Exhibit 10(b)
Part B Single Insured American
Life Insurance Application |General
|Financial Group
[_] 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 and Employer Information
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Proposed Name________________________________________________________________
insured Social Security #_________________________ Date of birth___________
Employer____________________________________________________________
Employer address ___________________________________________________
Zip___________ Phone #___________ Length of employment___________
Net worth $__________________________ Household income $___________
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Background Information
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Provide any additional details to "yes" answers for questions 1-6 in the
"Remarks" section on page 4.
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Proposed insured
1. Do you intend to travel or reside outside of the United States or Canada
within the next two years?
[_] yes [_] no
Country, purpose, and date___________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. In the past five years, have you participated in, or do you intend to
participate in: any flights as a trainee, pilot or crew member; scuba diving;
skydiving or parachuting; ultralight aviation; auto racing; cave exploration;
hang gliding; boat racing; mountaineering; or other hazardous activities?
[_] yes [_] no If yes, complete the Aviation and/or Avocation Questionnaire.
3. Has proposed insured:
a) during the past 90 days submitted an application for life insurance to any
other company or begun the process of filling out an application?
[_] yes [_]no If yes, explain.
__________________________________________________________________________
__________________________________________________________________________
b) ever had a life or disability insurance application modified, rated,
declined, postponed, withdrawn, canceled, or refused for renewal?
[_] yes [_] no If yes, explain.
__________________________________________________________________________
__________________________________________________________________________
AGLC 0034-99 Page 1
Background Information continued
4. Have you ever filed for bankruptcy?
[_] yes [_] no
Type of bankruptcy________________________________________________________
Date___________________________________ Date of discharge________________
5. In the past five years, have you been charged with or convicted of driving
under the influence of alcohol or drugs, or had two or more driving
violations? [_] yes [_] no If yes, explain.
State_______________________________ License #____________________________
6. Have you ever been convicted of or pled guilty or "no contest" to a felony
or do you have any such charge pending against you?
[_] yes [_] no If yes, explain.
State_______________________________ Date_________________________________
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Medical History
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Provide any additional details for answers to questions 7-9 in the
"Remarks" section on page 4.
Proposed insured
7. Name and address of your personal physician(s). Write "none" if you
don't have one.
__________________________________________________________________________
__________________________________________________________________________
Date, reason, findings of last visit._____________________________________
8. Height and weight.
ft.________________ in._____________ lbs.__________________
Have you had any weight change in excess of 10 lbs. in the past year?
[_] yes [_] no If yes, explain._________________________________________
__________________________________________________________________________
__________________________________________________________________________
9. What is your family history?
Age if living Age at death Current condition or
cause of death
Proposed insured
Father ____________ ____________ _____________________
Mother ____________ ____________ _____________________
AGLC 0034-99 Page 2
Medical History continued __________________
Proposed
insured
For questions 10-16, provide additional information as
requested in the "Remarks" section on page 4.
10. Have you ever been diagnosed as having, been treated
for, or consulted a licensed health care provider for:
a) any heart disease, heart attack, chest pain,
irregular heart beat, high cholesterol, high blood
pressure, or any other disorder of the heart or blood
vessels? [_] yes [_] no
b) any blood clot, aneurysm, stroke, or other disease,
disorder, or blockage of the arteries or veins? [_] yes [_] no
c) any cancer, cysts, tumors, masses, or other such
abnormalities? [_] yes [_] no
d) diabetes, disorder of the thyroid or other glands,
immune system disorder, or blood or lymphatic system
disorder? [_] yes [_] no
e) any disorder of the stomach or liver, colitis,
hepatitis, or any disorder of the digestive system or
other such organs? [_] yes [_] no
f) any disorder of the kidneys, prostate, urinary
system, or reproductive organs? [_] yes [_] no
g) any asthma, bronchitis, emphysema, sleep apnea, or
other breathing or lung disorders? [_] yes [_] no
h) any brain or spinal cord disorders, seizures, or
other nervous system abnormalities including mental
and nervous disorders? [_] yes [_] no
i) arthritis, muscle disorders, or other bone or joint
disorders? [_] yes [_] no
11. Are you currently taking any medication, treatment,
or therapy, or are you under medical observation? [_] yes [_] no
12. Have you in the past three years had:
a) fainting spells, nervous disorders, headaches,
convulsions, or paralysis? [_] yes [_] no
b) any pain or discomfort in the chest or shortness of
breath? [_] yes [_] no
c) disorders of the stomach, intestines, or rectum, or
blood in the urine? [_] yes [_] no
13. Have you ever:
a) sought or received advice, counseling, or treatment
by a medical professional for the use of alcohol or
drugs including prescription drugs? [_] yes [_] no
b) used cocaine, marijuana, heroin, controlled
substances, or any other drug except as legally
prescribed by a physician? [_] yes [_] no
(If "yes" answered to a or b, complete
Drug/Alcohol Questionnaire.)
14. Have you ever been diagnosed or treated by any member
of the medical profession for AIDS Related Complex (ARC)
or Acquired Immune Deficiency Syndrome (AIDS)? [_] yes [_] no
15. In the past 10 years, have you:
a) been hospitalized, consulted a health care provider,
or had any illness, injury, or surgery? [_] yes [_] no
b) had any laboratory tests, treatments, or diagnostic
procedures, including x-rays, scans, or EKGs? [_] yes [_] no
c) been advised to have any diagnostic test,
hospitalization, or treatment that was not completed? [_] yes [_] no
d) received or claimed disability or hospital indemnity
benefits or a pension for any injury, sickness,
disability, or impaired condition? [_] yes [_] no
AGLC 0034-99 Page 3
Medical History continued ________________
Proposed
insured
16. Do you have any symptoms or knowledge of any other
condition that is not disclosed above? [_] yes [_] no
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Remarks
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Identify question number and provide details to any questions answered "yes" in
the "Background Information" and "Medical History" sections. Include such
details as: date of first diagnosis; name and address of doctor; tests
performed; test results; medication(s) or recommended treatment. If necessary,
attach additional pages to record responses.
________________________________________________________________________________
________________________________________________________________________________
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________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
AGLC 0034-99 Page 4
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Your Signature
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Statements by I have read the above
the proposed statements or they have (LTLIA) for which all eligibility
insured been read to me. The requirements are met, I understand
above statements are and agree that no insurance will be
true and complete to the in effect pursuant to this
best of my knowledge and application, or under any policy
belief. I understand issued by the Company, unless or
that this application: until: the policy has been delivered
(1) will consist of Part and accepted; the full first modal
A, Part B, and, if premium for the issued policy has
applicable, Part C and been paid; and there has been no
related forms; and (2) change in the health of the proposed
shall be the basis for insured that would change the
any policy issued on answers to any questions in the
this application. I application.
understand that any
misrepresentation I understand and agree that no agent
contained in this is authorized to: accept risks or
application and relied pass upon insurability; make or
on by the Company may be modify contracts; or waive any of
used to: reduce or deny the Company's rights or
a claim or void the requirements.
policy, if it is within
its contestable period Insurance fraud
and if such
misrepresentation Any person who, with intent to
materially affects the defraud or facilitate a fraud
acceptance of the risk. against an insurer, submits an
Except as may be application or files a claim
provided in a Limited containing a false or deceptive
Temporary Life Insurance statement may be guilty of insurance
Agreement fraud.
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Signatures X Owner______________________________________ Date______________
Signed at (city, state)_________________________________________
X Witness____________________________________ Date______________
X Proposed insured___________________________ Date______________
(If under age 15, signature of parent or guardian)
I certify that I have truthfully and accurately recorded on the
Part B application the information supplied by the proposed
insured.
Agent name (please print)_______________________________________
Agent #__________________________State license #________________
X Agent_______________________________________ Date_____________
AGLC 0034-99 Page 5