EXHIBIT 10(c)
Part C Medical Exam Form American General Financial Group
Life Insurance Application
[_] 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.
---------------------------------------------------------------------------
Section 1-Statement to Medical Examiner
---------------------------------------------------------------------------
Proposed insured_____________________________ Date of birth________________
1. Name of your personal physician_________________________________________
Address_________________________________________________________________
City, state, zip________________________________________________________
Date and findings of last visit_________________________________________
Treatment given or medication prescribed________________________________
2. 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 [_] Yes [_] No
heartbeat, high cholesterol, high blood pressure, or
any other disorder of the heart or blood vessels?
b. any blood clot, aneurysm, stroke, or other disease, [_] Yes [_] No
disorder, or blockage of the arteries or veins?
c. any cancer, cysts, tumors, masses, or other such [_] Yes [_] No
abnormalities?
d. diabetes, disorder of the thyroid or other glands, [_] Yes [_] No
immune system disorder, or blood or lymphatic system
disorder?
e. any disorder of the stomach or liver, colitis, [_] Yes [_] No
hepatitis, or any disorder of the digestive system or
other such organs?
f. any disorder of the kidneys, prostate, urinary system, [_] Yes [_] No
or reproductive organs?
g. any asthma, bronchitis, emphysema, sleep apnea, or [_] Yes [_] No
other breathing or lung disorders?
h. any brain or spinal cord disorders, seizures, or other [_] Yes [_] No
nervous system abnormalities including mental or
nervous disorders?
i. arthritis, muscle disorders, or other bone or joint [_] Yes [_] No
disorders?
3. Are you currently taking any medication, treatment, or [_] Yes [_] No
therapy, or are you under medical observation?
4. Have you in the past three years had:
a. fainting spells, nervous disorders, headaches, [_] Yes [_] No
convulsions, or paralysis?
b. any pain or discomfort in the chest or shortness [_] Yes [_] No
of breath?
c. disorders of the stomach, intestines, or rectum, or [_] Yes [_] No
blood in the urine?
5. Have you ever:
a. sought or received advice, counseling, or treatment [_] Yes [_] No
by a medical professional for the use of alcohol or
drugs, including prescription drugs?
b. used cocaine, marijuana, heroin, controlled substances, [_] Yes [_] No
or any other drug except as legally prescribed by a
physician?
6. Have you ever been diagnosed or treated by any member of [_] Yes [_] No
the medical profession for AIDS Related Complex (ARC) or
Acquired Immune Deficiency Syndrome (AIDS)?
Page 1
Statement to Medical Examiner continued
7. In the past 10 years, have you:
a. been hospitalized, consulted a health care provider, [_] Yes [_] No
or had any illness, injury, or surgery?
b. had any laboratory tests, treatments, or diagnostic [_] Yes [_] No
procedures, including x-rays, scans, or EKGs?
c. been advised to have any diagnostic test, [_] Yes [_] No
hospitalization, or treatment that was not completed?
d. received or claimed disability or hospital indemnity [_] Yes [_] No
benefits or a pension for any injury, sickness,
disability, or impaired condition?
8. Do you have any symptoms or knowledge of any other [_] Yes [_] No
condition that is not disclosed above?
9. Family history:
Father: Age, if living____________ Mother: Age, if living_____________
Age at death______________ Age at death_______________
Current condition or cause Current condition or cause
of death_________________ of death__________________
10. Full details of any "yes" answers (please use additional sheet if
necessary):
Include such details as: date of first diagnosis; name and address of
doctor; tests performed; test results; medication(s) or recommended
treatment.
- -------------------------------------------------------------------------------
I have read the above statements or they have been read to me. The above
statements are true and complete to the best of my knowledge and belief. I
understand that this application: (1) will consist of Part A, Part B, Part
C, and, if applicable, any related forms; and (2) shall be the basis for any
policy issued on this application. 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 (LTLIA)for which all eligibility requirements are met. I
understand and agree that no insurance will be in effect pursuant to this
application, or under any policy issued by the Company, unless or until: the
policy has been delivered and accepted; the full first modal premium for the
issued policy has been paid; and there has been no change in the health of
any proposed insured that would change the answers to any questions in the
application.
In order to determine eligibility for insurance coverage, I hereby give my
consent to any of the entities listed below to give to the Company or its
legal representative, all information they have pertaining to: my medical
consultations, treatments, or surgeries; hospital confinements, which
concern the physical and mental condition of me, my spouse, or my minor
children; my use of drugs or alcohol; or any other non-medical information.
Non-medical information could include items such as: personal finances;
habits; hazardous avocations; motor vehicle or court records; or foreign
travel, etc. The list of entities for which I give my consent to provide the
information above is as follows: any physician or medical practitioner; any
hospital, clinic or other health care facility; any insurance or reinsurance
company; any consumer reporting agency or insurance support organization; my
employer; or the Medical Information Bureau (MIB).
I, as well as any person authorized to act on my behalf, may upon written
request, obtain a copy of this consent from the Company.
This consent will be valid for 30 months from the date of this application.
I agree that a photocopy of this consent will be as valid as the original.
I understand and agree that no agent is authorized to: accept risks or pass
upon insurability; make or modify contracts; or waive any of the Company's
rights or requirements.
Any person who, with intent to defraud or facilitate a fraud against an
insurer, submits an application or files a claim containing a false or
deceptive statement may be guilty of insurance fraud.
Signature of proposed insured___________________________________________
(If under age 15, signature of parent or guardian)
Signed at (city)_______________________ (state) __________ date ______
Signature of examiner___________________________________________________
Page 2
Section 2-Report by Medical Examiner
Proposed insured________________________________ Date of birth_____________
Instructions to Examiner:
To be completed in private by Examiner only. This report is confidential
between the Company and the Examiner. Examination of heart and lungs must be
with stethoscope against bare skin.
1. Build
a. Did you weigh proposed insured? [_] Yes [_] No
b. Is appearance unhealthy or older than stated age? [_] Yes [_] No
Height (in shoes) ________ft. ________in. Weight (clothed) _______lbs.
2. Blood pressure (Record all readings.)
If blood pressure exceeds 140/90, please repeat determination at
end of examination and record in space provided.
Treated [_] Yes [_] No Rx________________________
At rest After exercise 3 minutes later Repeat B.P.
Systolic
Diastolic 5th phase
Pulse rate
Irregularities per min.
3. Heart
a. Is there any cyanosis, dyspnea, edema, [_] Yes [_] No
arteriosclerosis, peripheral vascular, or other
cardiovascular disorder?
b. Is heart enlarged? (If Yes, describe.) [_] Yes [_] No
c. Is murmur present? (If Yes, complete 3. d.) [_] Yes [_] No
d. Before exercise, murmur is:
[_] Constant Transmitted to where
[_] Inconstant Localized at: [_] Apex [_] Base [_] Elsewhere
[_] Systolic (give details)
[_] Diastolic Murmur grade: 1/6 2/6 3/6 4/6 5/6 6/6
(please circle)
After exercise, murmur is:
[_] Unchanged [_] Decreased [_] Increased [_] Absent
Your impression:_______________________________________________________
4. Has this examination revealed abnormality of any of the following:
(circle applicable items)
a. Eyes, ears, nose, mouth, pharynx? (If vision or hearing [_] Yes [_] No
markedly impaired, indicate degree and correction.)
b. Endocrine system (including thyroid and breasts)? [_] Yes [_] No
c. Nervous system (including reflexes, gait, paralysis)? [_] Yes [_] No
d. Respiratory system? [_] Yes [_] No
e. Abdomen (including scars)? [_] Yes [_] No
f. Genito-urinary system (including prostate)? [_] Yes [_] No
g. Skin (including scars), lymph nodes, blood vessels [_] Yes [_] No
(including varicose veins)?
h. Musculoskeletal system (including spine, joints, [_] Yes [_] No
amputations, deformities)?
Page 3
Report by Medical Examiner continued
5. Have any of the following been completed in conjunction [_] Yes [_] No
with this exam?
[_] EKG [_] Chest x-ray [_] Blood drawn [_] Urine
6. Do you have any pertinent information not disclosed above? [_] Yes [_] No
7. Specimen kit
Please indicate where and when specimen kit was sent
[_] CRL [_] Other____________________________
Date mailed______________________________________
8. Details of "yes" answers to Questions 1 - 6. (Identify items. Please use
additional sheet if necessary.)
9. Examiner
Are you related to the proposed insured by blood or marriage or do
you have any business or professional relationship with
the proposed insured? [_] Yes [_] No
If yes, explain.
10. Please send this completed examination form directly to:
Underwriting Department
P.O. Box 2764
Houston, Texas 77252-2764
I certify that this exam was conducted the ______ day of _________, ____, at
[_] a.m. [_] p.m.
Location of exam____________________________________________________________
Authorized by_______________________________________________________________
Examiner's signature________________________________________________________
Examiner's name_____________________________________________________________
Examiner's Social Security # or tax I.D. #__________________________________
(must be furnished under authority of law)
Examiner's address__________________________________________________________
Examiner's phone #__________________________________________________________
Page 4