EXHIBIT 1.A.(10).
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PROTECTIVE LIFE'S SURVIVOR
VARIABLE UNIVERSAL LIFE
APPLICATION PACKET
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INCLUDES:
DESCRIPTION OF INFORMATION PRACTICES
(MUST BE GIVEN TO PROPOSED INSUREDS)
APPLICATION
CONDITIONAL RECEIPT
DESCRIPTION OF INFORMATION PRACTICES
(Including Medical Information Bureau Notice and Fair Credit Reporting Act
Notice)
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In considering the Proposed Insureds' application for insurance,
information from various sources must be considered. These include the results
of the Proposed Insureds' physical examination, if required, and any reports
Protective Life may receive from doctors and hospitals who have attended the
Proposed Insureds.
CONFIDENTIALITY
Information regarding the Proposed Insureds' insurability will be treated as
confidential. Protective Life, or its reinsurers, may, however, make a brief
report thereon to the Medical Information Bureau, a non-profit membership
organization of life insurance companies, which operates an information exchange
on behalf of its members. If the Proposed Insureds apply to another Bureau
member company for life or health insurance coverage, or a claim for benefits is
submitted to such company, the Bureau, upon request, will supply such company
with the information it may have in its file.
DISCLOSURE OF INFORMATION TO THIRD PARTIES
Upon receipt of a request from the Proposed Insureds, the Bureau will arrange
disclosure of any information it may have in the Proposed Insureds' file.
Medical information will be disclosed only to the Proposed Insureds' attending
physician. If the Proposed Insureds question the accuracy of information in the
Bureau's file, the Proposed Insureds may contact the Bureau and seek a
correction in accordance with the procedures set forth in the Federal Fair
Credit Reporting Act. The address of the Bureau's information office is: P.O.
Box 105, Essex Station, Boston, MA 02112. Their telephone number is
617-426-3660.
Protective Life or its reinsurers may also release information in its file to
other life insurance companies to whom the Proposed Insureds may apply for life
and health insurance, or to whom a claim for benefits may be submitted.
INVESTIGATIVE REPORT
As part of our procedures for processing the Proposed Insureds' insurance
application, an investigative consumer report may be prepared by one or more of
the commercial agencies offering this service whereby information is obtained
through personal interviews with the Proposed Insureds' neighbors, friends, or
others with whom the Proposed Insureds are acquainted. This inquiry includes
information as to character, general reputation, personal characteristics, and
mode of living except as may be related directly or indirectly to the Proposed
Insureds' sexual orientation. The Proposed Insureds have the right to be
personally interviewed if we order an investigative consumer report. The
Proposed Insureds also have the right to receive a copy of the report by making
a written request to Protective Life within a reasonable period of time to
receive additional, detailed information about the nature and scope of the
investigation.
PRIVILEGED INFORMATION
As a general practice, we will not disclose personal or privileged information
about the Proposed Insureds to anyone else without the Proposed Insureds'
consent, unless a legitimate business need exists or disclosure is required or
permitted by law. The Proposed Insureds are entitled, upon request, to receive a
more detailed statement of our information practices. The Proposed Insureds also
have the right to ask about personal information which we may have in our files
and the right to seek a correction of information the Proposed Insureds think is
wrong.
FOR MORE INFORMATION
Ask your Registered Representative for assistance, or call or write us at:
Protective Life Insurance Co., Variable Life Services, P.O. Box 830771,
Birmingham, AL 35283-0771, Telephone (800) 265-1545
THIS NOTICE MUST BE GIVEN TO PROPOSED INSUREDS
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PROTECTIVE LIFE'S SURVIVOR
VARIABLE UNIVERSAL LIFE APPLICATION
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1. NAME OF PROPOSED JOINT INSURED 1
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First Middle Last
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Birthdate State of Birth Driver's License # and State
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Sex Marital Status Social Security #
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Residence Address
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City State Zip
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Home Phone # Occupation
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Years Employed Employer Name/Phone #
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3. BENEFICIARIES
Primary Beneficiary: Full Name, Relationship & Percentage
Contingent Beneficiary: Full Name, Relationship & Percentage
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4. / / OWNER IF OTHER THAN A PROPOSED INSURED (Owner must sign Page 4)
/ / Payor (if other than Owner - furnish information in Remarks on Page 3)
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Name Relationship Soc. Sec. # or Tax I.D. #
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Address (Street Address - City, State, Zip)
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Phone #
ALL NOTICES AND REPORTS WILL BE SENT TO THE OWNER UNLESS OTHERWISE SPECIFIED
IN REMARKS.
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5. PLAN INFORMATION Initial Premium $________ Plan of Insurance ____________
Basic Face Amount $_____________ Supplemental Face Amount $____________
Premium Mode: / / Annual / / Semi-Annual / / Quarterly / / PAC
/ / Level Death Benefit / / Increasing Death Benefit
Issue best available Underwriting Class? /X/ Yes
Planned Periodic Premium $____________ Cash With Application $________
PLEASE MAKE CHECK PAYABLE TO:
PROTECTIVE LIFE INSURANCE COMPANY
VARIABLE LIFE SERVICES
P.O. BOX 830771
BIRMINGHAM, AL 35283-0771
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2. NAME OF PROPOSED JOINT INSURED 2
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First Middle Last
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Birthdate State of Birth Driver's License # and State
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Sex Marital Status Social Security #
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Residence Address
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City State Zip
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Home Phone # Occupation
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Years Employed Employer Name/Phone #
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1
6. REGARDING ALL PERSONS PROPOSED FOR INSURANCE:
PLEASE ANSWER ALL QUESTIONS. IF QUESTION #6a IS ANSWERED "YES" DO NOT ACCEPT CASH OR GIVE A CONDITIONAL
RECEIPT WITH THIS APPLICATION. IF ANY QUESTION BELOW IS ANSWERED "YES", GIVE DETAILS UNDER QUESTION 7.
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INSURED 1 INSURED 2
YES NO YES NO
a. Within the past 5 years have you been treated for cancer, diabetes,
cardiovascular disease, stroke, central nervous system disorders, muscular
disorders or respiratory disorders?....................................................................../ / / / / / / /
b. During the past 5 years have you consulted a physician or visited a clinic or
hospital as a patient?.................................................................................../ / / / / / / /
c. Will the policy applied for replace or change any life insurance or annuity in
force?.................................................................................................../ / / / / / / /
d. Do you have an application pending in another company? (If yes, give company and
amount in Remarks)......................................................................................./ / / / / / / /
e. Has any life or health insurance applied for ever been declined, postponed or
offered other than applied for?........................................................................../ / / / / / / /
f. Have you piloted or been a crew member aboard an aircraft within the past 2 years
or have any intention of becoming a pilot?.............................................................../ / / / / / / /
g. Have you ever participated in a sport or avocation such as racing, hang gliding,
scuba, sky or skin diving?.............................................................................../ / / / / / / /
h. Have you used tobacco or nicotine of any kind over the last 12 months?.................................../ / / / / / / /
i. Within the last 5 years have you had a DUI conviction, had your driver's license
restricted or revoked, or been cited for more than two moving violations?................................/ / / / / / / /
j. Within the last 10 years, have you been convicted of a felony?.........................................../ / / / / / / /
k. Do you have any intention of traveling or residing outside the U.S. or Canada
within the next two years?.............................................................................../ / / / / / / /
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7. DETAILS OF ALL "YES" ANSWERS
Insured No. Details, Diagnosis, Names & Address of Doctors, Hospitals
Item (1 or 2) Date/Duration Treatment, Medication, Results & Medical Facilities Consulted
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8. LIFE INSURANCE IN FORCE (INCLUDING BUSINESS INSURANCE): (If none, insert "none")
Insured No. Year Life Accidental Death Existing Loan? To Be
(1 or 2) Company Issued Amount Amount State Amount Replaced?
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SVUL-1040A 1/00 2
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9. TOTAL PREMIUM PAYMENT: $____________
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10. PREMIUM PAYMENT ALLOCATION: Select the allocation for your premium
payments. (MAXIMUM OF 10 FUND SELECTIONS. IF NO ALLOCATION IS SPECIFIED, ALL
PROCEEDS WILL BE ALLOCATED TO THE OPPENHEIMER MONEY FUND/VA.)
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MODEL PORTFOLIOS (CHECK BELOW)
___ Aggressive Growth ___ Growth and Income
___ Growth ___ Balanced
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TOTAL ALLOCATION MUST EQUAL 100%
GOLDMAN SACHS/PIC VAN KAMPEN LIFE INVESTMENT TRUST
___% International Equity ___% Emerging Growth
___% Small Cap Value ___% Enterprise
___% Capital Growth ___% Comstock
___% CORE-SM- U.S. Equity ___% Growth and Income
___% Growth and Income ___% Strategic Stock
___% Global Income ___% Asset Allocation
MFS OPPENHEIMER FUNDS
___% New Discovery ___% Global Securities/VA
___% Emerging Growth ___% Aggressive Growth/VA
___% Research ___% Capital Appreciation/VA
___% Utilities ___% Main Street Growth &
___% Growth Income/VA
___% Growth with Income ___% Strategic Bond/VA
___% Total Return ___% High Income/VA
___% Money Fund/VA
VAN ECK
___% Worldwide Hard Assets
___% Worldwide Real Estate CALVERT
___% Social Small Cap Growth
___% Social Balanced
OTHER
___% __________________
___% __________________
___% __________________ PROTECTIVE LIFE
___% __________________ GENERAL ACCOUNT
___% __________________ ___% Fixed Account
___% __________________
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11. PORTFOLIO REBALANCING
Rebalancing to begin on ____day of ______month (1ST - 28TH)
Rebalancing should occur: / / Quarterly / / Semi-Annually / / Annually
THE VARIABLE CONTRACT VALUE WILL BE AUTOMATICALLY REBALANCED TO THE CURRENT
ALLOCATIONS. THEREFORE, AMOUNTS PREVIOUSLY ALLOCATED TO SPECIFIC FUNDS WILL
ALSO BE REBALANCED.
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12. DOLLAR COST AVERAGING (Restrictions may apply)
Transfer the amount indicated below (MINIMUM $100)
/ / Monthly / / Quarterly ______ Months (MINIMUM 12 MONTHS)
Day of Month________________ (1ST - 28TH)
From Source Fund: _____________ Amt. $___________
To Destination Fund Amount
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------------------------------ $---------------
------------------------------ $---------------
------------------------------ $---------------
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13. ADDITIONAL BENEFITS/RIDERS
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14. TELEPHONE TRANSFERS PROTECTIVE LIFE WILL NOT BE HELD LIABLE FOR ANY LOSS,
LIABILITY, COST OR EXPENSE FOR ACTING ON TELEPHONE INSTRUCTIONS.
/ / By checking this box, I/we authorize the Company to honor telephone
instructions to transfer account values among Sub-Accounts, subject to
the conditions of the prospectus.
/ / By checking this box, I/we authorize the Registered Representative who
signs this application to transfer account values among Sub-Accounts,
subject to the conditions of the prospectus.
MAIDEN NAME OF MOTHER OF PROPOSED INSURED 1 (IN QUESTION #1) __________
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REMARKS:
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HOME OFFICE ENDORSEMENT: (NOT TO BE USED IN KY, MD, MN, OR, PA, WV OR WI.)
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SVUL-1040A 1/00 3
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PROCESSING PROCEDURES: Depending on the amount of insurance, Protective Life
will contact you to collect answers to pertinent medical information or a
paramedical organization will handle these requirements by a medical exam and/or
tests. Protective Life may call you regarding an investigative consumer report.
THE MOST CONVENIENT PLACE TO CALL: / / Home / / Business
BEST DAYS: / / Mon. / / Tue. / / Wed. / / Thur. / / Fri.
BEST TIME: / / Morning / / Afternoon / / Evening
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DECLARATIONS: Each of the undersigned declares that all statements and answers
made in all parts of this application are full, complete, and true to the best
of each person's knowledge and belief. It is agreed that:
(a) All such statements and answers shall be the basis of any insurance
issued.
(b) No agent or medical examiner can make, alter or discharge any
contract, accept risks, or waive the Company's rights or requirements.
(c) No insurance shall take effect unless: (1) a policy is delivered to
the Owner; (2) the full first premium is paid while the Proposed
Insureds are alive; and (3) there has been no change in health and
insurability from that described in this application. However, if the
premium is paid as set forth in the attached Conditional Receipt
Agreement and that Agreement is delivered to the Owner, the terms of
the Conditional Receipt Agreement shall apply.
(d) Acceptance of a policy by the Owner shall constitute ratification of
any changes made by the Company under "Home Office Endorsements." In
those states where it is required, changes as to plan, amount, age at
issue, classification or benefits will be made only with the Owner's
written consent.
AUTHORIZATION: The Proposed Insureds hereby authorize any licensed physician,
medical practitioner, hospital, clinic, or other medically related facility,
insurance company, the Medical Information Bureau (MIB), consumer reporting
agencies (CRA) or other organization, institution or person, that has any
records or knowledge of their health, to give to Protective Life Insurance
Company (Protective Life), its CRA or its reinsurer any such information. A
photographic copy of this authorization shall be as valid as the original.
Protective Life can give information to its affiliates, the MIB, consumer
reporting agencies, and its reinsurers. Protective Life can also give it to
persons doing services for it, or to other insurers. This is true only if it is
in connection with my/our application. Protective Life can disclose
non-sensitive information to the agent representing me/us on this application
only when it is necessary to provide an explanation of the reasons for the
Company's decision to require special underwriting requirements or whenever
my/our application cannot be approved as applied.
We also hereby authorize Protective Life to draw and test our blood and urine as
may be necessary to underwrite our application for insurance coverage. The tests
to be performed may include, but are not limited to, tests for cholesterol and
related blood lipids, diabetes, liver or kidney disorders, and the presence of
antibodies to the Human Immunodeficiency Virus (HIV) that has been associated
with Acquired Immune Deficiency Syndrome (AIDS). Without a court order, state or
federal law to the contrary, or a written authorization by us, these blood and
urine test results will be held in the strictest confidence and made known only
to Protective Life, its reinsurers, MIB. Protective Life can also give these
tests results to other insurers. This is true only if it is in connection with
my/our application. This authorization shall be valid for 30 months from the
date shown below, or, in the event of a claim for benefits, the duration of such
claim. Upon request, I/we or my/our authorized representative will be given a
copy of this authorization. Protective Life may, but is not obligated to,
release these results directly to me/us or my/our spouse(s). Where state and
federal regulations exist governing release of these tests, those regulations
will apply.
INSURED 1 INSURED 2
YES NO YES NO
DO YOU WANT TO BE INTERVIEWED IF AN INVESTIGATIVE CONSUMER REPORT WILL BE MADE? / / / / / / / /
DO YOU BELIEVE THAT THIS POLICY WILL MEET YOUR INSURANCE NEEDS AND FINANCIAL OBJECTIVES? / / / / / / / /
DID YOU RECEIVE THE PROSPECTUS FOR THE POLICY APPLIED FOR AND THE PROSPECTUS FOR EACH OF
THE FUNDS? / / / / / / / /
DO YOU UNDERSTAND THAT THE AMOUNT AND DURATION OF THE DEATH BENEFIT AND THE AMOUNT OF
POLICY VALUES MAY VARY, DEPENDING ON THE INVESTMENT EXPERIENCE OF THE VARIABLE ACCOUNTS? / / / / / / / /
DO YOU UNDERSTAND THAT THE DEATH BENEFIT WILL BE PAID UPON THE DEATH OF THE LAST SURVIVOR
OF THE JOINT INSUREDS? / / / / / / / /
ANY PERSON WHO KNOWINGLY WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE OR
STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING
ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL
PENALTIES.
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YOUR POLICY IS SUBJECT TO A BINDING ARBITRATION PROVISION. SEE YOUR POLICY FOR COMPLETE DETAILS.
Signed At ___________________________________________________ Date ___________________________________________________________
(City and State)
_____________________________________________________________ (X) ___________________________________________________________
Witness to: / /All Signatures / /Signature of Insured 1 Proposed Insured 1 (Sign Name in Full)
/ /Insured 2
(X) ___________________________________________________________
Proposed Insured 2 (Sign Name in Full)
_____________________________________________________________ (X) ___________________________________________________________
Witness to: / /Signature of Insured 1 / / Insured 2 / /Owner *Owner (LISTED ON PAGE 1, QUESTION 4)
PLEASE BE SURE QUESTION 4 IS COMPLETE
*If Owner is Corporation, Partnership or Trust, a Corporate Officer, Partner or the Trustee must sign and state title
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SVUL-1040A 1/00
4
REGISTERED REPRESENTATIVE REPORT
COMPLETE FOR ALL APPLICATIONS AND SEND TO HOME OFFICE
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1. ANSWER THE FOLLOWING QUESTIONS:
a. Will this policy replace or change any existing life insurance
policy(s) or annuity(s) or will the premium for this policy be funded
by withdrawal(s) from an existing life insurance policy or annuity?
/ / Yes / / No
b. I have explained to the Proposed Insureds that this policy is not
effective until a policy is issued and all of the terms of the
Conditional Receipt are satisfied. / / Yes / / No
c. Have you complied with all relevant state requirements, including any
"disclosure and comparison statements"? / / Yes / / No
d. On the basis of the Proposed Insureds' circumstances (including annual
income, net worth, marital and dependent status, long-term objectives
and current life insurance program) and their purpose for acquiring
this insurance, is the purchase of this insurance suitable?
/ / Yes / / No
e. Estimate of Proposed Insureds' combined income and net worth.
Financial Information: Proposed Insured #1 Proposed Insured #2
i. Annual income from occupation $________________ $_________________
ii. Annual income from other sources $________________ $_________________
iii. Estimated Net Worth $________________ $_________________
iv. Tax Bracket _______% _______%
f. Did you give an illustration to the Proposed Insureds? / / Yes / / No
(Protective Life requires a signed copy of an illustration in order to
issue the policy.)
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2. PRINT REGISTERED REPRESENTATIVE INFORMATION
Registered Representative #1 Registered Representative #2
Name
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Signature
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Percentage
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Street Address
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City / State / Zip
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Phone Number
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Broker / Dealer
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Agent Number
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3. PROCESSING INSTRUCTIONS
a. Each Proposed Insured must be given the Description of Information
Practices.
b. If cash is submitted with the application, complete and sign the
Conditional Receipt Agreement on the last page of this application and
give to the Proposed Insureds.
c. Complete and sign any additional forms (e.g. 1035 exchange or state
replacement forms, if applicable).
d. Advise the Proposed Insureds that they will be contacted by a Company
Representative to collect medical information and/or arrange a time
for a paramedical exam.
e. Please have your Broker Dealer send the complete paperwork to the
following address:
REGULAR MAIL OVERNIGHT MAIL
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Protective Life Insurance Co. Protective Life Insurance Co.
Variable Life Services Variable Life Services
P.O. Box 830771 2801 Highway 280 South
Birmingham, Alabama 35283-0771 Birmingham, Alabama 35223
FAX (205) 803-7079 Telephone (205) 879-9230
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SVUL-1040A 1/00 5
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[LOGO]
PROTECTIVE LIFE INSURANCE COMPANY
P.O. BOX 830771
BIRMINGHAM, AL 35283-0771
CONDITIONAL RECEIPT AGREEMENT
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THIS AGREEMENT PROVIDES ONLY A LIMITED AMOUNT OF INSURANCE, FOR A LIMITED PERIOD
OF TIME, AND THEN ONLY IF ALL THE TERMS AND CONDITIONS OF THIS AGREEMENT ARE
MET. NO AGENT OF THE COMPANY CAN ALTER OR WAIVE ANY OF THE PROVISIONS OF THIS
AGREEMENT.
RECEIVED: / / Check in the amount of $_____________________________________,
/ / Pre-Authorized Check (PAC) or / / Payroll Deduction Authorization or
/ / Assignment/Transfer of Ownership for Section 1035 Exchange (1035) from
________________________ as conditional payment of the first premium for an
insurance policy on the life of Proposed Insureds _______________________.
An application for the policy is being made today to Protective Life Insurance
Company. This conditional payment is received under and is subject to the exact
conditions set out below, all of which are a part of this Agreement.
ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO PROTECTIVE LIFE INSURANCE COMPANY, DO
NOT MAKE CHECKS PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK. CASH AND MONEY
ORDERS WILL NOT BE ACCEPTED.
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NOTE: Premium may not be collected where the face amount applied for on
this application plus any other in force life insurance and
accidental death benefits, including those applied for, with this
Company on either Insured exceeds $500,000.
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CONDITIONS UNDER WHICH INSURANCE MAY BECOME EFFECTIVE PRIOR TO POLICY DELIVERY
Unless each and every condition below has been fulfilled exactly, no insurance
will become effective prior to policy delivery to the Owner:
(A) on the Effective Date the Proposed Insureds are insurable exactly
as applied for under the Company's printed underwriting rules for
the plan amount and premium rate class applied for;
(B) that the amount paid with the application and shown above is equal
to the first full premium for the premium rate class applied for;
and
(C) the Proposed Insureds have completed all examinations and/or tests
requested by the Company.
EFFECTIVE DATE OF COVERAGE
Insurance issued based on the application will take effect on the latest of:
(A) the date of the application;
(B) the date requested in the application; or
(C) the date of the last of any medical examinations or tests required
under the rules and practices of the Company.
AMOUNT OF COVERAGE - $500,000 MAXIMUM
The total amount of insurance which may become effective prior to delivery of
the policy to the Owner shall not exceed $500,000. This amount includes other
life insurance and accidental death benefits then in force or applied for with
this Company.
TERMINATION AND REFUND OF PREMIUM
There shall be no insurance coverage under this Agreement and this Agreement
shall be void if:
(A) premium payment is
(1) by check, and it is not honored by the drawee bank upon
presentation;
(2) by PAC, and the deduction is not honored by the drawee bank;
(3) by PDA and the Employer does not make payroll deductions as
authorized by the Employee; or
(4) by 1035 and the cash surrender value received from the
assigned policy(s) is not equal to the first full premium for
the premium rate class applied for.
(B) if the application to which the Agreement was attached is not
approved as applied for by the Company within sixty business days
from its date, the Company's only liability in such event(s) will
be to return any money received.
NOTICE TO THE PROPOSED INSUREDS: You should retain a copy of this Agreement.
The Original will be retained by Protective Life.
Date: ______________________________ Agent: ____________________________
Date: ______________________________ Owner: ____________________________
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WHITE - HOME OFFICE YELLOW - OWNER
SVUL-1040A 1/00 6