Life Application
Use Dark Ink Only
PARAGON
LIFE INSURANCE COMPANY
100 South Brentwood
St. Louis, MO 63105
1. PROPOSED INSURED
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First Name Initial Last Name
_________________________________________________________
Date of Birth State of Birth Sex
/ / [_] Male [_] Female
_________________________________________________________
Day Phone Number Evening Phone Number
( ) - ( ) -
_________________________________________________________
Social Security Number
- -
_________________________________________________________
Best days and time to call
Days:____________ ________ [_]a.m. [_]p.m.
Time
_________________________________________________________
Home Address (Number, Street and Apt. #)
_________________________________________________________
_________________________________________________________
City State Zip
_________________________________________________________
Occupation Earned Income Net Worth
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2. REPLACEMENT
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Will this application replace or change any existing life
insurance or annuity? Yes [_] No [_]
_________________________________________________________
Is this to be considered for a "Section 1035 Exchange?"
Yes [_] No[_]
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3. BENEFICIARY
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Primary Date of Birth Relationship % Share
/ /
_________________________________________________________
Primary Date of Birth Relationship % Share
/ /
_________________________________________________________
Primary Date of Birth Relationship % Share
/ /
_________________________________________________________
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Contingent Date of Birth Relationship % Share
/ /
_________________________________________________________
Contingent Date of Birth Relationship % Share
/ /
_________________________________________________________
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4. HEALTH STATUS
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Have you been hospitalized within the previous 90 days?
[_] Yes [_] No
Have you used tobacco in any form within the last 12 months?
[_] Yes [_] No
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5. OWNERS
If different than Proposed Insured
_________________________________________________________
Owner's First Name Initial Last Name
_________________________________________________________
Owner's Relationship to Proposed Insured
_________________________________________________________
Owner's Address (Number, Street and Apt. #)
_________________________________________________________
CityState Zip Telephone Number
_________________________________________________________
Owner's Social Security Number or Tax ID Number
_________________________________________________________
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6. PLAN, BENEFITS & RIDERS
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Plan Name Desired Policy Date
_________________________________________________________
Face Amount Proposed Effective Date
_________________________________________________________
Benefit Riders (If available on plan selected)
Accelerated Death Benefit Settlement Option Rider [_]
Waiver of Deductions [_]
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Method of Payment (check one)
[_] One Payment
[_] Annual
[_] Monthly (Available only through electronic ACH
requires premium charge authorization)
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Policy Option
[_] Option A (Level) [_] Option B (Increasing)
default for One Payment default for Annual or Monthly
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33117
(10/97)
PARAGON
LIFE INSURANCE COMPANY
100 South Brentwood
St. Louis, MO 63105
7. VARIABLE LIFE INFORMATION
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1. Suitability Information:
a. Have you received the Paragon prospectus for the policy applied for? [_] Yes [_] No
Date of Prospectus: / /
___________
Date of any supplement: / /
____________
b. Have you received a prospectus for the underlying funds of the policy applied for? [_] Yes [_] No
c. Do you understand that:
(i) the death benefit and cash surrender value will increase or decrease
depending on investment experience, and
(ii) there is no guaranteed cash surrender value? [_] Yes [_] No
d. Do you believe that the policy applied for meets your insurance objectives and your
anticipated financial needs? [_] Yes [_] No
2. Net Premium Allocation (0 or minimum of 10%. Percentages must be in whole
numbers and total 100%); Default is 100% Money Market Portfolio:
[Fidelity - Contrafund Portfolio]..........................................._______________%
[Fidelity - Equity-Income Portfolio]........................................_______________%
[Fidelity - Growth Portfolio]..............................................._______________%
[Fidelity - Index 500 Portfolio]............................................_______________%
[MFS - Emerging Growth]....................................................._______________%
[Putnam - PVT High Yield Portfolio]........................................._______________%
[Putnam - PVT New Opportunities Portfolio].................................._______________%
[Putnam - PVT U.S. Government and High Quality Bond Portfolio].............._______________%
[Putnam - PVT Voyager Portfolio]............................................_______________%
[Scudder - International Portfolio]........................................._______________%
[Scudder - Money Market Portfolio].........................................._______________%
[T. Rowe Price - Limited-Term Bond Portfolio]..............................._______________%
[T. Rowe Price - New America Growth Portfolio].............................._______________%
[T. Rowe Price - Personal Strategy Balanced Portfolio]......................_______________%
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Endorsement/Remarks (Not applicable in Pennsylvania):
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I represent that the answers and statements in this application consisting of
all Parts, and any amendments, are true, complete and correctly recorded. I
acknowledge that the Company will rely on these answers and statements in
determining whether, and on what terms, to issue a policy. I understand if any
answers and/or statements are false, incomplete or incorrectly recorded, any
policy issued may be void. I agree any policy based on this application shall
not take effect unless and until: a) the policy is issued during the lifetime of
the Proposed Insured and b) the first full premium is received by the Company
during the lifetime of the Proposed Insured. I understand that no agent or
broker is authorized to accept risks or pass upon insurability, to make or
modify contracts or to waive any of the Company's rights or requirements. I
understand that no waiver or modification shall be binding upon the Company
unless in writing and signed by the president or vice president.
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Agent's Name (please print)
X
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Signature of Agent Agent No.
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State Where Signed
I authorize any physician, medical practitioner, hospital or medically related
facility, insurance company, the Medical Information Bureau ("MIB") or any other
institution or person having any records or knowledge of me or of my health, to
give such information to Paragon Life, if they choose to request such
information, or its reinsurers to determine eligibility for insurance. I
understand information obtained will only be released to reinsurers, the MIB,
persons performing services in connection with my application or claim or as
lawfully required. I agree that this authorization is valid for 26 months, that
a photocopy of it is as valid as the original and that I may request a copy of
this authorization. I understand and agree that the Company is under no
obligation to pay a claim under the policy applied for unless my beneficiaries
provide the Company with this same authorization in the event of a claim.
X
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Signature of Proposed Insured Date
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Signature of Owner
X
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Signature of Parent or Guardian (if necessary)
X
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Signature of Applicant (if other than Proposed Insured or Owner)