ACACIA NATIONAL LIFE INSURANCE COMPANY (ANLIC) 1010-V
APPLICATION FOR VARIABLE 7315 WISCONSIN AVENUE
UNIVERSAL LIFE BETHESDA, MD 20814
Please print clearly in black ink.
[ ] NEW POLICY [ ] CONVERSION
[ ] PRELIMINARY APPLICATION [ ] POLICY # _________________________________
[ ] INCREASE / ADDITION TO POLICY # ________________ [ ] RIDER ATTACHED TO POLICY # _______________
[ ] If increasing existing policy, enter NEW insurance CONTINUE THE BALANCE? [ ] YES [ ] NO
amount only $ _______________ [ ] RATE REDUCTION OF POLICY # _______________
[ ] Use policy funds, no change to planned period premium [ ] EXERCISE OF SPLIT OPTION
[ ] Increase planned periodic premium to $ ________________ 1st Insured Name and Amount $ ____________
If increase in premium, complete Section 10 Premium Name: ____________________________________
Amount 2nd Insured Name and Amount $ ____________
Name: ____________________________________
____________________________________________________________________________________________________________________________________
PRODUCT NAME: [ ] ALLOCATOR 2000 [ ] REGENT 2000
COMPLETE INSURED 2 INFORMATION IF APPLYING FOR REGENT 2000 PRODUCT
____________________________________________________________________________________________________________________________________
1. INSURED 1
Name of Insured 1 ___________________________________________________________ Sex ___ Date of Birth __/__/__ Bithplace _______
(State)
Former Name (if applicable) _________________________________________________ Social Security Number _________________________
Address _________________________________________________________________________________________________________________________
Occupation _____________________________ Duties _________________________________________________________________________________
(Date Employed)
Telephone - Home ________________________ Best Time To Call: _________ A.M. ________ P.M.
Telephone - Business ____________________ Best Time To Call: _________ A.M. ________ P.M.
____________________________________________________________________________________________________________________________________
2. INSURED 2
Name of Insured 2 ___________________________________________________________ Sex ___ Date of Birth __/__/__ Bithplace _______
(State)
Former Name (if applicable) _________________________________________________ Social Security Number _________________________
Address _________________________________________________________________________________________________________________________
Occupation _____________________________ Duties _________________________________________________________________________________
(Date Employed)
Telephone - Home ________________________ Best Time To Call: _________ A.M. ________ P.M.
Telephone - Business ____________________ Best Time To Call: _________ A.M. ________ P.M.
____________________________________________________________________________________________________________________________________
3. OTHER INSURED
Name of Other Insured _______________________________________________________ Sex ___ Date of Birth __/__/__ Bithplace _______
(State)
Former Name (if applicable) _________________________________________________ Social Security Number _________________________
Address _________________________________________________________________________________________________________________________
Occupation _____________________________ Duties _________________________________________________________________________________
(Date Employed)
Telephone - Home ________________________ Best Time To Call: _________ A.M. ________ P.M.
Telephone - Business ____________________ Best Time To Call: _________ A.M. ________ P.M.
____________________________________________________________________________________________________________________________________
4. OWNER Owner of the policy is to be (choose one): [ ] Insured 1 [ ] Insured 2 [ ] Joint Owner-Insureds [ ] Other please
complete below)
Full Name ___________________________________________________________________ Address __________________________________________
Date of Birth/Trust Date __/__/__ ______________________________________
Relationship to Insureds (or all Trustee's Names) ___________________________ Social Security#/TIN# ____________________________
____________________________________________________________________________________________________________________________________
5. BENEFICIARY IF LEFT BLANK, THE BENEFICIARY WILL BE THE ESTATE OF THE OWNER. UNLESS OTHERWISE INDICATED, MULTIPLE BENEFICIARIES
OF THE SAME CLASS SHALL BE PAID EQUALLY TO THE SURVIVOR OR SURVIVORS.
Primary _____________________________________________________________________ Rationship to Insured(s) _________________________
Contingent __________________________________________________________________ Relationship to Insured(s) _______________________
[ ] OR AS STATED IN AMENDMENT (attach amendment)
____________________________________________________________________________________________________________________________________
6. ALLOCATOR 2000 OPTIONAL RIDERS:
AMOUNT OF INSURANCE $___________________ [ ] Children's Insurance Rider (complete Section 8 below) $ ________
[ ] Other Insured Term Rider (complete Section 3 above) $ ________
[ ] Non-Family Other Insured Term Rider $ ________
DEATH BENEFIT OPTION (select one only) (Complete Section 3 above)
--------------------
[ ] Type A (death benefit is the amount [ ] Total Disability Rider $ ________
of insurance) [ ] Level Renewable Term Rider $ ________
[ ] Type B (death benefit is the amonut of [ ] Guaranteed Insurability Rider $ ________
insurance plus the accumulation [ ] Accidental Death Benefit Rider
value) [ ] Proposed Insured $ ________
[ ] Other Insured $ ________
[ ] Other Insured ________________________________________________________
____________________________________________________________________________________________________________________________________
VUL-ANLIC Ed. 3-99 Page 1 of 9 Pages 071699p
____________________________________________________________________________________________________________________________________
7. REGENT 2000 SURVIVORSHIP ONLY OPTIONAL RIDERS (CONT'D.)
AMOUNT OF INSURANCE $ ___________________ [ ] First To-Die Term Rider $ _______________
Beneficiary Designation
DEATH BENEFIT OPTION (select one only) Primary _________________ Relationship ________________
-------------------- Contingent ______________ Relationship ________________
[ ] Option A (death benefit is the amount of
insurance) [ ] Second To-Die Term Rider $ ______________
[ ] Option B (death benefit is the amount of [ ] Term Rider for Covered Insured $ _____________
insurance plus the accumulation value) [ ] Insured 1
Primary _____________ Relationship ________________
OPTIONAL RIDERS: Contingent __________ Relationship ________________
[ ] Estate Protection Beneficiary Designation
[ ] Disability Benefit $ _________________ [ ] Insured 2
[ ] Insured 1 or [ ] Insured 2 Primary ____________ Relationship ________________
Contingent _________ Relationship ________________
[ ] Other Insured (Complete Section 3 above).
____________________________________________________________________________________________________________________________________
8. CIR ONLY - Children: Unmarried, living with insured, under 18 yrs. old.
Birthdate Birthdate
Full Name Mo Day Yr. Ins. Age Ht. Wt. Sex Full Name Mo Day Yr. Ins. Age Ht. Wt. Sex
CHILD CHILD
CHILD CHILD
CHILD CHILD
____________________________________________________________________________________________________________________________________
9. PREMIUM MODE Please select one.
[ ] Annual [ ] Semi-Annual [ ] Quarterly [ ] Monthly Bank Withdrawal [ ] Monthly Billing
[ ] Non-Billing [ ] Invoice Billed [ ] Payroll Deduction(Additional form required) [ ] Single $ _______________
____________________________________________________________________________________________________________________________________
10. PREMIUM AMOUNT
Planned Annual Premium $ __________________ Planned Modal Premium $ _____________________
*Initial Premium (paid with application) $ __________________________ (leave receipt with payor).
____________________________________________________________________________________________________________________________________
*All premium checks must be made payable to ANLIC. Do not make check payable to the agent/registered representative or leave the
payee blank.
____________________________________________________________________________________________________________________________________
11. INSURANCE INFORMATION Insured 1 Insured 2 Other Insured
List all life insurance existing on each Insured. If none, check box. [ ] None [ ] None [ ] None
Will the Insurance now being applied for discontinue, reduce, change or replace any life insurance or annuity in this or any
other company? [ ] Yes [ ] No
(If yes, attach Comparative Information Form and/or Replacement Notice if required by State Law.)
ACCIDENTAL YEAR WILL THIS POLICY BE REPLACED?
NAME OF INSURED COMPANY POLICY NUMBER AMOUNT DEATH ISSUED YES NO AS A 1035?
_________________________________________________________________________________ [ ] [ ] [ ]
_________________________________________________________________________________ [ ] [ ] [ ]
_________________________________________________________________________________ [ ] [ ] [ ]
_________________________________________________________________________________ [ ] [ ] [ ]
_________________________________________________________________________________ [ ] [ ] [ ]
____________________________________________________________________________________________________________________________________
12. OTHER INFORMATION
INFORMATION BELOW RELATES TO ALL PERSONS PROPOSED FOR COVERAGE Yes No
a. Has any company declined, postponed, modified, cancelled or refused to renew, reinstate or issue insurance? [ ] [ ]
b. Is any other life insurance application now pending or contemplated with any other company? [ ] [ ]
c. Have you been charged with a driving violation or had your license suspended or had a restriction placed
on you licnese within the past 3 years? (If yes, provide)
Insured 1 Driver's license number _____________________ State of Issue __________ [ ] [ ]
Insured 2 Driver's license number _____________________ State of Issue __________ [ ] [ ]
Other Insured Driver's license number _____________________ State of Issue __________ [ ] [ ]
d. Have you participated in any vehicle racing, parachuting, hang gliding, scuba diving, mountain climbing or
rodeos within the past 2 years or is any such activity contemplated? (If yes, complete Avocation Form) [ ] [ ]
e. Have you ever flown within the past 2 years as a pilot, student pilot, crew member, or had any flying duties,
or is any such activity contemplated? (If yes, complete Aviation Form) [ ] [ ]
f. Do you anticipate travel or residence in a foreign country in the near future?
(If so, where and for how long? _____________________________) [ ] [ ]
____________________________________________________________________________________________________________________________________
DETAILS of "yes" answers. Identify question number "1", "2" or "Other Insured" where applicable:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Page 2 of 9 Pages
____________________________________________________________________________________________________________________________________
13. TOBACO USE Yes No
a. Have you smoked one or more cigarettes in the past 12 months? [ ] [ ]
b. Hou you used any form of tobacco or nicotine substitute in the past twelve months? [ ] [ ]
(If yes, please indicate Insured "1", "2" or "Other Insured" and type and frequency) ________________________
____________________________________________________________________________________________________________________________________
14. SPECIAL INSTRUCTIONS
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
15. ENDORSEMENTS/CORRECTIONS HOME OFFICE USE ONLY.
No change in the amount, age at issue, classification, plan of insurance or benefits shall be effective unless agreed to in
writing by me. This space will not be used in MD, PA, WV or any other state if not allowed by statute or Insurance Department
Regulations.
____________________________________________________________________________________________________________________________________
16. SUITABILITY INFORMATION
A. FINANCIAL INFORMATION Owner (if other
Insured 1 Insured 2 than Insureds or Trust)
i. Annual income from occupation $ ____________________ $ __________________ $ _______________________
ii. Annual income from other sources $ ____________________ $ __________________ $ _______________________
iii. Projected income for next 12 months $ ____________________ $ __________________ $ _______________________
iv. Estimated Net Worth $ ____________________ $ __________________ $ _______________________
v. Tax Bracket ____________________ % __________________ % _______________________ %
B. INVESTMENT OBJECTIVES & RISK TOLERANCE
This section applies to the Owner. In order to determine if this policy meets your investment objectives and continuing
financial needs, please complete the following:
INVESTMENT OBJECTIVES: Please check at least one. Multiple objectives can be selected. However, if more than one please rank
based on importance to you. Primary = 1, Secondary = 2, etc.
[ ] Preservation of Capital [ ] Income [ ] Growth [ ] Aggressive Growth [ ] Speculation [ ] Other _____________________
RISK TOLERANCE: Rank based on the level of risk. Tolerable = 1, Least Tolerable = 4.
_____________ Low Risk ___________ Moderate Risk ____________ Speculative Risk __________ High Risk
C. CITIZENSHIP INFORMATION Insured 1 Insured 2 Other Insured
Yes No Yes No Yes No
Are the Insureds citizens of the Unites States? [ ] [ ] [ ] [ ] [ ] [ ]
if not, permanent resident? [ ] [ ] [ ] [ ] [ ] [ ]
D. Do you understand the insurance features of this product? [ ] Yes [ ] No
NOTICE
All Registered Representatives must provide their Broker Dealer with client information applicable to suitability. (See your Broker
Dealer for details).
____________________________________________________________________________________________________________________________________
17. ALLOCATION
Choose EITHER a. or b. Acacia allows you to choose either the (A) MODEL ASSET ALLOCATION PROGRAM and its options or (B) OWNER
DIRECT ASSET ALLOCATION PROGRAM and its options.
a. I want to participate in the MODEL ASSET ALLOCATION PROGRAM (Quarterly rebalancing is automatic.)
[ ] Yes If yes, please select ONE Portfolio A-J.
Portfolio A Conservative (WITH International) [ ]
Portfolio B Conservative (WITH International) [ ]
Portfolio C Moderate (WITH International) [ ]
Portfolio D Moderate-Aggressive (WITH International) [ ]
Portfolio E Aggressive (WITH International) [ ]
Portfolio F Conservative (WITHOUT International) [ ]
Portfolio G Conservative-Moderate (WITHOUT International) [ ]
Portfolio H Moderate (WITHOUT International) [ ]
Portfolio I Moderate-Aggressive (WITHOUT International) [ ]
Portfolio J Aggressive (WITHOUT International) [ ]
Other _______________________________________________________
____________________________________________________________________________________________________________________________________
Page 3 of 9 Pages
b. I want to participate in the OWNER DIRECTED ASSET ALLOCATION PROGRAM.
[ ] Yes If yes, select using whole percentages only. Must total 100%
CALVERT SOCIAL FUNDS OPPENHEIMER FUNDS ALGER AMERICAN FUNDS
Money Market _____% High Income Fund/VA _____% Growth _____%
Balanced _____% Capital Appreciation Fund/VA _____% Small Capitalization _____%
Small Cap _____% Aggressive Growth Fund/VA _____% MidCap Growth _____%
Mid Cap Growth _____% Main Street Growth and Income Fund/VA _____%
International Equity _____% Strategic Bond Fund/VA _____%
DREYFUS FUNDS STRONG FUNDS ACACIA NATIONAL
Stock Index _____% International Stock Fund II _____% General/Fixed Account _____%
Discovery Fund II _____%
NEUBERGER BERMAN FUNDS VAN ECK FUNDS
Limited Maturity Bond _____% Worldwide Hard Assets Fund _____%
Growth _____% TOTAL 100%
____________________________________________________________________________________________________________________________________
18. DOLLAR COST AVERAGING Transfers totaling less than $100 are not permitted. Note: If this option is chosen, there must be
sufficient allocation to the Money Market in the Allocation Section on the application. This option will stay in effect until
until the fund is depleted or until I cancel this option in writing or with an authorized telephone instruction.
Transfer $ ___________ per month from the [ ] Money Market or from the [ ] Acacia National General Account (36 months minimum).
CALVERT SOCIAL FUNDS OPPENHEIMER FUNDS ALGER AMERICAN FUNDS
Money Market _____% High Income Fund/VA _____% Growth _____%
Balanced _____% Capital Appreciation Fund/VA _____% Small Capitalization _____%
Small Cap _____% Aggressive Growth Fund/VA _____% MidCap Growth _____%
Mid Cap Growth _____% Main Street Growth and Income Fund/VA _____%
International Equity _____% Strategic Bond Fund/VA _____%
DREYFUS FUNDS STRONG FUNDS ACACIA NATIONAL
Stock Index _____% International Stock Fund II _____% General/Fixed Account _____%
Discovery Fund II _____%
NEUBERGER BERMAN FUNDS VAN ECK FUNDS
Limited Maturity Bond _____% Worldwide Hard Assets Fund _____%
Growth _____% TOTAL 100%
____________________________________________________________________________________________________________________________________
19. PORTFOLIO REBALANCING (Automatic Rebalancing) [ ] Check here to change current and future allocations. Please rebalance the
values in my subaccounts to result in a portfolio allocation of: (Round to nearest tenth)
CALVERT SOCIAL FUNDS OPPENHEIMER FUNDS ALGER AMERICAN FUNDS
Money Market _____% High Income Fund/VA _____% Growth _____%
Balanced _____% Capital Appreciation Fund/VA _____% Small Capitalization _____%
Small Cap _____% Aggressive Growth Fund/VA _____% MidCap Growth _____%
Mid Cap Growth _____% Main Street Growth and Income Fund/VA _____%
International Equity _____% Strategic Bond Fund/VA _____%
DREYFUS FUNDS STRONG FUNDS ACACIA NATIONAL
Stock Index _____% International Stock Fund II _____% General/Fixed Account _____%
Discovery Fund II _____%
NEUBERGER BERMAN FUNDS VAN ECK FUNDS
Limited Maturity Bond _____% Worldwide Hard Assets Fund _____%
Growth _____% TOTAL 100%
The first rebalancing should occur every [ ] 3 months, [ ] 6 months or [ ] 1 year (check one),
beginning on (date) _________________________________, [ ] 3 months, [ ] 6 months, [ ] 1 year (check one) after issue date.
____________________________________________________________________________________________________________________________________
Page 4 of 9 Pages
20. EARNING SWEEP (Interest Sweep) Please calculate the gain on all subaccounts every [ ] 3 months, [ ] 6 months, [ ] 1 year
(check one) and deposit those gains in the subaccounts listed below:
CALVERT SOCIAL FUNDS OPPENHEIMER FUNDS ALGER AMERICAN FUNDS
Money Market _____% High Income Fund/VA _____% Growth _____%
Balanced _____% Capital Appreciation Fund/VA _____% Small Capitalization _____%
Small Cap _____% Aggressive Growth Fund/VA _____% MidCap Growth _____%
Mid Cap Growth _____% Main Street Growth and Income Fund/VA _____%
International Equity _____% Strategic Bond Fund/VA _____%
DREYFUS FUNDS STRONG FUNDS ACACIA NATIONAL
Stock Index _____% International Stock Fund II _____% General/Fixed Account _____%
Discovery Fund II _____%
NEUBERGER BERMAN FUNDS VAN ECK FUNDS
Limited Maturity Bond _____% Worldwide Hard Assets Fund _____%
Growth _____% TOTAL 100%
The first sweep of earnings should occur on (date) ___________________________________________________________.
or every [ ] 3 months, [ ] 6 months, [ ] 1 year (check one) after issue date.
____________________________________________________________________________________________________________________________________
21. TELEPHONE AUTHORIZATION UNLESS WAIVED, I THE OWNER AND AGENT/REGISTERED
REPRESENTATIVE WILL HAVE AUTOMATIC TELEPHONE TRANSFER AUTHORIZATION.
[ ] I elect NOT to have telephone authorization [ ] I elect NOT to have my Registed Representative
have transfer authorization
I hereby authorize and direct ANLIC to make allowable transfers of funds or
reallocation of net premiums among available subaccounts or to complete
other financial transactions as may be allowed by ANLIC at the time of
request, based upon instructions received by telephone from a) myself, as
Owner b) my Agent/Registered Representative in Section 31 below; and c) the
person(s) named below. ANLIC will not be liable for following instructions
communicated by telephone that it reasonably believes to be genuine.
ANLIC will employ reasonable procedures, including requiring the policy
number to be stated, tape recording all instructions, and mailing written
confirmations. If ANLIC does not employ reasonable procedures to confirm
that instructions communicated by telephone are genuine, ANLIC may be liable
for any losses due to unathorized or fraudulent instructions.
Name per (c) above: ________________________________________ SS# _________________________
Address: ____________________________________________________________________________________
I understand: a) all telephone transactions will be recorded; and b) this
authorization will continue in force until the earlier of 1) revocation by
the Owner is received in written form or by telephone by ANLIC; or 2)
ANLIC discontinues this privilege.
____________________________________________________________________________________________________________________________________
22. CONSENT FOR ELECTRONIC DELIVERY
By initaling here ________ the owner consents to receive the Acacia National
Prospectus dated May 1st of the prospective year and all subsequent
prospectus amendments thereto, electronically in lieu of paper version.
I would like to receive delivery: [ ] on diskette
or
[ ] Via E-Mail - My E-Mail address is _________________________________________
____________________________________________________________________________________________________________________________________
23. AUTOMATIC BANK DRAFT PLEASE ATTACH VOIDED CHECK. Note if voided check is NOT attached and a personal check accompanies this
application, the account referenced on the check will be used to establish this plan unless otherwise notified. Minimum
withdrawal amount is $15.00.
Please withdrawal $ ___________ from my bank account as shown below on the _______ (day) of each month and invest as
shown in Section 17. Note: Start date may be adjusted to occur on or before the policy date.
_________________________________________________________________________________________________________________________
Name of Depositor/Account Name
_________________________________________________________________________________________________________________________
Account Number Bank Phone Number
_________________________________________________________________________________________________________________________
Name of Bank, Branch and Bank Address
This authorization can be terminated upon 30 days written notice by the depositor or ANLIC to the other party. ANLIC may
terminate this authorization if any debit entry is not honored.
__X______________________________________________________________________________________________________________________
Authorized Signature for above account
____________________________________________________________________________________________________________________________________
Page 5 of 9 Pages
____________________________________________________________________________________________________________________________________
24. RELEASE OF POLICY INFORMATION Authorization Agreement to release policy information to designated individual. Policy
information is automatically sent to the policyowner, registered representative and Broker/Dealer.
As policyowner, I hereby authorize and direct the Company to send one copy of policy information relating to the above policy to
the following designated individual.
Name _______________________________________________________________________ SNN or TIN ________________________________________
Address ________________________________________________________________________________________________________________________
I understand that, as policyowner, I will continue to receive the originals of such policy information. The designated
individual is not authorized to withdraw monies from or make any other policy changes or to act in any way on my behalf in
regard to the above policy(ies). I also understand that monitoring policy activity is my responsibility.
TERMINATION OF AUTHORIZATION: This Authorization will continue to be in force until the earlier of (1) written notice is
received from the owner revoking this authorization or (2) the Company terminates this agreement by written notice to owner.
INDEMNIFICATION: Regarding the policy information released to the individual designated above, I agree to indemnify and hold
harmless the Company, their affiliates, and their directors, officers, employees, and agents from and against all claims,
actions, costs and liabilities, including attorney's fees, arising out of or relating to this Authorization Agreement.
____________________________________________________________________________________________________________________________________
25. HEALTH HISTORY
(ANSWER THE FOLLOWING QUESTIONS REGARDING INSURED 1)
Name of personal physician _______________________________________________________________________________________________________
(If none, so state)
Address _______________________________________________________________________________________________ Phone ____________________
Reason last consulted _________________________________________________________________________________ Date _____________________
What treatment was given or medication prescribed? _______________________________________________________________________________
(ANSWER THE FOLLOWING QUESTIONS REGARDING INSURED 2)
Name of personal physician _______________________________________________________________________________________________________
(If none, so state)
Address _______________________________________________________________________________________________ Phone ____________________
Reason last consulted _________________________________________________________________________________ Date _____________________
What treatment was given or medication prescribed? _______________________________________________________________________________
(ANSWER THE FOLLOWING QUESTIONS REGARDING OTHER INSURED)
Name of personal physician _______________________________________________________________________________________________________
(If none, so state)
Address _______________________________________________________________________________________________ Phone ____________________
Reason last consulted _________________________________________________________________________________ Date _____________________
What treatment was given or medication prescribed? _______________________________________________________________________________
INFORMATION BELOW RELATES TO ALL PERSONS PROPOSED FOR COVERAGE
For following questions "HIV" means Human Immunodeficiency Virus, "AIDS" means
Acquired Immune Deficiency Sydrome and "ARC" means AIDS Related Complex.
Yes No
a. Has the Insured within the past 10 years ever been treated or had any:
(1) Disorder of eyes, ears, nose or throat? [ ] [ ]
(2) Dizziness, fainting, convulsions, epilepsy, headach, speech defect,
paralysis or stroke, mental, brain, or nervous disorder? [ ] [ ]
(3) Asthma, emphysema, pleurisy, allergies, shortness of breath or any disorder
of the lungs or respiratory system? [ ] [ ]
(4) Chest pain, irregular or rapid pulse, high blood preasure, rheumatic fever,
heart murmur, heart attack, anemia or other disorder of the heart, blood* or
circulatory system? [ ] [ ]
*NJ AND WI RESIDENTS, YOU MAY EXCLUDE ANY BLOOD DISORDER RELATING TO AIDS, THE HIV ANTIBODY,
SERO-POSITIVITY, OR THE HIV VIRUS.
(5) Intestinal bleeding, ulcer, ulcerative colitis, spastic colitis, diverticulitis,
jaundice or any disorder of the liver, gallbladder, or digestive system? [ ] [ ]
(6) Sugar, albumin or blood in urine, nephritis, stone or other disorder of the
kidneys, bladder, prostate, reproductive organs or breasts? [ ] [ ]
(7) Diabetes or disorder ot the thyroid or other endocrine glands? [ ] [ ]
(8) Rheumatism, arthritis, gout, deformity or amputation or disorder of the
muscles or bones? [ ] [ ]
(9) Cancer, tumor or cyst or any disorder of the skin or lymph glands? [ ] [ ]
GA AND IL RESIDENTS, DO NOT RESPOND TO Q.25.B.(1) AND Q.25.B.(2).
ND, NJ, WA AND WI RESIDENTS, DO NOT RESPOND TO Q.25.B.(1) THROUGH Q.25.B.(4).
PA RESIDENTS, DO NOT RESPOND TO Q.25.B.(2).
CA, AND CT RESIDENTS, DO NOT RESPOND TO Q.25.B.(4).
b. During the past 10 years has the Insured:
(1) Had or been told they had AIDS or ARC? [ ] [ ]
(2) Had or been told they had AIDS related condition? [ ] [ ]
____________________________________________________________________________________________________________________________________
Page 6 of 9 Pages
(3) Received treatment in connection with any of the categories named in Q.25.b.(1)? [ ] [ ]
(4) Tested positive for antibodies to the AIDS (Human T-cell Lymphotropic,
HIV) virus? [ ] [ ]
ONLY - GA RESIDENTS, ANSWER Q.25.B.(5) AND Q.25.B.(6).
----
(5) Been diagnosed with AIDS or ARC caused by the HIV infection? [ ] [ ]
(6) Tested positive for the HIV infection? [ ] [ ]
ONLY - IL, NJ, WA AND WI RESIDENTS, ANSWER Q.25.B.(7) AND 25.B.(8).
(7) Been diagnosed or treated by a person licensed as a medical physician for AIDS? [ ] [ ]
(8) Been diagnosed or treated by a person licensed as a medical physician for ARC? [ ] [ ]
c. Except as stated in answer to previous questions, has the Insured within the past 5 years:
(1) Has any mental or physical disorder not previously listed? [ ] [ ]
(2) Been seen by a physician for a checkup, illness, injury or surgery? [ ] [ ]
(3) Been a patient in a hospital, clinic or other medical facility? [ ] [ ]
(4) Had an ECG, X-ray, CAT scan or other diagnostic test (FOR NJ AND WI
RESIDENTS, OTHER THAN AN AIDS RELATED TEST)? [ ] [ ]
WI RESIDENTS, DO NOT RESPOND TO Q.25.C.(5).
(5) Been advised to have any diagnostic test, hospitalization or surgery which
was not completed? [ ] [ ]
d. Is Insured now taking any medication or treatment? [ ] [ ]
e. Has Insured ever used narcotics, barbiturates, amphetamines, cocaine, LSD,
marijuana, or hallucinogenic drugs? [ ] [ ]
f. Has Insured ever received counseling or treatment for the use of alcohol or drugs? [ ] [ ]
NC RESIDENTS, DO NOT RESPOND TO Q. 25.G.
g. Has Insured ever been a member of a support group for the use of alcohol or drugs? [ ] [ ]
h. Does the Proposed Insured have any family history of diabetes, cancer, heart or
kidney disease? [ ] [ ]
i. Tobacco Use
(1) Has the Insured smoked one or more cigarettes in the past twelve months? [ ] [ ]
(2) Has the Insured used any form of tobacco in the past twelve months? [ ] [ ]
(If yes, please provide date of last use) Insured 1 __________ Insured 2 __________ Other Insured __________
(3) Has the Insured used any form of tobacco or nicotine in the past thirty-six months?
(If yes, please provide date of last use) Insured 1 __________ Insured 2 __________ Other Insured __________
INSURED I INSURED 2
_________________________________________________________________________________________________________________________________
j. Family Living Deceased j. Family Living Deceased
History Age Present Health Age Cause of Death History Age Present Health Age Cause of Death
Father Father
Mother Mother
Brothers Brothers
Sisters Sisters
________________________________________________________________________________________________________________________________
Insured 1 Insured 2
Exact Height ___ ft. ___ in. Exact Weight ___ lbs. Exact Height ___ ft. ___ in. Exact Weight ___ lbs.
[ ] Gained [ ] Lost _________ pounds within past year. [ ] Gained [ ] Lost _________ pounds within past year.
Reason ________________________________________________ Reason ________________________________________________
OTHER INSURED
_____________________________________________________________________________
j. Family Living Deceased
History Age Present Health Age Cause of Death Other Insured
Father Exact Height ___ ft. ___ in. Exact Weight ___ lbs.
Mother [ ] Gained [ ] Lost _________ pounds within past year.
Brothers Reason ________________________________________________
Sisters
____________________________________________________________________________________________________________________________________
DETAILS of "Yes" answers. Identify question number and Insured "1", "2" or "Other Insured". Circle applicable items. Include
nature of ailment (and pathological diagnosis, if applicable), dates, duration and names and addresses of all attending physicians
and medical facilities.
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Page 7 of 9 Pages
____________________________________________________________________________________________________________________________________
26. DISCLOSURES
I hereby acknowledge receipt of the current prospectus, and any supplements, for this policy including any required disclosure
if the policy applied for will be in a qualified plan.
____________________________________________________________________________________________________________________________________
27. AGREEMENTS
I AGREE AS FOLLOWS:
a. Any policy including any endorsements issued as a result of this application will, with this application and any supplemental
applications, be the entire insurance contract.
b. No agent, broker or medical examiner can: 1) waive the answers to any questions in this application; 2) make or change any
insurance contract; or 3) waive any rights or rules of ANLIC.
c. EXCEPT AS SPECIFIED OTHERWISE IN A RECEIPT PROVIDED UPON A PAYMENT OF PREMIUM AT THE TIME OF APPLICATION, INSURANCE WILL NOT
BE EFFECTIVE UNTIL ALL OF THE FOLLOWING ARE MET: A) THE POLICY ISSUED BY ANLIC IS DELIVERED TO AND ACCEPTED BY THE APPLICANT;
AND B) THE FIRST FULL PREMIUM IS PAID.
d. ANLIC may change this application by an appropriate notation in the space marked "Endorsements/Corrections": 1) to correct
apparent errors or omissions; and 2) to conform it with any policy rider that may be issued. No change will be made in the
following without the applicant's written consent: 1) amount of insurance; 2) plan of insurance; 3) classification of risks;
or 4) benefits. Acceptance of any policy issued under this application ratifies any amendments.
e. FOR RESIDENTS IN ALL STATES OTHER THAN COLORADO, NEW JERSEY, NEW MEXICO, PENNSYLVANIA AND VIRGINA:
Any person who, with 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 be guilty of insurance fraud.
f. NOTE FOR COLORADO RESIDENTS: NOTE FOR COLORADO RESIDENTS: 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 imprisionment, 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 policy holder or claimant
for the purpose of defrauding or attempting to defraud the policy holder 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.
g. NOTE FOR NEW JERSEY RESIDENTS: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal or civil penalties.
h. NOTE FOR NEW MEXICO RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss of
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
civil fines and criminal penalties.
i. NOTE FOR PENNSYLVANIA RESIDENTS: 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.
j. NOTE FOR VIRGINIA RESIDENTS: Any person who, with 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.
Page 8 of 9 Pages
k. I understand that: 1) THE AMOUNT AND DURATION OF THE DEATH BENEFIT MAY VARY WITH INVESTMENT EXPERIENCE, LOANS
AND OTHER SPECIFIED CONDITIONS; 2) POLICY VALUES NOT IN THE FIXED ACCOUNT WILL INCREASE OR DECREASE IN
ACCORDANCE WITH THE EXPERIENCE OF THE SELECTED INVESTMENT OPTIONS OF THE SEPARATE ACCOUNT; 3) the amount of
the benefit payable on surrender is not guaranteed, but is dependent on the then surrnder value; 4) illustrations of
benefits, including the death benefit, are available upon request; and 5) this policy meets my investment objectives and
anticipated financial needs.
____________________________________________________________________________________________________________________________________
28. AUTHORIZATION This authorization, or a photocopy of it, shall remain valid for use by ANLIC for two (2) years from the date
below. I authorize any licensed physician, medical practitioner, hospital, clinic or other medically related facility,
insurance company, agency conducting Investigative Consumer Reports or any information service, or financial institution,
family member, or associate to release to ANLIC or any person or entity acting on its behalf, any personal information
which is on file and relates to my health or mental condition, general character, driving records, use of alcohol and drugs, and
hobbies of hazardous nature. I understand that any information obtained will be used to determine my eligibility for insurance
and/or for any benefits in the event of a claim.
In addition, I authorize the Medical Information Bureau (MIB) to release to ANLIC or its reinsurers, any personal information
which is on file and relates to me.
I also agree that I have received and read the Notice of ANLIC's Insurance Information Practices, MIB and Investigative Consumer
Reports. I also understand that my authorized representative and I can receive a copy of this authorization if we so desire.
NOTE FOR NEW JERSEY AND VIRGINIA RESIDENTS: I authorize ANLIC to obtain an Investigative Consumer Report. An Investigative
Consumer Report commonly includes information regarding the consurmer's character, general reputation, personal characteristics
and mode of living. It also includes verification of residence, marital status and occupation. I understand tht I may request
a copy of the report upon its completion and that I may ask to be interviewed in conjunction with the preparation of
the report by contacting ANLIC.
NOTE FOR NEW JERSEY AND WEST VIRGINIA RESIDENTS: I also understand that none of the information collected concerning my sexual
orientation will be used to determine my eligibility for insurance.
____________________________________________________________________________________________________________________________________
29. SUBSTITUTE W-9 CERTIFICATION
For joint ownership, the first person's name and Soc. Sec. No. (TIN), i.e., Owner-Insured 1 will be listed as the TIN of record.
This person is certifying as follows:
I certify under penalty of perjury that: 1) the number shown on this form is my correct taxpayer identification number (or I am
waiting for a number to be issued to me); and 2) I am not subject to backup withholding because: a) I am exempt from backup
withholding; or b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result
of a failure to report all interest or dividends; or c) the IRS has notified me that I am no longer subject to backup
withholding.
You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup withholding because of
underreporting interest or dividends on your tax return.
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS
REQUIRED TO AVOID BACKUP WITHHOLDING.
____________________________________________________________________________________________________________________________________
30. SIGNATURES
I represent to the best of my knowledge and belief that all statements and answers to this application are complete and true.
Dated at __________________________________________________________________________________ On this Date _____________________
(City) (State)
X X
_____________________________________________________________________ ____________________________________________________
Signature of Proposed INSURED 1 (may be omitted below age 15) Signature of INSURED 2
X X
_____________________________________________________________________ ____________________________________________________
Signature of OTHER INSURED Signature(s) and Title of Officer or Trustee(s)
X
_____________________________________________________________________
Signature of Owner if not an Insured (If a corporation or Trust, show full name)
(A parent or gurdian must sign if Proposed Insured has not attained 18th birthday)
____________________________________________________________________________________________________________________________________
31. AGENT'S/REGISTERED REPRESENTATIVE'S STATEMENT
Do you have any knowledge or reason to believe that replacement of existing life insurance or annuity coverage may be involved?
[ ] Yes [ ] No
I certify that: (1) the information provided by the Owner has been accurately recorded; (2) a current prospectus and all
supplements were delivered; and (3) I have reasonable grounds to recommend the purchase of the policy as suitable for the Owner.
X
________________________________________________________________________________________________________________________________
Signature of Agent/Registered Representative
________________________________________________________________________________________________________________________________
Print Name Here ANLIC Agent Code Agency or Broker/Dealer
____________________________________________________________________________________________________________________________________
Page 9 of 9 Pages