1
GENERAL
AMERICAN
LIFE INSURANCE COMPANY
ST. LOUIS, MISSOURI 63166
GUARANTEED ISSUE APPLICATION
- -------------------------------------------------------------------------------
1. (a) Name of Proposed Insured (Print Last, First, MI)
(b) ___ Male (c) Soc. Sec. # (d) Date of Birth:
___ Female
- -------------------------------------------------------------------------------
(e) Residence Address: Number & Street, or RFD City State Zip
Area Home Phone No.
- -------------------------------------------------------------------------------
2. (a) Name of Employer/Premium Payor (b) Occupation
- -------------------------------------------------------------------------------
(c) Business Address: Number & Street, or RFD City State Zip
Area Bus. Phone No.
- -------------------------------------------------------------------------------
3. (a) Plan of Ins/Rider (b) Amount $ (c) Effective Date
of Coverage
- -------------------------------------------------------------------------------
4. Premiums are paid Annually. (Add to existing List Billing #____________)
Premium notices will be sent to the Employer/Premium Payor.
- -------------------------------------------------------------------------------
5. Dividend Option, if eligible, is:
- -------------------------------------------------------------------------------
6. (a) Have you been actively at work on a continuous full-time basis during
the last 90 days (other than vacation, normal non-working days and
other absences not totaling more than five days)? ___ Yes ___ No
(b) Have you used any form of tobacco within the last year? ___ Yes ___ No
- -------------------------------------------------------------------------------
7. Beneficiary of Death Benefit.
(Print full name, address, telephone number, and relationship of each
beneficiary to Proposed Insured):
(a) Primary Class (will receive payment first, if living and not
disqualified):
- -------------------------------------------------------------------------------
(b) Contingent Class (will receive payment only if living and not
disqualified and if no primary beneficiary receives payment)
(Print full name, address, telephone number, and relationship
of each beneficiary to Proposed Insured):
- -------------------------------------------------------------------------------
8. Original Owner of Policy. (Print full name, address, telephone number,
date of birth, Social Security Number or Tax Identification Number and
relationship of each Owner to Proposed Insured.):
___ Proposed Insured
___ Other:
- -------------------------------------------------------------------------------
9. Original Owner: Will any life insurance or annuities be discontinued or
changed if this policy is issued? ___ Yes ___ No
If "Yes," what is the paid to date of the coverage being replaced?
- -------------------------------------------------------------------------------
10. EXPLANATIONS OR ADDITIONAL INSTRUCTIONS 11. FOR HOME OFFICE ENDORSEMENT
ONLY. (Not applicable in
Kentucky, Maryland, Minnesota,
Pennsylvania, New Hampshire,
West Virginia or Wisconsin.)
- -------------------------------------------------------------------------------
9429
(9/96)
2
If applying for the Adjustable Benefit Option Rider, I acknowledge that the
Employer, as premium payor, has the right to exercise the Adjustable Benefit
Option Rider based on my salary with such Employer and such Employer's benefit
structure.
All the statements contained on this application are correct and true to the
best of my knowledge and belief. I agree that this application and any
supplement or amendment to it will be part of the policy issued. I further
agree that no insurance will take effect unless and until the policy has been
received, accepted and the first full premium paid.
CERTIFICATION: UNDER PENALTIES OF PERJURY, I CERTIFY THAT:
(1) THE NUMBER SHOWN ON THIS FORM IS MY CORRECT TAXPAYER IDENTIFICATION
NUMBER (OR, IF NO NUMBER IS SHOWN, I AM WAITING FOR A NUMBER TO BE
ISSUED TO ME); AND
(2) I AM NOT SUBJECT TO BACKUP WITHHOLDING EITHER BECAUSE 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 THE IRS HAS NOTIFIED ME THAT I AM NO LONGER SUBJECT
TO BACKUP WITHHOLDING.
PLEASE NOTE: YOU MUST CROSS OUT AND INITIAL #2 ABOVE IF YOU HAVE BEEN
NOTIFIED BY THE IRS THAT YOU ARE CURRENTLY SUBJECT TO
BACKUP WITHHOLDING BECAUSE OF UNDER-REPORTING INTEREST
OR DIVIDENDS ON YOUR TAX RETURN.
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF
THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP
WITHHOLDING.
- ----------------------------------- ----------------------------------------
- ----------------------------------- ----------------------------------------
Print Name of Proposed Insured Signature of Owner, if other than
Proposed Insured
- ----------------------------------- ----------------------------------------
- -----------------------------------
- -----------------------------------
Signature of Proposed Insured/Date
- -----------------------------------
Dated at ______________________________
- -----------------------------------
Signature of Employer/Applicant this __________________day of _________.
(Officer, other than insured,
of business)
Agent: To the best of your knowledge is the insurance applied for intended to
replace any existing life insurance or annuities? ___ Yes ___ No (If Yes,
complete and submit required replacement papers.)
----------------------------------------
Signature of Licensed Agent/Witness
----------------------------------------
Signature of General Agent
9429
(9/96)