EXHIBIT 1.(10)
Application for Last Survivor MONY Life Insurance Company
Adjustable Life Policy
Insured A: Name (Print name as it is to appear on the policy.)
1a. First Middle Last Sex Insurance Birthdate Birthplace Relationship
Age (to Insured B)
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Social Security Number Driver's License Number License State Marital Status (circle one)
single / married / widowed / divorced / separated
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2a. Address (for MILITARY personnel, Home = Home of Record; Business = Present Address; Business address will be billed)
Mail to: [] Home
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[] Business
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number street city state zip county
3a. Phone Number - Home (area code) # Preferred Calling Time: a.m. p.m.
------- --------------- ------ ------
(where proposed insured can be contacted)
Business (area code) # Preferred Calling Time: a.m. p.m.
------- ------------ ------ ------
4a. a) Occupation: (exact duties) b) Employer's Name and Address c) For Military Business
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Branch of Service
------------------------
Pay grade
--------------------------------
Estimated discharge date (mo/yr) /
--- ---
Is Insured a dependent? yes no
--- ---
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5a. Currently or during the past 12 months, has Insured A: 6a. Height: ft. in. Weight: lbs.
a) smoked one or more cigarettes? yes no ---- ---- ----
---- ---- Any weight gain or loss in last 6 months?
b) used another form of nicotine? yes no Weight gain
---- ---- -----
If "yes," specify type: pipe chewing tobacco Weight loss lbs. none
---- ------ ----- ----- ------------
nicotine gum cigar other (gain or loss)
--- --- ---------------------------
7a. Is Insured A now performing all the duties of his or her regular occupation
on a full-time basis at the usual place of business?
yes no (if "no," explain in Remarks. Include date of last full-time work)
---- ----
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Insured B: Name (Print name as it is to appear on the policy.)
1b. First Middle Last Sex Insurance Birthdate Birthplace Relationship
Age (to Insured B)
- ---------------------------------------------------------------------------------------------------------------------------
Social Security Number Driver's License Number License State Marital Status (circle one)
single / married / widowed /
divorced / separated
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2b. Address (for MILITARY personnel, Home = Home of Record; Business = Present Address; Business address will be billed)
Mail
to: [_]Home
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[_]Business
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number street city state zip county
3b. Phone Number - Home (area code) # Preferred Calling Time: a.m. p.m.
------- ------------------ --- ---
(where proposed insured can be contacted)
Business (area code) # Preferred Calling Time: a.m. p.m.
------- -------------- --- ---
4b. a) Occupation: (exact duties) b) Employer's Name and Address c) For Military Business
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Branch of Service
--------------------------
Pay grade
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Estimated discharge date (mo/yr) /
----- ---
Is Insured a dependent? yes no
----- -----
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5b. Currently or during the past 12 months, has Insured B: 6b. Height: ft. in. Weight: lbs.
a) smoked one or more cigarettes? yes no --- --- ---
--- --- Any weight gain or loss in last 6 months?
b) used another form of nicotine? yes no Weight gain
--- --- --- -----
If "yes," specify type: pipe chewing tobacco Weight loss lbs. none
--- --- --- --- ---
nicotine gum cigar other (gain or loss)
----- ---- ----- ------------
7b. Is Insured B now performing all the duties of his or her regular occupation on a full-time basis at the usual place
of business?
yes no (if "no," explain in Remarks. Include date of last full-time work)
------ -------
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8. Name of Applicant: Insured A Insured B
-------- ----------
Other: Full Name
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Address:
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93-404 (Rev. 8/1999) Form No. 15384 (1/2002)
Plan Information
9. Plan: Face Amount: Target Amount:
---------------- ----------------- -------------
Riders/Benefits
Death Benefit Option:
Option 1 Option 2
------- -------
4 Year Term Insurance Plan (EPR)
- ---
Other:
- --- -------------------------------------------------------------
Have Preferred Premiums been quoted? Ins A: Yes No Ins B: Yes No
--- --- --- ---
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10. Premium Frequency: Have you received a copy of the
-------------------- Temporary Insurance Agreement?
Scheduled Premium amount $
------- Yes No
Amount Paid: None $ ------- --------
----- -------
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11. Complete if specific Policy Date requested:
-------
a) / / (mo./day/yr.)
--------------------
b) Date Policy to save age of Insured A: Yes No
----- -----
(to save age of Insured B, specific policy date must be requested)
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12. Special Market: GA Method Common Remitter Plan Number
-------- ----------------
(if established)
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13. Replacement: Will coverage applied for replace or modify existing life insurance or annuities? Yes No
----- -----
If "yes ": Life Annuity Group
----- ----- -----
Is this a 1035 Exchange? Yes No (Submit any required replacement forms.)
----- -----
Insured A: Policy Number: Insured B: Policy Number:
-------------------------- ------------------------------------
Amount: $ Issue Year Amount: $ Issue Year
--------------- --------------- --------------- -------------------------
Company: Company:
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14. Beneficiary: Unless otherwise specified, joint beneficiaries will receive equally, or the surviving benificiary(ies)
will receive entire proceeds, subject to Policy Provisions:
1st: if living: if not:
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Full Name Relationship to Insured [_] A [_] B [_] Both
2nd: if living: if not:
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Full Name Relationship to Insured [_] A [_] B [_] Both
3rd: if living: if not:
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Full Name Relationship to Insured [_] A [_] B [_] Both
The Executors or Administrators of the last surviving Insured, OR [_] Other (Use "Remarks" Section)
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15. Ownership (Rights): During the lifetime of any insured, all rights belong to:
The Insureds Jointly or the survivor
----
OR: Name of Trust or Plan If rightsholder is other than one or both of the Insureds:
---- --------------------------
Trustee:
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Grantor: Name and relationship to insured
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Date of Trust: ----------------------------------------------------------
--------------------------------- Street Address
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OR: Other City State Zip County
---- Soc. Sec./Tax I.D. No.:
If "other" is checked above, final rightsholder is: -----------------------------------
the Insureds jointly, or the survivor, OR
----
the executors or administrators of:
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93-404 (Rev. 8/1999) Form No. 15384 (1/2002)
16. Attained Age Term Conversion: (Do not use if increase to existing Adjustable Life.)
a) Original Policy Numbers: a) Original Policy Numbers:
Insured A: Insured B:
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b) Conversion From Date of Issue b) Conversion From Date of Issue
Term Policy (mo./day/yr.) / / Term Policy (mo./day/yr.) / /
------------------ -------------------
Term Rider (mo./day/yr.) / / Term Rider (mo./day/yr.) / /
------------------ -------------------
Other (mo./day/yr.) / / Other (mo./day/yr.) / /
------------------ -------------------
c) Conversion Date c) Conversion Date
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(no later than date to which premiums are paid on original (no later than date to which premiums are paid on original
policy) policy)
d) Any term balance remaining after conversion shall be: d) Any term balance remaining after conversion shall be:
continued, if allowed discontinued continued, if allowed discontinued
------ ------ ------ ------
e) apply Term Conversion Credit as: e) apply Term Conversion Credit as:
Dump-in OR Defer Dump-in OR Defer
------ ------ ------ ------
(New policy subject to all rights and interests of any assignee of original policy.)
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17. Financial Information: Insured A Insured B Applicant (if other than insured)
Total Annual Income: Current Year: $ $ $
(less any tax deductible -------------------- -------------------- --------------------
business expense) Prior Year: $ $ $
-------------------- -------------------- --------------------
Net Worth: $ $ $
-------------------- -------------------- --------------------
Total Life Insurance in force: $ $ $
-------------------- -------------------- --------------------
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Insured A Insured B
18. Has either proposed Insured ever been convicted of an alcohol or drug
related driving offense, or had a driver's license suspended or revoked? Yes No Yes No
---- ---- ---- ----
19. Within the past 2 years has either proposed insured:
(a) (i) Been convicted of two or more moving motor vehicle violations? Yes No Yes No
---- ---- ---- ----
(ii) flown as a pilot or crewmember, or engaged in parachuting, hang
gliding, ballooning, motorized racing, or underwater diving below 60 feet? Yes No Yes No
---- ---- ---- ----
(iii) operated a motorcycle? Yes No Yes No
---- ---- ---- ----
(b) Does any proposed insured intend to engage in any activity in
question #19a(ii) in the future? Yes No Yes No
---- ---- ---- ----
(If "yes" to any of 19a (i), a (ii), or b, complete Automobile/Aviation/Avocation Information Section.)
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20. Has any proposed Insured: (Circle the applicable item) Insured A Insured B
a) ever been medically diagnosed, medically treated for, or had
symptoms of heart trouble, heart murmur, chest pain, stroke,
high blood pressure, diabetes, cancer or tumor? Yes No Yes No
---- ---- ---- ----
b) ever used cocaine, heroin, LSD, marijuana or any other narcotic
drug or controlled substance except as prescribed by a physician? Yes No Yes No
---- ---- ---- ----
c) during the past 2 years had a physical exam? Yes No Yes No
prompted by symptoms? ---- ---- ---- ----
findings normal? Yes No Yes No
---- ---- ---- ----
Yes No Yes No
---- ---- ---- ----
d) during the past 5 years had any illness, surgery or injury requiring
treatment by a physician, hospital or other medical facility? Yes No Yes No
---- ---- ---- ----
e) during the past 5 years been treated or counseled for mental or
emotional trouble, neurological disorder or the use of alcohol or
drugs by a physician, counselor, psychologist, hospital or clinic? Yes No Yes No
---- ---- ---- ----
f) during the past 10 years been diagnosed with or treated for AIDS
or HIV infection by a member of the medical profession? Yes No Yes No
---- ---- ---- ----
(If "yes" to any part of this question, include details in question 23)
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21. Is any proposed Insured (i) receiving special training or therapy because Insured A Insured B
of a physical or mental disability or (ii) unable to participate actively Yes No Yes No
at work or school or (iii) unable to perform normal activities? ---- ---- ---- ----
(If "yes ", give details below)
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93-404 (Rev 8/1999) Form No. 15384 (1/2002)
22. Personal Physician Information
Insured A: Insured B:
Dr. Name Dr. Name
--------------------------------- ----------------------------------
Address Address
---------------------------------- -----------------------------------
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Phone Number # Phone Number #
------- --------------------- ------- ----------------------
Date last seen: (mo./day/yr.) / / Date last seen: (mo./day/yr.) / /
---- -- -- --- ---- -- -- ---
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23. Details of all "yes" answers for Question 20. For any checkup or routine examination, indicate what symptoms, if any, prompted
it and include results of the examination and any special tests except HIV test. Include clinic identification number if applicable.
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Question Insured Illness, Treatment and Onset Recovery If disabled, Doctor, Clinic or Hospital, Pre-
Number (specify) Number of Attacks Date Date how long? Complete Address, and payment
(20 a,b,c, (including specific diagnosis mo/day/yr mo/day/yr (in months) Phone Number Fee
d,e or f) A B and medication)
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Life Remarks:
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93-404 (Rev 8/1999) Form No. 15384 (1/2002)
AUTOMOBILE/AVIATION/AVOCATION INFORMATION SECTION (Complete only if any of
question #19 is answered yes) (If question #19 is answered "yes" for both
Insured A and Insured B, use 2 separate forms
INSURED A [_]
24. Automobile Driving Record
a) Driver License Nos.
--------------------------------------------------
States of Expiration Date: (mo./yr.)
--------------- ------------------
b) Have you ever been convicted of driving while under
the influence of alcohol or drugs? yes no
---- ----
How many times?
-----
Conviction Dates: (mo./yr.)
------------------------------------------
c) Number of moving violations you have been
convicted of in the past?
------
How many speeding violations?
------
Speeding Date Speed Limit Speed Attained
(mo./yr.)
------------- ----------- --------------
d) Have you ever had your driver's license suspended
or revoked? yes no
---- ----
If yes: Date Suspended/ For how Date
Revoked long Restored
(mo./yr.)
------------- ----------- --------------
25. Aviation
a) Have you flown an aircraft within the past 2 years as
a pilot or crew member, or do you intend to do so in
the future? yes no
---- ----
b) Date of last flight as pilot? (mo./yr.) /
-------------------
c) Type of aviation license or certificate now held?
Student Private Commercial
----------- ------------ ------------
Military Instructor Other
---------- --------- -----------------
Date of Issue: (mo./yr.) /
------------------ -------------------------
Do you intend to renew? yes no
---- ----
d) Total hours flown as pilot?
----------------
e) Have you ever done any test flying, or do you intend
to do so? yes no
---- ----
(If "yes," explain in "Remarks.")
f) Do you have an Instrument Flight Rating (IFR)?
yes no
---- ----
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Type of Flying Hrs Flown Probable
Past 12 Mos Flying Hrs
Next 12 Mos
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Scheduled Airlines
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Employer Owned Plane
(for business transportation)
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Private Plane
(for pleasure or business)
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Nonscheduled Airlines
(explain in "Remarks")
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Charter
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Flight instructions as instructor
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Military (include duties and
type of aircraft in "Remarks")
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Other flying
(explain in "Remarks")
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g) If either is necessary under Company rules, which of the following do
you prefer?
Full aviation coverage at an extra premium
---------
Restricted aviation coverage
without extra premium
---------
INSURED B [_]
26. Avocations
a) Motor Vehicle Racing
1. Racing Status: Professional Amateur
------- -----
2. Type of vehicle you race:
Stock Car Sports Car
------- --------
Dragster Midget Car
------- --------
Boat Motorcycle
------- --------
3. Exact description of vehicle (Formula 1,
Thunderboat, etc.)
------------------------------------------------
4. Type of track:
Paved Dirt Other
------ ----- -----
5. Type of Race:
Speed Hill Climbing Other
----- ----- -----
Rally Dragstrip
----- -----
6. Number of Races in last 12 months:
--------------------------------
Maximum Speed: mph
---------------------
Date of last race: (mo./yr.) /
----------------------
b) Underwater Diving
1. Do you dive for:
Pleasure only Pleasure and employment
------- -------
2. Number of dives in last 12 months to:
60ft 61-75ft 76-100ft
----- ----- -----
101-150ft over 150ft
----- -----
3. Date of last dive below 60ft: (mo./yr.) /
------------------
4. Do you dive alone? yes no
----- -----
c) Parachute Jumping
1. Are you a member of a Parachute Club which
adheres to PCA safety rules and regulations?
yes no
----- -----
2. Total Number of Jumps made:
---------------------------------------
3. Date of last jump: (mo./yr.) /
-------------------------
d) Gliding
1. Glide Status: Professional Amateur
--------- ---------
2. Type of aircraft used:
Hang glider Sailplane Other
-------- --------- --------
(If sailplane, also complete Question 26.)
3. Are you affiliated with a hang glider club?
yes no
----- -----
4. Maximum altitude achieved:
to 50ft over 50ft
-------- -------
5. Total number of flights made:
-----------------------------------
6. Number of flights in last 12 months:
------------------------------
7. Date of last flight: (mo./yr.) /
---------------------
e) Ballooning
(Complete the following questions and Question 26.)
1. Do you fly over:
land only land and water
--------- ---------
2. Type of Balloon: Hot Air Gas
------- ---------
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Do you anticipate future participation in any of the
above avocations? yes no
----- -----
Do you anticipate future participation in any other
avocations? yes no
----- -----
(If "yes," give details in "Remarks.")
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Remarks:
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FOR HOME OFFICE USE ONLY: Any Home Office corrections and amendments made after
the application was signed are shown either in this space or on a separate form
requiring signed ratification.
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93-404 (Rev 8/1999) Form No. 15384 (1/2002)
I represent the statements and answers in this application to be true and
complete to the best of my knowledge and belief. I offer them to the appropriate
MONY Company to induce it to issue the policy or policies and to accept the
payment of premiums thereunder.
I agree that: (1) Payment of the first premium, if after the application date
below, will mean that I represent that such statements and answers would be the
same if made at the time of such payment; (2) no one but an Executive Officer of
the Company may change any contract or waive any of its provisions; (3) when
coverage takes effect: if a policy is issued exactly as applied for and required
cost has been received, the policy will take effect on the date we authorize its
delivery or on any later requested Policy Date. If a policy is issued either (a)
other than as applied for, or (b) exactly as applied for but any required cost
remains unpaid, the policy will take effect on the date it is delivered,
provided its delivery and payment of any required cost are made while each
person to be insured is living. But, in any case, a policy will not take effect
for any situations before the date indicated: (a) for the exercise of a Term
Conversion (Question 17); (b) for a Government Allotment authorization, its
Policy Date. "Required Cost" in the case of a Term Conversion is the full first
premium. In any other case, "required cost" is the amount necessary to put the
policy in force. (4) Acceptance of any policy issued will ratify any correction
in or amendment to the application noted by the Company in the space provided in
the "FOR HOME OFFICE USE ONLY" section of the application. A Copy of the
application attached to the policy will be sufficient notice of the change made.
If the laws where the application is made so require, any change of amount,
class of risk, age at issue, plan of insurance or benefits must be ratified in
writing.
Under the penalties of perjury, I certify that:
- - The number shown under Question 1a, 1b, or 16 on the application is the
correct taxpayer identification number of the rightsholder(s) (or the
rightsholder(s) are waiting for a number to be issued). 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 (IRS) 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 (does not apply to real estate transactions, mortgage interest paid,
the acquisition or abandonment of secured property, contribution to an
individual retirement arrangement (IRA), and payments other than interest and
dividends.)
I authorize the following persons/organizations to release the following types
of information about me. "I" means each insured.
Persons/Organizations: Any physician, health care provider or medical
practitioner; any hospital, clinic or other medically related facility; any
insurer (particularly MIB member companies from whom MONY may request code
details); any reinsurer; any consumer reporting agency or Medical Information
Bureau ("MIB"); financial source; employer; or government unit.
Types of Information: Mental and physical health; other insurance coverage;
hazardous activities; character; general reputation; finances; occupation;
avocation; motor vehicle driving record; and other personal traits. I further
understand that the specific types of information to be disclosed may, if
applicable, include: diagnosis, prognosis, and treatment for physical and/or
emotional illness, including treatment of alcohol or substance abuse for any
admission (information protected by federal regulation 42 CFR Pt. 2); and
diagnosis, prognosis, and treatment of serious communicable disease or
infection, including sexually transmitted diseases. This information will cover
all admissions.
Purposes: Underwriting all life and disability income insurance application(s)
made by me and my immediate family members; claim purpose (contestable
investigations); obtaining consumer reports and motor vehicle driving records.
Duration: This is valid for 24 months, but I may revoke it. Actions taken by
MONY before its receipt of notice of the revocation will be valid.
Acknowledgments: I understand that I may obtain a copy of this form and that a
copy will be as valid as the original. I also understand that MONY may send some
information to MIB, MIB member companies to whom I apply for insurance,
reinsurers, MONY employees and contractors who perform services related to this
application. I acknowledge that I have been given a copy of "MONY's Information
Practices and the Underwriting Process," which includes a notice about an
investigative consumer report and MIB.
Dated at (City and State) on
--------------------------- --------------------------
X X
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(Signature of Insured A) (Signature of Insured B)
Relationship between Insureds:
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Signature of Applicant (if other than one of the Insureds), who agrees to be
bound by the representations and agreements in this and in any other part of
this application.
X
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Signature of: Applicant [] Owner (Rightsholder) [] (Address)
Relationship to Insured A: Relationship to Insured B:
---------------- -----------
X
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Field Underwriter (Licensed Agent)
93-404 (Rev 8/1999) Form No. 15384 (1/2002)
PROVISIONS OF THE TELEPHONE/FAX AUTHORIZATION PRIVILEGE
MONY Life Insurance Company ("MONY") and MONY Life Insurance Company of America
("MONY America") ("MONY" and "MONY America" collectively referred to as the
"Company") have adopted the procedures set forth below to seek to prevent
transfers among the subaccounts of variable insurance contracts issued by the
Company from being made based upon unauthorized telephone instructions. The
Company believes that the procedures adopted are reasonable and also reflect
procedures prevalent in the industry. Accordingly, a purchaser of a variable
life insurance policy or a variable annuity contract issued by the Company
("rightsholder/contractholder") who elects to make, or to authorize a registered
representative of MONY Securities Corporation to make at such
Rightsholder/Contractholder's specific instruction for each transfer, transfers
of values among subaccounts by telephone assumes the risk of any loss in the
event that such instructions are not genuine. It is, therefore, extremely
important that a Rightsholder/Contractholder take extreme care not to disclose
information about themselves or their contracts or policies to persons whom the
Rightsholder/Contractholder would not want to authorize to make telephone
transfers.
1. A Rightsholder/Contractholder may elect to have transfers of values among
the subacounts of variable accounts made by telephone ("Telephone
Transfer") only upon completion, execution, and return of the form provided
by the Company for that purpose or the authorization contained on the
variable insurance contract application or the authorization contained on
the variable insurance contract application which, among other things,
acknowledges the agreement to the procedures set forth below. Unless the
Rightsholder/Contractholder signs the form provided by the Company or the
authorization contained on the variable insurance contract application and
that form or application is received and accepted by the Company at its
Syracuse Operations Center, a Rightsholder/Contractholder will not have
Telephone Transfer privileges.
2. Only the Rightsholder/Contractholder, or by specific written designation by
the Rightsholder/Contractholder, a registered representative of the MONY
Securities Corporation who is also a field underwriter of MONY and who (i)
has specific authority for each transfer, and (ii) is the primary field
underwriter/registered representative as designated on the Application (or,
if such person is no longer a MONY field underwriter and/or MSC registered
representative, then the registered representative assigned to the case)
("MSC designated representative"), may initiate a Telephone Transfer by
calling a telephone number specifically designated by the Company from time
to time for that purpose. A Rightsholder/Contractholder must give specific
direction to the MSC designated representative each time the
Rightsholder/Contractholder wishes to direct a Telephone Transfer.
Rightsholders/Contractholders who authorize telephone transfers to be made
by an MSC designated representative assume the risk that any Telephone
Transfer made at the direction of such MSC designated representative was
not, in each instance, in fact authorized.
3. The Rightsholder/Contractholder, or if so designated a MSC designated
representative a the specific direction of the rightsholder/contractholder,
shall call the designated telephone number, and provide the following
information:
a. name of rightsholder/contractholder
b. name of person calling
c. name of insured/annuitant
d. date of birth of insured/annuitant
e. policy or contract number
f. social security account number or insured/annuitant
g. daytime telephone number
4. The Company will compare the information provided in paragraph 3 above,
with that contained in the records of the Company and if such information
matches the information in the records of the Company, the telephone
instructions will be accepted by the Company.
5. The Company will record each telephone instruction and will retain such
recording for a period of not less than 6 months from the date the
telephone instruction was given by or on behalf of the contractholder. The
rightsholder/contractholder and the MSC designated representative hereby
consent to such recording and retention.
6. The Telephone Transfer instruction will be executed at the net asset value
next calculated by the Company if the Telephone Transfer instruction is
received before 3:00 P.M. (Eastern Time) on a day on which the New York
Stock Exchange is open for business. If the New York Stock Exchange is not
open for business on the day of receipt, the Telephone Transfer instruction
will be executed at the net asset value calculated at the close of business
on the first day thereafter on which the New York Stock Exchange is open
for business.
7. The Company will send a confirmation of the transfer to the
rightsholder/contractholder at the address on the records of the Company
within 5 days from the date of the telephone call.
8. If the Rightsholder/Contractholder does not contact the Company within 20
calendar days from the date of mailing of the confirmation, the
authenticity of the MSC designated representative's instructions and the
prior direction of the MSC designated representative, as reflected in the
confirmation, shall be conclusively presumed.
9. Should the Company impose a transfer fee under a variable insurance
contract, there will be a deduction of that charge from the subaccount from
which any such transfer is made; it being understood that each direction
which transfers values from one subaccount to another is considered a
separate transfer request, even though made in the same telephone call.
10. By accepting a Telephone Transfer, the Company will have no liability for
actions taken pursuant to Telephone Transfers so long as the Company
follows the guidelines set forth above, unless a
rightsholder/contractholder notifies the Company (and such notice, if
orally given, is confirmed in writing, postmarked within 2 working days
from the date of such oral notice and received within 7 calendar days from
the date of the postmark) that a transaction shown in a confirmation of the
Telephone Transfer was not authorized by the rightsholder/contractholder.
In the event an unauthorized transaction is discovered by the
rightsholder/contractholder, the Company's only responsibility, assuming
the Company followed the procedures in these guidelines, is to reverse the
transfer made as a result of the unauthorized Telephone Transfer
instruction at the net asset value next calculated following receipt of the
notice from the rightsholder/contractholder. This reversal, if made upon
notice orally given, will not be effective unless the written confirmation
is actually received within the time period set forth in this paragraph.
The effect of these provisions is to place the risk of loss for
unauthorized Telephone Transfer instructions on the
rightsholder/contractholder.
11. The Company reserves the right to withdraw Telephone Transfer privileges,
to terminate the Telephone Transfer program, and to modify any of the
foregoing procedures at any time upon notice to theRightsholder/
Contractholder who has filed an election on the form provided by the
Company. Holders of variable contracts whose executed form provided
by the Company has not been received and accepted by the Company prior to
any such change, shall not be entitled to notice.
[LOGO] MONY MONY Life Insurance Company Disclosure Statement for SVUL (NY)
PO Box 4830 Form No. 15562 (8/1999)
Syracuse NY 13221
Cash Value Accumulation Test (CVAT) and Guideline Premium Test (GPT)
These two tests are used to determine whether an insurance policy meets the
definition of life insurance under I.R.C. Section 7702. The CVAT test generally
permits more premiums to be paid into a policy during its initial years than the
GPT test. The CVAT test requires that you maintain a higher level of death
benefit in relation to cash value than the GPT test. You should consider the
CVAT test if you wish to maximize premium payments over a short period. You
should consider the GPT test if you wish to maintain a higher level of cash
value in relation to death benefit protection. Once you elect one of the tests,
you may never change it.
The definition of life insurance test that works best for you will depend on a
number of factors, including the amount of death benefit you want, the amount of
premium you plan to pay and whether you intend to make withdrawals or loans. You
should consult your Field Underwriter (Licensed Agent) for more information
about our policies so that you can select the one that best accomplishes your
goals. An illustration will be furnished to you by your Field Underwriter
(Licensed Agent) at the time of application. You may also request an
illustration on both IRC tests from your Field Underwriter (Licensed Agent) to
help in your decision.
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I have read and understand the above disclosure regarding the availability of
the different tests under I.R.C. 7702.
SIGNATURES
- ----------------------------- ------------------------------
Applicant/Owner Co Applicant/Joint Owner
- ----------------------------- -------------------------
Field Underwriter (Licensed Agent) Date
99-452
Form No. 15384 (1/2002)
[LOGO] MONY MONY Life Insurance Company Privacy Protection in Underwriting:
1740 Broadway MONY's Information Practices and
New York, New York 10019 The Underwriting Process
Form No. 10765 (7/2001)
Thank you for applying to MONY for insurance. This form provides important
information about the underwriting of your application and MONY's practices
respecting your personal and medical record information as required by those
states that have adopted the NAIC Model Insurance Information and Privacy
Protection Act. MONY Life Insurance Company provides underwriting services for
its subsidiary, MONY Life Insurance Company of America ("MLOA"). Therefore, this
notice also applies to those persons who apply for insurance with (and will be
insured by) MLOA.
About Underwriting
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Underwriting is the process by which an insurer decides whether and on what
basis a proposed insured is insurable according to the company's established
underwriting standards. The underwriting process also involves classifying that
person as a member of a "risk class" (a group of insureds with equivalent life
expectancy). Classifying insureds in this way enables an insurer to charge each
individual an equitable premium that is proportionate to the degree of risk he
or she presents to the company. Most people fall into the "standard" risk class
and are routinely approved.
Underwriting involves the collection and evaluation of "personal information"
(information regarding an individual's age, driving record, recreational
activities, hobbies, finances, occupation, credit, health or any other personal
characteristics) as well as "medical record information" (information regarding
physical or mental condition, medical history and treatment). This information
may also be described as "nonpublic personal financial and health information"
under MONY's Privacy Policy for Customers.
If we are unable to offer you the coverage that you applied for or we offer you
coverage on significantly different terms (amount, term or premium) than you
applied for, then we will notify you of our decision and the reasons for it. If
you then request additional details, we will try to give you a more specific
explanation.
Sources of Information
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The principal source of information for underwriting is your completed
application. Therefore, we urge you to review your application carefully to be
sure the answers are complete and accurate, especially if the answers were
recorded by your financial professional, a medical examiner or another person.
If you find any inaccuracy when your policy or certificate is delivered to you
(a copy of the application will be attached), then you should contact the
company immediately at the address above.
We may ask you to take a medical examination and, in some instances, we may
obtain a report from a consumer reporting agency (more information about this
appears below). You may also be asked to consent to the withdrawal of blood and
the submission of a urine sample, both of which are explained on a notice and
consent form that will be submitted to you. With your authorization, we may
request information from doctors, hospitals and other medical care providers
concerning your past, present or future mental, physical or behavioral health or
condition. In addition, we may seek information from the MIB, Inc. (Medical
Information Bureau), an information exchange described later in this notice. We
may also request information from other insurance companies to which you have
applied for insurance.
Protecting Your Privacy
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We seek only information that is relevant to the insurance transaction, and
respect its confidential nature. It is our practice to share with MONY financial
professionals only such non-sensitive underwriting and claims information as may
be necessary for their assistance with the insurance sale or in connection with
a related transaction, such as a claim evaluation or marketing other coverage
offered by MONY or its subsidiaries. Also, we may give an insurance support
organization (e.g., MIB) or persons performing a business, professional, or
other insurance function for us information necessary for the performance of
their requested function. When required by law or by regulatory or legal action,
we may release information to regulatory authorities, law enforcement agencies
and other third parties. On occasion, we may release information necessary for
the conduct of actuarial or underwriting studies, audits and similar activities
critical to the conduct of our business. A brief coded report of our
underwriting information (but not our underwriting decision) may be sent to MIB
(see below). In most cases, however, information will be sent to third parties
only when you have authorized the release of such information.
91-401
Form No. 15384 (1/2002)
If we require the performance of an HIV antibody (AIDS related) test for your
application, then our practices respecting the disclosure and confidentiality of
these sensitive test results will be explained in a notice and consent form that
will be submitted to you.
For more information about MONY's commitment to protecting the confidentiality
and security of information that we collect from individuals who obtain (or seek
to obtain) financial products or services from MONY and its affiliates, please
review MONY's Privacy Policy for Customers at www.mony.com
You Have Access
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We offer you access to relevant personal information that we have obtained about
you. To exercise this right of access, you must submit a written request to us.
If our file consists of medical information, you will then be asked to name a
physician or health care provider who can explain its nature and substance to
you. If we obtained a consumer report (described below) about you during
underwriting, then we will provide you with the name and address of the consumer
reporting agency that prepared it in response to your request. The consumer
reporting agency will then be responsible for providing you with a copy.
You also have the right to ask us in writing to correct or delete any recorded
personal information that you believe to be incorrect. In response, we will
correct, amend or delete the disputed item, or we will advise you why we cannot
agree to do so. You may then prepare a concise statement explaining your
position, and it will be filed with your application and included with any
subsequent disclosure of the disputed information.
MIB, Inc. (Medical Information Bureau)
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The Medical Information Bureau is a nonprofit membership organization of life
and health insurance companies that operates an information exchange on behalf
of its members. As an MIB member company, we may have to make a brief report to
MIB about your application. If you apply for or have life or health insurance
with another MIB member company, or submit a claim for benefits to such a
company, MIB will supply such company with the information it may have in its
file upon request. Upon receipt of a request from you, MIB will arrange
disclosure to you of any information that it may have about you. In some cases,
you will be asked to designate an attending physician to receive any medical
information that MIB may have. If you question the accuracy of information in
the MIB file, you may contact MIB and seek a correction in accordance with the
procedures set forth in the Fair Credit Reporting Act. The address of the MIB
information office is 160 University Avenue, Westwood, MA 02090, tel. no.
781-329-4500, fax no. 781-329-3379, www.mib.com
Notice About Possible Consumer Reports
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We are required to notify you that we may obtain (with your authorization) one
or more "consumer reports" to aid us in evaluating your application. One type of
report is known as a "consumer credit report." "Consumer credit reports" are
obtained from consumer reporting agencies and they address your credit
worthiness, credit history, credit standing and credit capacity. The other type
of consumer report ("investigative consumer report") provides information on
your character, general reputation, personal characteristics or mode of living
and it is obtained through personal interviews with third parties such as family
members, business associates, financial sources, friends, neighbors, former
employers, personal references, or others with whom you are acquainted. We often
find that investigative consumer reports assist us with risk appraisal. If we
order such a report, it will be prepared by a reputable commercial organization
and it will likely address, as appropriate, your age, insurance history,
residence, marital status, financial condition, driving record, aviation
activities, hazardous sports and recreational activities, health history, use of
alcohol and drugs, living conditions, and information relating to your personal
and business reputation. We will not share your "consumer credit report"
information with any MONY affiliate (except on MLOA applications underwritten by
MONY), or any nonaffiliated third party for the purpose of establishing your
eligibility for insurance without your written consent.
FINALLY ...
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If you have questions about this material or your application which cannot be
answered fully by the financial professional agency, plan administrator, or
other office through whom you submitted an application, please write to Director
of Consumer Affairs, MONY Life Insurance Company, P.O. Box 4830, Syracuse, New
York 13221. Be sure to include your full name and address, and your policy or
certificate number and any other identifying information (social security no.)
available to help us locate your records.
91-401
Form No. 15384 (1/2002)