Exhibit 10(b)
Part B
Multiple Insured
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.
Personal and Employer Information
Primary proposed Name
insured --------------------------------------------------------
Social Security # Date of birth
-------------------------------- -----------------------
Employer
---------------------------------------------------------
Employer address
---------------------------------------------------------
Zip Phone # Length of employment
------------ ------------------- ------------------------
Net worth $ Household income $
-------------------------- ------------------------------
- -------------------------------------------------------------------------------
Other proposed Name
insured ---------------------------------------------------------
Social Security # Date of birth
---------------------------------- ----------------------
Employer
---------------------------------------------------------
Employer address
---------------------------------------------------------
Zip Phone # Length of employment
---------- ------------------ ---------------------------
Net worth $ Household income $
------------------------- -------------------------------
Background Information
Provide any additional details to "yes" answers for questions 1-6 in the
"Remarks" section on page 4.
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Primary proposed insured Other proposed insured
1. Do you intend to travel or reside outside of the United States or Canada
within the next two years?
[_] yes [_] no [_] yes [_] no
Country, purpose, and date Country, purpose, and date
----------------------------------- ----------------------------------
----------------------------------- ----------------------------------
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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 [_] yes [_] no
If yes, complete the Aviation and/or If yes, complete the Aviation and/or
Avocation Questionnaire. Avocation Questionnaire.
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Background Information continued
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Primary proposed insured Other proposed insured
3. Has any proposed insured:
a) during the past 90 days submitted an application for life insurance to any
other company or has any proposed insured begun the process of filling out
an application?
[_] yes [_] no If yes, explain. [_] yes [_] no If yes, explain.
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b) ever had a life or disability insurance application modified, rated,
declined, postponed, withdrawn, canceled, or refused for renewal?
[_] yes [_] no If yes, explain. [_] yes [_] no If yes, explain.
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4. Have you ever filed for bankruptcy?
[_] yes [_] no [_]yes [_] no
Type of bankruptcy Type of bankruptcy
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Date Date of discharge Date Date of discharge
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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. [_] yes [_] no If yes, explain.
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State License # State License #
---------------------------------- ----------------------------------
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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. [_] yes [_] no If yes, explain.
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State Date State Date
---------------------------------- ----------------------------------
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Medical History
Provide any additional details for answers to questions 7-9 in the "Remarks"
section on page 4.
Primary proposed insured Other proposed insured
7. Name and address of your personal physician(s). Write "none" if you don't
have one.
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---------------------------------- ----------------------------------
---------------------------------- ----------------------------------
Date, reason, findings of last Date, reason, findings of last
visit visit
---------------------------------- ----------------------------------
---------------------------------- ----------------------------------
---------------------------------- ----------------------------------
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Medical History continued
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Primary proposed insured Other proposed insured
8. Height and weight.
ft. in. lbs. ft. in. lbs.
---------- ---------- ---------------- --------- ----------- -------------
Have you had any weight change in excess of 10 lbs. in the past year?
[_] yes [_] no If yes, explain. [_] yes [_] no If yes, explain.
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9. What is your family history?
Age if living Age at death Current condition
or cause of death
Primary proposed insured
Father ------------- ----------- -----------------
Mother ------------- ----------- -----------------
Other proposed insured
Father ------------- ----------- -----------------
Mother ------------- ----------- -----------------
For questions 10-16, provide additional information as requested in the
"Remarks" section on page 4.
Primary proposed Other proposed Child
insured insured
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 heartbeat, high cholesterol, high blood pressure,
or any other disorder of the heart or blood vessels? [_] yes [_] no [_] yes [_] no [_] yes [_] no
b) any blood clot, aneurysm, stroke, or other disease, disorder,
or blockage of the arteries or veins? [_] yes [_] no [_] yes [_] no [_] yes [_] no
c) any cancer, cysts, tumors, masses, or other such abnormalities? [_] yes [_] no [_] yes [_] no [_] yes [_] no
d) diabetes, disorder of the thyroid or other glands,
immune system disorder, or blood or lymphatic system disorder? [_] yes [_] no [_] yes [_] no [_] 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 [_] yes [_] no [_] yes [_] no
f) any disorder of the kidneys, prostate, urinary system, or
reproductive organs? [_] yes [_] no [_] yes [_] no [_] yes [_] no
g) any asthma, bronchitis, emphysema, sleep apnea, or other
breathing or lung disorders? [_] yes [_] no [_] yes [_] no [_] yes [_] no
h) any brain or spinal cord disorders, seizures, or other
nervous system abnormalities including mental and
nervous disorders? [_] yes [_] no [_] yes [_] no [_] yes [_] no
i) arthritis, muscle disorders, or other bone or joint disorders? [_] yes [_] no [_] yes [_] no [_] yes [_] no
11. Are you currently taking any medication, treatment, or therapy,
or are you under medical observation? [_] yes [_] no [_] yes [_] no [_] yes [_] no
12. Have you in the past three years had:
a) fainting spells, nervous disorder, headaches, convulsions, or
paralysis? [_] yes [_] no [_] yes [_] no [_] yes [_] no
b) any pain or discomfort in the chest or shortness of breath? [_] yes [_] no [_] yes [_] no [_] yes [_] no
c) disorders of the stomach, intestines, or rectum, or blood in the
urine? [_] yes [_] no [_] yes [_] no [_] yes [_] no
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Medical History continued
Primary proposed Other proposed Child
insured insured
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 [_] yes [_] no [_] yes [_] no
b) used cocaine, marijuana, heroin, controlled substances, or any other
drug except as legally prescribed by a physician? [_] yes [_] no [_] yes [_] no [_] 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 [_] yes [_] no [_] 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 [_] yes [_] no [_] yes [_] no
b) had any laboratory tests, treatments, or diagnostic procedures,
including x-rays, scans, or EKGs? [_] yes [_] no [_] yes [_] no [_] yes [_] no
c) been advised to have any diagnostic test, hospitalization, or
treatment that was not completed? [_] yes [_] no [_] yes [_] no [_] yes [_] no
d) received or claimed disability or hospital indemnity
benefits or a pension for any injury, sickness, disability,
or impaired condition? [_] yes [_] no [_] yes [_] no [_] yes [_] no
16. Do you have any symptoms or knowledge of any other condition
that is not disclosed above? [_] yes [_] no [_] yes [_] no [_] yes [_] no
Remarks
Identify question number and name of proposed insured, 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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Your Signature
Statements by the proposed insured(s)
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, and,
if applicable, Part C and 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.
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.
Insurance fraud
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.
Signatures X Owner Date
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Signed at (city, state)
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X Witness Date
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X Primary proposed insured Date
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(If under age 15, signature of parent or guardian)
X Other proposed insured Date
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I certify that I have truthfully and accurately recorded on the
Part B application the information supplied by the proposed
insured(s).
Agent name (please print)
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Agent # State license #
--------------------------------- -----------------------------
X Agent Date
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AGLC 8002-99
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