Exhibit 1.A.(10)
UNITED INVESTORS LIFE
Administrative Office
P. O. Box 10287
Birmingham, AL 25202-0287
1 800-340-3787
Titanium Investor
Variable Universal Life
Application
Complete the following forms in all cases:
All Parts of Application
Agent's Report
Complete the following when Needed:
HIV Consent Form, if required by state
Replacement Form
1035 Exchange Form
Pre-Authorized Bank Draft Agreement
For Additional Insured, complete Additional Insured Information
Directions
Y Give the Fair Credit / MIB Notice to the Applicant prior to completion of
the application
Y Complete and sign the Agent's Report
Y Print application using black ink
Y Get all required signatures
Y Have the applicant initial any changes
Y Don't accept or send money on applications totaling $1,000,000 or more
Y Don't use pencil or white-out
Y Complete and attach a signed copy of the Illustration
U-1300
United Investors Life Insurance Company
Federal Fair Credit Reporting Act Notice
We may request a consumer report which contains information about your
character, reputation, and mode of living, except as may be related directly or
indirectly to your sexual orientation. The information is obtained through
interviews with your friends, neighbors, and associates. It is part of our
underwriting procedure. We will furnish information about the nature of the
report if you write to us and ask.
This notification must be given to the Proposed Insured before the application
is completed.
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Medical Information Bureau Notice
Information about your insurability will be treated as confidential. United
Investors Life Insurance Company, or its reinsurers may, however, make a brief
report of this to the Medical Information Bureau, a non-profit membership
organization of life insurance companies, which operates an information exchange
on behalf of its members. If you apply to another Bureau member company 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
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 02112, telephone number
(617) 426-3660.
United Investors Life Insurance Company, or its reinsurers, may also release
information in its 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.
This notification must be given to the Proposed Insured before the application
is completed.
U-1300
Temporary Insurance Agreement
Accidental Death - $100,000 Maximum
Payment of the Insurance is subject to all the provisions of this Agreement.
DEFINITION OF TERMS: Insured, You, Your, Yours mean the Proposed Insured(s)
named in the application; or a child proposed to be insured under a Children's
Insurance Rider. We, Our, Ours, Us mean United Investors Life Insurance Company.
Insurance means the amount of temporary accidental death insurance provided by
this agreement. Application means the application to which this agreement is
attached. Policy means the policy applied for in the application. Beneficiary
means the beneficiary named in the application.
BENEFIT: We agree to pay the insurance to the beneficiary when we receive due
proof that the death of the insured: (1) resulted directly and independently of
all other causes, from accidental bodily injuries sustained while this agreement
was in force; (2) was not caused by suicide or any intentionally self-inflicted
injury (in Missouri, while sane); and (3) was not contributed to in any way by
bodily or mental infirmity or disease of any kind.
AMOUNT OF INSURANCE: The insurance provided under this Agreement and all other
such agreements issued by us to you will be the least of: (a) The death benefit
requested in the application less any death benefits we would pay on policies
intended to be replaced by the policy; or (b) $100,000 if you are the Proposed
Insured; or (c) $5,000 if you are a Proposed Insured Child.
STARTING DATE AND CONDITIONS: The limited insurance benefit provided by this
agreement will start when the application is signed by you, provided: (1) at
least one no-lapse monthly premium is received by us with the application; and
(2) any check or draft given for the above amount is honored when first
presented to the bank.
ENDING DATE: The insurance will automatically end on the earliest of: (a) the
date the policy is effective or is rejected by the applicant; (b) the date that
the policy issued other than as applied for is accepted or rejected by the
applicant; (c) the date we decline to issue a policy; or (d) 90 days after the
starting date.
RECEIPT FOR PREMIUM
Amount Paid: $__________________________________
Agent's Signature ______________________________
Date ___________________________________________
All premium checks must be made payable to United Investors Life. Do not make
checks payable to the Agent. Do not leave the payee blank.
If at least one no-lapse monthly premium is paid with the application, this
agreement must be given to the applicant.
U-1300
Application for Titanium Investor
Variable Universal Life Insurance
A. Proposed Insured(s)
1. Name of Proposed Insured (First-Middle-Last)
2. Birthdate: (Mo/Day/Yr) 3. Birthplace (State)
4. Sex: F M 5. Marital Status
6. Social Security # 7. Driver's License #/State
8. Residence Address
City State Zip Years There
9. Other Residence addresses during past 2 years (Street, City, St, Zip)
10. Occupation/Duties
11. Employer's Name & Address
1a. Name of Additional Insured (First-Middle-Last)
2a. Birthdate: (Mo/Day/Yr) 3a. Birthplace (State)
4a. Sex: F M 5a. Marital Status
6a. Social Security # 7a. Driver's License #/State
8a. Residence Address
City State Zip Years There
9a. Other Residence addresses during past 2 years (Street, City, St, Zip)
10a. Occupation/Duties
11a. Employer's Name & Address
B. Beneficiaries: Full Name and Relationship
Insured: Primary Beneficiary:_______________ Relationship to Insured:
Social Security#/TaxID#____________ ________________________
Contingent Beneficiary:_______________________ Relationship to Insured:
Social Security#/TaxID#____________ ________________________
Additional Insured: Primary Beneficiary:__________________________________
Social Security#/TaxID#____________ Relationship to Additional
Insured:________________
Contingent Beneficiary:_______________________ Relationship to Additional
Social Security#/TaxID#____________ Insured:________________
C. Owner - Complete if Owner is someone other than the Insured
Name of Owner if other than Insured:_______________________________________
Relationship:_________________ Social Security#/Tax ID#.:__________________
Birthdate: (mo/day/yr)________
Address:_________________________________ City:________________
State:______ Zip:____________
Name of Contingent Owner:_______________________________________
Relationship:_________________ Social Security#/Tax ID#.:__________________
Birthdate: (mo/day/yr)________
Address:_________________________________ City:________________
State:______ Zip:___________
D. Plan Information and Additional Benefits
1. Base Face Amount:$____________
Death Benefit Option: [ ] A (Level Death Benefit) [ ] B (Face Amount
plus Policy Value)
2. Additional Benefits:
[] Accidental Death Benefit Rider $________________
[] Additional Insured Term Rider $________________(Complete
Additional Insured Section for
each additional insured.)
[] Adjustable Term Insurance Rider $________________(Maximum 9 x Base
[] Change of Person Insured Rider Face Amount)
[] Children's Insurance Rider (CIR) ______Units (Maximum 10 Units). (The
following question must be answered if CIR is requested.) Has any
child proposed for the Children's Insurance Rider had or been treated
for a disorder or disease of the heart or brain, or diabetes, cancer
or AIDS? [] Yes [] No
(If "Yes," CIR is not available.)
[] Death Benefit Guarantee Rider: (Select One)
[] Later of 10 Years or 65 [] Lifetime
[] Option to Purchase Additional Insurance Rider
[] Waiver of Monthly Deductions Rider
[] Waiver of Specified Premium Rider: $________________
[] Other: (Specify Plan/Amount)____________________________________
E. Premium Payments and Notices
1. Amount Paid with this Application:$_________________
2. Planned Periodic Premium:_____________________ (Write "none," if no
future billing is
desired.)
3. Premium Payment Method and Frequency
(Check one box only)
Method Annual Semi-Annual Quarterly Monthly
------ ------ ----------- --------- -------
Direct Bill [] [] [] N/A
Bank Draft [] [] [] []
4. Send all Premium Notices and Reports to: [] Insured's Residence
[] Owner's Address [] Other Address:__________________________________
5. Premium Payment Allocation (Whole percentages only):
FIXED ACCOUNT ________%
VARIABLE ACCOUNT SUBACCOUNTS
AIM V.I. Fidelity VIP & VIP II cont'd
Capital Appreciation _______% VIP Growth Opportunities _______%
Growth _______% VIP High Income _______%
Growth and Income _______% VIP Money Market _______%
International Equity _______% VIP Overseas _______%
Value _______%
Alger American VIP II Balanced _______%
Growth _______% VIP II Contrafund _______%
Income and Growth _______% VIP II Fund _______%
Leveraged AllCap _______% VIP II Index 500 _______%
MidCap Growth _______% INVESCO VIF
Small Capitalization _______% Equity Income Fund _______%
BT Insurance Funds Technology Fund _______%
EAFE Equity Index _______% Utilities Fund _______%
Small Cap Index _______% Strong VIF
Fidelity VIP & VIP II Discovery Fund II _______%
VIP Equity Income _______% Mid Cap Growth Fund II _______%
VIP Growth _______% Opportunity Fund II _______%
VIP Growth and Income _______%
Total 100%
6. [] Dollar Cost Averaging
Automatic transfer each month of a preselected dollar amount from the Money
Market Subaccount or the Fixed Account.
Select day of the month on which you would like transfers to be made: ____
(1st through 28th). If the day of the month selected does not fall on a
Valuation Date, transfers will be made on the next following Valuation
Date. Transfers will be made at the unit values determined on the date of
each transfer.
Select Account from which transfers are to be made:
----
[] Fixed Account [] Money Market Subaccount
Enter total dollar amount to be transferred: $_________ ($100 minimum)
Select Accounts to which transfers are to be made and the dollar amount ($25
--
minimum) to be transferred to each Account.
FROM TO
AIM VI Capital Appreciation Fidelity VIP Growth Opportunities $_______
AIM VI Growth $_______ Fidelity VIP High Income $_______
AIM VI Growth and Income $_______
AIM VI International Equity $_______ Fidelity VIP Overseas $_______
AIM VI Value $_______ Fidelity VIP II Balanced $_______
Alger American Growth $_______ Fidelity VIP II Contrafund $_______
Alger American Income and Growth $_______ Fidelity VIP II Fund $_______
Alger American Leveraged AllCap $_______ Fidelity VIP II Index 500 $_______
Alger American MidCap Growth $_______ INVESCO VIF Equity Income Fund $_______
Alger American Small Capitalization $_______ INVESCO VIF Technology Fund $_______
BT Funds EAFE & Equity Index $_______ INVESCO VIF Utilities Fund $_______
BT Funds Small Cap Index $_______ Strong VF Discovery Fund II $_______
Fidelity VIP Equity Income $_______ Strong VF Mid Cap Growth Fund II $_______
Fidelity VIP Growth $_______ Strong VF Opportunity Fund II $_______
Fidelity VIP Growth and Income $_______
7. [] Automatic Asset Rebalancing - Automatic rebalancing of the Subaccounts
and the Fixed Account in your variable policy according to current
premium allocation instructions.
Select Rebalancing Frequency: [] Annual [] Semi-Annual [] Quarterly
Select Day of Month for Rebalancing:__________(1st - 28th)
8. [] Telephone Authorization: If selected, Owner must initial agreement
below.
I agree to hold United Investors Life harmless from all claims when
action is taken pursuant to a telephone request for transfers,
reallocations or changes in premium allocations based on the
Owner's correct name and policy number.________(Owner's initials)
9. Suitability:
a. Did you receive copies of the prospectuses for the variable life
policy and the Subaccounts selected? Yes No
b. Do you understand that the Policy Value and the amount and duration of
the Death Benefit may increase or decrease based on the Subaccounts
selected and that this policy may terminate without value depending on
the investment performance of such Subaccounts? Yes No
c. Do you believe that the insurance selected is suitable for
your financial objectives? Yes No
Page 3
U-1300
F. Other Insurance/Replacement
1. Life Insurance and/or annuities in force on the lives of all persons proposed
for insurance (If none, insert `NONE.'
Check one Insured/Additional Ins./Company and Policy No./Life Amount/
ADB Amount/Year
Issued
1. $
2. $
3. $
4. $
2. Is policy applied for intended to replace or change existing insurance or
annuities in force? (If `Yes,' identify by circling number preceding
Company Name.).................................... [] Yes [] No
If `Yes,' is this a 1035 Exchange................. [] Yes [] No
3. Do you have any other application for
life insurance pending? .......................... [] Yes [] No
Insured Additional
Insured
G. Underwriting Information
1. Has any person proposed for insurance:
(a) Used tobacco in any form in the past year?
(If `Yes,' describe type and amount.) [] Yes [] No
(b) Ever used tobacco? (If "yes," give date of
last use, frequency and amount used.) [] Yes [] No
(c) Flown as a pilot, student pilot, or crew
member? (If `Yes,' complete Aviation
Questionnaire) [] Yes [] No
(d) Participated in Auto Racing, Motorcycle
Racing, Parachuting, Ballooning, Hang
Gliding, Skin or Scuba Diving?
(If 'Yes,' provide complete details on
Avocation Questionnaire) [] Yes [] No
(e) Had driver's license suspended or revoked in
the past 5 years, or had more than 2 moving
violations in the past 3 years?
(If `Yes,' explain.) [] Yes [] No
(f) Been convicted of or awaiting trial for a
felony? (If 'Yes,' give details
including parole/probation status.) [] Yes [] No
(g) Been arrested, treated, or counseled for
excessive use of alcohol or for drugs?
(If `Yes,' give details.) [] Yes [] No
(h) Had any new insurance or reinstatement
refused, postponed, limited, withdrawn,
cancelled, or offered or quoted on a
substandard or rated basis? (If
'Yes,' explain.) [] Yes [] No
2. Does any person proposed for insurance:
(a) Participate in a physical fitness program?
(If 'Yes,' describe.) [] Yes [] No
(b) Drink alcoholic beverages? (If 'Yes,' report
frequency, amount, type, and
circumstances.) [] Yes [] No
(c) Intend to travel or reside outside the
United States or Canada within the next
year? (If 'Yes,' give details.) [] Yes [] No
3. Details of Any 'Yes' answers to Sections F & G.
Check One
---------
Item No. Insured Additional Ins. Details
-------- ------- --------------- -------
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H. Medical Questionnaire
1. Insured Height _______ ft. ______ in. Weight______ lbs.
1a. Additional Insured Height_______ ft. ________in. Weight_______ lbs.
Name and Address of Personal Physician____________________________________
Name and Address of Personal Physician____________________________________
__________________________________________________________________________
__________________________________________________________________________
___________________________________________________________Date and reason
last consulted____________________________________________________________
Date and reason last consulted____________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. In the past 10 years, have you had or been treated for:
Insured Additional Ins.
------- ---------------
a. disorder of eyes, ears, nose or
throat? [] Yes [] No [] Yes [] No
b. dizziness, fainting, convulsions,
head injury, headaches, paralysis or
stroke, tremor, muscle weakness,
depression, other mental or nervous
disorder? [] Yes [] No [] Yes [] No
c. shortness of breath, persistent
hoarseness or cough, blood spitting,
bronchitis, asthma, pleurisy,
emphysema, tuberculosis or chronic
respiratory disorder? [] Yes [] No [] Yes [] No
d. chest pain, palpitations, high blood
pressure, rheumatic fever, heart
murmur, varicose veins, phlebitis, or
other heart or blood vessel
disorder? [] Yes [] No [] Yes [] No
e. hepatitis, cirrhosis, ulcer,
intestinal bleeding, colitis,
diverticulitis, appendicitis or other
disorder of the esophagus,
stomach, intestines, rectum, liver,
gall bladder, pancreas or spleen? [] Yes [] No [] Yes [] No
f. sugar, albumin, blood or pus in
urine, sexually transmitted or
venereal disease, stone, or other
disorder of the kidney, bladder,
prostate or reproductive organs? [] Yes [] No [] Yes [] No
g. diabetes, thyroid or other
endocrine disorders? [] Yes [] No [] Yes [] No
h. arthritis, neuritis, neuralgia,
rheumatism, gout, or disorder of the
muscles or bones, including
the spine, back and joints? [] Yes [] No [] Yes [] No
i. disorder of the skin, breast, or
lymph glands, cancer, tumor or
cyst? [] Yes [] No [] Yes [] No
j. allergies, anemia, bleeding
tendency or other disorder of the
blood? [] Yes [] No [] Yes [] No
k. persistent fever, night sweats,
chills and/or diarrhea? [] Yes [] No [] Yes [] No
l. or been diagnosed with AIDS by a
member of the medical profession, or
had a positive test for the HIV
or HTLV-III (AIDS) virus? [] Yes [] No [] Yes [] No
3. Other than listed above, have you within
the past 5 years:
a. had or been treated for any mental or
physical disorder, illness or
injury; had or been advised to have any
checkup, consultation,
hospitalization, treatment or surgery
including an EKG,
X-ray or other diagnostic test? [] Yes [] No [] Yes [] No
b. received disability benefits or workers
compensation? [] Yes [] No [] Yes [] No
4. Are you now under observation or taking
treatment or medication? [] Yes [] No [] Yes [] No
5. Have you had any change in weight in the
past year? (If yes, give amount and reason) [] Yes [] No [] Yes [] No
6. In the past ten years have you used narcotics,
barbiturates, tranquilizers, hallucinogens,
heroin, morphine, cocaine,
amphetamines, LSD, marijuana or any other
habit-forming drugs or prescription drugs,
except as prescribed by a physician? [] Yes [] No [] Yes [] No
7. Have you had a father, mother, brother or
sister diagnosed before age 60 as having:
diabetes, cancer, high blood pressure, heart or
kidney disease, alcoholism, mental illness
or suicide? [] Yes [] No [] Yes [] No
8. IMPORTANT Details of `Yes' answers to questions
2 thru 7.
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Item Check one Name and Address of Each Physician, Dates and Nature and Severity
No. Ins./Additional Practitioner and Health Facility Durations of Condition,
Frequency of Attacks
Specific Diagnosis And
Treatment
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U-1300
Page 3
I. Additional Details and Remarks
J. Amendments and Corrections (For Home Office Use Only)
(Not to be used where prohibited by statute or Insurance Department
ruling.)
Agreement
I have read this completed application, and represent that the statements and
answers given herein are true, complete, and correctly recorded to the best of
my knowledge and belief. I agree that: (1) the entire contract will consist of
this application and the policy issued in response to it; (2) no agent of the
company can make or modify contracts, waive any rights of the Company, or waive
any information requested by the Company; and (3) except as provided in the
Temporary Insurance Agreement, if issued, no insurance will take effect unless:
(a) the policy is delivered to the Owner; (b) the first modal premium is paid;
and (c) between the date of this application and the date of policy delivery,
there has been no change in the health or insurability of any person proposed
for insurance; (4) the acceptance of any policy issued on this application shall
constitute acceptance and ratification of any changes made by the Company under
"Amendments and Corrections". In those states where required, any change in age,
amount, classification, plan of insurance or benefits shall be subject to
written ratification by the applicant.
Authorization
I hereby authorize any licensed physician, medical practitioner; hospital,
clinic or other medical or medically related facility, insurance company;
reinsurer, the Medical Information Bureau or other organization, institution or
person, that has any records or knowledge of me or my health, to give to United
Investors Life Insurance Company, or its reinsurers, any such information. This
authorization is valid for twenty-six months from the date this form is signed.
A photographic copy of this authorization shall be as valid as the original. I
know that I may request to receive a copy of this authorization. I have received
the notification about the Federal Fair Credit Reporting Act and the Medical
Information Bureau.
Signed at on
--------------------------------- ----------------------------------
City State Month/Day/Year
____________________________ _____________________ X_________________________
Agent's Name (Please Print) Agent# Reg/Div # Signature of Proposed
Insured
X X
-------------------------------------------------- -------------------------
Signature of Agent Signature of Additional
Insured
X
-------------------------
Signature of Owner, if
other than Proposed
Insured
U-1300
Agent's Report
1. How well do you know the Proposed Insured?
Know well Do not know well
Relative (state relationship)______________________
How long known?____________________________________
2. Did you personally see Proposed Insured? Yes No
(If No, explain in Remarks)
3. Who first suggested the purchase of this insurance?
Agent Owner/Applicant
Proposed Insured Other______________________
4. To the best of your knowledge, does the policy applied for involve the
replacement of existing insurance or annuities? Yes No
(If Yes, follow all applicable state requirements)
5. Purpose(s) which best describe the use of this Insurance:
Personal Business
Income Replacement Buy/Sell
Home Mortgage Key Person
Estate Conservation Stock Redemption
Debt Repayment Creditor
Other__________________ Other______________________
6. Financial Information of Proposed Insured
a. Annual Income $_________________
b. Est. Net Worth $_________________
c. Ever filed bankruptcy?: Yes No
Date Discharged/Explain in Remarks
7. Owner's Confidential Financial Information:
a. Age:_________________
b. Gross Family Income: $_______________________
c. TaxableIncome: $_____________________________
d. Number of Dependents:________________________
e. Occupation:__________________________________
f. Employers' Name:_____________________________
g. Employer Address:____________________________
h. Savings and Liquid Assets: $_________________
i. Other Assets (excluding home, furnishings, car): $__________________
j. Net Worth (Assets minus liabilities): $______________________
k. Are you associated with any NASD Member? Yes No
l. Investment Objectives (mark all that apply):
Retirement Savings Reserves
Children's College Income
Other Needs/Goods (specify in Special Remarks)
m. Special Remarks/Considerations:______________________________________
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8. If this is business insurance:
a. Are other principals being insured also? Yes No
(If No, explain reason; If Yes, give names, amounts, companies)
b. Business net worth $______________________
c. Business net income Year_______________ Amount $_______________
d. Percent of business owned by Proposed Insured __________%
9. If Proposed Insured is a Juvenile:
a. Did you see the child? Yes No
b. Does he/she live with parents? Yes No
c. Are all brothers and sisters insured
for like amounts? (If No, explain in Remarks) Yes No
d. How much insurance is in force on the life of the
person responsible for the child's support? $________________
10. Telephone Numbers Insured Additional Insured
Home:
Business:
Best Time a.m. Bus. a.m. Bus.
to Call:_______ p.m. Home p.m. Home
11. Is medical examination being completed Yes No
If Yes, appointment date________________________
Name of Para-Medical Service?___________________
12. Remarks:
I represent that: (1) I have personally seen the Proposed Insured(s); (2) I have
truly and accurately recorded on this application the information as supplied by
the Owner and the Proposed Insured(s); (3) to the best of my knowledge and
belief there is nothing adversely affecting the insurability of the Proposed
Insured(s) other than as indicated in this application; (4) the written
disclosure statement was given on or before the date the application was signed
in states where applicable; and (5) if I become aware of a change in the health
or habits of the Proposed Insured(s), occurring after the date of the
application but before I deliver the policy, I promise to inform the company of
the change and agree to withhold delivery of the policy until instructed by the
Company.
X_______________________________________________________________________________
Signature of Agent Date Phone No.
Pre-Authorized Bank Draft Agreement
As a convenience to me, I hereby request and authorize United Investors Life
Insurance Company, Birmingham, Alabama to initiate premium payments from my
checking account either by electronic funds transfer or by pre-authorized bank
draft order provided there are sufficient collected funds in said account to pay
the same upon presentation. I agree that your rights in respect to each such
transfer or draft shall be the same as if it were a check drawn on you and
signed personally by me. This authority is to remain in effect until revoked by
me in writing; and until you actually receive such notice, I agree that you
shall be fully protected in honoring any such transfer or draft.
I further agree that if any such transfer or draft is dishonored, whether with
or without cause and whether intentionally or inadvertently, you shall be under
no liability whatsoever, even though such dishonor results in the forfeiture of
insurance.
Name of Policyholder(s) Policy Number(s) Bank Draft Premium
Depositor(s)
Financial Institution
Name of Depositor(s) listed on the account
Name of Financial Institution
(Please Print or Type)
Signature of Depositor (as checks are signed)
Date
Financial Institution Address
Signature of Joint Depositor (as checks are signed)
Date
City
State
Zip Code
Requested Draft Date (1st thru 28th only)
Account Number to be debited
Please attach a sample "void" check
(Deposit slip cannot be used)
Indemnification Agreement
To: The financial institution named above
In compliance with our mutual client's request, we will draw monthly drafts
which are MICR encoded with your transit number and the drawee's bank account
number. Please contact our Bank Draft Department if you have any questions.
In consideration of your compliance with the request and authorization of the
depositor named on the reverse side, United Investors Life Insurance Company
Agrees That:
1. It will indemnify and hold you harmless from any liability to any person
having an account with you arising out of the payment by you of any check
drawn by United Investors Life Insurance Company to its own order on the
account of such person, or from any liability to any such person or to any
owner or beneficiary of any policy issued by United Investors Life Insurance
Company in respect of which such a check is drawn arising out of the dishonor
by you whether with or without cause of any such check drawn by United
Investors Life Insurance Company, provided there are sufficient funds in such
account to pay the same upon presentation, whether or not such claim or
liability asserted against you be based upon the forfeiture, or alleged
forfeiture of a policy the premiums on which is sought to be collected by
United Investors Life Insurance Company by any such check.
2. It will refund to you any amount erroneously paid by you to United Investors
Life Insurance Company on any such check if claim for the amount of such
erroneous payment is made by you within twelve months from the date of the
check on which such erroneous payment was made.