EXHIBIT 10(b)
AMERICAN GENERAL LIFE INSURANCE COMPANY
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Corporate Markets
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Home Office: Houston, Texas
CORPORATE MARKETS
APPLICATION FOR LIFE INSURANCE
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NAME OF [EMPLOYER] (OWNER): _______________ ABC CORP. _________________________________________________________________________
___________________________________________________________________________________________________
ADDRESS OF [EMPLOYER]: _______________ 999 HERE STREET ___________________________________________________________________
_______________ SOMEWHERE, TX 77076 _______________________________________________________________
___________________________________________________________________________________________________
[EMPLOYER] TAX ID # _______________ 999-9999999 _______________________________________________________________________
PLAN OF INSURANCE: _______________ CA-1 ______________________________________________________________________________
BENEFICIARY: _______________ ABC CORP. _________________________________________________________________________
___________________________________________________________________________________________________
Will this insurance replace, change, or use the cash value of any existing insurance policy or annuity by any
company? [x] NO [ ] YES (If "yes," indicate name of company.) __________________________________________________________
IT IS AGREED THAT:
1. This application, which includes the attached Schedule A, will be the basis for any life insurance issued in
response to it.
2. Application is made to the Company for life insurance on the lives of the individuals specified in Schedule A.
3. The amount of insurance applied for on the life of each individual is specified in Schedule A.
4. The plan of insurance applied for on the life of each individual listed in Schedule A shall be that specified
in the PLAN OF INSURANCE section above.
5. The beneficiary for each individual listed in Section A shall be that specified in the BENEFICIARY section above.
6. NO INSURANCE WILL BECOME EFFECTIVE UNTIL ALL OF THE FOLLOWING HAVE BEEN RECEIVED BY THE COMPANY:
A) THIS APPLICATION PROPERLY COMPLETED, SIGNED, AND DATED;
B) CONSENT OF EACH PROPOSED INSURED AS REQUIRED UNDER STATE LAW;
C) THE FIRST FULL PREMIUM.
I represent that the statements and answers in this application are true and complete to the best of my knowledge and belief
and that there exists between the Owner and each Proposed Insured a substantial economic interest.
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR INSURANCE POLICY IS SUBJECT TO CRIMINAL
AND CIVIL PENALTIES.
Signed at _________SOMEWHERE, TX __________________________ Date: _________ 4/30/99 __________________________________
(CITY, STATE)
Signed for the Owner by the following duly authorized official:
X ____________ SUE SMITH __________________________________ ____________________ PRESIDENT __________________________
SIGNATURE TITLE
AGENT'S STATEMENT: Do you have knowledge or reason to believe that replacement is involved in this transaction?
[x] NO [ ] YES (If "yes," submit replacement forms where required.)
____________ 01023 ____________ ______________ BOB DOE _______________ X ______________ BOB DOE ______________________
STATE LICENSE # AGENT'S NAME PRINTED SIGNATURE OF SOLICITING AGENT
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CM1014-31 CM
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SCHEDULE A
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PROPOSED INSURED FLEXIBLE
(ALPHABETICALLY, DATE SOCIAL TOBACCO USAGE IN INITIAL TERM DEATH DEATH
LAST, FIRST, OF SECURITY ANY FORM WITHIN SPECIFIED RIDER BENEFIT BENEFIT ANNUAL
MIDDLE) SEX BIRTH NUMBER THE PAST 24 MONTHS? AMOUNT AMOUNT OPTION TEST PREMIUM
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Smith, Linda, C. F 10/21/45 ###-##-#### N 50,000 500,000 1 CVAT 2,000
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Jones, Fred D. M 11/1/50 ###-##-#### N 75,000 700,000 1 CVAT 4,000
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I represent that, to the best of my knowledge and belief:
(a) the Proposed Insureds have not been absent from work due to illness or medical treatment for a period of more than 5
consecutive days in the last 90 days; and
(b) that the Proposed Insureds have been actively at work, full time, performing all duties of their regular occupations,
at the customary place of employment (exclusive of weekends, holidays and vacations.) for the last 90 days.
Signed for the Owner by the following duly authorized official:
X ____________ Sue Smith ___________________ ____________ President ________________ ____________ 4/30/99 ____________
OFFICER SIGNATURE TITLE DATE
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CM1014-31 CM
AMERICAN GENERAL LIFE INSURANCE COMPANY
-----------------
Corporate Markets
-----------------
Home Office: Houston, Texas
CORPORATE MARKETS
APPLICATION FOR LIFE INSURANCE
- ------------------------------------------------------------------------------------------------------------------------------------
NAME OF [EMPLOYER] (OWNER): _______________ ABC CORP. _________________________________________________________________________
___________________________________________________________________________________________________
ADDRESS OF [EMPLOYER]: _______________ 999 HERE STREET ___________________________________________________________________
_______________ SOMEWHERE, TX 77076 _______________________________________________________________
___________________________________________________________________________________________________
[EMPLOYER] TAX ID # _______________ 999-9999999 _______________________________________________________________________
PLAN OF INSURANCE: _______________ CA-1 ______________________________________________________________________________
BENEFICIARY: _______________ ABC CORP. _________________________________________________________________________
___________________________________________________________________________________________________
Will this insurance replace, change, or use the cash value of any existing insurance policy or annuity by any
company? [x] NO [ ] YES (If "yes," indicate name of company.) __________________________________________________________
IT IS AGREED THAT:
1. This application, which includes the attached Schedule A, will be the basis for any life insurance issued in
response to it.
2. Application is made to the Company for life insurance on the lives of the individuals specified in Schedule A.
3. The amount of insurance applied for on the life of each individual is specified in Schedule A.
4. The plan of insurance applied for on the life of each individual listed in Schedule A shall be that specified
in the PLAN OF INSURANCE section above.
5. The beneficiary for each individual listed in Section A shall be that specified in the BENEFICIARY section above.
6. NO INSURANCE WILL BECOME EFFECTIVE UNTIL ALL OF THE FOLLOWING HAVE BEEN RECEIVED BY THE COMPANY:
A) THIS APPLICATION PROPERLY COMPLETED, SIGNED, AND DATED;
B) CONSENT OF EACH PROPOSED INSURED AS REQUIRED UNDER STATE LAW;
C) THE FIRST FULL PREMIUM.
I represent that the statements and answers in this application are true and complete to the best of my knowledge and belief
and that there exists between the Owner and each Proposed Insured a substantial economic interest.
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR INSURANCE POLICY IS SUBJECT TO CRIMINAL
AND CIVIL PENALTIES.
Signed at _________SOMEWHERE, TX __________________________ Date: _________ 4/30/99 __________________________________
(CITY, STATE)
Signed for the Owner by the following duly authorized official:
X ____________ SUE SMITH __________________________________ ____________________ PRESIDENT __________________________
SIGNATURE TITLE
AGENT'S STATEMENT: Do you have knowledge or reason to believe that replacement is involved in this transaction:
[x] NO [ ] YES (If "yes," submit replacement forms where required.)
____________ 01023 ____________ ______________ BOB DOE _______________ X ______________ BOB DOE ______________________
STATE LICENSE # AGENT'S NAME PRINTED SIGNATURE OF SOLICITING AGENT
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CM1014-31 CM
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SCHEDULE A
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PROPOSED INSURED FLEXIBLE
(ALPHABETICALLY, DATE SOCIAL TOBACCO USAGE IN INITIAL TERM DEATH DEATH
LAST, FIRST, OF SECURITY ANY FORM WITHIN SPECIFIED RIDER BENEFIT BENEFIT ANNUAL
MIDDLE) SEX BIRTH NUMBER THE PAST 24 MONTHS? AMOUNT AMOUNT OPTION TEST PREMIUM
- ------------------------------------------------------------------------------------------------------------------------------------
Smith, Linda, C. F 10/21/45 ###-##-#### N 50,000 500,000 1 CVAT 2,000
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Jones, Fred D. M 11/1/50 ###-##-#### N 75,000 700,000 1 CVAT 4,000
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I represent that, to the best of my knowledge and belief:
(a) the Proposed Insureds have not been absent from work due to illness or medical treatment for a period of more than 5
consecutive days in the last 90 days; and
(b) that the Proposed Insureds have been actively at work, full time, performing all duties of their regular occupations,
at the customary place of employment (exclusive of weekends, holidays and vacations.) for the last 90 days.
Signed for the Owner by the following duly authorized official:
X ____________ Sue Smith ___________________ ____________ President ________________ ____________ 4/30/99 ____________
OFFICER SIGNATURE TITLE DATE
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CM1014-31 CM