15
A141
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1 Proposed Insured Information
Full |_|Male Date of
Name |_|Female Birth
First Middle Last Month Day Year
|_|Married |_| Divorced
|_|Widowed
State of Birth SSN |_|Single |_| Separated
Former Full Name
First Middle Last
Street Address City State Zip
Home Phone No. ( ) Driver's License No. State Issued
Occupation and Duties Work Phone No. ( ) Years Employed
Employer Street Address
City State Zip
Best Place to Call Best Time to Call
Former Occupation and
Employer Duties
(If employed less than 2 years, complete former employer information listed above.)
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2 Proposed Insured Information (Complete this Section for the second Insured if applying for Survivorship Variable Universal Life -
SVUL.)
Full |_|Male Date of
Name |_|Female Birth
First Middle Last Month Day Year
|_|Married |_| Divorced |_|Widowed
State of Birth SSN |_|Single |_| Separated
Former Full Name
First Middle Last
Street Address City State Zip
Home Phone No. ( ) Driver's License No. State Issued
Occupation and Duties Work Phone No. ( ) Years Employed
Employer Street Address
City State Zip
Best Place to Call Best Time to Call
Former Occupation and
Employer Duties
(If employed less than 2 years, complete former employer information listed above.)
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3 Ownership Information (If VUL, the Insured will be owner, unless otherwise stated. If SVUL, both Insureds will be the owner,
unless otherwise stated.)
Primary |_|Male Date of
Owner |_| Trustee |_|Female Birth
First Middle Last Month Day Year
State of SSN or Relationship
Birth Tax ID to Insured
Street Address City State Zip
Successor Relationship
Owner to Insured
(If multiple successor owners, show the order and distribution in Section 14, Special Requests.)
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4 Applicant Information (Complete this Section if the applicant is someone other than the Insured(s) or owner.)
|_|Male Relationship
Applicant |_| Trustee |_|Female to Insured
First Middle Last
Street Address City State Zip
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5 Beneficiary Information (Unless otherwise stated, benefits are payable equally to the named beneficiary(s) or to the survivor or
survivors. If benefits are payable other than equally, please indicate a contingent beneficiary for each primary beneficiary.)
Primary Beneficiary - First and Last Name (with right to change) Relationship to Insured
Contingent Beneficiary - First and Last Name (with right to change) Relationship to Insured
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6 Variable Universal Life (VUL) (Complete this Section if applying for VUL. Complete Section 7 if applying for SVUL.)
Coverage |_|A
Plan Name Specified Amount $ Option |_|B
Planned Proposed
Premium $ Risk Class
Special Class Reason for Special
Premium $ Class Premium
Riders/Benefits
|_| Disability Continuance of Insurance |_| Spouse's Term units |_| Living Benefits Rider
|_| Disability Payment of Premium $ |_| Children's Term units |_| Maturity Extension Rider
|_| Extra Protection Rider $ |_| Assured Insurability $ |_| Other
|_| Other Insured Coverage |_| Accidental Death $
(Complete OI information below)
Other Insureds (OI) Marital
Full Name Status Specified Amount
|_|Non-Tobacco
1st OI |_|Tobacco $ |_| ADB $
|_|Non-Tobacco
2nd OI |_|Tobacco $ |_| ADB $
First Middle Last
Complete the following for all Other Insureds. If years employed is less than 2, show prior occupation in Section 14, Special
Requests. If any information is identical to the Primary Insured's, write Same.
Occupations Employer's Name Yrs.
Social Security Number State of Birth and Exact Duties and Address Emp.
1st OI
2nd OI
Most Convenient Driver's
Street Address, Telephone No. Time and Place License Number &
City, State, Zip |_| home |_| work to Contact State Issued
1st OI ( )
|_| home |_| work
2nd OI ( )
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7 Survivorship Variable Universal Life (SVUL) (Complete this Section if applying for SVUL.)
Specified Coverage |_| A
|_| B
Plan Name Amount $ Option |_| L
Planned Proposed
Premium $ Risk Class
Special Class Reason for Special
Premium $ Class Premium
Riders/Benefits
|_| Additional Insurance Amount $ ; increase by % or $ annually
|_| Guaranteed Minimum Death Benefit Option (not available with Option B)
|_| Contract Split Option Rider
|_| Joint First-to-Die Term Rider: (First Insured) $ ; decrease by % or $ annually
(Second Insured) $ ; decrease by % or $ annually
|_| Joint Survivorship Four Year Term Rider $
|_| Other
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8 Premium Allocations
o Initial Premium $
o Select initial premium allocations on page 14 of this application. Show percent allocated to each fund. Use whole
percentages - total must equal 100%.
o A maximum of 15 fund selections is available at any one time.
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9 Monthly Dollar Cost Averaging
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o |_| Match initial premium allocations as shown on page 14 of this application.
o If fund selection options for the Monthly Dollar Cost Averaging Plan are different than the initial premium allocations,
make fund selections for this plan on page 14 of the application.
o To participate in the Monthly Dollar Cost Averaging Plan, a percentage must be directed to the Federated Prime Money Fund II
Subaccount when selecting the initial premium allocation.
o Transfer $ monthly over a month period from the Federated Prime Money Fund II Subaccount to the
selected subaccounts. The Monthly Dollar Cost Averaging Plan may be elected for a period from 3 to 36 months.
o At least $250 must be transferred from the Federated Prime Money Fund II Subaccount each month. Transfers under this plan may not
commence until the later of: (1) 30 days after the contract date; or (2) five days after the end of the free look period.
o Transfers made under this plan will not count toward the six free transfers permitted each contract year.
o To start this plan in the future, you must complete a Dollar Cost Averaging Request Form and send it to Kansas City Life.
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10 Quarterly Portfolio Rebalancing
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o |_| Match initial premium allocations as shown on page 14 of this application.
o If fund selection options for the Quarterly Portfolio Rebalancing Plan are different than the initial premium allocations,
make fund selections for this plan on page 14 of the application.
o Fixed account assets will not be included in the Quarterly Portfolio Rebalancing Plan.
o If you are not currently participating in the Monthly Dollar Cost Averaging Plan, Kansas City Life will redistribute funds in the
variable account on a quarterly basis according to the percentages selected, provided the account is in good order. The Quarterly
Portfolio Rebalancing Plan will not be available until the Monthly Dollar Cost Averaging Plan has been completed.
o If you make a change to premium allocations, we automatically change Quarterly Portfolio Rebalancing allocations to match
the new premium allocations, unless you give us other instructions.
o Any requested transfer, either by written request or telephone transfer, will automatically cancel the Quarterly Portfolio
Rebalancing Plan unless you authorize a change in premium allocation at that time. You may also cancel this plan by calling or
sending a written notice to Kansas City Life.
o Transfers made under this plan will not count toward the six free transfers permitted each contract year.
o To start this plan in the future, you must complete a Quarterly Portfolio Rebalancing Request Form and send it to Kansas
City Life.
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11 Telephone Access Authorization
|_| Yes |_| No If answered Yes, I am giving Kansas City Life authority to honor telephone instructions from me to transfer
among subaccounts and the fixed account, change the premium allocation, change Dollar Cost Averaging
allocations, change Portfolio Rebalancing allocations or request a contract loan.
|_| Yes |_| No If answered Yes, I am giving the Registered Representative/Agent of record authority to transfer among subaccounts
and the fixed account, change the premium allocation, change Dollar Cost Averaging allocations, change Portfolio
Rebalancing allocations, or request a contract loan.
This authorization is subject to the terms and provisions in the contract and prospectus. Kansas City Life will not be held liable
for any loss, liability, cost, or expense for acting on the telephone instructions. Kansas City Life's liability for erroneous
transactions, unless clearly contrary to instructions received, will be limited to the correction of the allocations on a current
basis. I understand that Kansas City Life will provide written confirmation of the telephone transaction, and that Kansas City Life
will monitor and record my telephone call.
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12 Switch/Replacement Disclosure
Since most investments are and should be considered long term in nature, we feel it is necessary to review your understanding of
your current position and the possible consequences of switching and/or replacing your investment.
Reason for requesting switch/replacement:
Please acknowledge the following statements by placing a check mark next to each statement. If the statement does not apply,
indicate N/A.
This exchange will result in a surrender charge on my current investment of %.
This exchange subjects my investment to a surrender charge for the next years.
This exchange may result in a taxable gain on the liquidation of my current investment.
My representative and I have reviewed the above items and have carefully considered my selection and believe that it coincides with
my investment objectives.
Name of product being replaced
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13 Billing Information
Premium |_| |_| |_| |_| |_| |_| |_| |_| |_| |_|
Mode Ann SA Qtly Mo PAC GA CB FAP Single Other
Premium |_|Owner |_| Other (If other, give name and address below.)
Notices to |_|Primary Insured
Modal Premium Amount for
Other Financial Services $
Branch of Service for
Government Allotment Payor's SSN for Government Allotment
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14 Special Requests (Contract date, alternate or additional contract, existing PAC or CB number, etc.) Home Office Endorsements
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15 Replacement
1. Will any existing life, health or annuity contract be lapsed, reissued, surrendered, or converted (to reduce
amount, premium or period of coverage including surrender options) if the proposed contract is issued?......... |_| Yes|_| No
2. Will the proposed contract be financed by loans from this or any other contract?................................ |_| Yes|_| No
3. Will the proposed contract be part of an IRC Section 1035 Exchange?............................................. |_| Yes|_| No
If any of the above questions are answered Yes, give name of company(ies) and amount(s)
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16 Evidence of Insurability (List details of insurance in force on all Proposed Insureds. If none, indicate none.)
Existing Insurance
Year Insurance ADB
Proposed Insured(s) Company Issued Amount Amount
$ $
$ $
$ $
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Insurance History
1. In the past 3 years have any of the Proposed Insureds applied for life or health insurance or reinstatement
thereof without receiving it exactly as requested?............................................................. |_| Yes|_| No
2. Do any of the Proposed Insureds have an application for life or health insurance pending with any other insurance
company or intend to apply for such insurance within the next 10 days?......................................... |_| Yes|_| No
Details to all Yes answers:
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Juvenile Insurance (Age 0-17)
1. If any Proposed Insured(s) is(are) less than 1, what was birth weight? (name and birth weight)
2. If any Proposed Insured(s) is(are) age 5-15, what is grade in school? (name and grade)
3. Are all children insured equally? |_|Yes |_|No If No, please explain.
4. Amount of insurance in force on father $
5. Amount of insurance in force on mother $
16 Evidence of Insurability (continued)
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Non Medical Underwriting Questions
Questions apply to all Proposed Insureds.
1. Do any of the family members listed on this application live outside the Primary Insured's household?.... |_| Yes|_| No
2. Are any Proposed Insureds not a U.S. citizen?............................................................ |_| Yes|_| No
If Yes, how long has(have) the Proposed Insured(s) been in the United States?
Type of Visa? Visa Number?
3. Have any of the Proposed Insureds in the last 12 months, or do any of the Proposed Insureds within the
4. In the past 3 years, has any Proposed Insured(s):
a. been cited or convicted for any moving motor vehicle violations? If Yes, explain below. ............. |_| Yes|_| No
b. had a driver's license suspended or revoked? If Yes, explain below. ................................. |_| Yes|_| No
c. flown as a pilot, co-pilot, or crew member of an aircraft? If Yes, complete the Aviation
d. engaged in sky or scuba diving, hang gliding, racing or any other hazardous sport or hobby? If Yes,
5. Has any Proposed Insured(s) ever been convicted of a felony? If Yes, explain below....................... |_| Yes|_| No
6. For Proposed Insured(s) (a) and Other Insureds (b), is there any family history of diabetes, cancer,
-------------------- ------------------------- ---------------------------------------------------------- ------------------------
Age if Living Age at Death
Relationship a b Family History or Cause of Death a b
-------------------- ------------- ----------- ---------------------------------------------------------- ------------ -----------
-------------------- ------------- ----------- ---------------------------------------------------------- ------------ -----------
Father
-------------------- ------------- ----------- ---------------------------------------------------------- ------------ -----------
-------------------- ------------- ----------- ---------------------------------------------------------- ------------ -----------
Mother
-------------------- ------------- ----------- ---------------------------------------------------------- ------------ -----------
-------------------- ------------- ----------- ---------------------------------------------------------- ------------ -----------
Brothers
and
Sisters
-------------------- ------------- ----------- ---------------------------------------------------------- ------------ -----------
Details to all Yes answers:
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Financial Information
Complete For Personal Insurance Sales
Purpose of insurance |_| Family Income Protection |_| Estate Planning |_|College Savings |_|Other
(Check all that apply) |_| Mortgage Protection |_| Retirement Savings |_|Final Expenses
Annual earned income (Include Salary, Bonus, Commissions)
|_| Proposed Insured $ |_|Other Insured $
|_| Spouse $ |_|Family net worth $
(Total assets minus total liabilities)
Has(Have) the Proposed Insured(s) ever filed bankruptcy? |_|Yes |_| No
If Yes, please provide type (Chapter |_| 7, |_| 11, |_| 13) and date closed.
Spouse's Occupation Amount of life insurance in force on Spouse $
Complete For Business Insurance Sales
Purpose of insurance |_|Key Person |_| Buy/Sell |_|Other
(Check all that apply) |_|Deferred Compensation |_| Creditor
For the option(s) checked, how was amount of insurance determined?
(Please provide documentation)
Annual earned income of Proposed Insured $ Proposed Insured's ownership of company %
Are other owners, officers or key persons being insured? |_|Yes |_|No If No, please explain.
Total assets of company $ Total liabilities of company $
Net worth of company $ Net income of company after taxes last fiscal year $
Has company ever filed bankruptcy? |_|Yes |_|No If Yes, please provide type (Chapter |_| 7, |_| 11, |_| 13) and date closed.
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17 Health Statement
---------------------------------------- --------------- -------------------- ----- ---- -------------------- -------------------
-------------- *Weight Change
Relationship Birthdate Build in past year
to Primary
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---------------------------------------- --------------- ------- ----- ------ ----- ---- ----- ------- ------ --------- ---------
Print full names of all to be insured. Insured Month Day Year Age Sex Ft. In. Lb. Gain Loss
---------------------------------------- --------------- ------- ----- ------ ----- ---- ----- ------- ------ --------- ---------
---------------------------------------- --------------- ------- ----- ------ ----- ---- ----- ------- ------ --------- ---------
1. Primary Insured X X X X X X
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---------------------------------------- --------------- ------- ----- ------ ----- ---- ----- ------- ------ --------- ---------
2.
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3.
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4.
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5.
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6.
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------ ------ --------------------------------------
*Questions apply to all Proposed Insureds Yes No *Give DETAILS to Yes answers. Identify
------ ------ Proposed Insured(s),question,
1. Do you take prescription medicine?....................................... ------ ------ specify conditions,severity,dates,
------ ------ duration, after-effects, weight gain
2. Are you currently pregnant? Due date? ................ ------ ------ or loss, and names and addresses of
3. Have you ever used or received treatment or counseling for the use of all attending physicians and
marijuana, heroin, cocaine, amphetamines, barbiturates, hallucinogenic ------ ------ medical facilities.
agents or opium or its derivatives?...................................... ------ ------ --------------------------------------
4. Have any of the Proposed Insureds used any form of nicotine/tobacco in the ------ ------
last 12 months? (i.e., cigar, pipe, smokeless tobacco, cigarettes, etc.). ------ ------
If cigarettes, how many packs per day? ------ ------
5. Have you sought advice, been treated or arrested for the use of alcohol?. ------ ------
During the last 5 years have you:
6. been hospitalized or had medical advice, diagnostic tests recommended, or ------ ------
treatment by a physician or other medical practitioner?.................. ------ ------
During the last 10 years have you been diagnosed or treated for any disease or
disorder of:
7. brain and nervous system - mental illness, epilepsy, seizures, stroke, ------ ------
paralysis?............................................................... ------ ------
8. sight or hearing?........................................................ ------ ------
9. blood - anemia or leukemia?.............................................. ------ ------
10. tumor or cancer?......................................................... ------ ------
11. heart/blood vessels - murmur, chest pain or pressure, palpitations, heart ------ ------
attack?.................................................................. ------ ------
12. blood pressure?.......................................................... ------ ------
13. thyroid or glandular trouble?............................................ ------ ------
14. lungs - asthma, emphysema, tuberculosis?................................. ------ ------
15. digestive system - ulcer, intestines or rectum, polyps, colitis?......... ------ ------
16. liver - elevated enzymes, cirrhosis, hepatitis?.......................... ------ ------
17. diabetes - sugar in urine?............................................... ------ ------
18. kidney/bladder or prostate - albumin, blood or pus in urine?............. ------ ------
19. bone, joint, muscles, back or spine - arthritis?......................... ------ ------
20. breasts, uterus, ovaries?................................................ ------ ------
21. menstruation or pregnancy?............................................... ------ ------
Have you ever been diagnosed or treated for: ------ ------
22. a sexually transmitted disease?.......................................... ------ ------
23. Acquired Immune Deficiency Syndrome (AIDS) or tested HIV positive?....... ------ ------ --------------------------------------
Names, addresses and phone numbers of personal or family physicians. (If none, list last physician, clinic or hospital consulted.)
Date and Reason Clinic or VA
last consulted Claim Number
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18 Civilian Aviation Questionnaire
Name of Proposed Insured(s)
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As a pilot or student pilot, indicate the number of hours flown in command Date of last flight
Type of license currently held |_| Commercial |_| Student |_| Private Do you hold a valid instrument rating? |_| Yes |_|No
Number of hours flown Number of hours flown Number of flying hours
in the last 12 months in the last 12-24 months contemplated in next 12 months
Purpose of present |_| Pleasure |_|Personal Business
and future flying |_| Commercial |_|Other (specify)
Type and class |_| Propeller |_|Glider |_|Home-Built |_|Helicopter
of aircraft flown |_| Jet |_|Balloon |_|Ultralite |_|Hang Glider
Do you expect to engage in any of the following type of flying during the next 12 months? If Yes, state which and number of hours.
Hours Hours Hours
|_| Scheduled Airlines |_|Charter Flying |_| Test or Inspection Flying
|_| Nonscheduled Airlines |_|Freight or Mail Carrying |_| Aerobatics
|_| Employer Owned Aircraft |_|Pipeline Inspection |_| Racing
|_| Crop Dusting |_|Air Taxi or Sight Seeing |_| Any Other for Pay Flying
|_| Water Bombing |_|Photography Type
|_| Student Instruction |_|Mapping
Have you ever:
a. been in an aircraft accident? |_|Yes |_|No If Yes to a., b., or c., explain below.
b. been grounded? |_|Yes |_|No
c. been fined or reprimanded? |_|Yes |_|No
Do you have any operational limitations on your medical certificate? |_|Yes |_|No If Yes, explain below.
Do you contemplate any flying in Alaska? |_| Yes |_| No
Do you contemplate any flying outside the continental United States? |_|Yes |_|No If Yes, explain below.
If aviation required an extra premium or exclusion rider, which would you prefer? |_| Extra Premium |_| Exclusion Rider
Details to all Yes answers:
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19 Military Questionnaire
Name of Permanent Address
Proposed Insured(s) (non-military residence)
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Status
Branch of Service Date entered active service Present pay grade
Name and location of present unit
Have you or your unit been alerted for overseas assignment? |_|Yes |_|No If Yes, where?
Usual duty assignment (i.e., Tank Mechanic, Cook, Radar Operator, etc.)
Do you qualify for hazardous duty pay? |_| Yes |_|No If Yes, why? (i.e., flying duty, submarine duty, etc.).
Have you any reason to believe you will, within the next 90 days, be transferred or have you any knowledge of any change in
activities? |_|Yes |_|No If Yes, give details.
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Military Aviation
How many total hours have you accumulated as a pilot or as a crew member?
Hours estimated next 12 months as a pilot or as a crew member?
Job title Aviation activity and duties
Do you fly for proficiency only? |_| Yes |_| No If Yes, specify hours flown and give full details.
Duty assignment (MAC, SAC, TAC, etc.) Aircraft in which duties are performed (F4, B52, T28, HO-1, etc.)
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20 Avocations Questionnaire
Name of Proposed Insured(s)
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Underwater Diving
Average Average Time Last 1 to 2 Estimated Next
Frequency (Days) Depth (minutes) 12 Months Years Ago 12 Months
0-65 ft.
66-100 ft.
Type |_| Scuba 101-150 ft.
|_| Skin or snorkel Over 150 ft.
Purpose
|_| Recreation |_| Wreck/Salvage/Retrieval |_|Commercial
|_| Search/Rescue |_| Instructor |_|Other
Certification (Check highest certificate attained.)
|_| Basic |_|Open-Water |_|Advanced Open Water |_| Dive Master/Instructor |_|No Certificate
Locations
|_| Lakes |_| Rivers |_|Oceans
|_| Quarries |_| Pools |_|Other
Do you use the "buddy system"? |_| Yes |_| No Do you do any ice diving? |_|Yes |_|No
Do you do any cave diving? |_| Yes|_|No Date of last dive
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Parachuting or Skydiving
|_| Amateur Association
|_| Professional or club member |_|Yes |_|No
Number Date of Average number
of years last jump of jumps per year
Do you compete for record attempts? |_|Yes |_|No Do you use experimental equipment? |_| Yes |_|No
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Automobile Racing
Type of vehicle What is the maximum What is the average
used in races? speed attained? speed attained?
Purposes |_|Amateur |_|Both (give details)
of racing |_|Professional
How many races did you How many races did you How many races do you
enter in the last 12 months? enter in the last 13-24 months? contemplate in the next 12 months?
|_| Championship (Indy Cars)
|_| Demolition
|_| Drag Racing (Check all that apply: |_| Funny Car, |_| Top Fuel, |_| Pro Stock, |_| Modified Production, |_| Modified Super
Stock, |_| Pure Stock)
|_| Formula Racing (Check all that apply: |_| Formula One, |_| Supervee, |_| Vee, |_| Ford)
|_| Midget Car Racing
|_| Sports Car Racing (Check all that apply: |_| CanAm, |_| TransAm, |_| Production, |_| A, |_| B, |_| C, |_| All American GT, |_|
Showroom Stock, |_| Vintage Sports)
|_| Stock Car (Check all that apply:|_|NASCAR Winston Cup Division, |_| Winston Division, |_| NASCAR Busch Grand National Division,
|_| NASCAR Modified Division, |_| USAC Super Modified Division, |_| Amateur, |_| Street Stock,
|_| Hobby Division)
|_| Racing not covered above: Give type and details.
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Other Avocations (Please give details in Remarks Section)
|_| Ballooning |_|Mountain or Rock Climbing |_| Bungee Jumping
|_| Hang Gliding |_|Motorboat or Powerboat Racing |_| White Water Rafting
|_| Ultralite Flying |_|Motorcycle Racing |_| Other
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Remarks
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21 Agreement and Signatures
It is understood and agreed as follows:
1. The statements and answers recorded in all parts of this application are true and complete.
2. No information regarding any Proposed Insured(s) will be considered known by the Company unless explicitly set out in
writing on this application.
3. This application, and the answers to any required medical exam, will become a part of any contract issued on it.
4. No agent has the authority to waive any of the Company's rights or rules, or to make or change any contract.
5. The insurance applied for will take effect only after the following occur while the Proposed Insured(s) is(are) living and
his/her(their) health is as stated in this application: (1) the contract is delivered to the applicant; and (2) the first full
premium is paid in cash. The only exception to this is provided in the Temporary Insurance Agreement if the agreement has been
issued and the advance payment required by the agreement has been made.
6. Any changes or additions made by the Company in " Home Office Endorsements" will be ratified by the applicant's acceptance
of any life insurance contract issued on this application. However, any change in the classification, amount of insurance, issue
age, plan of insurance or any benefits will not be effective unless accepted in writing by me(us).
7. I(We) have received the Notice of Information Practices which explains my(our) rights under the Fair Credit Reporting Act.
8. I(We) have paid $ * to the agent in exchange for the Temporary Insurance Agreement and I(we)
acknowledge that I(we) fully understand and accept its terms.
9. No minimum cash value is guaranteed.
10.I(We) understand that past performance does not guarantee future results.
11.The variable life plan applied for is suitable for my investment objectives, financial situations and needs.
12.I(We) understand, unless otherwise documented, that this investment is not an obligation of, or otherwise guaranteed by
Kansas City Life, Sunset Financial Services, Inc. or any of its affiliates.
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This application will not be accepted unless each of the following have been initialed by the applicant(s):
- ------ ------ I(We) understand that this product involves risk, and the amount and duration of the death benefit and cash
value of the contract may increase or decrease daily depending on the contract's investment results.
- ------ ------ I(We) understand that this product involves certain fees and/or charges and I(we) have received the most recent
prospectus dated , where these fees are discussed in detail.
- ------ ------ I(We) understand that I(We) are buying life insurance.
- ------ ------ I(We) understand that this plan is a long term commitment and that canceling or surrendering this contract may
result in a loss of some or all of the premiums paid.
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*All premium checks must be made payable to Kansas City Life Insurance Company.
Do not make check payable to the agent or leave the payee blank.
AUTHORIZATION: I(We) authorize the following to give information (defined below) to Kansas City Life or any person or group acting
on the part of Kansas City Life: any medical professional, medical care institution, the Medical Information Bureau, Inc., insurer,
reinsurer, government agency, consumer reporting agency or employer. "Information" means facts of: a medical nature in regard to
my(our) physical or mental condition; employment; other insurance coverage; or any other non-medical facts. I(We) understand that
this information will be used by Kansas City Life to determine eligibility for insurance.I(We) agree this Authorization is valid for
two and one-half years from the date signed. I(We) know that I(we) have a right to receive a copy of this Authorization upon
request. I(We) agree that a photographic copy of this Authorization is as valid as the original.
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding
the company. Penalties may include imprisonment, fines or denial of insurance benefits.
Dated at this day of ,
City State Month Year
Primary Insured's Signature (if under 15, parent/guardian signature) Primary Insured's Signature - for SVUL (if under 15,
parent/guardian signature)
Spouse's Signature (if spouse coverage applied for) Applicant's Signature (if other than Primary Insured)
First Other Insured's Signature (if over age 18) Second Other Insured's Signature (if over age 18)
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22 Statement of Agent
I certify that the statements of the Primary Insured, applicant and any other Proposed Insured(s) have been correctly recorded in
this application and that any premium payment shown in item 8, Section 21 has been collected by me and a Temporary Insurance
Agreement given to the applicant.
To the best of my knowledge the insurance applied for in this application |_|will |_|will not replace existing insurance.
Were all Proposed Insureds seen by you at the time of application? |_|Yes |_| No If No, an examination may be required.
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Agent Code Registered Representative/Agent Signature* Agent Code Signature of Other Agent(s) (if split case)
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Agency Code Agency
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23 Broker-Dealer Information
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Broker-Dealer Name (print) R/R Code Registered Representative/Agent Phone No.
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Broker-Dealer Address Broker-Dealer Authorized Signature
*Registered Representative/Agent Certification
By signing above, the Registered Representative/Agent certifies that he/she is NASD registered and state licensed for variable life
contracts in the appropriate state.
Kansas City Life Insurance Company Pre-Authorized Check Plan (PAC)
PAC Instructions:
1. This form is to be used to request the establishment of a new PAC plan or change banks or accounts under an existing PAC plan. Do
not use this form to add a policy to an existing PAC plan. Instead, simply provide the existing PAC plan number in the Section
14, Special Requests Section of the application.
2. Attach a personalized sample check from the account to be used.
3. The total monthly premium on all policies in a PAC plan must be at least $10.
Request for PAC: I request Kansas City Life Insurance Company to make monthly withdrawals from my checking account to pay premiums
on this policy applied for, or to make monthly withdrawals from my checking account to pay premiums on the following additional
pending applications. Name of Proposed Insured(s). (Include policy number if available.)
Draft Date: I request the Company to draw the PAC check or debit entry on or after the * day of the month.
*Available draft days are the 1st through the 28th.
Account Information:
Payor's Name
Bank Name Branch Name (if any)
|_| Checking |_| Savings Account Number Bank Transit Number
Address where account
is maintained City State Zip
Agreement for Automatic Premium Payments and Authorization to Honor Checks Drawn by the Company
It is agreed that:
1. This PAC plan does not change any policy provisions. The payors authorization is not in lieu of payment in cash of the first
premium, and does not constitute advance payment required by the Temporary Insurance Agreement.
2. Upon 30 days written notice, this PAC plan may be stopped or changed at any time by the owner of any policy under this PAC plan,
the Company or the payor.
3. Withdrawals will be made on or about the premium draft date shown above.
4. No premium notices or receipts will be sent. Debit entries or checks, when paid, will constitute receipts for premiums.
5. The privilege of paying premiums under this PAC plan may be revoked by the Company if any check or debit entry is not paid upon
presentation.
6. The Company's rights in respect to each check and/or debit entry will be the same as if it were signed personally by me.
7. If any debit or check entry is dishonored, the Company will be under no liability whatsoever, even if such dishonor results in
forfeiture of insurance.
8. I authorize the Company to pay and charge to my(our) account, debit entries or checks drawn by and payable to the order of the
Company, provided there are sufficient collected funds present to pay same upon presentation. This authorization will remain in
effect until revoked by me in writing, a copy of which will be sent to the Company. Until the Company receives such notice, I
agree that the Company will be fully protected in honoring any such debit.
Date Signature of Premium Payor
Kansas City Life Insurance Company To obtain further information contact:
New Business Department
Kansas City Life Insurance Company
PO Box 219371
Kansas City, MO 64121-9371
NOTICE OF INFORMATION PRACTICES
Including Fair Credit Reporting Act Notice and MIB, Inc. Notice
Thank you for your application. t is the major source of information about you which we use in evaluating your application and
issuing your policy. However, we wish to inform you that an investigative consumer report may be ordered as to your insurability. If
an investigative consumer report is prepared in connection with this application, you may request to be interviewed in connection
with the preparation of this report. This report may include, if applicable, information as to your character, general reputation,
personal characteristics and mode of living (except as may be related directly or indirectly to your sexual orientation) as may be
obtained through interviews with family members, friends, neighbors and associates. If you would like to know whether such a report
was ordered and, if so, receive additional information as to its nature and scope, including the name, address and phone number of
the reporting agency, we will be pleased to furnish this information upon your written request to our Home Office at the address
above. You may receive a copy of such report by contacting the reporting agency.
Our experience shows that information from investigative reports usually does not have any adverse effect on our underwriting
decision. However, if it should, we will notify you in writing of this fact as well as provide you the identity by name and address
of the reporting agency. You may then wish to discuss the matter with that agency.
We usually will not disclose information about you without your prior written authorization. However, in certain situations we
may disclose some of this information about you to third parties having a business interest in an insurance transaction involving
you, or having a contract with us to perform part of our insurance function. This could include disclosures to persons or
organizations that will use the information for sales purposes, unless you indicate to us that you do not want the information
disclosed for this purpose.
You have the right to obtain access to certain items of information we have collected about you, and you have the further right
to request correction of information if you feel it is inaccurate.
If you wish to have a more detailed description of our information practices, we will be pleased to furnish this information
upon your written request to our New Business Department, Kansas City Life Insurance Company, PO Box 219371, Kansas City,
MO 64121-9371. MIB, Inc. Notice
While the information you provide to us regarding you insurability is treated as confidential, Kansas City Life or its
reinsurers may make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life insurance
companies, which operates an information exchange on behalf of its members. Should you apply for life or health insurance, or submit
a claim for benefits to another member company, the Medical Information Bureau, upon request from that member company, will supply
the information in its file.
Upon written 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
procedure set forth in the Federal Fair Credit Reporting Act. The address of the Bureau's information office is PO Box 105, Essex
Station, Boston, MA 02112. Telephone (617) 426-3660.
We or our reinsurers may also release information in our file to other life insurance companies to whom you apply for life or
health insurance, or to whom a claim for benefits may be submitted.
Portfolio of Funds for Variable Contracts
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PREMIUM ALLOCATIONS
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---------- ------------
MONTHLY QUARTERLY
FUND SELECTION* LUMP PLANNED DOLLAR COST PORTFOLIO
SUM PERIODIC AVERAGING** REBALANCING **
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[MFS Emerging Growth Series % % % %
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MFS Research Series % % % %
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MFS Total Return Series % % % %
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MFS Utilities Series % % % %
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MFS Global Governments Series % % % %
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MFS Bond Series % % % %
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American Century VP Capital Appreciation % % % %
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American Century VP Income & Growth % % % %
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American Century VP International % % % %
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American Century VP Value % % % %
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Federated American Leaders Fund II % % % %
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Federated High Income Bond Fund II % % % %
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Federated International Small Company Fund II % % % %
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Federated Prime Money Fund II % % % %
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Dreyfus Appreciation Portfolio % % % %
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Dreyfus Small Cap Portfolio % % % %
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Dreyfus Stock Index Fund % % % %
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The Dreyfus Socially Responsible Growth Fund, Inc. % % % %
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J.P. Morgan U. S. Disciplined Equity Portfolio % % % %
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J.P. Morgan Small Company Portfolio % % % %
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Franklin Real Estate Fund (Class 2) % % % %
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Franklin Small Cap Fund (Class 2) % % % %
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Templeton Developing Markets Securities Fund (Class 2) % % % %
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Templeton International Securities Fund (Class 2) % % % %
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Calamos Convertible Portfolio % % % %
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AIM V.I. Dent Demographic Trends Fund % % % %
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AIM V.I. Telecommunications and Technology Fund % % % %
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AIM V.I. Value Fund % % % %
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Seligman Capital Portfolio (Class 2) % % % %
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Seligman Communications and Information Portfolio (Class 2) % % % %
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KCL Fixed Account] % % %
============================================================= ========== ============ ==================== =======================
(Use whole percentages only. 100% 100% 100% 100%
Percentages must total 100 %) Total
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* A maximum of 15 fund selections is available at any one time.
** NOTE: It is not necessary to fill in the percentages on this page for Monthly Dollar Cost Averaging and/or Quarterly
Portfolio Rebalancing allocations if they are the same as the initial premium allocations. Simply check the appropriate
box in Section 9 and 10 of this application that tells us they are the same.