EXHIBIT (10)(a)
THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK ("USL")
Administrative Center: Houston, TX
APPLICATION FOR VARIABLE LIFE INSURANCE
NOTICE: The amount of duration of the Death Benefit Proceeds and the Cash
Values provided by the policy when based on the investment experience of a
Separate Account, are variable, may increase or decrease, and not guaranteed
as to fixed dollar amount. Upon the owner's written request, USL will
provide an illustration of the benefits and values of the policy, including
the Death Benefits and Cash Values.
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PART 1. GENERAL INFORMATION
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1. NAMES OF PERSONS PROPOSED FOR INSURANCE Date of Birth Ins. Place of Height
FIRST MIDDLE LAST Sex Relationship Mo Day Yr Age Birth Ft In Weight
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A. JOHN M DOE M Primary 1 - 1 - 62 35 TEXAS 5"10" 175
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Drivers Lic Num & State:____________________________ SS# ___________________
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B.
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Drivers Lic Num & State:____________________________ SS# ___________________
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C.
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D.
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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.
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2. PRESENT RESIDENCE OF PRIMARY PROPOSED INSURED | 7. PREMIUMS TO BE PAID
Address 123 Main St. | [ ] Automatic Bank Check [ ] Direct
City Houston State Texas ZIP 77041 | [ ] List Bill or Government Allotment List Bill #____________
Telephone (713) 466-3800 No. of Yrs. 10 | Company_____________________________________________________
_____________________________________________________________| [ ] Annually [ ] Semi-Annually [ ] Quarter
3. OCCUPATION Proposed Insured A | Amount paid with application $ _______________ or [ ] None
Occupation Banker Yrs. 10 |_____________________________________________________________________
------------------- ---- | 8. BENEFICIARY DESIGNATION Proposed Insured A
Employer Name Bank One |
--------------------------------- | ----------------------------------------------------------
Address --------------------------------------- | First Relationship
City State Zip | _______________________________________________________________
------------------- ----- ----- | Second Relationship
Telephone ( ) |
-------------------------------- | _______________________________________________________________
| Trust Name Date of Trust
Proposed Insured B |
| Proposed Insured B
Occupation Yrs. |
------------------ ---- | _______________________________________________________________
Employer Name | First Relationship
---------------------------------- |
Address | _______________________________________________________________
---------------------------------------- | Second Relationship
City State Zip |
------------------- ----- ----- | _______________________________________________________________
Telephone ( ) | Trust Name Date of Trust
-------------------------------- |
|_____________________________________________________________________
_____________________________________________________________| 9. PREMIUM PAYOR
4. HAS PROPOSED INSURED A OR B USED TOBACCO IN ANY FORM | Name_____________________________________________________________
IN THE PAST 24 MONTHS? | Address__________________________________________________________
Proposed Insured A [ ] Yes [X] No | City_____________________________________ State _____ ZIP_______
Proposed Insured B [ ] Yes [ ] No | Relationship to Primary Proposed Insured_________________________
_____________________________________________________________| Secondary Payor
5. PLAN OF BASIC INSURANCE: Amount | Name John Doe
Variable Universal Life | Address 123 Main St.
---------------------------------------- $ 25,000 | City Houston State TX ZIP 77041
Planned Periodic Premium $__________ |_____________________________________________________________________
Lump Sum Payment $__________ | 10. POLICYOWNER AND TAXPAYER IDENTIFICATION NUMBER
Benefit Option: [ ] 1 - Level 2 - Increasing | (must be completed)
Are you requesting Select Rates? [ ] Yes [ ] No | Policyowner Name_______________________________________________
_____________________________________________________________| Address________________________________________________________
6. ADDITIONAL BENEFITS TO BE ADDED Amount | City_______________________________________State_____ ZIP______
[ ] Terminal Illness Rider | Social Security or Tax ID Number_______________________________
[ ] Waiver of Monthly Deduction | Policyowner Date of Birth______________________________________
[ ] Accidental Death Benefit............. $_____________ | [ ] Insured [ ] Other Relationship____________________
[ ] Spouse/Other Insured Rider........... $_____________ | Contingent Owner Designation
[ ] CIB __________ Units | Contingent Policyowner Name____________________________________
[ ] Automatic Increase Rider _____________% | Social Security or Tax ID Number_______________________________
[ ] Return of Premium Death Benefit Option | (Contingent Policyowner designation becomes effective upon
[ ] Other _______________________________ $_____________ | the death of the Primary Owner)
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11. 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 [X] 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 [X] No
____________________________________________________________________________________________________________________________________
Temporary insurance is not available if there are any "yes" answers to question number 11
___________________________________________________________________________________________________________________________________
12. REPLACEMENTS, EXCHANGES, CONVERSIONS
If this is a replacement, required state replacement forms and disclosures must be used.
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 Coverage Amount Is Beneficiary Replace
Insured Insured Year Business or
A B Company Issued Life ADB Personal? Yes NO
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Proposed Insured:
A B-D
Yes No Yes No
b. Is this insurance intended to be a 1035 tax-free exchange? [ ] [X] [ ] [ ]
c. Is this insurance intended to be a term conversion? [ ] [X] [ ] [ ]
d. Will this insurance replace, change, or use the cash value of any existing insurance policy or annuity? [ ] [X] [ ] [ ]
___________________________________________________________________________________________________________________________________
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?...................................................................................... [ ] [X] | [ ] [ ]
(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?. [ ] [X] | [ ] [ ]
(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?........................................................................................ [ ] [X] | [ ] [ ]
d. ever had a life insurance application modified, rated, declined, postponed, withdrawn, canceled, or |
refused for renewal?................................................................................. [ ] [X] | [ ] [ ]
e. any intention of traveling or residing outside the United States or Canada within the next 24 months. [ ] [X] | [ ] [ ]
f. during the past 3 years been refused a driver's license, had a moving violation, or been involved in |
1 or more accidents?................................................................................. [ ] [X] | [ ] [ ]
(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?........................................................................................... [ ] [X] | [ ] [ ]
h. ever sought, received advice, counseling or treatment for the use of alcohol, marijuana, barbiturates, |
or drugs including prescription drugs?............................................................... [ ] [X] | [ ] [ ]
_____________________________________________________________________________________________________________________| ____________
2. Has any Proposed Insured ever been diagnosed or treated by any member of the medical profession for |
Acquired Immune Deficiency Syndrome (AIDS)? [ ] [X] |
_____________________________________________________________________________________________________________________| ____________
3. Has any Proposed Insured in the past 3 years ever had: |
a. fainting spells, nervous disorder, convulsions or paralysis?........................................ [ ] [X] | [ ] [ ]
b. pain or discomfort in the chest, or shortness of breath?............................................ [ ] [X] | [ ] [ ]
c. disorder of the stomach, intestines, rectum or blood in the urine?.................................. [ ] [X] | [ ] [ ]
_____________________________________________________________________________________________________________________| ____________
4. Has any Proposed Insured, ever consulted a physician for or been diagnosed or treated for: |
a. mental disorder, epilepsy or stroke?................................................................. [ ] [X] | [ ] [ ]
b. disease or disorder of the heart or blood vessels, heart attack, high blood pressure, or |
rheumatic fever?..................................................................................... [ ] [X] | [ ] [ ]
c. elevated cholesterol?................................................................................ [ ] [X] | [ ] [ ]
d. disease or disorder of the lungs, asthma, emphysema, or tuberculosis?................................ [ ] [X] | [ ] [ ]
e. disease or disorder of stomach, intestines, rectum, liver, or gall bladder?.......................... [ ] [X] | [ ] [ ]
f. disease or disorder of the kidney, bladder, or prostate gland?....................................... [ ] [X] | [ ] [ ]
g. sugar, albumin, blood, or pus in the urine?.......................................................... [ ] [X] | [ ] [ ]
h. cancer, tumor, syphilis, diabetes, gland or blood disorder, ulcer, rupture, or disease or disorder |
of the breast or reproductive organs?................................................................ [ ] [X] | [ ] [ ]
_____________________________________________________________________________________________________________________| ____________
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?.................................................................... [ ] [X] | [ ] [ ]
b. had any other impairment, sickness, laboratory tests, or diagnostic procedures?...................... [ ] [X] | [ ] [ ]
c. been confined in a hospital or other health care facility, had a blood transfusion, or had surgery |
performed, advised, or contemplated?................................................................. [ ] [X] | [ ] [ ]
_____________________________________________________________________________________________________________________| ____________
6. Is any Proposed Insured now taking any medication or under any treatment? [ ] [X] | [ ] [ ]
_____________________________________________________________________________________________________________________| ____________
7. MEDICAL EXAM CERTIFICATE (Complete when submitting a medical examination from another company.) |
a. Attached examinations 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?............................................................ [ ] [X] | [ ] [ ]
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?............................................................. [ ] [X] | [ ] [ ]
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8. FAMILY HISTORY
Proposed Insured A Proposed Insured B
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Family If living If not living, State of health or Family If living If not living, State of health or
History current age(s) age at death cause & date of death History current age(s) age at death cause & date of death
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Father Father
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Mother Mother
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Brothers Brothers
& Sisters & Sisters
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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 ___________ Zip________
Phone: ( )_______________________________________________ Phone: ( )_______________________________________________
Date personal physician was last seen? _____________________ Date personal physician was last seen? _____________________
Reason Seen? _______________________________________________ Reason Seen? _______________________________________________
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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.
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QUES (Proposed) Insured A QUES (Proposed) Insureds B-D
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PART 3. FINANCIAL INFORMATION
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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.
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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 $________________ 4) Total liabilities $______________
(include retained earnings)
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?__________%
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SPECIAL INSTRUCTIONS
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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 THE
UNITED STATES LIFE Insurance Company In the City of New York ("USL") 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, USL 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 USL.
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 USL 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 11.
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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.
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Signed at __________________________________________________________ Date:______________________________
CITY STATE
X____________________________________ X________________________________________ X___________________________________
SIGNATURE OF PROPOSED INSURED A SIGNATURE OF OWNER/TRUSTEE (If other than SIGNATURE OF OWNER
(If below age 15, signature of parent Primary Proposed Insured. Show officer's
or guardian.) title if signing for firm.)
X____________________________________ X________________________________________ X___________________________________
SIGNATURE OF PROPOSED INSURED B SIGNATURE OF OWNER 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).
______________________________ _________________________________ ______________________________ ____________________
AGENT NAME (Please Print) SIGNATURE OF AGENT AGENT NO. STATE LICENSE NO.
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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? Proposed Insured
A B
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
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a.
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b.
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c.
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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," was Definition of Replacement form completed and signed as
required? [ ] YES [ ] NO If "No," please explain:
REMARKS:
( ) X
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Date Contact Person if other than Agent SIGNATURE OF AGENT
( )
---------------------------------- --------------------------------
Telephone No. of Agent PLEASE PRINT NAME
( ) X
---------------------------------- --------------------------------
Facsimile No. of Agent STREET ADDRESS (Please Print)
--------------------------------
CITY STATE ZIP
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BANK DRAFT INFORMATION
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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 THE
UNITED STATES LIFE Insurance Company In the City of New York ("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 Administrative Center.
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
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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
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THE UNITED STATES LIFE Insurance Company In the City of New York ("USL")
Administrative Center: Houston, TX
LIMITED TEMPORARY LIFE INSURANCE AGREEMENT
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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 11
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 11 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
-7-
DETACH THIS
NOTICE & LEAVE
IT WITH THE
PROPOSED INSURED
THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK ("USL")
Administrative Center: Houston, TX
NOTICE TO PROPOSED INSURED
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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 Administration Center
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 The United States Life Insurance Company In
the City of New York, P.O. Box 4880, Administrative Center, Houston, Texas
77210-4880. 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. USL
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.
USL 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: The United States Life Insurance Company In the City of New
York, Administrative Center, P.O. Box 4880, Houston, Texas 77210-4880.
Telephone Interview Information (If Applicable)
To help us process your application as rapidly as possible, USL 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.
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