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THE TRAVELERS INSURANCE COMPANY - ONE TOWER SQUARE - HARTFORD, CT - 06183
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APPLICATION FOR CORPORATE OWNED LIFE INSURANCE
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NAME OF CORPORATION: ______________________________________________________________________
NAME OF POLICY OWNER: ______________________________________________________________________
ADDRESS OF POLICY OWNER: ______________________________________________________________________
POLICY OWNER TAX ID #: __________________________ POLICY DATE: ____________________
PLAN OF INSURANCE: _____Guideline Premium Test _____Cash Value Accumulation Test
PREMIUM PAYMENT PLAN: _____Single ____Annual _____Semi-Annual _____Quarterly _____Monthly
DEATH BENEFIT OPTION: _____Level Death _____Variable Death ____Annual Increase Death
Benefit Benefit Benefit
BENEFICIARY: ______________________________________________________________________
Is the Beneficiary designation irrevocable? _____Yes_____No
It is agreed that:
1. This application, which includes the attached Schedule A, will be the basis
for any policies issued in response to it.
2. Application is made to Travelers Insurance Company for individual life
insurance policies on the lives of the individuals specified in Schedule A.
3. The amount of insurance for each policy applied for shall be the amount
specified for each individual in Schedule A.
4. Each policy applied for shall be of the plan specified in the Plan of
Insurance section above.
Based on information provided by the Corporation, it is my understanding that
for the most recent 90 days, all of the Proposed Insureds been actively at work
for at least 30 hours per week, at their usual place of business, performing
their regular occupations. _____Yes_____No
Based on information provided by the Corporation, it is my understanding that
during the most recent 90 days, none of the Proposed Insureds have been
hospitalized or absent from work (other than recreational days and holidays) for
more than 5 consecutive workdays. _____Yes_____No
AGENT'S STATEMENT: Will this insurance replace, change or use the cash value of
any existing insurance policy or annuity on these insureds? _____Yes_____No
Is this insurance intended to be a 1035 tax-free exchange? _____Yes_____No
If you answered "Yes" to either of these replacement questions, has the required
replacement forms been completed? _____Yes_____No
List company name, amount and attach applicable forms required by state in which
application is signed.
Employer-Applicant hereby represents to The Travelers Insurance Company that
based upon applicable state law, it has sufficient insurable interest in the
lives of the proposed insureds to support issuance of the life insurance
contracts applied for. In support of this representation, Employer-Applicant
further represents that it has sought legal counsel and advice with respect to
the facts and issues surrounding issuance of the proposed contracts.
Employer-Applicant acknowledges that The Travelers Insurance Company is issuing
the life insurance contracts applied for in reliance upon these representations.
The Travelers Insurance Company and ______________ [Broker] hereby expressly
agree that the Applicant, including the Employer-Sponsor of the Applicant, is
authorized to disclose every aspect of the proposed life insurance purchase that
is the subject of this application with any and all persons, without limitation
of any kind.
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Signature of Agent Signature of Owner / Designated Representative
Dated: Dated:
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SCHEDULE A
PROPOSED DATE OF INITIAL BASE TERM INITIAL PLANNED SMOKER/
INSURED SEX BIRTH SS# POLICY INSURANCE PREMIUM PREMIUM NONSMOKER
DEATH BENEFIT RIDER ("S" OR "N")
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I represent that I have read the questions and answers on this application, and
declare that they are complete and true to the best of my knowledge and belief.
Furthermore, I understand that this application will become a part of any policy
issued. I agree that no Agent/Representative of the Company shall: have the
authority to waive a complete answer to any question on this Application;
transfer insurability; make or alter any contract; or, waive any of the
Company's other rights or requirements. I further agree that no insurance shall
take effect unless and until the Policy has been delivered to and accepted by
me; and, the initial modal premium is paid during the lifetime and prior to any
change in health of the Proposed Insured.
Signed for the Policy Owner by the following duly authorized official:
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Signature Title Date
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Print Name
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THE TRAVELERS INSURANCE COMPANY - ONE TOWER SQUARE - HARTFORD, CT - 06183
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VARIABLE LIFE SUPPLEMENT
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This supplement accompanies an application for a Variable Universal Life
Insurance Policy to be issued by The Travelers Insurance Company.
ALL QUESTIONS MUST BE ANSWERED COMPLETELY AND THE APPLICATION AND SUPPLEMENT
MUST BE SIGNED IN ORDER FOR THE COMPANY TO PROCESS THE APPLICATION. MAY BE
REFERENCED BY ATTACHMENT.
Corporation Name _________________________________________
Tax ID# _________________________________________
Owner Name _________________________________________
Tax ID# _________________________________________
FUND INFORMATION
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Select one or more funds and indicate percentage of allocation. Total must equal
100%; allocations must be whole percentages of 5% or more.
[ ] [Capital Appreciation Fund ___ % [ ] Worldwide Growth Portfolio - Service Shares ___ %
[ ] High Yield Bond Trust ___ % [ ] PIMCO VARIABLE INSURANCE TRUST
[ ] Money Market Portfolio ___ % [ ] Total Return Bond Portfolio ___ %
ALLIANCE VARIABLE PRODUCT SERIES FUND, INC. PUTNAM VARIABLE TRUST
[ ] Premier Growth Portfolio - Class B % [ ] Putnam VT International Growth Fund - %
___ Class IB Shares ___
CREDIT SUISSE WARBURG PINCUS TRUST [ ] Putnam VT Small Cap Value Fund-Class IB Shares ___ %
[ ] Emerging Markets Portfolio ___ % [ ] Putnam VT Voyager II Fund - Class IB Shares ___ %
DELAWARE GROUP PREMIUM FUND SALOMON BROTHERS VARIABLE SERIES FUND, INC.
[ ] REIT Series ___ % [ ] Capital Fund ___ %
DEUTSCH ASSET MANAGEMENT, INC. [ ] Investors Fund ___ %
[ ] EAFE Equity Index Fund ___ % [ ] Strategic Bond Fund ___ %
[ ] Small Cap Index Fund ___ % [ ] Total Return Fund ___ %
DREYFUS VARIABLE INVESTMENT FUND TRAVELERS SERIES FUND, INC.
[ ] Appreciation Portfolio - Initial Shares ___ % [ ] AIM Capital Appreciation Portfolio ___ %
[ ] Small Cap Portfolio - Initial Shares ___ % [ ] Alliance Growth Portfolio ___ %
FRANKLIN TEMPLETON VARIABLE INSURANCE [ ] MFS Total Return Portfolio %
PRODUCTS TRUST ___
[ ] Franklin Small Cap Fund - Class 2 % [ ] Smith Barney International All Cap Growth %
___ Portfolio ___
GREENWICH STREET SERIES FUND [ ] Smith Barney Large Capitalization Growth %
Portfolio ___
[ ] Equity Index Portfolio - Class I Shares ___ % [ ] Van Kampen Enterprise Portfolio ___ %
JANUS ASPEN SERIES TRAVELERS SERIES TRUST
[ ] Balanced Portfolio - Service Shares ___ % [ ] Convertible Bond Portfolio ___ %
[ ] Global Technology Portfolio - Service Shares ___ % [ ] Disciplined Mid Cap Stock Portfolio ___ %
[ ] Equity Income Portfolio (Fidelity) ___ % [ ] Quality Bond Portfolio ___ %
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[ ] Large Cap Portfolio (Fidelity) ___ % [ ] U.S. Government Securities Portfolio ___ %
[ ] Lazard International Stock Portfolio ___ % VARIABLE INSURANCE PRODUCTS FUND II
[ ] MFS Emerging Growth Portfolio ___ % [ ] Asset Manager Portfolio - Initial Class ___ %
[ ] MFS Mid Cap Growth Portfolio ___ % [ ] Contrafund Portfolio - Service Class 2 ___ %
[ ] MFS Research Portfolio ___ % VARIABLE INSURANCE PRODUCTS FUND III
[ ] Social Awareness Stock Portfolio ___ % [ ] Mid Cap Portfolio - Service Class 2] ___ %
SUITABILITY
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a) Have you received the prospectus relating to the policy applied for?
_____Yes_____No
Date of prospectus:__________________________________ Date of prospectus
supplement(s): ______________________
b) Do you understand that the Contract Value and Death Benefit associated with
the policy you have applied for may increase or decrease depending upon the
investment experience of the investment options which you have selected?
_____Yes_____No
c) With this in mind, is the policy in accord with your insurance objectives and
anticipated financial needs? _____Yes_____No
APPLICANT declares to the best of his/her knowledge and belief that all of the
statements made in his/her application and supplement, if required, are complete
and true.
ALL VALUES AND BENEFITS PROVIDED BY THE BASIC POLICY APPLIED FOR ARE VARIABLE
AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. EXCEPT AS STATED IN THE
TEMPORARY INSURANCE AGREEMENT/ADVANCE PAYMENT RECEIPT CORRESPONDING TO THIS
APPLICATION, THE COMPANY WILL APPLY THE FIRST NET PREMIUM PAYMENT TO THE CREDIT
OF THE BASIC POLICY APPLIED FOR AS OF THE VALUATION DATE ON OR NEXT FOLLOWING
THE POLICY DATE.
Except as stated in the Employer-Sponsored Temporary Life Insurance Binder
Agreement, no insurance will take effect until: (1) the policy is delivered to
the Applicant; and (2) the first modal premium is paid in full while the health
and other conditions relating to insurability remain as described in the
application. No agent is authorized: (1) to make, alter, or discharge any
policy; (2) to waive or change any condition or provision of any policy,
application or receipt; and (3) to accept any risk or to pass on insurability.
The Proposed Insured will be the Applicant of any policy issued on this
application unless otherwise indicated. The right to privacy is protected as
required by law. Authorized individuals to perform transactions:
Name: Name:
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(Please Print) (Please Print)
Title: Title:
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Signature: Signature:
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Print Name of Owner/Designated Representative Signature of Owner/Designated Representative
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Print Name of Witness Signature of Witness (Licensed Resident Agent)
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Print Name of Principal Signature of Principal
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Name of Broker/Dealer Signature of Broker/Dealer