Insured during the past 3 years:
a. received or claimed disability or hospital indemnity benefits or a
pension for any injury, sickness, disability or impaired condition?
b. had any other impairment, sickness, laboratory tests, or diagnostic
procedures? c
been confined in a hospital or other health care facility, had a blood
transfusion, or had surgery performed, advised, or contemplated?
6. Is any Proposed Insured now taking any medication or under any treatment?
7. Medical Exam Certificate (Complete when submitting a medical examination
from another company.)
a. Attached examination is on the life of:
b. Name of insurance company for which examination was made and date of
the examination:
Company Date of Exam
c. Has Proposed Insured A or B consulted a doctor or other practitioner
or received medical or surgical advice since the date of the
examination?
d. To the best of Proposed Insured A's or B's knowledge and belief, are
any statements in the examination now inaccurate, as of today?
Page 3
FAMILY HISTORY
Proposed Insured A
Family If living If not living, State of health or
History current age(s) age at death cause & date of death
Father
Mother
Brothers
& Sisters
Proposed Insured B
Family If living If not living, State of health or
History current age(s) age at death cause & date of death
Father
Mother
Brothers
& Sisters
9. PERSONAL PHYSICIAN INFORMATION
Proposed Insured A Proposed Insured B
Who is your personal physician? Who is your personal physician?
Name:_______________________ Name:________________________
Address:____________________ Address:_____________________
City State Zip______________ City State Z_________________
Phone:______________________ Phone:_______________________
Date personal physician was last seen? Date personal physician
was last seen?
Reason Seen? Reason Seen?
EXPLANATIONS:
Details of any "Yes" answers to questions 1-7. Identify question number; circle
applicable items; include diagnosis, treatment dates, duration, and names and
addresses of all attending physicians and health care facilities.
QUES (Proposed) Insured A QUES (Proposed) Insureds B-D
PART 3. FINANCIAL INFORMATION
FINANCIAL INFORMATION MUST BE COMPLETED (1) FOR BUSINESS INSURANCE OR (2) FOR A
PROPOSED INSURED AGE 65 OR OVER OR (3) WHERE THE FACE AMOUNT EXCEEDS $250,000
FOR PROPOSED INSUREDS UNDER AGE 65. IF FACE AMOUNT APPLIED FOR IS $1 MILLION OR
MORE, PROVIDE AN EXPANDED FINANCIAL STATEMENT. I BELIEVE THAT THIS PURCHASE OF
LIFE INSURANCE IS SUITABLE FOR THIS APPLICANT/INSURED, BASED UPON THE
APPLICANT'S NEEDS, FINANCIAL SITUATION AND INSURANCE OBJECTIVES.
1. For personal insurance:
a. What is the purpose of the insurance? Check all that apply.
Estate preservation Family protection Mortgage protection Charitable
Other _______
b. What is the Proposed Insured(s)
1) Annual earned income $_______________ 3)Total assets $____________
2) Annual interest & other income $____________(include retained
earnings)
4) Total liabilities $_______________________
2. For business insurance:
a. What is the purpose of the insurance? Check all that apply.
Key person Buy-Sell Split dollar Stock redemption
Creditor Other
b. Annual net profit before taxes: Last year $__________
2 years ago $____________ net worth $______________
c. If key person insurance: Retained earnings $____________ Yes No
1) Are all partners or key people to be covered?
2) Does either Proposed Insured have an ownership interest in the
business?
If "Yes" what is Proposed Insured A's percent of ownership?_______%
If "Yes" what is Proposed Insured B's percent of ownership?_______%
Page 4
SPECIAL INSTRUCTIONS
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
I hereby give my consent to: (1) any physician or medical practitioner; (2)
hospital, clinic, or other health care facility; (3) insurance or reinsurance
company; (4) consumer reporting agency, insurance support organization; (5) my
employer; or (6) the Medical Information Bureau, Inc., to give to American
General Life Insurance Company (American General Life) all information it has
pertaining to: (1) my medical consultations, treatments or surgeries; (2)
hospital confinements which concern the physical and mental condition of myself,
my spouse or my minor children; (3) my use of drugs or alcohol; or (4) any other
non-health (non-medical) information.
In turn, American General Life is free to disclose such information and any
information developed during its evaluation of my application to: (1) its
reinsurers; (2) the Medical Information Bureau, Inc.; (3) other insurance
companies; (4) me; (5) any physician designated by me; or (6) 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 American General Life.
This consent shall be valid for thirty (30) months from the date stated below.
I agree that a photocopy of this consent shall be as valid as the original.
I authorize American General Life to obtain an investigative consumer report on
me. I understand that I may: (1) request to be interviewed in connection with
the preparation of the investigative consumer report; and (2) receive, upon
written request, a copy of such report if no personal interview is in fact
conducted.
DECLARATION. I have read the above statements or they have been read to me. I
represent that the above statements are true and complete to the best of my
knowledge and belief. 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 for which all
eligibility requirements are met, I understand and agree that no insurance shall
be in effect pursuant to this application, or under any policy issued by the
Company, until: (1) the policy has been delivered and accepted; (2) the full
first mode premium for the issued policy has been paid; and, (3) between the
date of the application and the delivery and acceptance of the policy, there has
been no material change in the health of any person proposed for insurance. I
understand and agree that no agent is authorized to: (1) accept risks or pass
upon insurability; (2) make or modify contracts; or (3) waive any of the
Company's rights or requirements.
I have received a copy of the Fair Credit Reporting Act, Medical Information
Bureau (MIB), Insurance Information Practices, and Telephone Interview
Information notices.
IF ELIGIBLE: I have received and accepted the Limited Temporary Life Insurance
Agreement. Temporary insurance is available only if: (1) the full first mode
premium is submitted with this application; and (2) only "No" answers have been
given in Part 1, Question 12.
Any person who includes any false or misleading information on an application
for insurance policy is subject to criminal and civil penalties.
Under penalties of perjury, I certify: (1) that the number shown on this
application is my correct social security (or taxpayer identification) number
and (2) 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 your consent to any provision of
this document other than the certifications required to avoid backup
withholding.
Signed at ___________________________ Date: ________________
city state
X__________________________________ X_______________________________
SIGNATURE OF PROPOSED INSURED A SIGNATURE OF OWNER/TRUSTEE
(If below age 15, signature of parent Primary Proposed Insured. Show
or guardian.) officer's title if signing for
firm.)
X__________________________________
SIGNATURE OF OWNER
X X X
X___________________________________ X_______________________________
SIGNATURE OF PROPOSED INSURED B SIGNATURE OF OWNER
X___________________________________
SIGNATURE OF OWNER
I certify that I have truthfully and accurately recorded on the application the
information supplied by the Proposed Insured(s) and personally witnessed the
signature(s) of the Proposed Insured(s).
X_______________________ ______________________ ______________
AGENT NAME (Please Print) SIGNATURE OF AGENT AGENT No.
X_______________________
STATE LICENSE NO.
Page 5
AGENT'S REPORT (MUST be completed to issue policy.)
1. If Primary Proposed Insured has lived at present address less than 5 years,
list previous addresses for the past 5 years, with dates.
List address where correspondence should be sent, if different than the
Primary Proposed Insured's or Owner's address shown in Part 1.
2. Current marital status
Married Single Divorced Separated Widowed
3. If married, what amount of insurance is in force on the spouse? $__________
4. If primary proposed insured is a child, what amount of insurance is in
force on the father and/or mother?
$__________________
5. How long have you known the proposed insured(s)?
Insured A ______________ Insured B ______________
6. Are you related by blood or marriage to any proposed insured?
Yes No Relationship
7. Did you personally see all proposed insureds and ask each and every
question and accurately record their answers yourself?
Yes No If "No" give details in Remarks.
8. Which of the following have you scheduled?
Blood Profile
HOS
Inspection
Resting EKG
Stress EKG
Chest X-Ray
Para Med
NAME OF EXAMINER/SERVICE DATE
Medical
NAME OF EXAMINER/SERVICE DATE
APS from
DOCTOR DATE
APS from
DOCTOR DATE
9. Complete if Part 3 not completed
a. Purpose of insurance. Check all that apply.
Estate preservation Family protection
Charitable Mortgage protection Other_____________________
b. Annual earned income of the Proposed Insured(s) or of the Payor,
if other than the Primary Proposed Insured
Proposed Insured A $_____________________
Proposed Insured B $_____________________
10. Telephone interview information
Best time to call Proposed Insured(s) at
Business ( )______________ Home ( )_____________
Time __________Time ______________
11. AGENT(S) TO RECEIVE COMMISSION & VOLUME CREDIT
(Circle letter to indicate who Agency Agent Percent
should receive correspondence.) Number Number of credit
a.
b.
c.
12. To the best of your knowledge, will the insurance applied for replace or
change existing insurance or annuity in this or any other company?
Yes No
(If "Yes", complete requirement of the state of residence.)
REMARKS:
Date Contact Person if other than Agent SIGNATURE OF AGENT
Telephone No. of Agent PLEASE PRINT NAME
Facsimile No. of Agent STREET ADDRESS (Please Print)
Page 6
BANK DRAFT INFORMATION
The Automatic Bank Check plan, commonly known as ABC or Electronic Funds
Transfer, is a preauthorized debit service which offers a convenient way to pay
your insurance premiums. Under the ABC plan, your insurance premiums are
collected from your bank account electronically. After each premium payment has
been withdrawn from your bank account, a single-line entry in the amount of your
premium payment will appear on your bank statement. That entry will be your
receipt for payment of your premium. When paying with ABC, you no longer have to
write additional checks or mail any premium payments. As long as you maintain a
sufficient balance in your bank account, your insurance premiums are
automatically paid from your account with no further effort on your part.
PREAUTHORIZED DEBIT AGREEMENT
I, the undersigned bank account owner, hereby authorize and request American
General Life Insurance Company ("Company") to initiate electronic or other
commercially accepted type debits against the indicated bank account in the
depository institution named below ("Depository") for the payment of premiums
and other indicated charges due on the insurance policy or policies listed below
(hereafter referred to as "Policy", whether one or more), and to continue to
initiate such debits in the event of a conversion, renewal or other change to
any such policy. I hereby agree to indemnify and hold the Company harmless from
any loss, claim or liability of any kind by reason or dishonor of any debit.
I understand that this Authorization will not affect the terms of the Policy,
other than the mode of payment, and that if premiums are not paid within the
applicable grace period, the Policy will terminate, subject to any applicable
nonforfeiture provision. I acknowledge that the debit appearing on my bank
statement shall constitute my receipt of payment, but no payment is deemed made
until the company receives actual payment in its Home Office. I understand that
this Authorization will not result in any insurance becoming effective under any
conditional receipt or temporary insurance unless all terms of such conditional
receipt or temporary insurance have been met.
I agree that this Authorization may be terminated by me or the Company at any
time and for any reason by providing written notice of such termination to the
non-terminating party and may be terminated by the Company immediately if any
debt is not honored by the Depository named below for any reason.
Policy No. Insured Premium Amount
Bank Account Number_________________FREQUENCY: ___Monthly
Transit Routing Number _________________ ___Quarterly
Name of Depository_____________________ ___Semi-Annually
Address of Depository___________________ ___Annually
Preferred withdrawal date__________________________________
___Please initiate debits against my account for all outstanding premiums due.
Signature of Bank Account Owner Date
PLEASE ATTACH VOIDED CHECK
Page 7
American General Life Insurance Company
Home Office: Houston, Texas
LIMITED TEMPORARY LIFE INSURANCE AGREEMENT
Received $________________on this date from___________________________
This amount was paid when, on this date, a life insurance application was signed
in which is named as the Primary Proposed Insured. We agree to provide temporary
life insurance coverage as described below, subject to the rules that follow:
ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO THE COMPANY: DO NOT MAKE CHECK
PAYABLE TO THE AGENT OR LEAVE THE 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 THE
DECLARATION CANNOT BE MET; IF ANY PART OF QUESTION 12 HAS BEEN ANSWERED "YES",
ANSWERED FALSELY, OR LEFT BLANK, THIS AGREEMENT WILL BE VOID AND ANY PAYMENT
SUBMITTED WILL BE REFUNDED.
1. The full first mode premium must be submitted with this application. (Any
payment submitted must be honored on its first presentation for payment.)
2. The answer to all parts of question 12 must be "NO".
3. Upon receipt of due proof of the death of any person to be insured during
the period covered by this agreement, the total amount we will pay under
the policy, any riders, and this agreement, will be the lesser of:
(a) the amount applied for on such person; or
(b) $300,000 and the amount of any premium paid for coverage in excess of
$300,000 on such person.
4. Such payment will be made in one sum to the beneficiary stated in the
application. If death is due to suicide, payment will be limited to the
return of the amount paid. Coverage under this agreement will be subject to
the terms of the policy for which application is made.
5. Coverage will begin on the latest of the following dates:
(a) the date of the application;
(b) the date that all medical examinations have been taken; or
(c) the date requested in the application.
6. Coverage under this agreement will cease on the earliest of the following
dates:
(a) the date we issue the policy as applied for;
(b) the date a policy issued other than as applied for is offered to the
applicant;
(c) the date we decline the application;
(d) the date we state that the application will not be considered on a
prepaid basis; or
(e) 60 days from the date coverage begins under this agreement.
7. Any payment submitted to and accepted by the Company will be:
(a) applied to pay the first premium due if the policy is issued as applied
for;
(b) applied toward payment of the first premium if a policy is issued other
than as applied for and is accepted by the applicant;
(c) refunded if we decline the application or if the applicant refuses to
accept a policy issued other than as applied for.
No changes may be made in the terms and conditions of this form.
No statement which claims to make such a change will bind the Company.
I understand and agree that no agent is authorized to accept risks or pass upon
insurability, to make or modify contracts, or to waive any of the company's
rights or requirements.
Signed at_____________________________________Date:_______________
CITY STATE
X _____________________________________________
SIGNATURE OF AGENT AGENT NUMBER
Page 8
DETACH THIS NOTICE &
LEAVE IT WITH THE
PROPOSED INSURED
American General Life Insurance Company
Home Office: Houston, Texas
NOTICE TO PROPOSED INSURED
Fair Credit Reporting Act
In compliance with the Fair Credit Reporting Act, as amended, we advise you that
we may, as a part of our normal procedure for processing your contract
application, request that an investigative consumer report be prepared whereby
information is obtained through personal interviews with your neighbors,
friends, former employers, primary insurance company or others with whom you are
acquainted. This inquiry includes information as to your character, general
reputation, personal characteristics and mode of living.
You have the right to make a written request to our home office within a
reasonable period of time to receive additional, detailed information about the
nature and scope of this investigation, if one is made. Please address your
request to New Business, American General Life Insurance Company, P.O. Box 1931,
Houston, Texas 77251-1931. These reports are obtained in your best interest.
They assist us in determining that the Company's insureds meet certain
standards, thus allowing us to continue offering coverage at the lowest possible
cost to all who qualify.
Medical Information Bureau
Information regarding your insurability will be treated as confidential.
American General Life Insurance Company or its reinsurers may, however, make a
brief report thereon to the Medical Information Bureau, 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
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 01112, telephone number
(617) 426-3660.
American General Life Insurance Company 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.
Insurance Information Practices
To issue an insurance policy, we need to obtain information about you and any
other persons proposed for insurance. Some of that information will come from
you and some will come from other sources. That information and any subsequent
information collected by us may in certain circumstances be disclosed to third
parties without your specific authorization.
You have a right of access and correction with respect to the information
collected about you except information which relates to a claim or civil or
criminal proceeding.
If you wish to have a more detailed explanation of our information practices,
please contact: American General Life Insurance Company, New Business, P.O. Box
1931, Houston, Texas 77251-1931.
Telephone Interview Information (If Applicable)
To help us process your application as rapidly as possible, American General
Life may have one of its representatives contact you by telephone and at your
convenience to secure additional underwriting information.
You may be assured that all information developed in this interview will be kept
in strictest confidence and used solely for insurance purposes.