Exhibit 1.A(10)
[logo of ING Security Life] Security Life of Denver Insurance Company
Variable Life Customer Service Center
P.O. Box 173888
Denver, CO 80217-3885
1-800-848-6362
Fax: 303-860-2695
GUARANTEED ISSUE VARIABLE LIFE INSURANCE APPLICATION
_
1 |_| Check here if for PENSION or similar tax qualified plan. State plan type
in Special Instructions.
SECTION A - PROPOSED INSURED
2 Name (First Middle Last) Birthdate (Mo/Day/Yr) Birthstate Sex
_ _
|_| M |_| F
Home Address (Street, Apt. No.) City State Zip Code
Social Security Number Home Phone ( ) Work Phone ( )
3a Occupation:________________________________ 3b Date of Hire:_____________
4a Is Proposed Insured currently actively at work on a full time basis
performing all duties of Proposed Insured's regular occupation, at Proposed
Insured's customary place of employment for at least 30 hours per week?
_ _
|_| Yes |_| No If "No" explain:
____________________________________________________________________________
4b Has Proposed Insured: (1) been absent from work due to illness or medical
treatment for a period of 5 business days or more within the last 90 days;
or (2) been hospitalized for any reason during this same period?
_ _
|_| Yes |_| No If "Yes" explain:
____________________________________________________________________________
5 Has Proposed Insured used tobacco (cigarettes, cigars, chewing tobacco,
pipe, nicotine substitutes, etc.) or any other substance containing nicotine
within the last 12 months?
_ _
|_| Yes |_| No If "Yes," what type and frequency?
____________________________________________________________________________
6 Is this insurance to replace, or will it cause any change in, any existing
life insurance or annuity on any person proposed for coverage?
_ _
|_| Yes |_| No If "Yes" submit a completed replacement form with this
application.
SECTION B - OWNER (IF OTHER THAN PROPOSED INSURED)
7a Owner's Name and Address 7b Owner's Social Security Number
(or Tax I.D. Number)
7c Owner's Relationship to Proposed
Insured
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Q2009-11/97 (Guaranteed Issue Application)
SECTION C - BENEFICIARIES
8a Primary Beneficiary_______________________ Relationship to Insured_________
(or Trust information) Social Security Number (or Tax I.D. Number)________
8b Contingent Beneficiary____________________ Relationship to Insured_________
(or Trust information) Social Security Number (or Tax I.D. Number)________
SECTION D - BILLING
9 Employer's Name and Address 10 Mailing address (for Premium
Notices and Correspondence)
11 Payment Method: List bill 12 Premium Mode:
SECTION E - PLAN INFORMATION - FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY
13 Product 14 Policy Issue Date
(Mo/Day/Yr):________________________
15 Guaranteed Issue Version 16 Unisex Version
17 Stated Death Benefit
SECTION F - GUARANTEED MINIMUM DEATH BENEFIT OPTION
18 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:
a. You fail to pay the required Guarantee Period Annual premium defined in
your prospectus; or
b. Your Account Value on any Monthly Processing date is not diversified
according to the following rules:
1. No more than 35% of your Net Account Value may be invested in any one
division; and
2. 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.
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SECTION G - PREMIUM INFORMATION
19 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 _____% Equity Income _____% Worldwide Emerging Markets
_____% V.I. Capital Appreciation _____% High Yield _____% Worldwide Bond
_____% Utilities _____% Worldwide Real Estate
ALGER AMERICAN _____% Total Return
_____% Small Capitalization _____% VIF Small Company Growth
_____% MidCap Growth
_____% Growth NEUBERGER & BERMAN
_____% Limited Maturity Bond
FIDELITY INVESTMENTS _____% Partners Portfolio
_____% Growth Portfolio
_____% Overseas
_____% Index 500
SECTION H - SUITABILITY
20 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
21 Special Instructions
HOME OFFICE CORRECTIONS (INSURANCE COMPANY USE ONLY)
(NOT APPLICABLE IN NORTH DAKOTA, OREGON, PENNSYLVANIA, AND WEST VIRGINIA.)
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Q2009-11/97 (Guaranteed Issue Application)
FRAUD WARNINGS (FOR ALL STATES EXCEPT OREGON)
FOR APPLICANTS IN ALL STATES Any person who knowingly and with intent to injure, defraud, or deceive any insurance company,
EXCEPT COLORADO, CONNECTICUT, files an application, statement or claim containing any false, incomplete, or misleading information
PENNSYLVANIA AND VIRGINIA: may be guilty of insurance fraud.
FOR APPLICANTS IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY
INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT
OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION
TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE
POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OF AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL
BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
FOR APPLICANTS IN CONNECTICUT: 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 as determined by a court of competent jurisdiction.
FOR APPLICANTS IN PENNSYLVANIA: Any person who knowingly and 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.
FOR APPLICANTS IN VIRGINIA: Any person who with intent to defraud, or knowing that he is facilitating a fraud against an
insurer, submits an application, statement or files a claim containing false, or deceptive statement
may have violated state law.
AGREEMENTS: All statements and answers in this application (which
includes 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 ALASKA, MAINE, MISSOURI, OREGON, SOUTH CAROLINA, SOUTH DAKOTA
AND WISCONSIN.)
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.
(THIS PARAGRAPH DOES NOT APPLY IN THE STATES OF NORTH DAKOTA, OREGON,
PENNSYLVANIA, AND WEST VIRGINIA.) In those states, including Maryland, where
change in amount, age at issue, 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 PRO- VIDED IN ANY
COVERAGE PROVIDED BY A CONDITIONAL RECEIPT, 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. 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.
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.
I know of nothing else affecting the risk. In addition to the Agreements above,
I have read and agree to the information and agreements contained in Section 21,
Special Instructions.
- -> Signature of Proposed Insured________________________ -> Date______________
- -> Signature of Owner___________________________________ -> Date______________
(If other than Proposed Insured)
- -> Name and Title of Owner______________________________________________________
(If owner is a business entity, print the business entity's name and the
title of person signing.)
- -> APPLICATION SIGNED BY PROPOSED INSURED OR OWNER (IF OTHER THAN PROPOSED
INSURED) IN: -> STATE ____________
AGENT USE ONLY (Please print)
Do you have knowledge or reason to believe that replacement of existing life
_ _
insurance or annuity may be involved? |_| Yes |_| No
If "Yes" please provide appropriate replacement forms.
Signature of Agent/Registered Rep________________________________ Reg. Rep Number____________ % Split__________
Signature of Agent/Registered Rep________________________________ Reg. Rep Number____________ % Split__________
Signature of Agent/Registered Rep________________________________ Reg. Rep Number____________ % Split__________
________________________________________ _____________________________________
Name of Broker/Dealer/Branch/OSJ Name of Broker/Dealer/Branch/OSJ
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Q2009-11/97 (Guaranteed Issue Application)
[Logo of Security Life] Security Life of Denver
Insurance Company
1290 Broadway
Denver, CO 80203-5699
Guaranteed Issue
Binding Limited Life Insurance Coverage
For premium(s) received from the employer in connection with the following
Guaranteed Issue Applications, 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. This coverage is subject to the
terms and conditions set out below.
AMOUNT | AMOUNT
PROPOSED PREMIUM OF LIMITED | PROPOSED PREMIUM OF LIMITED
APP.# INSURED RECEIVED LIFE INS. | APP.# INSURED RECEIVED LIFE INS.
- -----------------------------------------------------------------------------------------------------------------------------
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
______ _________________________ ________ ___________ | ______ _________________________ ________ ___________
TERMS AND CONDITIONS
AMOUNT OF COVERAGE
If a Proposed Insured dies while this coverage is in effect, Security Life will
pay the Amount of Limited Life Insurance on the Proposed Insured set out above.
There is no premium waiver coverage.
DATE COVERAGE BEGINS
Coverage on the Proposed Insured under this agreement starts when a premium has
been accepted while the Proposed Insured is currently engaged in active
full-time work. Active full-time work is working at least 30 hours per week in a
normal capacity with no hospitalizations and no absences from work due to
illness or accident (except absences due to minor illnesses or accidents for no
more than 5 total days during the 3-month period).
DATE COVERAGE ENDS
The coverage on the Proposed Insured will end automatically on the EARLIEST of
the dates:
o Security Life returns the premium(s)
o Five days after Security Life mails a notice of termination to the owner's
address on the Application; or
o Coverage starts under any Security Life policy or certificate resulting from
Application.
Security Life may send the notice of return premium(s) at any time before
delivery of the policy or certificate.
There is no insurance coverage if:
o The Proposed Insured dies by suicide, or self-inflicted injury;
o The premium check is not honored; or
o The Proposed Insured is not currently engaged in active full-time work at
the time the premium is accepted.
BENEFICIARY
Any benefit will be paid to the beneficiary named in the application on the
Proposed Insured. If death is before such an application is completed, it will
be paid to (check one):
_
|_| Proposed Insured's estate, or
_
|_| Other __________________________________________________
Premiums for an application will be returned if: an application is not approved;
or a benefit is paid under this coverage; or any condition of the Guaranteed
Issue offer is not met.
No agent can waive or modify this coverage in any way.
- --------------------------------------------------------------------------------
No premium may be accepted if:
o the Proposed Insured is not currently engaged in active
full-time work; or
o any condition of the Guaranteed Issue offer is not met.
The amount of Limited Life Insurance shall be no more than the lesser of:
the amount specified in the Guaranteed Issue offer; or $3 million.
- --------------------------------------------------------------------------------
Agreed to on ______________________________, 19________
_____________________________________________(EMPLOYER)
By ____________________________________________________
Print employer's name and have officer sign.
Agent _________________________________________________
Q1112 B-6/98 HOME OFFICE COPY