[PARAGON LOGO]
100 South Brentwood
St. Louis, MO 63105
REPLACEMENT
- - --------------------------------------------------------------------------------
Will this application replace, and/or change any existing life insurance or
annuity? [_] Yes [_] No
If "yes," include copies of any replacement forms or any other special forms
required by state law.
- - --------------------------------------------------------------------------------
PREMIUM INFORMATION
- - --------------------------------------------------------------------------------
Total premium submitted $_____ Check #_____
Premium that applies to this app. $_____
If this application is to be cross-referenced or considered with another
application, please provide:
Name SS# Premium to be applied
___________________________________
Name SS# Premium to be applied
___________________________________
Name SS# Premium to be applied
___________________________________
Name SS# Premium to be applied
___________________________________
Mode of Premium Payment [_] Annually
[_] Monthly ACH
__________________________________________
Premium paid by Proposed Insured? [_] Yes [_] No
If no, Payor Name:
__________________________________________
Address City State/ZIP
__________________________________________
- - --------------------------------------------------------------------------------
ILLUSTRATIONS
- - --------------------------------------------------------------------------------
Were illustrations provided to the applicant in accordance with company
guidelines? [_] Yes [_] No
If no, explain ___________________________
___________________________________________
___________________________________________
- - --------------------------------------------------------------------------------
Agent or Broker Report
All questions below must be answered.
BUSINESS INSURANCE
- - --------------------------------------------------------------------------------
Is firm: [_] Sole Proprietorship [_] Partnership
[_] Corporation
What is purpose of insurance?
[_] Key Person [_] Stock Redemption
[_] Buy/Sell [_] Loan
What is approximate net worth of business?______
What percentage of business does Proposed Insured own or control? _____%
What is approximate net yearly income of business?
______________
How much business insurance is in force on life of Proposed Insured? ________
Is Business insurance carried by other Owners, Officers, Partners or Key
Person(s)? [_] Yes [_] No
If yes, provide their names, titles, amount carried, amount applied for, and
company on a separate sheet.
- - --------------------------------------------------------------------------------
ACKNOWLEDGMENT
- - --------------------------------------------------------------------------------
I acknowledge and represent: (1) I am not aware of any requested information
that was not disclosed or was misrepresented on the application; and (2) all
information provided on this Report, or in response to Company inquires about
the application or the Proposed Insured, is true and correct to the best of my
knowledge and belief.
_________________________________________________________
Writing Agent or Broker (please print) Agent No.
_________________________________________________________
Signature of Writing Agent or Broker Date
- - --------------------------------------------------------------------------------
Premium Payment
Charge Authorization
[PARAGON LOGO]
100 South Brentwood
St. Louis, MO 63105
- - --------------------------------------------------------------------------------
This authorization shall apply to the following policies/application:
NAME OF INSURED POLICY NUMBER(S) if existing
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
- - --------------------------------------------------------------------------------
HOME OFFICE USE ONLY
DATE RECEIVED_________
INITIALS______________
DATE COMPLETED________
INITIALS______________
- - --------------------------------------------------------------------------------
1. I authorize you to pay premium from my account on the policies listed on
this form.
2. This authorization will be effective only after the first premium has been
paid.
3. The presentation of withdrawal request forms shall constitute due notices of
premiums due on the policy or policies.
4. This authorization may apply to any conversion, renewal, or change later
made in said policies.
5. This authorization shall not apply to any indebtedness.
6. The privilege of paying premiums under this plan may be revoked by the
Company if any withdrawal request is not paid upon presentation.
7. The payment of premiums under this plan may be discontinued by the Company
or the undersigned upon ten (10) days' written notice.
____________________________________ ________________________________
Date Customer's Signature
- - --------------------------------------------------------------------------------
- - --------------------------------------------------------------------------------
DETAILS OF PAYMENT:
FINANCIAL INSTITUTION NAME AND ADDRESS Type of Account:
[_] Checking [_] Savings
BANK NAME___________________________
A. TRANSIT ROUTING NUMBERS:
STREET
ADDRESS_____________________________ ________________________________
CITY, B. BANK ACCOUNT NUMBER:
STATE, ZIP__________________________
________________________________
Please contact financial institution
for correct ACH information. Please
notify us if there were any other
policies on your previous bank
information.
- - --------------------------------------------------------------------------------
PLEASE TAPE (DO NOT STAPLE) A VOIDED CHECK OR DEPOSIT SLIP BELOW FOR NEW
BUSINESS CASES.
- - --------------------------------------------------------------------------------
IMPORTANT
VOIDED CHECK ONLY
(TAPE HERE. DO NOT STAPLE.)
- - --------------------------------------------------------------------------------
DO NOT SEPARATE FROM APPLICATION PACKAGE
PARAGON LIFE INSURANCE COMPANY
TEMPORARY INSURANCE AGREEMENT
BROKER: DO NOT DETACH TEMPORARY INSURANCE AGREEMENT UNLESS AT LEAST THE FIRST
FULL PREMIUM FOR THE PLAN AND MODE IS SUBMITTED WITH THE APPLICATION, AND THE
APPLICATION SATISFIES THE CONDITIONS BELOW.
MAKE CHECKS PAYABLE ONLY TO PARAGON LIFE INSURANCE COMPANY
- - --------------------------------------------------------------------------------
Received from _______________________ the sum of $______ on this date__________
(Broker's Initials)
Any reference in this Temporary Insurance Agreement to the Proposed Insured,
the policy, or an amount applied for, refers to the Proposed Insured and the
policy and amount applied for on the application to which this Temporary
Insurance Agreement was originally attached.
- - --------------------------------------------------------------------------------
COVERAGE
- - --------------------------------------------------------------------------------
This Agreement provides life insurance coverage on a temporary basis, but only
if ALL CONDITIONS are met and then only to the extent of the LIMITS OF
COVERAGE. Upon due proof of death of the Proposed Insured while coverage under
this Agreement is in force, the Company will pay the benefits hereunder to the
beneficiaries listed on the application to which this Agreement was attached.
- - --------------------------------------------------------------------------------
CONDITIONS
- - --------------------------------------------------------------------------------
1. The answers in all parts of the application and any medical examination,
report, application supplement or amendment must be true and complete as to
all material facts; and
2. You must not have ever been treated for, or been advised by a member of the
medical profession to seek treatment for: shortness of breath, emphysema,
chronic respiratory disorder, chest pains, discomfort or tightness of the
chest, palpitations, heart attack, any disorder of the heart, lymph glands,
enlargement of lymph nodes (glands), a cyst, a tumor, cancer, or any
immunological disorder, or Acquired Immune Deficiency Syndrome (AIDS).
3. A check or draft, for the first full premium for the plan and mode applied
for, must be submitted with the application to which this Temporary
Insurance Agreement was attached. A check or draft returned for
nonsufficient funds, or otherwise uncollectable, will void this agreement.
IF, AND ONLY IF the above CONDITIONS are met, Temporary Insurance shall begin
on the date of this Agreement.
- - --------------------------------------------------------------------------------
LIMITS OF COVERAGE - $500,000
- - --------------------------------------------------------------------------------
Temporary Insurance based on this Agreement, and all other temporary agreements
issued by the Company covering the life of any Proposed Insured, shall not
exceed $500,000 or the amount applied for, WHICHEVER IS LESS.
Suicide - If the Proposed Insured dies by suicide while sane or insane, while
coverage under this Agreement is in force, the amount payable by the Company
will be equal to the premium(s) paid.
- - --------------------------------------------------------------------------------
WHEN COVERAGE TERMINATES
- - --------------------------------------------------------------------------------
Temporary Insurance shall terminate automatically, and no coverage will be
provided on the earliest of:
1. the Company's offer to issue a policy other than as applied for, or
2. the date the Company returns any premium paid and/or declines to issue a
policy, or
3. the date the policy, as applied for, goes into force, which is the date the
policy is issued or any additional premium is received by the Company,
whichever is later, or
4. the date the Proposed Insured fails to accept delivery of a policy which has
been issued as applied for; or
5. ninety days after the date of this Agreement.
- - --------------------------------------------------------------------------------
X ___________________________________________________
Agent's Name (please print)
X ___________________________________________________
Signature of Agent Agent No.
X ___________________________________________________
Florida Agent License ID# (for Florida apps only)
X ___________________________________________________
State Where Signed
X ___________________________________________________
Signature of Proposed Insured Date
X ___________________________________________________
Signature of Owner
X___________________________________________________
Signature of Parent or Guardian (if necessary)