EXHIBIT 1.(10)(a)(ii)
(USAA LOGO (R)) USAA LIFE INSURANCE COMPANY
APPLICATION FOR
LIFE INSURANCE POLICY CHANGE
1-800-292-8444 o In San Antonio 456-9050
Please complete entire application unless otherwise indicated.
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1 CHANGE REQUESTED
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FOR CONTRACT / POLICY NUMBER __________________________________
INCREASE COVERAGE:
[ ] Increase coverage to $______________
[ ] Increase Accidental Death Benefit to $_______________
[ ] Increase Child Rider to $___________
(PLEASE COMPLETE SECTIONS 5 THROUGH 8 AND THE PERSONAL PROFILE STATEMENT OF
HEALTH.)
OPTION CHANGE:
[ ] Change Universal Life Option from A to B (known as Flexible Premium
Adjustable Life in DC, GA, IL, IN, MD, PA, TN, and VA)
[ ] Change Variable Universal Life Option from A to B (known as Flexible
Premium Variable Life in DC, GA, IL, IN, MD, PA, TN, and VA)
ADD OPTIONAL BENEFITS:
[ ] DISABILITY WAIVER OF PREMIUM. NOT AVAILABLE FOR UNIVERSAL LIFE OR
VARIABLE UNIVERSAL LIFE. If you suffer an accident or illness which
results in a covered disability, this option guarantees that your
premiums will be paid for you while you are disabled.
[ ] WAIVER OF MONTHLY DEDUCTION. AVAILABLE FOR UNIVERSAL LIFE AND VARIABLE
UNIVERSAL LIFE. If you suffer an accident or illness which results in a
covered disability, this option guarantees that your cost of insurance
will be paid for you while you are disabled.
[ ] INCREASING COVERAGE BENEFIT (ICB). AVAILABLE FOR ANNUAL RENEWABLE TERM
(ART) ONLY. This optional benefit automatically increases your coverage
by five percent each year up to a maximum of $15,000 per year,
whichever is less, WITHOUT having to prove insurability ($225,000
lifetime total maximum). There's no initial cost for this rider; you
pay only the additional premium amount for the five percent increase
when it is added to your policy each year.
[ ] ACCIDENTAL DEATH BENEFIT (ADB) OF $___________. AVAILABLE FOR ALL OF
OUR LIFE INSURANCE POLICIES. If you die as a result of a covered
accident, this option will pay your beneficiary an ADDITIONAL amount
above the face amount you have selected for the policy. The selected
ADB can be up to a maximum of $200,000, or the face amount of the
policy, whichever is less. The premium for ADB is $.84 per $1,000 of
coverage per year.
[ ] CHILD RIDER FOR $__________. NOT AVAILABLE FOR SEVEN-YEAR TERM. An easy
way to provide coverage for your child(ren). This rider is available in
$1,000 increments from $2,000 to a maximum of $25,000. The cost for
this rider is $6 per $1,000 of coverage per year. Premiums remain the
same, regardless of the number of children covered. The Proposed
Insured must be age 20 through 55 to select the Child Rider option.
(PLEASE COMPLETE SECTIONS 5 THROUGH 8 AND THE PERSONAL PROFILE
STATEMENT OF HEALTH.)
[ ] SPOUSE RIDER. AVAILABLE ON MOST TERM LIFE INSURANCE POLICIES. Provides
annual renewable term or level term coverage on the spouse of the
primary insured at a generally lower cost than a separate policy. (YOU
SHOULD COMPLETE THIS APPLICATION AND HAVE YOUR SPOUSE COMPLETE THE
SEPARATE SPOUSE RIDER APPLICATION.)
[ ] ANNUAL RENEWABLE TERM (ART) RIDER OF $ __________. AVAILABLE FOR WHOLE
LIFE ONLY. The ART Rider allows you to purchase additional term
coverage at a generally lower cost than a separate policy.
PREMIUM RATING REVIEW [ ]
OTHER: [ ] Increase Planned Periodic Payment To: $ _________________________
(Universal Life/FPAL or Variable Universal Life/FPVL only)
[ ] _________________________________________________________________.
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2 PROPOSED INSURED (PLEASE PRINT OR TYPE)
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NAME: FIRST MIDDLE LAST BIRTH DATE: MO DAY YR
____________________________________________|________________/_____/________
SOCIAL SECURITY NUMBER USAA NUMBER (IF ANY) DRIVER'S LICENSE NUMBER AND
STATE OF ISSUE
________________________|_____________________|_____________________________
OCCUPATION ANNUAL INCOME
______________________________________________|$____________________________
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3 TOBACCO USE (PLEASE LIST DETAILS FOR EACH "YES" ANSWER IN THE
SPACE PROVIDED BELOW)
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A. Has the Proposed Insured smoked one or more cigarettes in the last 12
months? [ ] Yes [ ] No
B. Has the Proposed Insured used any other form of tobacco or tobacco
surrogate in the last 12 months? [ ] Yes [ ] No
C. Has the Proposed Insured ever used any form of tobacco? [ ] Yes [ ] No
____|___________________|______________
TYPE AVERAGE DAILY USAGE DATE LAST USED
____|___________________|______________
TYPE AVERAGE DAILY USAGE DATE LAST USED
____|___________________|______________
TYPE AVERAGE DAILY USAGE DATE LAST USED
____|___________________|______________
TYPE AVERAGE DAILY USAGE DATE LAST USED
31571-0198
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USAA LIFE INSURANCE COMPANY 9800 FREDERICKSBURG ROAD SAN ANTONIO, TEXAS 78288
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4 REPLACEMENT
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Is this application for insurance intended to replace or modify any life
insurance or annuities now in force on the life of any Proposed Insured? (This
information is required by state regulations.) [ ] NO [ ] YES IF YES, PLEASE
LIST EACH POLICY TO BE REPLACED.
_____________________________________________________________________________
COMPANY AMOUNT ISSUE DATE POLICY NUMBER
_____________________________________________________________________________
COMPANY AMOUNT ISSUE DATE POLICY NUMBER
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5 CHILD RIDER (AVAILABLE FOR CHILDREN AGE 17 AND UNDER; NOT
AVAILABLE IN HAWAII)
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If coverage is not desired, proceed to Question 6
CHILD'S NAME BIRTH DATE: MO/DAY/YR SOCIAL SECURITY NUMBER HEIGHT WEIGHT AMOUNT OF LIFE
INSURANCE NOW
IN FORCE
1.______________|______/______/________|_________________________|__FT __IN |___LBS |_______________
2.______________|______/______/________|_________________________|__FT __IN |___LBS |_______________
3.______________|______/______/________|_________________________|__FT __IN |___LBS |_______________
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6 AVOCATION
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Complete this section for all persons covered, including those covered under
the Child Rider. Has any Proposed Insured ever participated in or does any
Proposed Insured plan to participate in (within the next 12 months) any of the
following: [ ] No [ ] Yes IF YES, CHECK ALL THAT APPLY AND PROVIDE DETAILS
BELOW.
[ ] AUTOMOBILE RACING [ ] ROCK OR MOUNTAIN CLIMBING [ ] ULTRALIGHT FLYING
[ ] HANG GLIDING [ ] BALLOONING
[ ] SKYDIVING [ ] POWERBOAT RACING [ ] MOTORCYCLE RACING
[ ] SCUBA DIVING
_____________________________________________________________________________
PROPOSED INSURED AVOCATION TIMES PER MONTH DETAILS (SPEEDS ATTAINED,
DEPTHS/HEIGHTS REACHED, ETC.)
_____________________________________________________________________________
PROPOSED INSURED AVOCATION TIMES PER MONTH DETAILS (SPEEDS ATTAINED,
DEPTHS/HEIGHTS REACHED, ETC.)
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7 FOREIGN RESIDENCE / TRAVEL
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Complete this section for all persons covered, including those covered under
the Child Rider. This questions applies to active duty personnel as well as to
civilians. Do not include vacation travel of 30 days or less to Europe,
Canada, Mexico or Japan.
Do any of the Proposed Insureds plan to travel or reside in a foreign country
within the next 12 months? [ ] No [ ] Yes
IF YES, PROVIDE DETAILS AS INDICATED BELOW.
_____________________________________________________________________________
PROPOSED INSURED COUNTRY NAME PURPOSE OF VISIT LENGTH OF STAY
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PROPOSED INSURED COUNTRY NAME PURPOSE OF VISIT LENGTH OF STAY
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8 AVIATION
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Complete this section for all persons covered, including those covered under
the Child Rider. Please give name of Proposed Insured and details regarding
type of aircraft, FAA certificate type(s), and hours flown.
Has the Proposed Insured ever flown or does any Proposed Insured plan to fly
in the next 24 months as a pilot, crew member, student, or in any capacity
other than as a passenger? [ ] NO [ ] YES IF YES, COMPLETE THE FOLLOWING.
NAME OF PROPOSED INSURED: HOURS FLOWN
____________________________________________________________________________________________________________________
ACTIVE DUTY OR RESERVE BRANCH OF SERVICE MAJOR COMMAND TYPE(S) OF AIRCRAFT NEXT 12 LAST 12 13-24 MOS
MONTHS MONTHS AGO
[ ] PILOT
[ ] CREW MEMBER
________________________|___________________|________________|_______________________|_________|_________|__________
COMMERCIAL [ ] PILOT
[ ] CREW MEMBER
_____________________________________________________________|_______________________|_________|_________|__________
CIVILIAN PLEASURE [ ] PILOT
[ ] CREW MEMBER
_____________________________________________________________|_______________________|_________|_________|__________
TOTAL HOURS FLOWN WHILE IN CHARGE OF AN AIRCRAFT: ____ MILITARY ____ CIVILIAN
If aviation participation requires a restriction for the additional coverage,
which do you prefer?
[] Pay additional premium
[] Have policy contain an Aviation Exclusion except when traveling as
a passenger.
NOTE: THE ABOVE OPTIONS DO NOT APPLY TO THE ACCIDENTAL DEATH BENEFIT. THE
AVIATION EXCLUSION FOR THAT BENEFIT CANNOT BE WAIVED.
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USAA LIFE INSURANCE COMPANY 9800 FREDERICKSBURG ROAD SAN ANTONIO, TEXAS 78288
PERSONAL PROFILE
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STATEMENT OF HEALTH (COMPLETE THIS SECTION FOR ALL PROPOSED INSURERS
INCLUDING ANY PERSON TO BE COVERED BY THE CHILD RIDER)
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Give full details of any "YES" answers to questions #3 or #4. Include dates,
name of Proposed Insured, name and address of physician consulted, reason for
visit, type of treatment, and any medication prescribed in the MEDICAL DETAILS
section listed below.
1. Height and weight of Proposed Insured. _______ Feet _______ Inches
_______ Lbs.
2. Has there been any change in weight during the last 12 months?
[ ] Yes [ ] No If yes, please explain. Gain: ____ Lbs. Loss: ____ Lbs.
3. Has any Proposed Insured under the basic policy or under the Child Rider
ever: YES NO
A. Had a life or health insurance application declined,
postponed, modified or rated? [ ] [ ]
B. Had or been treated by a physician or consulted with
a health advisor for any of the following:
1. Disorder of eyes, ears, nose or throat? [ ] [ ]
2. High blood pressure, chest pain, heart attack
or other cardiovascular disorder? [ ] [ ]
3. Disorder of the kidney, genitourinary tract, or
reproductive system? [ ] [ ]
4. Diabetes, hyperthyroidism or other endocrine
gland disorder? [ ] [ ]
5. Ulcers, hepatitis, disorder of pancreas, liver
or intestines? [ ] [ ]
6. Cancer, tumors, arthritis, disorder of the
bones or joints, or connective tissue disease? [ ] [ ]
7. Disorder of the blood, lymph glands or
respiratory system? [ ] [ ]
8. Mental, nervous system, or brain disorder? [ ] [ ]
9. Alcoholism or advised to reduce or discontinue
the use of alcohol for health reasons? [ ] [ ]
C. Consulted for any other reason a physician or other
physical or mental health advisor within the last
five years? [ ] [ ]
D. Used marijuana, cocaine, heroin, barbiturates,
hallucinogens or amphetamines unless on the advice of
a physician? [ ] [ ]
E. Been diagnosed or treated by a physician for Acquired
Immune Deficiency Syndrome (AIDS), AIDS-related
complex (ARC), or AIDS-related condition? [ ] [ ]
F. Been diagnosed or treated by a physician for any
other sexually transmitted disease (other than
AIDS/ARC)? [ ] [ ]
4. Did mother or father of any Proposed Insured die before age
60 of cardiovascular disease? [ ] [ ]
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MEDICAL DETAILS (ATTACH A SEPARATE SHEET IF MORE SPACE IS REQUIRED)
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QUESTION # PROPOSED INSURED VISIT DATE VISIT REASON
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DOCTOR'S NAME/ADDRESS TREATMENT MEDICATION
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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SPECIAL REQUESTS (WRITE IN ANY SPECIAL INSTRUCTIONS HERE)
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_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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USAA LIFE INSURANCE COMPANY 9800 FREDERICKSBURG ROAD SAN ANTONIO, TEXAS 78288
AUTHORIZATION
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HOME OFFICE ADDITIONS AND CORRECTIONS (DO NOT WRITE IN THIS SPACE)
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No change in age at issue, plan of insurance, amount, risk classification, or
benefits shall be effective unless agreed to in writing by the Proposed
Insured and the applicant it other than the Proposed Insured.
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CONDITIONS RELATING TO THIS APPLICATION / NOTICES
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The Proposed Insured and the applicant, if other than the Proposed In sured,
represent that all statements and answers contained in this application are
complete and true as written to the best of their knowledge and belief and are
offered as consideration for the insurance applied for. It is expressly agreed
that:
1. The company is authorized to amend this application by an appropriate
notation in the space designated HOME OFFICE ADDITIONS AND CORRECTIONS in
order to correct any apparent errors or omissions. However, no change in age
at issue, plan of insurance, amount, risk classification, or benefits shall be
effective unless agreed to in writing by the Proposed Insured and the
applicant if other than the Proposed Insured. The acceptance of any insurance
issued as a result of this application shall constitute an acceptance of such
amendments.
2. The company shall incur no liability under this application prior to
delivery of written confirmation of coverage unless and until all conditions
expressed hereinafter are met:
(a) an amount equal to the first full premium for the method of payment you
selected is received by the company, and
(b) all underwriting requirements, including any medical examinations re
quired by the company's rules are complete.
If the Proposed Insured is an acceptable risk for insurance exactly as ap
plied for without modification of plan, premium rate, or amount of insurance
under the company's rules and practices, then the insurance under the coverage
applied for shall become effective on the latest of: the date the company
receives the application, the date of completion of all underwriting
requirements, or any date of issue requested in the application. If any of the
above conditions are not met, the liability of the company shall be limited to
the return of the premium submitted. PRIOR TO DELIVERY OF WRITTEN CONFIRMATION
OF COVERAGE, THE COMPANY'S MAXIMUM LIABILITY UNDER THIS APPLICATION SHALL NOT
EXCEED $200,000, INCLUDING ACCIDENTAL DEATH BENEFIT.
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AUTHORIZATION
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I hereby authorize any licensed physician, medical practitioner, hospital,
clinic, or medically-related facility, insurance company, Medical Information
Bureau, or any other organization, institution, or person that has any records
or knowledge of me or my health or that of any child to be insured, to provide
USAA Life Insurance Company any such information, including information about
AIDS, HIV, drugs, alcoholism, or mental illness. I further authorize USAA Life
Insurance Company to release any information obtained by this authorization to
its reinsurers, to the Medical Information Bureau, and other insurance
companies with which I have policies or to which I may apply or to which a
claim for benefits may be submitted, and to other persons or organizations
performing business or legal services in connection with my application or
claim. I agree that this authorization will remain in force for 2 1/2 years
from its date and that a reproduction shall be as valid as the original.
I authorize the company to obtain an investigative consumer report on me or
any child to be insured and elect the opportunity to be interviewed if such a
report is prepared.
I agree that any new insurance coverage issued as a result of this application
will be subject to the suicide and contestability provisions of my existing
contract, beginning on the effective date of such new insurance coverage.
I have read and understand the above authorization. I also acknowledge receipt
and review of the Notice of Privacy and Disclosure practices attached to the
application envelope.
NOTE: The following certification is required by the Internal Revenue Service
(IRS) and does not affect your insurability.
CERTIFICATION - Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number
(or I am waiting for a number to be issued to me), AND
2. I am not subject to backup withholding either because I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup
withholding as a result of failure to report all interest or dividends, or the
IRS has notified me that I am no longer subject to backup withholding (does
not apply to real estate transactions, mortgage interest paid, the acquisition
or abandonment of secured property, contributions to an individual retirement
arrangement (IRA), and payments other than interest and dividends).
CERTIFICATION INSTRUCTIONS - You must cross out item (2) above if you have
been notified by IRS that you are currently subject to backup withholding
because of underreporting interest or dividends on your tax return. The IRS
does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
DATED AT__________________THIS___________DAY OF___________________,___________
CITY STATE YEAR
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SIGNATURE OF PROPOSED INSURED OF BASIC POLICY (PARENT IF UNDER 15)
_____________________________________________________________________________
SIGNATURE OF WITNESS (A NOTARY IS NOT REQUIRED)
_____________________________________________________________________________
SIGNATURE OF POLICYOWNER IF OTHER THAN PROPOSED INSURED
31571-0198
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USAA LIFE INSURANCE COMPANY 9800 FREDERICKSBURG ROAD SAN ANTONIO, TEXAS 78288