EXHIBIT 1.A.(10)
APPLICATION FOR FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY
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Legacy Builder Plus
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PFL Life
Insurance Company
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Application for
Life Insurance
PFL LIFE INSURANCE COMPANY
Cedar Rapids, Iowa
NOTICE TO PROPOSED INSURED
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Thank you for your application. We appreciate your efforts in completing each
part of the application truthfully, accurately, and completely.
Once we receive your application, we will begin an evaluation process called
underwriting to determine whether you are eligible for insurance and, if so, the
rate you should pay for that insurance. We may find that we are unable to give
you the insurance you have applied for or that we are able to give it to you
only on a modified basis or at a rate greater than our lowest rate. For example,
if you have ever used any kind of tobacco or any other nicotine product, you may
not be eligible for our lowest rate. Your application will be our primary source
of information; therefore, it must be true, complete, and accurate. You must
inform us of a change to any part of your application before accepting delivery
of a policy, in fact, you agree to do so when you sign your application. We may
seek information from other sources to help us evaluate the information you give
us on your application.
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CONTESTABILITY
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We strongly urge you to review the completed application closely for accuracy.
During the first two policy years, a claim may be denied or your coverage may be
rescinded or contested by a lawsuit if the application is incomplete or if it
contains false statements, misrepresentations, acts, omissions, or is procured
by fraud. If the policy is rescinded or the lawsuit is successful, the policy
will be void and coverage will be lost. Any policy that is delivered to you will
indicate when and under what circumstances it may be contested. The policy can
only be contested for non-payment of premium after the policy is in force for
two (2) years during the lifetime of the insured. Please be aware that if the
application contains false or deceptive statements and you submitted it with the
intent to defraud or to facilitate fraud against us, you may also be guilty of
insurance fraud.
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REPLACEMENT OF EXISTING COVERAGE
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If you intend to replace existing coverage, tell the agent of your intention and
answer "yes" to the replacement question in the application; state law may
require the agent to give you information that will help you compare the policy
you are applying for with the policy you intend to replace. If you are undecided
about keeping existing coverage, indicating an intention to replace existing
coverage may help you get the information you need to make a decision. If you do
replace existing coverage, the new policy may contain new suicide and
contestable periods. The following would be considered replacement: you stop
paying premiums for the insurance for which you are applying. State laws define
replacement to include other situations. Please ask your agent if you are
unsure.
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INSURANCE INFORMATION PRACTICES
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We will rely primarily on information provided by you. We may supplement that
information with information from other sources such as medical professionals
who have treated you. In some cases, we may ask a consumer-reporting agency to
collect information and submit an investigative consumer report to us as
explained in this Notice under Federal Fair Credit Reporting Act. You may
request to be interviewed in connection with the preparation of this report. You
have the right to be told about and to see the copy if you wish, items of
personal information about you that appear in our files, including information
contained in investigated consumer reports. You also have the right to seek
correction of information you believe to be inaccurate. We will send you a more
detailed explanation of our information practices if you send us a written
request. You may send your request to the Director of Underwriting, P.O. Box
3183, Cedar Rapids, Iowa 52406-3183.
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FAIR CREDIT REPORTING PRE-NOTICE
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A routine investigative consumer report may possibly be made regarding your
general reputation, character, mode of living, and personal characteristics.
This information may be obtained through personal interviews with your friends,
neighbors, and associates. Should you desire additional information on the
nature and scope of such a report, you may write the Underwriting Department,
P.O. Box 3183, Cedar Rapids, Iowa 52406-3183. You have the right to request
additional information concerning the nature and scope of the investigation to
be performed. A summary of your rights is set forth on the attached signature
page of the application. To make this request, you must write the Underwriting
Department, P.O. Box 3183, Cedar Rapids, Iowa 52406-3183.
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MIB DISCLOSURE NOTICE
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Information regarding your insurability will be treated as confidential. The
Company or its reinsures may, however, make a brief report to the Medical
Information Bureau, a non-profit membership organization of life insurance
companies, which operates on information exchange on behalf of its members. If
you apply to another Bureau member for life or health insurance coverage, or a
claim for benefits is submitted to such a Company, the Bureau, upon request,
will supply such company with the information in its file.
Upon receipt of a request from you, the bureau will arrange disclosure of any
information it may have in your file. If you question the accuracy of the
information in the Bureau's file, you may contact the Bureau and seek a
correction in accordance with the procedures set forth in the Federal Fair
Credit Reporting Act. The address of the Bureau's information office is Post
Office Box 105, Essex Station, Boston, Massachusetts 02122, telephone number
(617) 426-3660.
The Company or its reinsures may also release information in this file to other
life insurance companies to whom you may apply for life or health insurance or
to whom a claim for benefits may be submitted.
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6001 V799 Page 2
PFL Life Insurance Company
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Section 1. PLAN OF INSURANCE
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Plan of Insurance: Premium Amount: $
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Section 2. INSURED INFORMATION
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Name: Social Security Number: Sex: [_] Male [_] Female
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Street Address: Date of Birth: Age:
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City: Place of Birth:(State or Country):
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State: Zip Code: Occupation:
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Beneficiary: Relationship to Insured: Soc. Sec. Number:
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Contingent Beneficiary: Relationship to Insured: Soc. Sec. Number:
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Will this policy replace or change any existing life
insurance or annuity policy(ies)? [_] Yes [_] No
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If yes, indicate policy number(s) and Company name(s)?
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Is this intended to be a
1035 Exchange? [_] Yes [_] No Indicate Exchange amount:
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If this policy will replace an existing policy, complete required replacement
forms.
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Section 3. CONTACT INFORMATION
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Insured's Home Telephone: Business Telephone: Fax:
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Preferred Place to call: [_] Home [_] Business
Best Time to call: [_] A.M. [_] P.M.
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E-mail Address: Special Comments:
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Secondary Addressee:
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Street Address:
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City: State: Zip Code:
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Section 4. OWNER INFORMATION: (if other than proposed insured)
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Name:
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Street Address: Date of Birth:
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City: State: Zip Code:
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Relationship To Insured: Social Security Or Tax ID Number:
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Section 5. BASIC HEALTH QUESTIONS
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A. Insured: Height: Weight:
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B. Within the last 5 years, have you been treated for or been told by a member
of the medical profession that you had heart disease or circulatory
problems, stroke, cancer, diabetes, kidney or liver disorder, lung or
respiratory disorder, Alzheimer's Disease, mental or psychiatric disorder,
alcohol or drug abuse? If yes, please circle the applicable ailment(s).
[_] Yes [_] No
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C. Within the last 10 years, have you been diagnosed by a member of the
medical profession as having AIDS (Acquired Immune Deficiency Syndrome), or
have you tested positive for exposure to the HIV (Human Immunodeficiency
Virus)? [_] Yes [_] No
Information concerning diagnostic testing and blood studies may be limited
to those blood tests licensed by the United States Food and Drug
Administration. The Applicant need not reveal the results of any test
performed at an anonymous counseling and testing site.
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D. Within the past 12 months, have you smoked cigarettes, cigars, pipes or
used chewing tobacco? [_] Yes [_] No
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E. Within the past 12 months, have you been admitted to a hospital
or nursing home? [_] Yes [_] No
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F. Have you ever been declined, rated or postponed for insurance or
reinstatement of life, accident or sickness insurance or has a policy ever
been canceled or renewal refused? [_] Yes [_] No
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Section 6.SPECIAL REQUEST
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If this life insurance cannot be issued, do you want to apply for an annuity
policy? [_] Yes [_] No
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6001V799 Page 3
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Section 7. PERSONAL FINANCIAL STATEMENT
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A) Gross Income Current Yr $_____________________
B) Gross Income Previous Yr $_____________________
C) Net Worth $_____________________
For over $1 million applied coverage complete a separate financial questionnaire
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Section 8. ADDITIONAL BENEFITS - PRIMARY INSURED ONLY
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[_] Asset Rebalancing
[_] Dollar Cost Averaging (Refer to Section 12)
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Section 9. SUITABILITY FOR VARIABLE LIFE INSURANCE POLICY - Complete for all
variable plans
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A) Have you, the Proposed Insured, and Purchaser, if other
than the Proposed Insured, received the current Prospectus
for the policy? [_] Yes [_] No
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B) DO YOU UNDERSTAND THAT UNDER THE POLICY APPLIED FOR
(EXCLUSIVE OF ANY OPTIONAL BENEFITS), THE AMOUNT OF DEATH
BENEFIT AND THE ENTIRE AMOUNT OF THE POLICY CASH VALUE MAY
INCREASE OR DECREASE DEPENDING UPON THE INVESTMENT
EXPERIENCE? [_] Yes [_] No
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C) With this in mind, is the policy in accord with your insurance
objectives and your anticipated financial needs? [_] Yes [_] No
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Section 10. TO BE COMPLETED BY APPLICANT/OWNER
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Telephone Transfer Authorization: (See Prospectus for telephone transfer
procedures.) The following individual(s) is/are authorized to make telephone
transfer requests (check one only)
[_] Owner(s) only, or
[_] Owner(s) and Owner's Registered Representative
(Print Representative's Name) ___________________________________________
[_] I do not want telephone transfer privileges
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Section 11. ACCOUNT ALLOCATIONS - (For Variable Plans Only) Must equal a whole
number and total 100%
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VARIABLE OPTIONS
AIM V.I. Capital Appreciation Fund ___%
AIM V.I. Growth & Income Fund ___%
AIM V.I. Value Fund ___%
AIM V.I. Government Securities Fund ___%
Dreyfus Small Company Stock Portfolio ___%
Dreyfus Stock Index Fund ___%
Dreyfus Money Market Portfolio ___%
MFS Emerging Growth Series ___%
MFS Research Series ___%
MFS Total Return Series ___%
MFS Utilities Series ___%
Oppenheimer Capital Appreciation Fund/VA ___%
Oppenheimer Growth & Income Fund ___%
Oppenheimer Global Securities Fund/VA ___%
Oppenheimer Strategic Bond Fund/VA ___%
Oppenheimer High Income Fund/VA ___%
WRL Janus Growth ___%
WRL VKAM Emerging Growth ___%
WRL Janus Global ___%
DCA Dreyfus Money Market Portfolio ___%
FIXED OPTIONS
Fixed Fund ___%
DCA Fixed Fund One (Six Months), OR ___%
DCA Fixed Fund Two _____________________________ ___%
Total Variable & Fixed 100%
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Section 12. DOLLAR COST AVERAGING - (Authorized by Owner in Section 8.)
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A percentage can be systematically transferred from the DCA account and
transferred to one or more of the investments options listed below. Please refer
to the prospectus for more information on the Dollar Cost Averaging option.
Transfers will be made on a monthly basis.
DCA Transfer Options: Transfer to (investment option and percentage):
______________ ________.0% ______________ ________.0%
______________ ________.0% ______________ ________.0%
______________ ________.0% ______________ ________.0%
______________ ________.0% ______________ ________.0%
______________ ________.0% ______________ ________.0%
Total: 100.0%
6001 V799 Page 4
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TAXPAYER IDENTIFICATION NUMBER STATEMENT
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Taxpayer Identification Number (of) policyowner: _____________________________
Social Security Number
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Check the box if you ARE NOT subject backup withholding Under the provisions of
section 3406(a)(1)(C) of the Internal Revenue Code....................[_]
Check the box if you ARE subject to backup withholding under The provisions of
section 3406(a)(1)(C) of the Internal Revenue Code....................[_]
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The Internal Revenue Service does not require your consent to any provision of
this document other than the following certification required to avoid backup
withholding.
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Under penalties of perjury, I hereby certify (1) that the Social Security or
Taxpayer I.D. number listed above is correct and (2) that my current status
regarding backup withholding is correct.
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I agree that: (1) If the receipt is issued in return for the full first premium,
the Company's liability will be as set forth in such receipt. If the receipt has
not been issued, the Company shall incur liability under this application only
when a policy has been delivered and the full first premium specified in the
policy has been paid during the lifetime and continued insurability of the
Persons to be Insured, as determined by the Company from this application. (2)
No modification may be made to the policy or no right of the Company waived
unless agreed to in writing and signed by: (A) The President; (B) The Vice
President; or (C) The Secretary of the Company.
The Proposed Insured acknowledges receipt of the MIB Disclosure Notice and Fair
Credit Reporting Pre-Notice.
I represent that all the statements and answers in this application are complete
and true to the best of my knowledge and belief. I agree that the statements and
answers given in this application, and any amendments or application supplements
to it will be the basis of any insurance issued.
Unless we have been notified of a community or marital property interest in this
policy, we will rely on our good faith belief that no such interest exists and
will assume no responsibility for inquiry.
AUTHORIZATION: I hereby authorize any licensed physician, medical practitioner,
hospital, clinic or medically related facility, insurance company, the Medical
Information Bureau, consumer reporting agency, or other organization, employer,
institution or person that has any records or knowledge of me or my health (or
of additional insured(s), if included in the coverage applied for), to give to
the Company, or its reinsurers, any such information. This includes information
about drugs and alcohol and about diagnosis, treatment and prognosis of any
physical or mental condition, as well as any other non-medical information. A
photographic copy of this authorization shall be as valid as the original. The
authorization shall be valid from the date signed below for a period of two and
one half years.
I also hereby authorize PFL Life Insurance Company to provide its affiliated
companies any and all information provided herein and obtained hereafter on me.
I have reviewed my existing coverage and find this policy suitable for my needs.
I know that I have a right to receive a copy of this authorization upon request.
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Signed at: (City and State) Date:
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Signature of Proposed Insured:
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Signature of Owner: (if other than Proposed Insured)
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TO BE COMPLETED BY AGENT
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Do you have reason to believe the policy applied for is to replace or change any
existing annuity or insurance owned by the applicant?
[_] Yes [_] No (If Yes, include state replacement forms if applicable)
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If yes, indicate policy number(s) and Company name(s):
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Did you give the "MIB Disclosure Notice" to the Proposed Insured?
[_] Yes [_] No
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Did you comply with all requirements relative to obtaining Informed Consent for
HIV and AIDS testing? [_] Not required [_] Yes [_] No
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I have reviewed the applicant's existing coverage and find this policy is
suitable for his/her needs.
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Signature of Agent: Agent's State License Number:
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Agent's Social Security Number:
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Print Agent's Name: Telephone Number:
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6001 V799 Page 5
FRAUD WARNING
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The following states require that insurance applicants (owners) acknowledge a
fraud warning statement. If you reside in one of the states listed below, please
refer to the applicable fraud warning.
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For applicants (owners) in ARKANSAS, NEW MEXICO AND PENNSYLVANIA
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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.
Applicant's Signature Date
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For applicants (owners) in COLORADO
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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, and denial
of insurance, and civil damages. Any insurance company or agent or an insurance
company who knowingly provides false, incomplete, or misleading facts or
information to the policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement
or award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory Agencies.
Applicant's Signature Date
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For applicants (owners) in DISTRICT OF COLUMBIA
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It is a crime to provide false or misleading information to an insurer for the
purpose of defrauding the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may deny insurance benefits
if false information materially related to a claim was provided by the
applicant
Applicant's Signature Date
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For applicants (owners) in FLORIDA
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Any person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony in the third
degree.
Applicant's Signature Date
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For applicants (owners) in KENTUCKY, OHIO and OKLAHOMA
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Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance 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.
Applicant's Signature Date
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For applicants (owners) in NEW JERSEY
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Any person who includes any false or misleading information on an application
for an insurance policy is subject to criminal and civil penalties.
Applicant's Signature Date
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For applicants (owners) in MAINE and VIRGINIA
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Any person who, with the intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement may have violated state law.
Applicant's Signature Date
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6001 V799 Page 6
CONDITIONAL RECEIPT (DO NOT COMPLETE AND GIVE TO APPLICANT UNLESS PAYMENT IS
MADE)
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CONDITIONS UNDER WHICH THIS PAYMENT SHALL CAUSE CONDITIONAL COVERAGE TO TAKE
EFFECT
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(1) Each and every person proposed for insurance must be insurable and
acceptable to the Company under its underwriting rules for the amount, plan and
risk classification applied for on the later of: (A) the date of application, or
(B) the date of completion of all medical tests and examinations required by the
Company. (2) Any check given for payment must be honored on first presentation.
(This receipt and all coverages applied for on the application are void if
check or draft received for payment of the initial premium is not honored for
payment on its first presentation.)
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AMOUNT OF CONDITIONAL LIFE INSURANCE COVERAGE
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If conditional coverage becomes effective under the terms of this receipt, then
the amount of conditional life insurance coverage on any person proposed for
insurance is the lesser of: (1) the amount of life insurance applied for on such
person, or (2) $300,000 reduced by the amounts payable under all other life
insurance or accidental death benefits then in force or pending with the
Company.
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WHEN CONDITIONAL COVERAGE BEGINS
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If the conditions listed above are fulfilled, then the amount of conditional
coverage specified above shall take effect on the later of (1) the date of the
application, or (2) the date of the completion of all medical tests and
examinations required by the Company. All conditional coverages for each and
every person proposed for insurance will be deemed void if the application
contains material misrepresentations or is fraudulently completed. Benefits
under this conditional receipt coverage will be denied if any person proposed
for insurance commits suicide.
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WHEN CONDITIONAL COVERAGE ENDS
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Conditional coverage shall terminate automatically, without notice, on the
earliest of the following dates: (1) the date the Company approves the policy as
applied for; (2) 10 days following any counter offer by the Company to offer
insurance to any person proposed for insurance under a different plan or at an
increased premium or on a different rate class; (3) at the end of the fraction
of a year which the payment bears to the premium required to provide one month
of insurance coverage in the amount as described above; or (4) at the beginning
of the 60th day following the date of this receipt.
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CONDITIONAL RECEIPT
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PFL Life Insurance Company has received from ___________________________________
this_____________ day of________________, ______________ a premium deposit of
$ ____________ in connection with an application for life insurance. Unless the
conditions stated above this receipt are fulfilled, no conditional coverage
shall take effect and this payment will be refunded. All premium checks must be
made payable to the Insurance Company indicated above. Do not make checks
payable to the agent or leave payee blank.
Date__________________________ Signature of Owner ______________________________
Date__________________________ Signature of Agent ______________________________
NOTE: If you do not receive a policy or refund of the amount you paid within 60
days from the date of this receipt please notify:
PFL LIFE INSURANCE COMPANY
Cedar Rapids, Iowa
P.O. Box 3183, Cedar Rapids 52406-3183
Page 7
6001 V799
PFL Life Insurance Company
Cedar Rapids, Iowa
P.O. Box 3183, Cedar Rapids 52406-3183