EXHIBIT 1.A(10)

FLEXIBLE
PREMIUM
VARIABLE
LIFE
INSURANCE
APPLICATION
------------
------------
------------
------------
------------
------------
------------
------------
------------
------------
------------
------------

[Logo of Security Life appears here]
Q2006-9/97

FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE APPLICATION
INSTRUCTIONS
FOR ALL APPLICATIONS
o Use the application approved for the state in which the applicant owner
will sign the application.
o Use dark ink to complete the application.
o Print LEGIBLY to avoid issue errors.
o Attach a complete illustration and all schedules associated with this
application to expedite policy issue process and ensure that the policy is
issued accordingly.
o Incomplete applications may require an amendment to be signed upon
delivery, or may be returned, which will delay the issue process.
o The issue state and appropriate application form will be determined by the
state in which the application was signed by the owner-applicant.
- --------------------------------------------------------------------------------
SIGNATURES REQUIRED, PAGE 10:
o The signature of all proposed insureds (parent or guardian of the proposed
insured if below age 15).
o The signature(s) of the owner. If a corporation is the owner, one officer,
other than the proposed insured, should sign and indicate name of
corporation and title of signing officer.
o The signature of all agent/registered representative(s) included in the
sale. (Page 10 and Registered Representative's Report.)

APPLICATION -- PART I
- --------------------------------------------------------------------------------
SECTION A:

A-3: Exercise Right of Exchange Rider -- complete this box to identify policy to
be exchanged and return the policy along with the application and medical
information on the new proposed insured.
A-4: If the application is employer sponsored, and the policy will be
CORPORATE owned, this question should be answered "No."
- --------------------------------------------------------------------------------
SECTION B: PROPOSED INSURED INFORMATION

B-1: The legal name of the insured will appear on the policy as indicated in
this space.
B-4 Insurance age is calculated as age nearest birthday.
- --------------------------------------------------------------------------------
SECTION C AND SECTION D: OWNER AND BENEFICIARY DESIGNATIONS

o If you are designating more than one owner and/or beneficiary, use
Special Instructions, Section O, and indicate the second owner's name
and/or percentage of the beneficiary split. For example:
John Doe, Husband, 70%
Mary Doe, Mother, 30%
NOTE: The amount must be stated in percentages. A dollar amount may not be
specified.
o If you are designating a trust as the owner and/or beneficiary, include
the name of the Trustee, the name of the Trust and the date of the
Trust. For example:
John Doe, Trustee, of the Revocable Life Insurance Trust of
James Doe, dated November 1, 1991.
o When you are designating more than one owner, include the social security
number or tax identification number for each respective owner in Special
Instructions, Section O.
o If you have children as owners or beneficiaries, please refer to the
brochure entitled "Your Minor Child."
- --------------------------------------------------------------------------------
SECTION F: SPECIAL DATING REQUESTED

o This section provides an option for indicating a specific age and date on
which the policy applied for will be issued. This date is the POLICY
DATE only, and may differ from the INVESTMENT DATE.
- --------------------------------------------------------------------------------
SECTION J: PREMIUM INFORMATION

J-1: Consult your Service Guide for List Bill and EFT guidelines.
J-2: Electronic Funds Transfer (EFT) is a premium payment method which the
payor may elect. If selected, the scheduled premium will automatically be
drafted from the payor's checking account.
J-3: If any Authorized Withdrawal/EFT is collected with this application, the
required premium amount as outlined in the prospectus must be collected in
order to put the policy inforce.
- --------------------------------------------------------------------------------
SECTION K: SUITABILITY

o Must be completed or application will be returned.
o The prospectus date should reflect the date printed on the cover of the
prospectus provided at the time of solicitation.
- --------------------------------------------------------------------------------
SECTION L: 1035 EXCHANGE INFORMATION

L-4: For purposes of 1035 Exchanges, this information is required to carry over
the correct cost basis and loan amount.
- --------------------------------------------------------------------------------
SECTION O: SPECIAL INSTRUCTIONS

o Used for any additional information (for example, billing and mailing
instructions) and continuing your answers for owner and beneficiary
designations.
o If you are requesting child rider(s) and need to request beneficiary(ies)
other than shown in Section D, please indicate here. Include name(s)of
beneficiary(ies) and relationship.
o May be used to continue answers to question L-12, if necessary.
o Payor, accepting rating on formal application only.

APPLICATION -- PART II
- --------------------------------------------------------------------------------
MEDICAL INFORMATION
This part of the application must be completed for each person proposed for
coverage unless the person is medically examined.

ATTACHMENTS
- --------------------------------------------------------------------------------
VARIABLE LIFE SERVICE REQUEST FORM
This form communicates to us the owner's instructions regarding the
financial administration of the policy, with respect to Dollar Cost
Averaging, Automatic Rebalancing and Telephone Privileges/Pin Number. This
form must be returned to us if the policyowner desires any of these
features. Instructions for this form can be found on the page preceding the
form.
- --------------------------------------------------------------------------------
TEAR OFF AND DELIVER TO APPLICANT
State and Federal law require the Fair Credit Summary of Rights and Notice
of Information Procedures be given to the owner/ applicant at the time of
application. Detach the last two pages of the application and leave with
the owner/applicant BEFORE submitting the application to us.
- --------------------------------------------------------------------------------

[Logo of Security Life appears here] Security Life of Denver Insurance Company
Variable Life Customer Service Center
P.O. Box 173888
Denver, CO 80217-3885
1-800-848-6362

APPLICATION FOR FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE TO SECURITY LIFE OF
DENVER INSURANCE COMPANY
- --------------------------------------------------------------------------------
PART I
- --------------------------------------------------------------------------------
Please Print All Information Using Dark Ink
- --------------------------------------------------------------------------------
SECTION A -- GENERAL INFORMATION (Complete for all cases)
A-1 [ ] Check here if insurance is for PENSION or similar tax qualified ERISA
plan.
A-2 If above statement checked, list plan type________________________________
(Example: Profit-Sharing; Defined Contribution; etc.)

A-3 [ ] Exercise Right of Exchange Rider A-4 Employer Sponsored Plans check one:

Name of Insured under Policy to be Exchanged Policy Number Employee Owned? [ ] Yes [ ] No
____________________________________________ _______________

- --------------------------------------------------------------------------------
SECTION B -- PROPOSED INSURED (Complete for all cases. To apply for additional
insureds complete Section G)
B-1 Name (Print full name, include suffix)
(First, Middle, Last, Suffix)
___________________________________________________________________________
B-2 Sex B-3 Birthdate B-4 Insurance Age B-5 Birthplace
[ ] Male Month Day Year (Age Nearest Birthday) (State)
[ ] Female [ | ] [ | ] [ | | | ] [ | ] __________
B-6 Social Security Number B-7 Telephone Number B-8 Height ________
[ | | ]-[ | ]-[ | | | ] [ | | ]-[ | | ]-[ | | | ] B-9 Weight ________
B-10 Address
(Street, Apt. No.)
___________________________________________________________________________
(City) (State) (Zip Code)
________________________________________ _____ [ | | | | ]-[ | | | ]
B-11 Occupation B-12 Describe duties
_______________________________ ____________________________________
B-13 Employer Name Month Year
_____________________________________ B-14 Employment date: [ | ] [ | ]
- --------------------------------------------------------------------------------
SECTION C -- OWNER (Complete only if other than Proposed Insured)
C-1 Owner Name (Print full name, include suffix - if name to appear differently
on policy, indicate in Section O)
(First, Middle, Last, Suffix)
---------------------------------------------------------------------------
C-2 Relationship to Proposed Insured C-3 Social Security Number or Tax I.D. No.
(Include any hyphens)
-------------------------------- [ | | | | | | | | | | ]
C-4 Owner Address
(Street, Apt. No.)
___________________________________________________________________________
(City) (State) (Zip Code)
________________________________________ _____ [ | | | | ]-[ | | | ]
- --------------------------------------------------------------------------------
SECTION D -- BENEFICIARIES (Complete for all cases)

D-1

Primary Beneficiary(ies) (Print Full Names) Relationship to Proposed Insured Birth date
_______________________________________________ ____________________________________ _____________
Contingent Beneficiary(ies) (Print Full Names) Relationship to Proposed Insured Birth date
_______________________________________________ ____________________________________ _____________

Q2006-9/97 1

- --------------------------------------------------------------------------------
SECTION E -- PLAN INFORMATION (Complete for all cases)
E-1 FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY
a. Product Name ___________________________________________
b. Stated Death Benefit $ ________________
c. Adjustable Term Rider [ ] Yes [ ] No
If Yes: Initial Target Death Benefit $ _______________
(Attach Schedule from Illustration for subsequent Target Death
Benefit changes.)
d. Scheduled Periodic Premium $ ________________
(If premium varies from year to year attach schedule)
e. [ ] Option 1 (Stated Death Benefit. If no option selected, Option 1
will apply.)
[ ] Option 2 (Stated Death Benefit plus Account Value.)
f. [ ] Guideline Premium Cash Value Corridor Test
[ ] Cash Value Accumulation Test
g. First Year Pour-In (if any) $ _______________
h. Additional Riders
[ ] Accidental Death $ ________________
[ ] Additional Insured $ _______________(Complete section G)
[ ] Right to Exchange
[ ] Waiver of Cost of Insurance
[ ] Waiver of Specified Premium $ ______________
[ ] Child's Insurance Rider (# of Units) ______ (Complete section H)
[ ] Guaranteed Insurability Rider _________________
[ ] Other _____________________________________________________________
- --------------------------------------------------------------------------------
SECTION F -- SPECIAL DATING REQUESTED
(If neither box checked below, policy will be issued at age nearest birthday as
of issue date.)

Mo Day Year

F-1 [ ] Date to Save Age Specify Requested Age ____ F-2 [ ] Specific Date [ | ] [ | ] [ | | | ]

- --------------------------------------------------------------------------------
SECTION G -- ADDITIONAL INSURED RIDER
G-1 Name of Proposed Additional Insured (If more than one additional insured,
specify details in special instructions, Section O)
(First, Middle, Last, Suffix)
___________________________________________________________________________
G-2 Relationship to proposed insured _________________________________________

Month Day Year

G-3 Birthdate [ | ] [ | ] [ | | | ] G-4 Social Security Number [ | | ]-[ | ]-[ | | | ]

G-5 Height _____ G-6 Weight _____ G-7 Insurance Age (Age nearest birthday)[ | ]
G-8 Show beneficiary for additional insured if different from beneficiary named
in Section D.
Name: __________________ Relationship: ______________ Birth date: _______
- --------------------------------------------------------------------------------
SECTION H -- CHILD RIDER
Birthdate Mo/Day/Yr Height Weight
H-1 Child ____________________________|_____/______/________|_________|________
H-2 Child ____________________________|_____/______/________|_________|________
H-3 Child ____________________________|_____/______/________|_________|________
H-4 Child ____________________________|_____/______/________|_________|________

- --------------------------------------------------------------------------------
SECTION I -- GUARANTEED MINIMUM DEATH BENEFIT OPTION

I-1 GUARANTEE PERIOD (SELECT ONE, IF OPTION DESIRED; OTHERWISE THERE WILL BE NO GUARANTEED PERIOD)

[ ] Later of ten years or proposed insured's age 65 [ ] Lifetime of proposed insured

Note: The Guarantee Period will terminate if:
1. You fail to pay the required Guarantee Period Annual premium defined in
your prospectus; or
2. Your Account Value on any Monthly Processing date is not diversified
according to the following rules:
a. No more than 35% of your Net Account Value may be invested in any
one division; and
b. Your Net Account Value must be invested in at least five divisions.

You will satisfy these diversification requirements if: (i) you
participate in the Automatic Rebalancing feature defined in and
governed by the policy prospectus in effect at the time you elect
the Guarantee Period and your Automatic Rebalancing allocations
comply with the diversifications specified above; or (ii) you elect
Dollar Cost Averaging and direct the resulting transfers into at
least four other Divisions with no more than 35% of any transfer
being to any one division.

There may be other circumstances that will cause the Guarantee Period
to terminate before its scheduled expiration date. See your prospectus
for further information.
- -------------------------------------------------------------------------------
SECTION J -- PREMIUM INFORMATION
J-1 PREMIUM MODE (If no option selected - Premium mode will be quarterly)
[ ] Annual
[ ] Quarterly
[ ] Semi-Annual
[ ] Monthly (only available for List Bill and Authorized Withdrawal/EFT)

J-2 PAYMENT METHOD (If no option selected - Payment Method will be Direct Bill
for Annual, Semi-Annual or Quarterly Premium Mode or EFT for Monthly Mode)
[ ] Direct Bill (not available for monthly)
[ ] Single Premium
[ ] List Bill Existing List Bill Number _________________________
[ ] Authorized Withdrawal (Complete Authorized Withdrawal/EFT Form)

J-3 PREMIUM COLLECTED WITH APPLICATION
The agent is not authorized to collect any premium before delivering a
policy unless the Binding Limited Life Insurance Coverage form has been
completed and signed by the agent, applicant and proposed insured and a
copy given to the applicant. THERE IS NO COVERAGE BEFORE DELIVERY OF THE
POLICY EXCEPT AS PROVIDED BY THAT FORM.

Yes No

[ ] [ ] a. Has agent collected any premium (including any Authorized
Withdrawal/EFT Form) with this application? If yes, total
premium (including any pour-in) collected $ _____________
[ ] [ ] b. If answer to (a) is "Yes," has agent complied with the
Binding Limited Life Insurance Coverage requirements?
[ ] [ ] c. Has the applicant signed and received a Binding Limited
Life Insurance Coverage form in connection with this
application? Attach signed copy of Binding Limited Life
Insurance Coverage form.

NOTE: If any Authorized Withdrawal/EFT is collected with this application, the
required premium amount as outlined in the prospectus must be collected in order
to put the policy inforce.

- --------------------------------------------------------------------------------
SECTION J -- PREMIUM INFORMATION (continued)

J-4 INITIAL PREMIUM ALLOCATION. Please allocate your Initial Premium to the
Guaranteed Interest Division and/or among the Variable Account Divisions.
Please use whole number percentages for each Division elected. You must
allocate at least 1% of your Premium Allocation to each Division in which
you elect to invest. The total must equal 100%.

_______% GUARANTEED INTEREST DIVISION

VARIABLE ACCOUNT DIVISIONS

AIM Invesco Van Eck
____% V.I. Government Securities ____% Industrial Income ____% Worldwide Hard Assets
____% V.I. Capital Appreciation ____% High Yield ____% Worldwide Emerging Markets
____% Utilities ____% Worldwide Bond
Alger American ____% Total Return ____% Worldwide Real Estate
____% Small Capitalization ____% VIF Small Company Growth
____% MidCap Growth
____% Growth Neuberger & Berman
____% Leveraged AllCap ____% Limited Maturity Bond
____% Growth Portfolio
Fidelity Investments ____% Partners Portfolio
____% Asset Manager
____% Growth Portfolio
____% Money Market
____% Index 500

- --------------------------------------------------------------------------------
SECTION K -- SUITABILITY
a. Have you, the Proposed Insured, and the Owner, if other than the
Proposed Insured, received a current Prospectus dated _________________
for the Variable Life Insurance policy applied for and current
prospectus for each of the Variable Account Divisions? [ ] Yes [ ] No
b. Do you understand that under the policy applied for the amount or
duration of the death benefit may vary under specified conditions;
policy values may increase or decrease in accordance with the
investment experience of investment divisions in a Separate Account,
and may increase in accordance with the interest credited in the
Guaranteed Interest Division; and the amount payable at the Final
Policy Date is not guaranteed but is dependent on the amount then in
the Account Value? [ ] Yes [ ] No
c. Do you understand that any personalized illustrations received are
based on hypothetical interest assumptions which may not be indicative
of actual future investment experience of our Separate Account or of
actual interest credited in our Guaranteed Interest Division? [ ] Yes
[ ] No
d. With this in mind, is the policy in accord with your insurance
objectives and your anticipated financial needs? [ ] Yes [ ] No

- --------------------------------------------------------------------------------
SECTION L -- PERSONAL INFORMATION
L-1 List life insurance policies on all persons proposed for coverage (1) now
in force or (2) applied for within the last 12 months, or (3) pending now.
If NONE, Check this box [ ]

Name of Year A.D. Business or Indicate if Inforce,
Proposed Insured Company Issued Amount Amount Personal Applied for, or Pending

--------------------|---------------------|-----------|-----------|---------|-------------|-----------------------------|
--------------------|---------------------|-----------|-----------|---------|-------------|-----------------------------|
--------------------|---------------------|-----------|-----------|---------|-------------|-----------------------------|

Yes No

L-2 Has any proposed insured ever been declined for insurance (or reinstatement)
or been offered insurance with restricted benefits or at other than
standard rates? (If "Yes" give details in section L-12) [ ] [ ]
L-3 Is this insurance to replace, or will it cause any change in, any insurance or
annuity on any person proposed for coverage? (If "Yes" submit a completed replacement form
with this application.) [ ] [ ]
L-4 a. Is this insurance intended to be a tax free exchange - 1035 Exchange?
(If "Yes" indicate Company in section L-12) [ ] [ ]
b. If "Yes" will any policy loan be carried over? [ ] [ ]
L-5 Has any person proposed for coverage:
a. ever smoked cigarettes? (If "Yes," give name and details in section L-12) [ ] [ ]
b. ever used tobacco in any form other than cigarettes? (If "Yes" give name and
details in section L-12) [ ] [ ]
c. ever stopped smoking cigarettes? (If "Yes" give name and date last smoked in
section L-12) [ ] [ ]
d. ever stopped using tobacco in any form other than cigarettes. (If "Yes" give
name, type and date last used in section L-12) [ ] [ ]
L-6 Within the last 3 years or within the next 12 months, has any person proposed
for coverage:
a. flown (or planned to fly) other than as a passenger on a regularly scheduled
airline?
(If "Yes" complete Aviation Supplement.) [ ] [ ]
b. had a drivers license denied, revoked, or suspended; had three or more moving
violations; been convicted of an alcohol or drug related driving offense; been
involved in two or more auto accidents?
(If "Yes" give details in section L-12) [ ] [ ]
c. participated in (or intend to participate in) vehicle racing (on land or water),
ballooning, bobsledding, hang gliding, ultralight aviation, horse racing,
mountaineering, rodeo, scuba/skin diving, skydiving/parachuting, or bungee cord
jumping? (If "Yes" complete Avocation Supplement) [ ] [ ]
L-7 List Driver's License No. here [ | | | | | | | | | | | ] State _____
L-8 Does any person proposed for coverage contemplate traveling or residing outside the U.S.A.
or Canada within the next 12 months? (If "Yes" give details in section L-12) [ ] [ ]
L-9 Has any person proposed for coverage been convicted of a felony within the last
5 years? (If "Yes" give details in section L-12) [ ] [ ]
L-10 Has any person proposed for coverage:
a. ever had, or now have, any type of heart disease, cancer, leukemia, or
malignant tumor? (If "Yes" give details in section L-12) [ ] [ ]
b. ever been diagnosed by a licensed member of the medical profession as having
Acquired Immune Deficiency Syndrome (AIDS) or any immune deficiency or disorder?
(DO NOT ANSWER THIS QUESTION IF YOU RESIDE IN NEVADA.) (If "Yes" give details in
section L-12) [ ] [ ]
L-11 Does any person proposed for coverage now participate in any regular physical
exercise program? [ ] [ ]

L-12 Details of "YES" Answers to Questions L-2 through L-11

- --------------------------------------------------------------------------------
SECTION M -- MEDICAL EXAM CERTIFICATE (Complete when submitting medical
examination of another insurance company.)
M-1 The attached examination is on the life of: _______________________________
M-2 Name of insurance company for which examination was made and date of
examination:
Company Date of Examination
________________________________________________ _________________________
M-3 To the best of the proposed insured's knowledge and belief, are the
statements in the examination true as of today? [ ] Yes [ ] No
(If "No," explain in "Remarks")
M-4 Has the proposed insured consulted a doctor or other practitioner or
received medical or surgical advice since the date of the examination?
[ ] Yes [ ] No
(If "Yes," explain in "Remarks")
Remarks to No. M-3 and M-4

- --------------------------------------------------------------------------------
SECTION N -- FINANCIAL INFORMATION Must be completed where the face amount
exceeds (1) $200,000 for business insurance, (2) $300,000 for an insured 65 and
under, or (3)$100,000 for an insured over 65.

N-1 What is the purpose of the insurance applied for? _________________________
If the insurance applied for is personal, what is the proposed insured's:
Annual Earned Income $ __________ Total Assets $ ___________
Annual Interest & Other Income $ __________ Total Liabilities $ ___________
Total Net Worth $ ___________

N-2 If Business Insurance: Last Year 2 Years Ago
a. Annual net profit
(before taxes, past two years) $ _______________ $ ________________
b. Business reason for insurance (check at least one box and furnish
details)
[ ]Key Person [ ]Stock Redemption/Buy and Sell [ ]Other _____________
c. If Key Person insurance:
(1) Are all partners or key people to be covered? [ ] Yes [ ] No
(If "No," explain)

(2) Does proposed insured have an ownership interest in the business?
[ ] Yes [ ] No
If "Yes," what is proposed insured's percent of ownership? ______%
(3) What is proposed insured's annual income? $ _______________

- --------------------------------------------------------------------------------
SECTION N -- FINANCIAL INFORMATION (Continued) Must be completed where the
face amount exceeds (1) $200,000 for business insurance, (2) $300,000 for an
insured 65 and under, or (3)$100,000 for an insured over 65.
d. If to fund stock redemption, is there a written agreement?
[ ] Yes [ ] No
(1) What is the book value of the business? $ ____________________
(2) What is the market value of the business? $ _____________________
(3) How was the value determined? ____________________________________
N-3 Is this insurance to guarantee a loan? [ ] Yes [ ] No
a. If "Yes," is the lender requiring this insurance? [ ] Yes [ ] No
b. Is the loan finalized? [ ] Yes [ ] No
c. What is the term of the loan? (Months) _____________
d. Name of lender: ______________________________________________________
e. Amount of loan: ______________________________________________________
f. Purpose of loan: ______________________________________________________
g. Are others being insured for the same purpose? [ ] Yes [ ] No
If Yes, who and for what amount?
________________________________________ Amount $ ____________________
________________________________________ Amount $_____________________
N-4 Additional remarks about purpose of the insurance and how the amount of
insurance was determined.

Remarks to Section N

- --------------------------------------------------------------------------------
SECTION O -- SPECIAL INSTRUCTIONS

- --------------------------------------------------------------------------------
PART II
- --------------------------------------------------------------------------------
Please Print All Information Using Dark Ink

Part II MUST be completed for EACH person proposed for coverage unless the
person is medically examined.
- --------------------------------------------------------------------------------
SECTION A -- PERSONAL PHYSICIANS
A-1 For each person proposed for coverage, give the name and address of the
personal physicians and the date and reason the physician was last seen.
IF NONE, CHECK HERE [ ]

Proposed Insured's Name Name and Address of Physician Date and Reason Last Seen

|---------------------------------------|-------------------------------
|---------------------------------------|-------------------------------
- -------------------------|---------------------------------------|-------------------------------
|---------------------------------------|-------------------------------
|---------------------------------------|-------------------------------
- -------------------------|---------------------------------------|-------------------------------
|---------------------------------------|-------------------------------
|---------------------------------------|-------------------------------
- -------------------------|---------------------------------------|-------------------------------

- --------------------------------------------------------------------------------
SECTION B -- MEDICAL INFORMATION (Complete for each person proposed for
coverage.) (For all of Section B, circle each specific condition and give
details of all "Yes" answers in the Details Section following question B-11.
Give name of disease, symptoms, etc.; the date of onset; the duration; number of
attacks; and name and addresses of medical professional or hospital providing
services.)
B-1 Has any person proposed for coverage ever been treated for, or been told by
a member of the medical profession that the person has:

Yes No

a. pain, pressure, or discomfort in the chest or arms; high blood pressure; heart murmur; irregular
heartbeat; or any other disease or disorder of the heart? [ ] [ ]
b. anemia; leukemia; or any other disorder of the blood, veins or arteries? [ ] [ ]
c. asthma; bronchitis; pneumonia; tuberculosis; emphysema; shortness of breath; chronic cough,
or any other disorder of the lungs or respiratory system? [ ] [ ]
d. mental or emotional disorder, nervous breakdown; epilepsy; convulsions; chronic fatigue;
fainting spells; paralysis; stroke; or any other disorder of the brain or nervous system? [ ] [ ]
e. significant weight loss; ulcer; colitis; diverticulitis; hepatitis; cirrhosis; persistent diarrhea;
or other disease of the liver, gall bladder, pancreas, stomach or intestines? [ ] [ ]
f. diabetes; thyroid; recurrent enlarged glands; or other glandular disease or disorder? [ ] [ ]
g. arthritis; gout; or any bone, joint, muscle, or skin disorder? [ ] [ ]
h. polyp, tumor, or cancer? [ ] [ ]
i. disorder of the urinary tract or kidneys; urethritis; cystitis; sugar, albumin, or blood in the
urine? [ ] [ ]
j. prostate or testicular disease; venereal disease; herpes; or disease of the uterus, ovaries or
breasts? [ ] [ ]
k. any disorder of the eyes; ears; nose; or throat? [ ] [ ]
l. any other health impairment or medically or surgically treated condition within the last 5 years
not mentioned above? [ ] [ ]

Yes No

B-2 Has any person proposed for coverage ever been treated for or been told by a licensed member
of the medical profession that the person has Acquired Immune Deficiency Syndrome (AIDS) or
any disorder or deficiency of the Immune System? (DO NOT ANSWER THIS QUESTION IF YOU RESIDE
IN NEVADA.) [ ] [ ]
B-3 Within the past 10 years, has any person proposed for coverage:
a. tested positive in a test to detect antibodies to the AIDSvirus (Human T-Cell Lymphotrophic
virus type III; HTLV-III, Human Immunodeficiency Virus [HIV])? (DO NOT ANSWER
THIS QUESTION IF YOU RESIDE IN CONNECTICUT OR MAINE.) [ ] [ ]
b. had a blood transfusion? [ ] [ ]
B-4 Within the past 5 years, has any person proposed for coverage been a patient in or had treatment
at a hospital, clinic, sanitarium or other medical facility? [ ] [ ]
B-5 Is any person proposed for coverage now under regular medical observation by, or taking
treatment from, a member of the medical profession? [ ] [ ]
B-6 Other than as stated in the answers above, has any person proposed for coverage, within the
last 5 years:
a. had a checkup or consultation with a member of the medical profession? [ ] [ ]
b. had an electrocardiogram, x-ray, blood test or other test? [ ] [ ]
c. been advised by a member of the medical profession to have any diagnostic test,
hospitalization, or surgery which was not completed? [ ] [ ]
B-7 Does any person proposed for coverage have a deformity or an amputation? [ ] [ ]
B-8 Does any person proposed for coverage now take any medicine prescribed by a member
of the medical profession? [ ] [ ]
B-9 Except as legally prescribed by a physician, has any person proposed for coverage ever
used narcotics, cocaine, marijuana, or any hallucinatory or mind altering substances in the
past 10 years? [ ] [ ]
B-10 In the last 5 years, has any person proposed for coverage received treatment for or joined an
organization because of the alcoholism or drug addiction of that person? [ ] [ ]
B-11 Has any parent, brother, or sister of any person proposed for coverage ever
had cancer; diabetes; high blood pressure; heart or kidney disease; nervous
or mental disorder; tuberculosis; or hereditary disorder? [ ] [ ]

Details of "Yes" answers to questions B-1 through B-11

Ques. Name of
No. Proposed Insured Complete Details (including, if any, name of physician noted in Section A-1)

- ------|--------------------|-----------------------------------------------------------------------------------------------
- ------|--------------------|-----------------------------------------------------------------------------------------------
- ------|--------------------|-----------------------------------------------------------------------------------------------
- ------|--------------------|-----------------------------------------------------------------------------------------------
- ------|--------------------|-----------------------------------------------------------------------------------------------
- ------|--------------------|-----------------------------------------------------------------------------------------------

- --------------------------------------------------------------------------------
SECTION C -- FAMILY HISTORY

Living Deceased
Family Member Age State of Health Age at Death/Cause
- ------------- --- --------------- ------------------
Father
Mother
Brothers

Sisters

AGREEMENTS

All statements and answers in this application (which includes Part I, Part II,
and supplements and amendments) are true and complete to the best of my
knowledge and belief. I also agree that:
1. The statements and answers in this application will be relied upon and form
the basis of any insurance.
2. No information will be considered as having been given to Security Life
unless it is written in this application. (THIS PARAGRAPH DOES NOT APPLY IN
THE STATES OF MAINE, MISSOURI, OREGON, SOUTH CAROLINA, AND SOUTH DAKOTA.)
3. No agent or any other unauthorized person can make or change any insurance
contract or give up any of Security Life's rights or requirements. Any
change must be in writing and signed by an officer of Security Life.
4. Security Life may amend this application by an appropriate notation in the
space designated "Home Office Corrections" in order to correct errors or
omissions or to conform the application with any policy that may be issued.
The acceptance of the policy constitutes a ratification of such amendments.
In those states, including Maryland, where change in amount,
classification, plan, premium, or benefit requires the written consent of
the applicant, no change may be ratified except by a written acceptance. We
reserve the right to make any changes required by law.
5. INSURANCE UNDER POLICY APPLIED FOR - EXCEPT AS MAY BE PROVIDED IN ANY
BINDING LIMITED LIFE INSURANCE COVERAGE, NO POLICY OF INSURANCE WILL BE IN
FORCE UNTIL (1) THE FIRST POLICY PREMIUM IS PAID AND (2) THE POLICY IS
DELIVERED WHILE THE FACTS AND HEALTH CONDITION OF THE PROPOSED INSURED(S)
ARE AS REPRESENTED IN THIS APPLICATION. WHEN THESE CONDITIONS ARE
SATISFIED, THE POLICY AS DELIVERED WILL THEN TAKE EFFECT.
6. Binding Limited Life Insurance Coverage - Any pre-delivery insurance
coverage is provided in the Binding Limited Life Insurance Coverage form.
That coverage is available only if: a premium is accepted by the agent; the
agent has authority to accept premium as set out in that form; and the form
is completed and signed by the agent, applicant, and proposed insured.
7. If the contract applied for is for a pension, profit-sharing, HR10, or
other tax qualified plan, any policy issued shall not be transferable other
than to the Insurer, except as directed by the Plan Administrator. Other
applicable provisions may be added to the contract.
8. I certify, under penalty of perjury, that my social security/tax
identification number(s) is shown and is correct and that I am not subject
to back up withholding.

AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION

Security Life of Denver Insurance Company ("Security Life") may obtain
information about me or my minor children from: any physicians; medical
practitioner; hospital, clinic or other medical facility; employer; other
insurance companies or institutions; consumer reporting agency; or Medical
Information Bureau, Inc. (MIB, Inc.). The purpose is to evaluate my application
for insurance or benefits. Security Life may obtain an investigative consumer
report and any records or other information available as to diagnosis, treatment
and prognosis of any physical or mental condition.

Security Life may obtain any drug, physical and mental health, and
alcohol-related information which may be protected by federal or state laws and
regulations. As it pertains to alcohol and drug information covered by federal
regulation, this authorization may be revoked at any time by written notice to
Security Life. But any action taken before my written revocation is received by
Security Life will not be affected.

Security Life may make a brief report about me or my children to MIB, Inc.
Security Life may disclose information to: its reinsurers; those who perform
services for Security Life on my application for insurance or benefits: or those
companies to which I have applied or may apply for life or health insurance or
benefits. Disclosure may be made when required or permitted by law.

This is valid for two and one-half years from the date below. An original or
copy may be used by Security Life or its authorized representatives to obtain
information. I have read and received a copy of this authorization. I also have
a copy of the Notice of Information Procedures. It includes the MIB, Inc.
and Fair Credit Reporting Notices.

NOTICE: Any person who knowingly and with intent to injure, defraud, or deceive
any insurance company, files an application, statement or claim containing any
false, incomplete, or misleading information may be guilty of insurance fraud.

Signature of
Proposed Insured ________________________________________ Date ________________
(If below age 15, signature of parent or guardian)
Signature of Owner (If other than proposed insured)
OR (IF APPLICABLE) Corporate Owner Signature ___________________________________
(If a firm or corporation is to be owner, the signature and
title of an officer other than the proposed insured is required.)
Signed by Owner at (State) _______________

Signature of Spouse _________________________________

Signature of Additional Insured(s)
(If proposed for coverage) _____________________________________________

Except for any medical exam form, I certify that I have asked and recorded completely and accurately the answers to all questions
on this application. I know of nothing else affecting the risk.

Signature of Agent/Registered Rep. ______________________________________ Reg.Rep. Number ________________________
Signature of Agent/Registered Rep. ______________________________________ Reg.Rep. Number ________________________
Signature of Agent/Registered Rep. ______________________________________ Reg.Rep. Number ________________________

_______________________________________ ______________________________________
Name of Broker/Dealer/Branch/OSJ Address of Broker/Dealer/Branch/OSJ

HOME OFFICE
CORRECTIONS
(FOR HOME OFFICE
USE ONLY)
(Not applicable in West Virginia)
10

REGISTERED REPRESENTATIVE'S REPORT
(Must be completed and signed for every application)

Yes No Yes No

1) Do you have knowledge or reason to 5) What is the amount of insurance in force
believe that replacement of existing on the spouse of the proposed insured?
insurance or annuity may be involved? [ ] [ ] $_______________________
If Yes, explain:_________________________ 6) If any proposed insured is a minor, what
2) How long have you known the proposed is the amount of insurance on:
insured? ______ Years
Are you related? [ ] [ ] Father $___________ Mother $__________
If so, how? ____________________________ Brothers $___________ Sisters $__________
3) Does the proposed insured speak English? [ ] [ ]
7) Will the applicant accept this policy if it
Was the application interpreted for and is a "Modified Endowment" at issue? [ ] [ ]
understood by the proposed insured? [ ] [ ] 8) If a medical exam is required, has it been
ordered? [ ] [ ]
Are all persons proposed for coverage 9) What is the source of the first premium payment:
U.S. citizens? [ ] [ ] [ ] Applicant check
If not, how long in U.S.? _____Mos. _____Yrs. [ ] Other (specify):________________________
4) Did proposed insured approach you for
this insurance? [ ] [ ]

- --------------------------------------------------------------------------------

10) Writing Registered Representative (Print) ______________________________________ Production Credit Split
Variable
Writing Registered Representative (Sign) Agent Number Percent
_______________ _______
Date _________________________ Registered Representative Number: [ | | | | | ] _______________ _______
_______________ _______

- --------------------------------------------------------------------------------
11) What was the PRIMARY purpose of the insurance?

PERSONAL PLANNING Business Planning
A [ ] Estate/Death Tax J [ ] Executive Bonus
B [ ] Family Protection K [ ] Qualified Plan
C [ ] Mortgage Protection L [ ] Deferred Compensation
D [ ] College Funding M [ ] Buy-Sell
E [ ] Gift/Charitable N [ ] Key Executive
F [ ] Retirement Maximizer O [ ] Employee Benefit
G [ ] IRP/PPP/PRO P [ ] Other ______________________
H [ ] Savings
I [ ] Other _________________________
- --------------------------------------------------------------------------------
12) Who was the PRIMARY decision-maker involved?

PERSONAL PLANNING BUSINESS PLANNING

A [ ] Insured D [ ] Grandparent G [ ] Businessowner J [ ] Board of Directors
B [ ] Insured and Spouse E [ ] Child(ren) H [ ] Attorney K [ ] Trustee
C [ ] Parent F [ ] Other ______________ I [ ] Accountant L [ ] Other __________________

- --------------------------------------------------------------------------------

13) Did the Home Office or Regional Staff assist you? [ ]Yes [ ]No (If yes, check all that apply.)

A [ ] Illustration D [ ] Template design G [ ] Family Asset Review J [ ] Other __________________
B [ ] Case design E [ ] Estate Analysis H [ ] Competition Services
C [ ] Sample Documents F [ ] Business Analysis I [ ] Legal Consultation

INSTRUCTIONS FOR COMPLETING VARIABLE LIFE SERVICE REQUESTS FORM

SECTION 1 -- SECTIONS TO BE COMPLETED
- -------------------------------------------------------------
> Complete each of the sections indicated for each option.
> Obtain signatures and date in Section 9.

SECTION 2 -- POLICY INFORMATION:
- -------------------------------------------------------------
> New Policies. If the service request is in connection with a new policy
application please enter the name of the proposed insured, the proposed
policyowner, the policy face amount and the date the application was signed
in Section 2A.
> Existing Policies. If the service request is for an existing policy, please
enter the policy number in Section 2B.

SECTION 3 -- PREMIUM PAYMENT ALLOCATION CHANGE REQUEST
- -------------------------------------------------------------
o Enter your future premium allocation.
o Premium allocations must be made only in whole percentages.
o The sum of all premium allocations must equal 100%.

SECTION 4 -- TELEPHONE PRIVILEGE AUTHORIZATION OR REVOCATION:
- -------------------------------------------------------------
> You may give each policyowner and your Registered Representative the
authority to transfer policy values among the divisions or to request a
partial withdrawal by telephone. If you elect telephone privileges, you must
also have a PIN number. If you wish to use a specific PIN number, please
indicate that number on the request form in Section 6.
o Mark the boxes indicating the individuals for whom telephone
authority is granted.
o To revoke telephone privileges for a specific individual, mark the box next
to the persons for whom privileges are to be revoked.
o If you are revoking telephone privileges for your registered
representative, the PIN number will be changed.

SECTION 5 -- AUTOMATIC REBALANCING OPTION:
- -------------------------------------------------------------
> GENERAL
o The total of all automatic rebalancing allocations must equal 100%.
o Automatic rebalancing may be done at the same time as dollar cost
averaging. If you do these simultaneously, exclude the division from which
the dollar cost averaging transfers will be taken.
o Automatic rebalancing percentages may be different from the premium
allocation percentages.
> TO INITIATE AUTOMATIC REBALANCING OPTION:
o Enter the percentage for each Division you wish to include in
automatic rebalancing. The total of all percentages must equal 100%.
[IMPORTANT REMINDER: If you also have elected the Guaranteed Minimum
Death Benefit, you must invest your funds in at least 5 Divisions with no
more than 35% in any one Division.]
o Indicate the frequency and date with which you wish automatic rebalancing
to occur.
> TO CHANGE YOUR AUTOMATIC REBALANCING PERCENTAGES OR FREQUENCY:
o Enter the percentage for each division you wish to include in
automatic rebalancing. The total of all percentages must equal 100%.
o Indicate the frequency and date with which you wish automatic
rebalancing to occur.

SECTION 6 -- PIN NUMBER CHANGE:
- -------------------------------------------------------------
o You must have a PIN number if you elect the telephone privilege option.
o If you wish to use a specific PIN number, please indicate that number in
this section.

SECTION 7 -- DOLLAR COST AVERAGING OPTION:
- -------------------------------------------------------------
> TO INITIATE OR CHANGE DOLLAR COST AVERAGING:
o Changes to Dollar Cost Averaging allocations are allowed once each policy
year.
o Enter the total percentage/dollar amount you wish to have transferred from
either the Money Market or the Bond Division into the Divisions of the
Variable Account.
o Enter the percentage/dollar amount you wish to have transferred into
each selected Division of the Variable Account.
[IMPORTANT NOTE: When transferring funds from one Division to
another, you may:
-- transfer dollar amounts to dollar amounts
-- transfer dollar amounts to percentages
-- transfer percentages to percentages
You may not transfer percentages to dollar amounts.]
o Percentages must add up to 100%.
o Dollar amounts must add up to the total dollar amount to be
transferred.
o Indicate the frequency and date with which you wish dollar cost averaging
to occur.
o You may specify a date for Dollar Cost Averaging to terminate. You may also
specify a dollar amount so that when the Accumulation value reaches this
dollar amount, Dollar Cost Averaging will terminate.

SECTION 8 -- DIVISION TRANSFER REQUEST:
- -------------------------------------------------------------
> Fund Transfers Among Divisions
o Enter the dollar/percentage you wish to transfer in the "Transfer
From" column. Enter the dollar/percentage you wish to transfer into a
Division in the "Transfer To" column.
[IMPORTANT NOTE: When transferring funds from one Division to
another, you may:
-- transfer dollar amounts to dollar amounts
-- transfer dollar amounts to percentages
-- transfer percentages to percentages
You may not transfer percentages to dollar amounts.]
o A minimum of $100 must be transferred. This minimum need not come
from any one Division or be transferred to any one Division as long as the
total amount requested to be transferred equals at least $100.
o The total dollar amount shown in the "Transfer To" column must equal the
total dollar amount shown in the "Transfer From" column.
o The total percentages shown in the "Transfer To" column must equal 100%.
o Transfers to or from the Guaranteed Interest Division have specific time
and amount limitations. Please refer to your policy or prospectus for
additional information.

VARIABLE LIFE SECURITY LIFE OF DENVER INSURANCE COMPANY [Logo of Security Life appears here]
SERVICE REQUESTS FORM Variable Life Customer Service Center
FOR NEW AND EXISTING VARIABLE LIFE POLICIES P. O. Box 173888, Denver, CO 80217-3885
1-800-848-6362

- --------------------------------------------------------------------------------
SECTION 1: SECTIONS TO BE COMPLETED
- --------------------------------------------------------------------------------

For Automatic Rebalancing Option-- Complete Sections 2, 5 & 9 For Division Transfer Requests-- Complete Sections 2, 8 & 9
For Dollar Cost Averaging Option-- Complete Sections 2, 7 & 9 For Telephone Transfer Authorization/Revocation -
Complete Sections 2, 4 & 9
For Premium Allocation Change Requests-- Complete Sections 2, 3 & 9 For PIN Number Changes-- Complete Sections 2, 6 & 9

- --------------------------------------------------------------------------------
SECTION 2: POLICY INFORMATION
- --------------------------------------------------------------------------------
A. [ ] FOR NEW POLICIES:
Proposed Policyowner Name:___________________________
Proposed Insured's Name:___________________________
Policy Face Amount:___________________________
Policy Application Date:___________________________
B. [ ] FOR EXISTING POLICIES:
Policyowner Name:___________________________
Policy No.:___________________________

- --------------------------------------------------------------------------------
SECTION 3: PREMIUM ALLOCATION CHANGE REQUEST
- --------------------------------------------------------------------------------

NEUBERGER & BERMAN ALGER AMERICAN
_____% Limited Maturity Bond _____% Small Capitalization
_____% Growth Portfolio _____% MidCap Growth
_____% Partners Portfolio _____% Growth
VAN ECK _____% Leveraged AllCap
_____% Worldwide Hard Assets FIDELITY INVESTMENTS
_____% Worldwide Real Estate _____% Growth Portfolio
_____% Worldwide Bond Fund _____% Overseas
_____% Worldwide Emerging _____% Money Market
Markets _____% Index 500
INVESCO _____% Asset Manager
_____% Industrial Income AIM
_____% High Yield _____% V.I. Government
_____% Utilities Securities
_____% Total Return _____% V.I. Capital
_____% Small Company Growth Appreciation
_____% GUARANTEED INTEREST DIVISION

- --------------------------------------------------------------------------------
SECTION 4: TELEPHONE PRIVILEGE AUTHORIZATION OR REVOCATION
- --------------------------------------------------------------------------------
[ ] TELEPHONE PRIVILEGE AUTHORIZATION: I/We authorize Security Life of
Denver to accept telephone instructions from the Owners/ Registered
Representative of the policy listed above:
[ ] Owners Only [ ] Owner and Registered Representative
[ ] REVOCATION OF TELEPHONE PRIVILEGE AUTHORIZATION: I/We revoke all
telephone privilege authorization in place on the policy listed above for
the following persons:
[ ] Owners and Registered Representative
[ ] Registered Representative Only

By signing this form, I/we agree to hold harmless and indemnify Security Life
for any losses arising from such authorization/revocation instructions. We
further authorize Security Life to record telephone conversations with any
person utilizing telephone privileges on the policy listed in Section 2. I/We
understand that Security Life reserves the right to discontinue the telephone
privilege at any time.

- --------------------------------------------------------------------------------
SECTION 5: AUTOMATIC REBALANCING OPTION
- --------------------------------------------------------------------------------
[ ] INITIATE AUTOMATIC REBALANCING (complete below)
[ ] CHANGE AUTOMATIC REBALANCING (complete below)

AUTOMATIC REBALANCING ALLOCATION

FREQUENCY AND DATE OF AUTOMATIC REBALANCING:
(If no options are marked, frequency will be quarterly and/or date will be last
valuation date of calendar period.)
FREQUENCY:
[ ] Monthly [ ] Quarterly [ ] Semi-annually [ ] Annually
DATE:
[ ] Policy Processing Date - Date on which processing will occur based on
frequency selected beginning______________________________
(Month/Date)
[ ] Last Valuation Date of Calendar Period
[ ] Specific Date each Period beginning_______________________
(Specify Date)

- --------------------------------------------------------------------------------
SECTION 6: PIN NUMBER CHANGE
- --------------------------------------------------------------------------------
[ ] Please issue a new Personal Identification Number (PIN #) for the policy
listed above.
[ ] Use the following specific number ____________________

I/We understand that only individuals with telephone privilege authority will be
notified of the PIN Number change.

FOR HOME OFFICE USE ONLY.

- --------------------------------------------------------------------------------
SECTION 7: DOLLAR COST AVERAGING OPTION
- --------------------------------------------------------------------------------
[ ] INITIATE DOLLAR COST AVERAGING (complete below)
[ ] CHANGE DOLLAR COST AVERAGING (complete below)
Please transfer $_________ or _________% from:
(check one only)
[ ] Fidelity Investment Money Market Division
[ ] Neuberger & Berman Limited Maturity Bond Division
into: the Variable Account Division(s) selected below.

DOLLAR COST AVERAGING ALLOCATION
NEUBERGER & BERMAN
$________or________% Limited Maturity
$________or________% Growth
$________or________% Partners
ALGER AMERICAN
$________or________% Small Capitalization
$________or________% Midcap Growth
$________or________% Growth
$________or________% Leveraged AllCap
FIDELITY INVESTMENTS
$________or________% Asset Manager
$________or________% Growth Portfolio
$________or________% Overseas
$________or________% Money Market
$________or________% Index 500
INVESCO
$________or________% Industrial Income
$________or________% High Yield
$________or________% Utilities
$________or________% Total Return
$________or________% Small Company Growth
VAN ECK
$________or________% Worldwide Hard Assets
$________or________% Worldwide Emerging Markets
$________or________% Worldwide Real Estate
$________or________% Worldwide Bond
AIM
$________or________% V.I. Government Securities
$________or________% V.I. Capital Appreciation

$________or________% GUARANTEED INTEREST DIVISION

FREQUENCY AND DATE OF DOLLAR COST AVERAGING:
(If no options are marked, frequency will be monthly and/or date will be policy
processing date.)
FREQUENCY:
[ ] Monthly [ ] Quarterly [ ] Semi-annually [ ] Annually
DATE:
[ ] Policy Processing Date - Date on which processing will occur based on
frequency selected beginning_________________________
(Month/Date)
[ ] Specific Date each Period beginning__________________
(Specify Date)
TERMINATE:
[ ] Terminate Dollar Cost Averaging on (date)___________________
[ ] Terminate Dollar Cost Averaging when Division from which money is being
transferred reaches $______________________

- --------------------------------------------------------------------------------
SECTION 8: DIVISION TRANSFER REQUEST
- --------------------------------------------------------------------------------
[ ] CHANGE PREMIUM PAYMENT ALLOCATION
[ ] TRANSFER BETWEEN DIVISIONS
TRANSFER FROM DIVISION TRANSFER TO
NEUBERGER & BERMAN
$_______or_______% Limited Maturity $_______or_______%
$_______or_______% Growth $_______or_______%
$_______or_______% Government Income
$_______or_______% Partners $_______or_______%
ALGER AMERICAN
$_______or_______% Small Capitalization $_______or_______%
$_______or_______% Midcap Growth $_______or_______%
$_______or_______% Growth $_______or_______%
$_______or_______% Leveraged AllCap $_______or_______%
FIDELITY INVESTMENTS
$_______or_______% Asset Manager $_______or_______%
$_______or_______% Growth Portfolio $_______or_______%
$_______or_______% Overseas $_______or_______%
$_______or_______% Money Market $_______or_______%
$_______or_______% Index 500 $_______or_______%
INVESCO
$_______or_______% Industrial Income $_______or_______%
$_______or_______% High Yield $_______or_______%
$_______or_______% Utilities $_______or_______%
$_______or_______% Total Return $_______or_______%
$_______or_______% Small Company Growth $_______or_______%
VAN ECK
$_______or_______% Worldwide Balanced
$_______or_______% Worldwide Hard Assets $_______or_______%
$_______or_______% Worldwide Emerging Markets $_______or_______%
$_______or_______% Worldwide Real Estate $_______or_______%
$_______or_______% Worldwide Bond $_______or_______%
AIM
$_______or_______% V.I. Government Securities $_______or_______%
$_______or_______% V.I. Capital Appreciation $_______or_______%

$_______or_______% GUARANTEED INTEREST $_______or_______%
DIVISION

- --------------------------------------------------------------------------------
SECTION 9: SIGNATURES
- --------------------------------------------------------------------------------
I/We acknowledge that we have read and understand:

1. the terms and conditions listed in the instructions to this form, the
Prospectus and the Policy for each of the options or changes requested.
2. I/we can cancel or change any elections requested in Sections 5 and 7 above
by sending written notice to the Customer Service Center at least 7 days
before the next transfer date.
3. that dollar cost averaging and automatic rebalancing will begin on the date
specified only if Security Life has received this signed form at least 7
days before the date specified.

Signature of Owner(s):
________________________________________ Date_________________________
________________________________________ Date_________________________
________________________________________ Date_________________________
Daytime Phone Number:___________________________________

- - - - - - - - - - - - - - - Detach and Give to Applicant - - - - - - - - - - -

[Logo of Security Life appears here] Security Life of Denver
Insurance Company
P.O. Box 173888
Denver, CO 80217-3885

SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

The Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness,
and privacy of information in the files of every "Consumer Reporting Agency"
(CRA). Most CRAs are credit bureaus that gather and sell information about
you--such as if you pay your bills on time or have filed bankruptcy--to
creditors, employers, landlords, and other businesses. You can find the complete
text of the FCRA, 15 U.S.C. 1681-1681u, at the Federal Trade Commission's
website (HTTP://WWW.FTC.GOV). The FCRA gives you specific rights as outlined
below. You may have additional rights under state law. You may contact a state
or local consumer protection agency or a state attorney general to learn those
rights.

o YOU MUST BE TOLD IF INFORMATION IN YOUR FILE HAS BEEN USED AGAINST YOU.
Anyone who uses information from a CRA to take action against you--such as
denying an application for credit, insurance, or employment--must give you
the name, address, and phone number of the CRA that provided the report.

o YOU CAN FIND OUT WHAT IS IN YOUR FILE. At your request, a CRA must give you
the information in your file, and a list of everyone who has requested it
recently. There is no charge for the report if a company/person has taken
action against you because of information supplied by the CRA, if you
request the report within 60 days of receiving the notice of action. You
are also entitled to one free report every twelve months upon request if
you certify that (1) you are unemployed and plan to seek employment within
60 days, (2) you are on welfare, or (3) your report is inaccurate due to
fraud. Otherwise, a CRA may charge you a fee of up to eight dollars.

o YOU CAN DISPUTE INACCURATE INFORMATION WITH THE CRA. If you tell a CRA that
your file contains inaccurate information, the CRA must reinvestigate the
items (usually within 30 days) by presenting to its information source all
relevant evidence you submit, unless your dispute is frivolous. The source
must review your evidence and report its findings to the CRA. (The source
also must advise national CRAs--to which it has provided the data--of any
error.) The CRA must give you a written report of the investigation, and a
copy of your report if the investigation results in any changes. If the
CRAs investigation does not resolve the dispute, you may add a brief
statement to your file. The CRA must normally include a summary of your
statement in future reports. If an item is deleted or a dispute statement
is filed, you may ask that anyone who has recently received your report be
notified of the change.

o INACCURATE INFORMATION MUST BE CORRECTED OR DELETED. A CRA must remove or
correct inaccurate or unverified information from its files, usually within
30 days after you dispute it. HOWEVER, THE CRA IS NOT REQUIRED TO REMOVE
DATA FROM YOUR FILE THAT IS ACCURATE UNLESS IT IS OUTDATED (AS DESCRIBED
BELOW) OR CANNOT BE VERIFIED. If your dispute results in any change to your
report, the CRA cannot reinsert into your file a disputed item unless the
information source verifies its accuracy and completeness. In addition, the
CRA must give you a written notice telling you it has reinstated the item.
The notice must include the name, address, and phone number of the
information source.

o YOU CAN DISPUTE INACCURATE ITEMS WITH THE SOURCE OF THE INFORMATION. If you
tell anyone--such as a creditor who reports to a CRA--that you dispute an
item, they may not then report the information to a CRA without including a
notice of your dispute. In addition, once you've notified the source of the
error in writing, it may not continue to report it if it is, in fact, an
error.

o OUTDATED INFORMATION MAY NOT BE REPORTED. In most cases, a CRA may not
report negative information that is more than seven years old; ten years
for bankruptcies.

o ACCESS TO YOUR FILE IS LIMITED. A CRA may provide information about you
only to those who have a need recognized by the FCRA--usually to consider
an application you have submitted to a creditor, insurer, employer,
landlord, or other business.

o YOUR CONSENT IS REQUIRED FOR REPORTS THAT ARE PROVIDED TO EMPLOYERS, OR
REPORTS THAT CONTAIN MEDICAL INFORMATION. A CRA may not report to your
employer, or prospective employer, about you without your written consent.
A CRA may not divulge medical information about you without your consent.

o YOU MAY CHOOSE TO EXCLUDE YOUR NAME FROM CRA LISTS FOR UNSOLICITED CREDIT
AND INSURANCE OFFERS. Creditors and insurers may use file information as
the basis for sending you unsolicited offers of credit or insurance. Such
offers must include a toll-free number for you to call if you want your
name and address removed from future lists. If you call, you must be kept
off the lists for two years. If you request, complete, and return the CRA
form provided for this purpose, you must be taken off the lists
indefinitely.

o YOU MAY SEEK DAMAGES FROM VIOLATORS. You may sue a CRA or other party in
state or federal court for violations of the FCRA.

S-5044A-97

THE FCRA GIVES SEVERAL DIFFERENT FEDERAL AGENCIES AUTHORITY TO ENFORCE ITS PROVISIONS:

- --------------------------------------------------------------------------------
For Questions or Concerns Regarding: Please Contact:
- --------------------------------------------------------------------------------

CRAs, creditors, and others not listed below Federal Trade Commission
Consumer Response Center - FCRA
Washington, DC 20580
Phone: 202-326-3761
- --------------------------------------------------------------------------------
National banks, federal branches/agencies of Office of the Comptroller of the Currency
foreign banks (word "National" or initials "N.A." Compliance Management, Mail Stop 6-8
appear in or after bank's name) Washington, DC 20219
Phone: 800-613-7643
- --------------------------------------------------------------------------------
Federal Reserve System member banks Federal Reserve Board
(except national banks, and federal Division of Consumer & Community Affairs
branches/agencies of foreign banks) Washington, DC 20551
Phone: 202-452-3693
- --------------------------------------------------------------------------------
Savings associations and federally chartered Office of Thrift Supervision
savings banks (word "Federal" or initials "F.S.B." Consumer Programs
appear in federal institution's name) Washington, DC 20552
Phone: 800-842-6929
- --------------------------------------------------------------------------------
Federal credit unions (words "Federal Credit National Credit Union Administration
Union" appear in institution's name) 1775 Duke Street
Alexandria, VA 22314
Phone: 703-518-6360
- --------------------------------------------------------------------------------
State-chartered banks that are not members Federal Deposit Insurance Corporation
of the Federal Reserve System Division of Compliance & Consumer Affairs
Washington, DC 20429
Phone: 800-934-FDIC
- --------------------------------------------------------------------------------
Air, surface, or rail common carriers regulated Department of Transportation
by former Civil Aeronautics Board or Office of Financial Management Interstate
Commerce Commission Washington, DC 20590
Phone: 202-366-1306
- --------------------------------------------------------------------------------
Activities subject to the Packers and Stockyards Department of Agriculture
Act, 1921 Office of Deputy Administrator - GIPSA
Washington, DC 20250
Phone: 202-720-7051
- --------------------------------------------------------------------------------

- - - - - - - - - - - - - - DETACH AND GIVE TO APPLICANT - - - - - - - - - - - - -
AGREEMENTS

NOTICE OF INFORMATION PROCEDURES

OUR UNDERWRITING PROCESS
This process is an evaluation of information about you. It is to see if you
qualify for the insurance requested. The information we review may vary with the
insurance applied for. We look at information about you such as: your age;
occupation; health; mode of living; avocation; and other personal information.
Answers on the application are the principal source of information. We may
contact other people or institutions personally, by phone, or by letter. The
purpose is to confirm or add to information you have provided. For example, we
may obtain information from your doctor, clinic, hospital, or other insurers. In
some cases, your Security Life agent may obtain information on our behalf. A
medical examination or laboratory tests may be requested.

NOTICE
Any person who knowingly and with intent to injure, defraud, or deceive any
insurance company, files an application, statement or claim containing any
false, incomplete, or misleading information may be guilty of insurance fraud.

MIB, INC.
Medical Information Bureau, Inc. ("MIB, Inc.") may provide Security Life with
a brief report about you. This is a nonprofit organization of life insurance
companies which has an information exchange for its members. Information that
is sent to MIB, Inc. by one member may be given to their member companies who
have a business need for it.

Upon your written request, MIB, Inc. will arrange for disclosure of any
information it may have in your file. If you question the accuracy of MIB's
information, you may request a correction according to the procedures in the
Federal Fair Credit Reporting Act. MIB's address is: P.O. Box 105, Essex
Station, Boston, Massachusetts 02112, telephone 617/426-3660.

CONSUMER REPORTS
In some cases, a Security Life representative may prepare a consumer report or
investigative consumer report about you or, Security Life may ask an independent
agency to prepare a consumer report or an investigative consumer report about
you. These reports may include information on your character; general
reputation; personal characteristics such as health, finances, and job, and mode
of living except as may be related directly or indirectly to your sexual
orientation. Any information obtained by the agency may be kept in its file and
later given to others who have a business need for it

If an investigative consumer report is ordered by Security Life, the report will
include information obtained through interviews with your neighbors, friends, or
others you know. You may request a personal interview. The agency will make a
reasonable attempt to talk to you. It will include that information in its
report. The Federal Fair Credit Reporting Act gives you the right to make a
written request within a reasonable period of time, to receive additional
information from Security Life about the nature and scope of an investigation,
if one is made. We will provide the name, address, and phone number of any
agency we ask to prepare such a report. You may contact the agency directly to
learn about the contents of the report.

DISCLOSURE OF INFORMATION
Information we obtain about you is confidential. As permitted by law, we may
disclose information without further authorization to others such as: consumer
reporting agencies hired to prepare investigative reports; insurance companies
to which you have applied for coverage or benefits; those providing services for
us; those conducting bona fide actuarial, marketing, or scientific studies or
audits; and your attending doctor.

Upon written request, we will give you more information about these procedures.

YOUR RIGHT TO REVIEW INFORMATION
These are procedures by which you can make a written request to review personal
information in our policy file. However, Security Life will not disclose
information to you that was prepared for any anticipated claim or any civil or
criminal proceeding. We also have procedures by which you may request
correction, amendment, or deletion of any information in our files which you
believe to be inaccurate or irrelevant. Upon written request, we will provide
you with further information about these procedures.

We hope this notice helps explain our underwriting process. If you have any
additional questions, discuss them with your agent or contact us directly.

Security Life of Denver Insurance Company
P.O. Box 173888
Denver, CO 80217-3885
1-800-848-6362

[Logo of Security Life appears here]
P.O. Box 173888
Denver, CO 80217-3885

SECURITY LIFE OF DENVER INSURANCE COMPANY

IMPORTANT INFORMATION
INSTRUCTIONS FOR SUBMITTING APPLICATIONS
FOR VARIABLE SURVIVORSHIP UNIVERSAL LIFE INSURANCE

o Two individual variable universal life applications are required - one for
each insured. They must be submitted at the same time. IF NOT RECEIVED AT
THE SAME TIME, WE WILL DELAY UNDERWRITING AND PROCESSING UNTIL THE SECOND
APPLICATION IS RECEIVED.
o Each application should reference the other application. Sample wording
could be, "This application is taken in conjunction with John Doe, SSN
#123-45-6789."
o Each proposed insured must sign his/her respective application and the
owner must sign BOTH applications.
o If a trust is the owner and/or beneficiary, be sure to name the trustee
and give the date of the trust.
o The first insured's application must be completed in full. On the
SECOND INSURED'S APPLICATION, you only need to complete the following
sections:
o Part I
o Sections A, B and C
o Section L
o Section M, if applicable
o Part II
o Sections A, B and C
o Signatures

o Available riders are Adjustable Term Insurance and Single Life Term
Insurance.

SINGLE LIFE TERM INSURANCE RIDER. In SECTION E, ITEM H "ADDITIONAL RIDERS",
indicate whether Single Life Term Insurance is requested. Check the box titled
"Other" and write in language similar to the following: "Single Life Term
Insurance Rider on John Doe in the amount of $300,000."

DESIGNATED WITHDRAWAL INVESTMENT DIVISION. You can designate a specific
investment division from which your monthly charges will be deducted. This
feature will be available on or before November 1, 1999. Please indicate the
name of the division in "Special Instructions."

NOTE: SECTION J - PREMIUM INFORMATION (CONTINUED). FUND NAME CHANGE: INVESCO'S
INDUSTRIAL INCOME FUND HAS BEEN RENAMED EQUITY INCOME FUND.

- --------------------------------------------------------------------------------

THE INFORMATION BELOW AND SIGNATURES MUST BE PROVIDED WHEN EITHER THE ENHANCED
DEATH BENEFIT CORRIDOR OPTION OR THE GUARANTEED MINIMUM DEATH BENEFIT ARE
ELECTED. YOU MAY WRITE THIS INFORMATION IN "SPECIAL INSTRUCTIONS" ON THE
APPLICATION IF YOU PREFER.

PROPOSED INSUREDS' NAMES ______________________________________________________

I. ENHANCED DEATH BENEFIT CORRIDOR OPTION. THIS OPTION IS AVAILABLE ONLY
AT ISSUE. IF YOU DO NOT INDICATE THAT YOU WANT THE ENHANCED DEATH
BENEFIT CORRIDOR OPTION, WE WILL ISSUE THE POLICY WITH THE REGULAR
FACTORS.
[ ] ENHANCED DEATH BENEFIT CORRIDOR OPTION

II. GUARANTEED MINIMUM DEATH BENEFIT (GMDB) OPTION. THIS OPTION IS
AVAILABLE ONLY AT ISSUE. IF GMDB IS NOT INDICATED, THE POLICY WILL BE
ISSUED WITHOUT THIS BENEFIT. IF ELECTED, GMDB WILL CONTINUE UNTIL THE
YOUNGER INSURED'S AGE 100. THERE IS A MONTHLY CHARGE FOR THIS OPTION.
[ ] GMDB TO YOUNGER INSURED'S AGE 100.

SIGNATURE OF OWNER:
_________________________________________________________DATE:__________________

[Logo of Security Life appears here] Security Life of Denver Insurance Company
1290 Broadway
Denver, CO 80203-5699

BINDING LIMITED LIFE INSURANCE COVERAGE FORM

For premium(s) received in connection with the Application(s) listed below,
Security Life provides a limited amount of life insurance coverage for a short
time while it decides whether to issue and deliver the policy or certificate
applied for (the "policy"). This coverage is subject to the terms and conditions
set out below.

(For second to die coverage, use two
Application # ____________ Proposed Insured ________________________________________ applications and show both application
Application # ____________ Proposed Insured ________________________________________ numbers and name both insureds.)

I. REPRESENTATIONS -- Applicable to each Proposed Insured named above

1. Has the Proposed Insured(s): Yes No
a. had unintentional weight loss, or any symptoms of a disease or an impairment for which the Proposed Insured(s)
has not consulted a physician? [ ] [ ]
b. ever had, or now have, any type of heart disease, stroke, or other vascular disease? [ ] [ ]
c. ever had, or now have, any type of cancer, leukemia, malignant tumor, or disorder of the immune system? [ ] [ ]
d. attained age 70? [ ] [ ]
2. For each Proposed Insured, is the initial amount of life insurance applied for on all applications pending with
Security Life plus the current amount of all existing life insurance with Security Life and Midwestern United Life
Insurance Company more than $3,000,000? [ ] [ ]
3. For each Proposed Insured, does existing life insurance with all insurers
plus amount applied for in pending application(s) with all insurers exceed
$10,000,000? [ ] [ ]
(For #2 and #3 amount of insurance calculations, include all policies, term riders, and accidental death coverage
and second to die coverage for each Proposed Insured.)

If any of the above questions are answered YES or LEFT BLANK, the agent is not
authorized to accept a premium, and there will be NO COVERAGE. Premium is either
cash, check or authorized withdrawal. Make all checks payable to Security Life,
not the agent.

II. TERMS AND CONDITIONS

AMOUNT OF COVERAGE
If the Proposed Insured(s) dies while this coverage is in effect, Security Life
will pay to the beneficiary named in the Application the lesser of: (a) the
amount of death benefit, if any, which would be payable under the policy and any
riders if issued as applied for under the Application; or (b) $3,000,000. This
coverage is subject to any limits or exclusions which would be part of the
issued coverage. If for any reason Security Life is liable for any coverage as a
result of any other pending applications or Binding Limited Insurance Coverage
on the lives of Proposed Insured(s), Security Life's total liability shall not
exceed $3,000,000; and the $3,000,000 will be prorated among the respective
coverages. There is no premium waiver coverage, or coverage for the death of any
person other than the Proposed Insured(s). No death benefit is payable for a
second to die or last survivorship policy unless both Proposed Insureds die
while this coverage is in effect.

GENERAL
Premium(s) will be returned if no policy is delivered and no benefit is paid
under this coverage. If a policy is delivered, premium(s) will be applied to the
first policy premium.
All the above representations are true and complete to the best of my knowledge
and belief. I agree that they are to be relied on for this coverage.
No agent can waive or modify this coverage in any way.

Agreed to on _____________________________________________, 199__

Signature of Proposed Insured(s) ________________________________

_________________________________________________________________
(If below age 15, signature of parent or guardian required)

Agent/Witness ___________________________________________________

DATE COVERAGE BEGINS
Coverage under this Agreement starts when: Part I of the Application is
completed; a premium has been accepted; and this form has been completed and
signed.

DATE COVERAGE ENDS
This coverage will end automatically on the EARLIEST of the date:
o Premium(s) are returned.
o Five days after a notice of termination is mailed to the owner's address
on the application.
o Coverage starts under any policy resulting from the Application.
o A policy resulting from the Application is refused.
o 90 days after the date this form is signed.
Security Life may send a notice or return premium terminating this coverage any
time before delivery of the policy.

NO COVERAGE
There is no insurance coverage if:
o There is a material misrepresentation in the answers to the questions above
or any question or statement in the Application.
o A Proposed Insured dies by suicide or intentional self-inflicted injury.
o The premium check or authorized withdrawal is not honored.

Signed at _______________________________________________________

Applicant-Owner _________________________________________________
(If not signing as Proposed Insured)

_________________________________________________________________
If a firm or corporation is owner, print company name and have corporate officer
sign.

Q-1134
1/98