Exhibit 99.A.10
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[LOGO OF MASSMUTUAL]
Survivorship
Life
Application
Part 1 (A20GE) - General Version
This application package may be used to apply for the following survivorship
policies:
. Survivorship Whole Life
. Survivorship Variable Universal Life
. Blue Chip Estate Manager
. Blue Chip Survivor Universal Life
. Non-Convertible Survivorship Term
Survivorship policies are only available in the non-qualified market.
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Contents
This package includes:
. Part 1 of Application, A20GE199
. Investment Suitability Form for Variable Life, IAC-9800
. Agent's Statement, A2AGE199
. Temporary Life Insurance Receipt, R10GE199
. MIB and Fair Credit Reporting Act Notice, N148-9000
. Consumer Notification and Summary of Consumer Rights, L7024
. Pre-authorized Check Premium Payment Form, F6445
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See additional information on reverse side.
Massachusetts Mutual Life Insurance Company and affiliated insurance companies
Springfield MA 01111-0001
A20GE199
Notes On Using This Application Package
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. Do not use this application for changes, additions or reinstatements, or
for increases on universal life (BCSUL) or variable life (SVUL) policies;
instead, use the appropriate Change Application.
. Fully complete the Agent's Statement. Do not omit item 8 (Telephone
Numbers).
. If more space is needed in answering questions, use the "Remarks" sections
included throughout the application.
Checklist
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Complete the appropriate Company Name in the Header on Page 1 and Product Data
section for the product selected:
Product Name Issuing Company/Part 1 Product Data Section Questions
Header Information
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Survivorship Whole Life MassMutual Complete Ques. 23 through 28
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Survivorship Variable Universal Life C.M. Life Complete Ques. 29 through 37
MassMutual in CA, NY only.
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Blue Chip Estate Manager MassMutual Complete Ques. 38 through 43
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Blue Chip Survivor Universal Life C.M. Life Complete Ques. 44 through 50
MassMutual in NY
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Non-Convertible Survivorship Term MassMutual Complete Ques. 23 through 28; write product name
on the blank line provided in Ques. 23.
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For Survivorship Variable Universal Life:
[_] Complete and forward Investment Suitability Form.
[_] Give the policyowner the current SVUL prospectus.
[_] SVUL monies must be remitted immediately; do not hold them while
completing requirements for other products being applied for
concurrently.
Signature Instructions for Part 1 of Application (Agreement and Signatures):
[_] Both Proposed Insureds must always sign.
[_] Applicant must be indicated. If different from either Proposed
Insured, the Applicant's signature is also required.
[_] Owner(s) must always sign at the bottom of page 6, even if already
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signed as Insured or as Applicant, for tax ID purposes.
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[_] If the Owner/Applicant is a trust or corporation, include title and
corporation name as appropriate.
For Conversion or Insurability Option Exercise:
[_] In all cases, the Owner and any Assignee of the original policy must
sign.
[_] Each Proposed Insured, if not the Owner of the original policy, must
also sign.
[_] For Option Exercises, both Proposed Insureds and the Owner must
always sign, even if no additional amount of insurance is applied
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for.
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For Prepaid Cases, Use the Temporary Life Insurance Receipt (TLIR):
[_] Complete the health questions on the TLIR for both Proposed Insureds.
[_] If all health questions are answered "No":
[_] Complete the Receipt and give the Premium Payer Part to the
client.
[_] Obtain a separate check for SVUL premium.
[_] Do not use the TLIR with applications for Insurability Option
exercises or Term Conversions.
[_] If any health question is answered "yes" or is left unanswered:
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[_] Do not accept any monies.
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[_] Do not give the receipt to the client.
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Give Client:
[_] MIB and Fair Credit Notice, N148, and Consumer Notification and
Summary of Consumer Rights, L7024.
[_] Buyer's Guide (if applicable).
A20GE199
APPLICATION NO.
SURVIVORSHIP LIFE INSURANCE APPLICATION (PART 1)
To: [_] Massachusetts Mutual Life Insurance Co. [_] MML Bay State Life Insurance Co. [_] C.M. Life Insurance Co.
1295 State Street, Springfield, Massachusetts 01111-0001
For: [_] New Survivorship Life Insurance Policy [_] New Policy as Conversion of Term Insurance / Guaranteed Insurability Option
[_]
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Client Data
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1. Proposed Insured No. 1 first name middle name
Name [_][_][_][_][_][_][_][_][_][_][_][_][_][_] [_][_][_][_][_][_][_][_]
(hereinafter referred to last name suffix (e.g., Jr.)
as Insured 1) [_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_] [_][_][_]
2. Current Address ________________________________________[_][_][_][_][_]-[_][_][_][_]
street & no. city state zip
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3. Business/Employer name
Name & Address ________________________________________[_][_][_][_][_]-[_][_][_][_]
street & no. city state zip
4. Social Security Number [_][_][_]-[_][_]-[_][_][_][_] 5. Date of Birth
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mo. day yr.
6. [_] Male [_] Female 7. Birthplace
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8. Citizen of USA [_] Yes [_] No If "No," what country? ____________ Type of Visa [_] Perm. [_] Temp.
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9. Proposed Insured No. 2 first name middle name
Name [_][_][_][_][_][_][_][_][_][_][_][_][_][_] [_][_][_][_][_][_][_][_]
(hereinafter referred to last name suffix (e.g., Jr.)
as Insured 2) [_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_] [_][_][_]
10. Current Address ________________________________________[_][_][_][_][_]-[_][_][_][_]
street & no. city state zip
11. Business/Employer ------------------------------------------------------- ------------
Name & Address name
________________________________________[_][_][_][_][_]-[_][_][_][_]
street & no. city state zip
12. Social Security Number [_][_][_]-[_][_]-[_][_][_][_] 13. Date of Birth
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mo. day yr.
14. [_] Male [_] Female 15. Birthplace
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16. Citizen of USA [_] Yes [_] No If "No," what country? ____________ Type of Visa [_] Perm. [_] Temp.
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17. Owner (Select only one of (a) through (e).) (For all Owners, print full
name(s) and relationship(s) to the Insureds.)
(a) [_] The Insureds, jointly, or to the survivor of them.
(b) [_] Insured No. ______, if living, otherwise Insured No. _____, if
living.
(c) [_] Joint Ownership: __________________, or to the survivor(s) of them.
(d) [_] ___________________________ as Trustee(s), or the then-acting
Trustee(s), under the Trust Agreement dated _________________.
(Copy of signed Trust Agreement required)
(e) [_] Other
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Unless otherwise requested in 22, if the last Owner is other than an
Insured and all Owners predecease the Insureds, then the Owner shall be the
estate of the last Owner to die.
18. Owner's (if other than an Insured) Soc. Sec. No. or Taxpayer ID
No. ____________________________________________________
(If more than one Owner, give name, address and Soc. Sec. No. of all Owners
in 22.)
19. Owner's (if other than an Insured) Address
_______________________________________________[_][_][_][_][_]-[_][_][_][_]
street & no. city state zip
20. Insured assumed to have died first in the event of simultaneous deaths
[_] Insured 1 [_] Insured 2
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A20GE199
APPLICATION NO. Page 2
21. Beneficiary (Select only one of (a) through (d). (For all Beneficiaries,
print full name(s) and relationship(s) to the Insureds.) Payment to all
Beneficiaries shall be made in one sum unless otherwise requested.
(a) [_] Estate of Insured who dies last
(b) [_] See Memo attached
(c) [_] ______________________________________________ as Trustee(s), or
the then-acting Trustee(s), under the Trust Agreement dated
____________________. (Copy of signed Trust Agreement required.)
(d) Other _______________________________________________________________
Unless otherwise requested in 22, payment shall be made in one sum.
Unless otherwise requested in 22, if two or more persons are the
beneficiaries in any class, payment shall be made to them equally or to the
survivor(s).
If there is no beneficiary entitled to payment when both the Insureds die
and one of the Insureds was the last Owner, payment shall be made to the
estate of the Owner. But if an Insured is not the Owner, payment shall be
made to the Owner.
22. Remarks
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Product Data (one of the following four sections to be completed)
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23. [_] Survivorship Whole Life (SWL) [_] ____________________________
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24. Amount of Insurance (a or b)
(a) Face Amount $_________________
(b) Face Amount purchased by a premium of $_________________ at premium
frequency elected in 58
[_] This premium includes all riders.
25. Riders
[_] Waiver of Premium (WP) O Insured 1 O Insured 2
[_] Suppl. Ins. Purch. (SWL Term) $
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SIPR Payment $
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[_] SWL-Additional Life Insurance Rider (ALIR) $
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[_] Estate Protection Rider (EPR)
[_]
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26. Dividend Option
(If SWL Term applied for, dividends will be applied to buy Supplemental
Insurance)
[_] Paid-up Additions [_] Accumulate at Interest
[_] Reduce Premiums [_] Cash
[_]
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27. Automatic Premium Loan [_] Yes [_] No
28. Loan Interest Rate (where elective)
[_] Adjustable (Variable) [_] 8% [_] _____%
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29. [_] Survivorship Variable Universal Life (SVUL) [_] _____________________
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30. Face Amount $
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31. Initial Premium $
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32. Planned (billed) Premium $
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33. Riders
[_] Estate Protection Rider (EPR) $
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[_]
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34. Death Benefit Option [_] 1 [_] 2 [_] 3 [_] _____
35. Loan Interest Rate (where elective)
[_] Adjustable (Variable) [_] 5% [_] ______%
36. Election for Definition of Life Insurance
[_] Cash Value Test [_] Guideline Premium Test
37. For Variable Life Insurance, the Applicant acknowledges:
. That the variable value of the policy may increase or decrease in
accordance with the experience of the Separate Account(s);
. That there are no minimum guarantees as to the variable value;
. That the fixed value of the policy earns interest at a rate not less
than a minimum specified rate; and
. That the death benefit may be variable or fixed under specified
conditions.
A20GE199
APPLICATION NO. Page 3
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38. [_] Blue Chip Estate Manager (BCEM) [_] _______________________________
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39. Face Amount $
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40. Riders
[_] Survivorship Additional Benefits Rider (SABR) [_] Term Options Rider (TOR)
O Unscheduled Premium $_________ O Option 5
O Initial modal premium amount $_________ O Option 6
Total number of years payable O Option 7 Target amount $_________
O Option 8 Target amount $_________
(Select if desired)
[_] Decrease [_] Split Option Rider (SOR)
Modal Adjustment Amount $_________
Number of years of adjustment _________ [_] Estate Preservation Rider (EPR)
[_] Survivorship Flexible Term Rider (SFTR)
Initial target amount $_________
[_] First Death Rider (SFDR) $_________ Increase factor _________%
Increase expiry age _________
First Death Rider Beneficiary Designation (Select one)
[_] The surviving insured. [_] The Executors or Administrators of the first
insured to die.
[_] ___________________________________________, its successors or assigns.
(Corporation Name)
[_] If Insured No.____ is the first to die, then to ___________________________ of that Insured, or
(Name and Relationship)
if Insured No.____ is the first to die, then to ___________________________ of that Insured.
(Name and Relationship)
[_] If Insured No.____ is the first to die, then to ___________________________ of that Insured if he/she survives
(Name and Relationship) the Insured, otherwise in equal
shares to the surviving children
of that Insured, or
if Insured No.____ is the first to die, then to ___________________________ of that Insured if he/she survives
(Name and Relationship) the Insured, otherwise in equal
shares to the surviving children
of that Insured.
[_] Other
41. Dividend Option
[_] Paid-up Additions [_] Accumulate at Interest
[_] Premium Payment [_] Cash
[_] _______________________
42. Automatic Premium Loan [_] Yes [_] No
43. Loan Interest Rate (where elective)
[_] Adjustable (Variable) [_] 8% [_] ______ %
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44. [_] Blue Chip Survivor Universal Life (BCSUL) [_] _______________________
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45. Face Amount $_____________
46. Initial Premium $_____________
47. Planned (billed) Premium $_____________
48. Riders
[_] Estate Preservation Rider (EPR)
[_] Policy Split Option Rider (PSO)
[_] _______________________
49. Death Benefit Option [_] 1 [_] 2 [_] ____
50. Loan Interest Rate (where elective)
[_] Adjustable (Variable) [_] 8% [_] ______ %
A20GE199
APPLICATION NO. Page 4
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Life Insurance Data - All Products
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51. Policy Date (optional) __________________________
52. To Save Issue Age (optional) ___ Insured 1 ___ Insured 2
53. If the policy applied for will be used in connection with an
employer-sponsored plan involving both males and females, will the policy be
issued on a Unisex basis? [_] Yes [_] No
54. Life Insurance currently applied for, contemplated, or now in force on
either Insured in this and all companies. (Exclude amounts shown in 56(a).)
If none, check here [_]
Insd. Currently
1 or 2 Company Name Face Amount Year(s) Issued or Applied For
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$ [_]
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[_]
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[_]
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55. Total amount of new insurance to be placed in all companies
$____________ Insured 1 $ ____________ Insured 2
56. Replacement/Section 1035 Exchange (For each policy listed in (a), include
completed replacement forms with this application.)
(Do not complete for Term Conversions)
(a) Will the insurance now being applied for replace or change, or is it
intended to replace or change, any insurance or annuity, in whole or in
part, issued by this or any other company? Insured 1 O Yes O No
Insured 2 O Yes O No
If "Yes," complete the following.
Ins. 1 or 2 Company Name Policy Number Yr. Issued Product Face Amount
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$
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(b) If the policy applied for is intended to qualify for a Section 1035
exchange, the approximate value of the policy to be exchanged is $__________
and will be applied for on the new policy in the form of:
O ALIR O SIPR O SABR O Additional Premium (UL,VL) O Initial Premium
(If exchanging another company's policy, the policy, a completed absolute
assignment form, and the other company's blank surrender form should
accompany this application.)
57. Remarks
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Payment Data
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58. Premium Payments
(a) Billing Type
[_] Automatic Bank Account Withdrawal
[_] Direct Bill
[_] Invoice/Franchise
(b) Frequency
[_] Annual [_] Quarterly
[_] Semiannual [_] Monthly (not with Direct Bill)
[_]
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59. Premium Payer [_] Insured 1 [_] Insured 2 [_] Owner [_] Other ________
Mailing Address [_] Insured 1 O Home O Business O Other ________________
[_] Insured 2 O Home O Business ________________
[_] Owner's Address ________________
60. Has the first premium on the insurance applied for been paid?
[_] Yes (complete temporary life insurance receipt except on
conversion/option)
[_] No
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Conversion and Option Data
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61. Request is hereby made to exchange either:
[_] (1) the option to purchase new insurance on the next Option Date
available under an Insurability Rider of an existing policy; or
[_] (2) existing term insurance,
for a new survivorship life insurance policy or an increase in face amount under
an existing survivorship policy, as applied for.
The new Policy or insurance shall take effect as provided in the application for
insurance.
The Term Insurance or Insurability Option being exchanged shall terminate when
the new insurance takes effect. For an exchange of Term Insurance, an exchange
allowance equal to the allowance on conversion will be calculated as of the date
the new Policy takes effect. The Part 2 of the application for Term Insurance or
Insurability Option being exchanged or exercised shall become a Part 2 of the
application of the new Policy and a Copy of that Part 2 shall be made a part of
the new Policy.
A20GE199
APPLICATION NO. Page 5
62. (a) Conversion of term insurance on
[_] Insured 1 under policy(ies) numbered __________________________
[_] Insured 2 under policy(ies) numbered __________________________
Date of New Policy (required) _____________________
Complete Only If Not Converting All
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Balance to be
Amt. To Be Conv. -----------------------
Insd. 1 or 2 Policy Number Type of Term Convert All Terminated Continued
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[_]Yes [_] No [_] [_]
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[_]Yes [_] No [_] [_]
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Any applied for amounts not being converted on either life and any
riders which do not carry over automatically, require evidence of
insurability.
(b) If the term insurance provides that Waiver of Premium is to be included
in the new policy if available, the rider will automatically be included
unless otherwise requested here.: [_] Do not include Waiver of Premium
63. Guaranteed Insurability Option on
[_] Insured 1 under policy(ies) numbered __________________________
[_] Insured 2 under policy(ies) numbered __________________________
Indicate if Regular Option Date or Substitute Option Date (and reason for
Substitute Option Date) in 64.
Any applied for amounts on either life not the result of exercising an
option, and any riders which do not carry over automatically, require
evidence of insurability.
64. Remarks
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Personal Data Regarding the Insureds
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Insured 1 Insured 2
65. (a) Has the Insured smoked cigarettes during the past 12 months? [_] Yes [_] No [_] Yes [_] No
(b) If "No," has the Insured used tobacco or nicotine in any
other form during the past 12 months? [_] Yes [_] No [_] Yes [_] No
(c) Has the Insured used tobacco or nicotine in any form
during the past 3 years? (If "Yes," give details in 73.) [_] Yes [_] No [_] Yes [_] No
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Complete the following only if Evidence of Insurability is required.
Explain "Yes" answers in 73.
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66. What are the Occupation(s) and Exact Duties of each of the Insureds?
Occupation(s) Exact Duties
Insured 1
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Insured 2
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67. Insured 1 current driver's license no. ____________________ State_________
Insured 2 current driver's license no. ____________________ State_________
Insured 1 Insured 2
68. Within the last 5 years has the Insured been in a motor vehicle accident,
been convicted of operating a motor vehicle while under the influence of
alcohol or other drugs, been convicted of a moving violation, or received a
driver's license restriction or revocation? [_] Yes [_] No [_] Yes [_] No
69. Does the Insured now contemplate any foreign travel? [_] Yes [_] No [_] Yes [_] No
70. Within the last 3 years has the Insured been, or does the Insured now expect
to become, a pilot, student pilot, or crew member of any type of aircraft?
If "Yes," complete Aviation Supplement A3310 [_] Yes [_] No [_] Yes [_] No
71. Within the last 3 years has the Insured taken part in, or does the Insured
now intend to take part in, underwater diving, hang gliding, para sailing,
para kiting, parachuting, skydiving, mountain climbing, or organized racing
by automobile, motorcycle, motorboat, or snowmobile, or any other form(s) of
hazardous activity? If "Yes," complete Avocation Supplement A3320 [_] Yes [_] No [_] Yes [_] No
72. Has the Insured ever been convicted of a felony? [_] Yes [_] No [_] Yes [_] No
73. Remarks
A20GE199
APPLICATION NO. Page 6
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Agreement and Signatures
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The persons signing below agree that:
The Application -- This is Part 1 of an application for Life Insurance. The
application includes any Part 2 that may be required and any amendments and
supplements to either Part. To the best of the knowledge and belief of the
persons signing below, all statements in this Part 1 are complete and true and
were correctly recorded. Each person signing below adopts all of the statements
made in the application and agrees to be bound by them.
Company, as used in this application, refers to Massachusetts Mutual Life
Insurance Company and/or MML Bay State Life Insurance Company and/or C.M. Life
Insurance Company.
Liability of Company -- The insurance applied for will not take effect unless
each of the applicable conditions is met:
1. For all cases: The first premium has been paid during the lifetime of all
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persons to be insured by the policy and the application has been approved by
the Company at its Home Office/Administrative Office.
2. For insurance purchased under a guaranteed insurability rider or agreement:
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The first premium must be paid within the time period specified in the rider
or agreement. If all applicable conditions are met, the insurance purchased
under such rider or agreement becomes effective according to its terms.
3. For conversion: If all applicable conditions are met, the insurance
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purchased under a conversion becomes effective, and coverage being converted
terminates, on the Issue Date of the policy applied for. The first premium
may be reduced by any conversion allowances permitted.
4. For insurance not provided for in 2 or 3 above: The first premium may be
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paid to the agent in exchange for a Temporary Life Insurance Receipt signed
by that agent. If this is done, the Company shall be liable only as set
forth in that Receipt. If not, (i) the policy must be delivered to the
person named as Owner therein; and (ii) at the time of payment and delivery,
all statements that relate to the insurability of all persons to be insured
under the policy are complete and true as though they were made at that
time.
Authority of Agents -- No agent can change the terms of this application or any
policy issued by the Company. No agent can waive any of the Company's rights or
requirements or extend the time for any payment.
Changes and Corrections -- Any change or correction of the application will be
shown on an Amendment of Application attached to the policy. Acceptance of any
policy issued shall be acceptance of any change or correction of the application
made by the Company. However, any correction or change of amount,
classification, plan of insurance, or riders applied for in this application
must be agreed to in writing.
Authorization To Obtain and Disclose Information (For Each Insured And/Or
Applicant) -- I have received the Notice about the Medical Information Bureau,
Inc. (MIB). I have also received the Notice about the Fair Credit Reporting Act.
I understand and authorize an investigative report to be made. This report may
include information about my character, general reputation, personal
characteristics, and mode of living. I hereby authorize certain parties that
have any records or knowledge of me and my health, to make such information
available to the Company and its reinsurers. These parties include: any licensed
physician, medical practitioner, hospital, clinic, other medical or medically
related facility, insurance company, the MIB, or other organization. I agree
that a photocopy or facsimile of this authorization may be used to obtain
information.
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ANY POLICY ISSUED AS A RESULT OF A MATERIAL MISSTATEMENT OR OMISSION
OF FACTS MAY BE VOIDED, AND THE COMPANY'S ONLY OBLIGATION SHALL BE TO
RETURN PREMIUMS PAID.
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For All Cases
Proposed Insured 1 Applicant Signature (if other than Insured)
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Proposed Insured 2 Applicant: [_] Insured 1 or
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- --------------------------------- [_] Insured 2 Print Name
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For Conversions and Option Purchases
Owner(s) of Original Policy(ies) Assignee(s) of Original Policy(ies)
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(include company name(s) and (include company name(s) and title(s)
title(s) if applicable) if applicable)
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Signed at ____________________________________________ on ____________________
city state date
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General Agent submitting Agent who actually solicited this
application (Agcy. No.) application (print name here)
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A20GE199 Massachusetts Mutual Life Insurance Company
and affiliated insurance companies Springfield MA 01111-0001
Taxpayer Identification -- The Owner of the policy applied for herein certifies,
under penalties of perjury, that: (i) the number referred to in 4, 12 or 18 of
this application is his/her correct Taxpayer Identification number (or he/she is
waiting for a number to be issued); and (ii) he/she is not subject to backup
withholding either because he/she has not been notified by the Internal Revenue
Service (IRS) that he/she is subject to backup withholding as a result of a
failure to report all interest or dividends, or the IRS has notified him/her
that he/she is no longer subject to backup withholding. If the IRS has notified
the Owner that he/she is subject to backup withholding and he/she has not
received notice from the IRS that backup withholding has terminated, he/she
should strike out the language here in (ii) that he/she is not subject to backup
withholding due to notified payee underreporting.
on
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Signature(s) and Title (if corporate owned) of Owner(s) Date
of New Policy