Make check payable to:
Business Men's Assurance Company of America (BMA)
BMA Service Center, P.O. Box 795066, St. Louis, MO 63179-0795
(800) 423-9398 Fax: (314) 525-9941
Overnight deliveries: BMA Service Center, SW-04
9735 Landmark Parkway, St. Louis, MO 63127
Variable Life Application
1. Proposed Insured
_______________________________________________________________ ________________________________________________________________
Name (First, Middle, Last) [ ] Male [ ] Female Social Security Number
_______________________________________________________________ ( ) ( )
Street Address ________________________________________________________________
Home Telephone Business Telephone
_______________________________________________________________
City, State, Zip ________________________________________________________________
E-Mail Address
_______________________________________________________________
Birthdate (M/D/Y) State of Birth
2. Owner (if different from Insured)
_______________________________________________________________ ________________________________________________________________
Name (First, Middle, Last) [ ] Male [ ] Female Social Security Number/Tax Identification Number
_______________________________________________________________ ( ) ( )
Street Address ________________________________________________________________
Home Telephone Business Telephone
_______________________________________________________________
City, State, Zip ________________________________________________________________
E-Mail Address
_______________________________________________________________
Birthdate (M/D/Y) State of Birth
3. Contingent Owner
_______________________________________________________________ ________________________________________________________________
Name (First, Middle, Last) [ ] Male [ ] Female Social Security Number/Tax Identification Number
_______________________________________________________________ ( ) ( )
Street Address ________________________________________________________________
Home Telephone Business Telephone
_______________________________________________________________
City, State, Zip ________________________________________________________________
E-Mail Address
_______________________________________________________________
Birthdate (M/D/Y) State of Birth
4a. Primary Beneficiary Designation
________________________________________________________________________________
Name Relationship to Insured %
________________________________________________________________________________
Name Relationship to Insured %
________________________________________________________________________________
Name Relationship to Insured %
4b. Contingent Beneficiary
________________________________________________________________________________
Name Relationship to Insured %
________________________________________________________________________________
Name Relationship to Insured %
________________________________________________________________________________
Name Relationship to Insured %
5. Initial Premium Payment
Paid with Application $ ____________ Estimated 1035 Exchange Amount $ __________
A1015 C (5/98)
Variable Life Application - Page 2
6. Portfolio Selection (Please select Portfolio(s) and use only whole number percentages.
Subadvisors shown in parenthesis.)
[Balanced (Kornitzer Capital Management) (265) _________% Large Cap Value (Babson) (268) _________%
Global Fixed Income Mid Cap Equity (Standish, Ayer & Wood) (263) _________%
(Standish International Management) (264) _________%
Growth & Income (Lord Abbett) (269) _________% Small Cap Equity (Stein Roe) (266) _________%
Intermediate Fixed Income
(Standish, Ayer & Wood) (262) _________% Money Market (Standish, Ayer & Wood) (261) _________%
Large Cap Growth (Stein Roe) (267) _________% Berger/BIAM IPT-International Fund (270) _________%
Fixed _________%
Total _____100_%]
7. Insurance $ ____________ amount of life insurance coverage.
Additional Benefits:
Payment Mode (Check one.) [ ] Accelerated Death Benefit Rider
[ ] Annual [ ] Semiannual [ ] Monthly (Only with PAC/EFT) [ ] Accidental Death Benefit Rider
[ ] Children's Term Rider
Method of Payment: [ ] Notice [ ] PAC/EFT [ ] Covered Insured Rider
[ ] Extension Maturity Rider
Payment: Premium Quoted $ ________________ [ ] Future Purchase Option Rider
Premium Received $ ______________ [ ] Guaranteed Minimum Death Benefit Rider
[ ] Primary Insured Rider
Choose one: [ ] Waiver of Monthly Deductions Rider
[ ] Level-Death Benefit remains constant. [ ] Waiver of Planned Premium Rider
[ ] Adjustable-Death Benefit changes with the accumlation [ ] Other ___________________________________
value. (If not checked, option will automatically be level.)
8. Replacement of Other Contracts
Will the proposed policy replace any existing annuity or life insurance
contract? [ ] Yes [ ] No
If yes, list company name and policy number:
________________________________________________________________________________
How much life insurance coverage do you currently have in force?
________________________________________________________________________________
9. Information About the Insured
a. Current Employment
Name of Employer _______________________________________________________________
Occupation and Responsibilities ________________________________________________
________________________________________________________________________________
b. Have you ever been told you had or been treated for diabetes, cancer, heart
disease, or high blood pressure? (If yes, preferred rates are unlikely.) [ ] Yes
[ ] No If yes, please explain:
________________________________________________________________________________
c. Has or does any proposed insured:
a) Drink alcoholic beverages? If yes, provide amount per week.
(One drink equals 12 oz. beer, 4 oz. wine, or 1 oz. hard liquor.) [ ] Yes [ ] No
If yes, please explain:
________________________________________________________________________________
b) Ever had or been advised by a physician, practitioner, or court of law to
have treatment for alcohol, drug or substance use? [ ] Yes [ ] No If yes, please
explain:
________________________________________________________________________________
c) Now use or ever used cocaine, marijuana, or other drugs (except as prescribed
by a physician)? [ ] Yes [ ] No If yes, please explain:
________________________________________________________________________________
d. During the past three years, have you had a motor vehicle license suspended
or revoked or been convicted of driving while intoxicated? [ ] Yes [ ] No If
yes, please explain:
________________________________________________________________________________
e. During the past three years, have you participated in or do you intend to
participate in: [ ] Scuba Diving [ ] Skydiving [ ] Motor Racing [ ] Hang gliding
or similar flying activity
f. During the past three years, have you flown as or do you intend to fly as a
trainee, pilot, or crew member? [ ] Yes [ ] No
g. During the past two years, have you used any type of tobacco? [ ] Yes [ ] No
If yes, please specify
________________________________________________________________________________
h. Have you had any insurance or reinstatement refused, postponed, limited,
offered, or quoted on a substandard or rated basis? [ ] Yes [ ] No
Variable Life Application - Page 3
10. Telephone Transfer Authorization
[ ] I hereby authorize and direct BMA to accept telephone asset transfer
instructions from any person who can furnish proper identification. This
authorization is subject to the terms and provisions in the policy and
prospectus. I agree that BMA will not be responsible for any loss, liability,
cost, or expense for acting on the telephone instructions. BMA will employ
reasonable procedures to confirm that telephone instructions are genuine. If BMA
does not do so, it may liable for any losses due to unauthorized or fraudulent
transfers.
11. Dollar Cost Averaging
You need a total cash surrender value of at least $5,000 to participate. The
transfers will occur over a minimum of six months into the Portfolios designated
below on the 15th day of the month (or next business day if the 15th falls on a
weekend or holiday). The DCA program automatically terminates if the
accumulation value in the selected transfer portfolio is zero. This program
cannot be done at the same time as the Asset Rebalancing program.
A. Select the amount to transfer monthly (minimum $250) $____________
B. Indicate total amount to be transferred (minimum $1,500) $____________
C. Select the Portfolios and indicate how total is to be allocated in whole
dollars.
Balanced (265) $ ________ Intermediate Fixed Small Cap Equity (266) $ __________
Income (262) $ __________
Global Fixed Income (264) $ ________ Large Cap Growth (267) $ __________ Berger/BIAM IPT-International
Fund (270) $ __________
Growth & Income (269) $ ________ Large Cap Value (268) $ __________
Mid Cap Equity (263) $ __________
12. Asset Rebalancing
(Rebalanced quarterly; minimum period: 6 months; $5,000 cash surrender value
minimum)
[ ] Yes, I choose to participate in the asset rebalancing program. This program
allows you to automatically rebalance your policy each quarter to your original
percentage allocations. The minimum period to participate in this program is 6
months. The transfer date will be the 15th of the month (or the next business
day if the 15th falls on a weekend or holiday). The fixed account is not part of
asset rebalancing. This program cannot be done at the same time as the Dollar
Cost Averaging program.
13. Anti-Fraud Statement
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.
SPECIAL REQUEST BOX
________________________________________________________________________________
________________________________________________________________________________
Variable Life Application - Page 4
14. Signatures
I acknowledge receipt of the current Prospectus, Medical Information Bureau, and
Fair Credit Report Act notices.
I UNDERSTAND THAT ANY DEATH BENEFITS IN EXCESS OF THE SPECIFIED AMOUNT AND ANY
POLICY VALUE OF THE FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY APPLIED FOR,
MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE OF THE SUBACCOUNTS
OF THE VARIABLE ACCOUNT AND THAT THE DEATH BENEFIT MAY BE VARIABLE OR FIXED
UNDER SPECIFIED CONDITIONS. The policy value allocated to the Fixed Account will
accumulate interest at a rate set by the Company which will not be less than the
minimum guaranteed rate of 4% annually. There is no guaranteed minimum policy
value. The policy value may decrease to the point where the policy will lapse
and provide no further death benefit without additional payments. The policy
values may also be affected by any changes in monthly deductions, the investment
performance of the selected Subaccounts and the amount of interest the company
credits to the Fixed Account depending upon my selections.
It is agreed: (1 ) The application consists of this application form, the
Medical History Statement, and any supplemental application to apply for
insurance on family members, if it applies; (2) All statements in this
application are, to the best of my (our) knowledge and belief, complete and
true. This application and any amendments to it, with the answers made to the
medical examiner (should an exam be required), shall be the basis of any
insurance issued. (3) All information given to the registered
representative/agent in response to the questions in this application has been
correctly recorded herein. (4) Unless otherwise stated in a Conditional Coverage
Receipt or Deduction Order for Insurance bearing the date of this application,
no liability exists until a policy is delivered to and accepted by the owner and
the first premium is paid while the health and occupations of all persons
proposed for health coverage are as described in this application. (5) The
acceptance of any policy issued on this application shall be an acceptance and
ratification of all corrections, additions, or changes made by BMA. The changes
made by BMA are shown in the space below. However, any change in amount, class,
plan of insurance, benefits, or the age at issue shall be subject to written
ratification by the applicant. THIS AGREEMENT (or a copy of it) authorizes any
person or business listed as follows to give BMA, or its reinsurers, any records
or knowledge of me (us) or my (our) health: a) any licensed physician, medical
practitioner, hospital, clinic or other medical or medically related facility;
b) any insurance company; or c) the Medical Information Bureau or other agency
employed by BMA.
If the owner is different from the proposed insured, the proposed insured agrees
that the owner alone is entitled to all privileges incident to the ownership of
the policy. It is agreed that the application by the proposed insured is made on
behalf of the owner and that the owner agrees to all statements, answers, and
agreements by the proposed insured in the application.
Proposed Insured (Owner unless otherwise specified) Proposed Owner (if other than Proposed Insured)
X ____________________________________________________ X ____________________________________________________
Completed at: City ___________________________________ Completed at: City ___________________________________
State __________________________ Date ________________ State __________________________ Date ________________
Spouse (if coverage applied for) Child (if age 18 or older and coverage applied for)
X ____________________________________________________ X ____________________________________________________
Completed at: City ___________________________________ Completed at: City ___________________________________
State __________________________ Date ________________ State __________________________ Date ________________
[ ] I consent to the delivery of the following documents to me in electronic
format, if available electronically: Profiles, prospectuses, prospectus
supplements, annual reports, semi-annual reports and proxy statements/materials.
I understand that BMA will send me the above documents in electronic format,
when available, until I revoke this consent.
[ ] I prefer to receive printed copies of profiles, prospectuses, prospectus
supplements, annual reports and semi-annual reports.
15. Replacement
Do you have any knowledge or reason to believe that replacement of existing
insurance or annuities may be involved? [ ] Yes [ ] No If yes, complete
replacement form, if required, and submit with this form.
Representative's Signature ____________________________ Broker-Dealer/Branch _____________________ / ID#________
Print Name ___________________________________________ Address ________________________________________________
Broker Number ____________________ /SSN ______________ ________________________________________________
Compensation Option [ ] A [ ] B [ ] C Telephone ______________________________________________
Authorized B/D Signature ______________________________
________________________________________________________________________________
This space is for the use of BMA's Service Center.
________________________________________________________________________________