EXHIBIT 10(d)
AMERICAN GENERAL LIFE INSURANCE COMPANY
-----------------
Corporate Markets
-----------------
Home Office: Houston, Texas
LIFE INSURANCE CONSENT FORM
INSTRUCTIONS:
Please mark appropriate boxes in each section and sign below.
- ------------------------------------------------------------------------------------------------------------------------------------
1.
[x] YES, I, _________________ LINDA C. SMITH ________________ ____ 333/33/3333 ____ ____ F ____ ____ 10/21/45 ____
PRINT NAME OF PROPOSED INSURED SOCIAL SECURITY# SEX DATE OF BIRTH
do hereby consent to have insurance purchased on my life by _________________________ ABC Corp _________________________________
(EMPLOYER)
[ ] NO, I, _________________________________________ , do not want the [Employer] to purchase insurance on my life.
PRINT NAME OF PROPOSED INSURED
2.
[x] I agree and understand that the [Employer] will be the Owner and the Beneficiary of the insurance contract.
[ ] I agree and understand that the Owner and the Beneficiary of the insurance contract will be as stated in the application
for coverage.
3.
[x] YES, I 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 I have been actively at work, full time, performing all duties of my regular occupation, at the customary
place of employment (exclusive of weekends, holidays and vacation) for the last 90 days.
[ ] NO, I have not been actively at work as described above. The reasons for my absence(s) are as follows:
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
4.
[ ] YES, I have used tobacco within the past 24 months.
Please state the type of tobacco used and the frequency of usage: ______________________________________________________________
[x] NO, I have not used tobacco within the past 24 months.
X __________________ LINDA C. SMITH __________________________ __________________ 4/29/99 _______________________
SIGNATURE OF PROPOSED INSURED DATE
_____________123 NOWHERE STREET__________________ _____SOMEWHERE____ _______ TX _______ _________ 77777 ____________
ADDRESS CITY STATE ZIP
- ------------------------------------------------------------------------------------------------------------------------------------
CM 1017-99
AMERICAN GENERAL LIFE INSURANCE COMPANY
-----------------
Corporate Markets
-----------------
Home Office: Houston, Texas
LIFE INSURANCE CONSENT FORM
INSTRUCTIONS:
Please mark appropriate boxes in each section and sign below.
- ------------------------------------------------------------------------------------------------------------------------------------
1.
[x] YES, I, _________________ LINDA C. SMITH ________________ ____ 333/33/3333 ____ ____ F ____ ____ 10/21/45 ____
PRINT NAME OF PROPOSED INSURED SOCIAL SECURITY# SEX DATE OF BIRTH
do hereby consent to have insurance purchased on my life by _________________________ ABC Corp _________________________________
(EMPLOYER)
[ ] NO, I, _________________________________________ , do not want the [Employer] to purchase insurance on my life.
PRINT NAME OF PROPOSED INSURED
2.
[x] I agree and understand that the [Employer] will be the Owner and the Beneficiary of the insurance contract.
[ ] I agree and understand that the Owner and the Beneficiary of the insurance contract will be as stated in the application
for coverage.
3.
[x] YES, I 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 I have been actively at work, full time, performing all duties of my regular occupation, at the customary
place of employment (exclusive of weekends, holidays and vacation) for the last 90 days.
[ ] NO, I have not been actively at work as described above. The reasons for my absence(s) are as follows:
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
4.
[ ] YES, I have used tobacco within the past 24 months.
Please state the type of tobacco used and the frequency of usage: ______________________________________________________________
[x] NO, I have not used tobacco within the past 24 months.
X __________________ LINDA C. SMITH __________________________ __________________ 4/29/99 _______________________
SIGNATURE OF PROPOSED INSURED DATE
_____________123 NOWHERE STREET__________________ _____SOMEWHERE____ _______ TX _______ _________ 77777 ____________
ADDRESS CITY STATE ZIP
- ------------------------------------------------------------------------------------------------------------------------------------
CM 1017-99