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Exhibit 10
THE TRAVELERS INSURANCE COMPANY - ONE TOWER SQUARE - HARTFORD, CT - 06183
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APPLICATION FOR CORPORATE OWNED LIFE INSURANCE
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NAME OF CORPORATION: _____________________________________________________
NAME OF POLICY OWNER: _____________________________________________________
ADDRESS OF POLICY OWNER: _____________________________________________________
POLICY OWNER TAX ID #: _________________ POLICY DATE: ______________
PLAN OF INSURANCE: _____Guideline Premium Test _____Cash Value
Accumulation Test
PREMIUM PAYMENT PLAN: _____Single ____Annual _____Semi-Annual
_____Quarterly _____Monthly
DEATH BENEFIT OPTION: _____Level Death _____Variable Death ____Annual
Benefit Benefit Increase Death
Benefit
BENEFICIARY: _____________________________________________________
_____________________________________________________
Is the Beneficiary designation irrevocable? _____Yes_____No
It is agreed that:
1. This application, which includes the attached Schedule A, will be the basis
for any policies issued in response to it.
2. Application is made to Travelers Insurance Company for individual life
insurance policies on the lives of the individuals specified in Schedule A.
3. The amount of insurance for each policy applied for shall be the amount
specified for each individual in Schedule A.
4. Each policy applied for shall be of the plan specified in the Plan of
Insurance section above.
Based on information provided by the Corporation, it is my understanding that
for the most recent 90 days, all of the Proposed Insureds been actively at work
for at least 30 hours per week, at their usual place of business, performing
their regular occupations. _____Yes_____No
Based on information provided by the Corporation, it is my understanding that
during the most recent 90 days, none of the Proposed Insureds have been
hospitalized or absent from work (other than recreational days and holidays) for
more than 5 consecutive workdays. _____Yes_____No
AGENT'S STATEMENT: Will this insurance replace, change or use the cash value of
any existing insurance policy or annuity on these insureds?
_____Yes_____No
Is this insurance intended to be a 1035 tax-free exchange? _____Yes_____No
If you answered "Yes" to either of these replacement questions, has the required
replacement forms been completed?
_____Yes_____No
List company name, amount and attach applicable forms required by state in which
application is signed.
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Signature of Agent Signature of Owner /
Designated Representative
Dated :____________________________________ Dated:______________________
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SCHEDULE A
PROPOSED DATE OF INITIAL BASE TERM INITIAL PLANNED SMOKER/
INSURED SEX BIRTH SS# POLICY INSURANCE PREMIUM PREMIUM NONSMOKER
DEATH BENEFIT RIDER ("S" OR "N")
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I represent that I have read the questions and answers on this application, and
declare that they are complete and true to the best of my knowledge and belief.
Furthermore, I understand that this application will become a part of any policy
issued. I agree that no Agent/Representative of the Company shall: have the
authority to waive a complete answer to any question on this Application;
transfer insurability; make or alter any contract; or, waive any of the
Company's other rights or requirements. I further agree that no insurance shall
take effect unless and until the Policy has been delivered to and accepted by
me; and, the initial modal premium is paid during the lifetime and prior to any
change in health of the Proposed Insured.
Signed for the Policy Owner by the following duly authorized official:
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Signature Title Date
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THE TRAVELERS INSURANCE COMPANY - ONE TOWER SQUARE - HARTFORD, CT - 06183
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SUPPLEMENT FOR SIMPLIFIED ISSUE LIFE INSURANCE
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NAME OF PROPOSED INSURED:______________________________________________________
PROPOSED INSURED SSN: __________________PROPOSED INSURED DOB:_______GENDER:____
NAME OF POLICY OWNER: ________________________________________________________
ADDRESS OF POLICY OWNER:_______________________________________________________
___________________________________________________________
BENEFICIARY: ___________________________________________________________
___________________________________________________________
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Signature of Agent Signature of Owner
Dated:______________________________ Dated:________________________________
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SECTION B:
1. Personal Physician (Give full name, address and telephone number of your
doctor who you consult for routine check-ups and physicals):___________________
_______________________________________________________________________________
Date and Reason last consulted: ______________________________________________
2. Proposed Insured: Height __________ Weight __________ Amount of weight loss
in past 12 months ______________
(If weight loss, please explain below)
3. Have you within the past 2 years:
a) Flown or plan to fly as a pilot, student pilot or crew member or intend to
do so in the future? _____Yes_____No
b) Engaged in scuba diving, vehicle racing, parachute jumping or any form of
motorcycling, or any other hazardous sport or hobby? _____Yes_____No
4. In the past 10 years have you:
a) Used Drugs not prescribed by a doctor? _____Yes_____No
b) Been treated for alcoholism? _____Yes_____No
c) Been advised to have medical treatment or counseling from a commonly
recognized practitioner or organization for alcohol or drug use? _____Yes_____No
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SECTION B CONTINUED:
5. In the past 10 years have you:
a) Been diagnosed or treated for Acquired Immune Deficiency Syndrome (AIDS) by
a member of the medical profession? _____Yes_____No
b) Been diagnosed or treated for immune deficiency (other than AIDS), anemia or
other blood disorder (other than for HIV)? _____Yes_____No
c) Had recurrent fever, fatigue or unexplained weight loss? _____Yes_____No
6. Other than the above, have you ever been diagnosed or treated for:
a) Chest pain, high blood pressure, stroke, or disease of the heart, blood
vessels, or lungs? _____Yes_____No
b) Diabetes, mental or emotional disorder, disease of the brain or nervous
system, convulsions? _____Yes_____No
c) Cancer, tumor, disease of the stomach, intestines, liver or kidneys? _____Yes_____No
7. Have you been hospitalized in the last five years, been advised to have
any diagnostic test, hospitalization or surgery by any licensed physician,
practitioner or health facility that has not yet been performed? _____Yes_____No
FOR ALL QUESTIONS ANSWERED "YES," FURNISH DETAILS.
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I represent that the above statements are true and complete to the best of my
knowledge and belief. I understand that this application will become a part of
any policy issued . I also understand that any misrepresentations contained in
this application and relied on by the Company may be used to reduce or deny a
claim or void the contract if: (1) it is within its contestable period; and (2)
if such misrepresentation materially affects the acceptance of the risk.
____________________________________Dated ___________ At______________________
Signature of Proposed Insured (City, State)
Name of Proposed Insured (printed):____________________________________________
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AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
I authorize The Travelers Insurance Company (referred to as The Travelers), its
Reinsurers, insurance support organizations, and their authorized
representatives to obtain medical and other information in order to evaluate
this application for insurance. I authorize any physician, medical practitioner,
hospital, clinic, other medical or medically related facility, insurance
company, the Medical Information Bureau, Inc., employer, consumer reporting
agency, or other insurance coverage, medical care, treatment, supplies or advice
with respect to me to furnish such information to The Travelers, its Reinsurers
or their authorized representatives.
This authorization will be valid from the date signed for a period of 26 months.
I agree that a photographic copy of this authorization is as valid as the
original. Information given in my application, including health care
information, may be made available without my prior authorization to other
insurance companies to which I make application for life or health insurance
coverage or to which a claim is submitted.
I have read this authorization and understand that I have a right to receive a
copy. I acknowledge receipt of the notice regarding: "Notification Regarding
Use and Release of Information to the Medical Information Bureau, Inc. and Other
Life Insurance Companies"
____________________________________Dated ___________ At______________________
Signature of Proposed Insured (City, State)
L-15240-A
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THE TRAVELERS INSURANCE COMPANY
NOTIFICATION REGARDING USE AND RELEASE OF INFORMATION TO THE MEDICAL
INFORMATION BUREAU, INC. AND OTHER LIFE INSURANCE COMPANIES
Any health care information developed is necessary to classify insurance risks,
conduct normal administrative procedures and process claims, and will be used
for those purposes only. No other use of this information will be made without
first obtaining your written consent.
This information will be treated as confidential except that The Travelers
Insurance Company or its Reinsurer(s) may make a brief report to the Medical
Information Bureau, Inc., a non-profit membership corporation of life insurance
companies which operates an information exchange on behalf of its members. Upon
request by another member insurance company to which you have applied for life
or health insurance coverage or to which a claim is submitted, the Bureau will
supply such company with the information it may have in its files.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your files. Medical information will be disclosed
only to your attending physician. If you question the accuracy of information in
the Bureau's file, you may contact the Bureau and seek a correction in
accordance with the procedures set forth in the federal Fair Credit Reporting
Act. The address of the Bureau's information office: Post Office Box 105, Essex
Station, Boston, Massachusetts 02112, Telephone: (617)426-3660.
The Travelers Insurance Company or its Reinsurer(s) may release information
given in your application file, including health care information, to other life
insurance companies to which you apply for life or health insurance or to which
a claim is submitted.
L-15240-A