1
EXHIBIT 1A(10)
PEOPLES BENEFIT LIFE INSURANCE COMPANY
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HOME OFFICE:
4333 EDGEWOOD RD., N.E.
CEDAR RAPIDS, IA 52499
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New Business
Conversion Policy #
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Rewrite Number
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APPLICATION FOR LIFE INSURANCE
Agent Name:
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Agent Number:
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Broker/Dealer: (If Applicable)
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Date Faxed: (If Applicable)
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Amount of initial premium with application $ | |,| | | |,| | | |.| | |
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Amount to be applied with application
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$ | |,| | | |,| | | |.| | |
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-----------------
$ | |,| | | |,| | | |.| | |
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-----------------
$ | |,| | | |,| | | |.| | |
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DO: DON'T
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[ ] Complete the entire application (front and back). [ ] Do not use pencil or whiteout.
[ ] Print application in black ink. [ ] Do not accept or send money on applications
that total more than $1,000,000.00
[ ] Have applicant initial all changes. [ ] Do not submit an agent check as the initial premium.
[ ] Obtain all required signatures. [ ] Do not submit starter checks or deposit slips for
checkomatic withdrawals.
[ ] Include certification if a trust is owner of the policy.
[ ] Attach additional sheet of paper if necessary.
6800 R1200
2
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LIFE APPLICATION-PART 1 PBL - PEOPLES BENEFIT LIFE INSURANCE COMPANY APPLICATION #
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SECTION 1. PROPOSED PRIMARY INSURED
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1. Last Name First Name M.I.
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2. Address Apt# City
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State Zip Code 3. Years at Address 4. Home Phone 5. Driver License Number State
( ) - -
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6. Sex 7. Date of Birth 8. Age 9. Place of Birth - State/County 10. Social Security Number
[ ] Male
[ ] Female
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11. Height 12. Weight 13. Marital Status 14. Employer Years
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15. Occupation & Duties
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16. Employer's Address 17. Business Phone Number
( ) - -
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18. Have you used TOBACCO or any other product containing NICOTINE in the last 5 years? [ ] No [ ] Yes, Date of last use
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19. Rate Class Quoted: [ ] Super Preferred [ ] Preferred [ ] Preferred Tobacco [ ] Tobacco
[ ] Other
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SECTION 2. PROPOSED ADDITIONAL/JOINT INSURED - IF MORE THAN ONE PLEASE USE A SUPPLEMENTAL APPLICATION
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1. Last Name First Name M.I.
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2. Address Apt# City
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State Zip Code 3. Years at Address 4. Home Phone 5. Driver License Number State
( ) - -
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6. Sex 7. Date of Birth 8. Age 9. Place of Birth - State/County 10. Social Security Number
[ ] Male
[ ] Female
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11. Height 12. Weight 13. Marital Status 14. Relationship to Proposed Insured 15. Employer Years
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16. Occupation & Duties
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17. Employer's Address 18. Business Phone Number
( ) - -
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19. Have you used TOBACCO or any other product containing NICOTINE in the last 5 years? [ ] No [ ] Yes Date of last use
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20. Rate Class Quoted: [ ] Super Preferred [ ] Preferred [ ] Preferred Tobacco [ ] Tobacco
[ ] Other
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SECTION 3. APPLICANT/OWNER IF OTHER THAN THE PROPOSED PRIMARY INSURED
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1. Last Name First Name M.I.
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2. Address Apt# City
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State Zip Code 3. Home Phone 4. Social Security Number/Tax ID #
( ) - -
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5. Date of Birth/Trust Date 6. Relationship to the Proposed Primary Insured
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SECTION 4. CHILDREN'S INSURANCE RIDER
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COVERAGE AMOUNT ($1,000 MINIMUM TO $25,000 MAXIMUM COVERAGE FOR CHILDREN 18 AND UNDER) $|_|_|,|_|_|_|
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Name Relationship Date of Birth Height Weight
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- - ft in lbs
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- - ft in lbs
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- - ft in lbs
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Are all children listed? [ ] Yes [ ] No Are children living with proposed primary insured? [ ] Yes [ ] No If not, explain why:____
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3
LIFE APPLICATION
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SECTION 5. PRIMARY BENEFICIARY - IF PERCENTAGE SHARES ARE NOT GIVEN THEY WILL BE
EQUAL, OR TO the survivor
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Name Percent R&ationship Social Security Number/Tax lD#
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SECTION 6. CONTINGENT 8ENEFICIARY - IF PERCENTAGE SHARES ARE NOT GIVEN THEY WILL
BE EQUAL, OR TO the survivor
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Name Percent R&ationship Social Security Number/Tax lD#
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SECTION 7. PROPOSED PLAN OF INSURANCE:
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1. Variable Life__________________________________________________ 9. BenefitlRiders Benefit Units
2. No Lapse /Minimum Premium Period (if applicable) Monthly $ Amount
[ ]5 years [ ] 20 years [ ]30 years [ ]Age 100 [ ] Other [ ] Waiver of Premium Benefit (WP) _____________
3. Modal Premium $ ____________ [ ] Waiver of Monthly Deduction(WMD) _____________
[ ]Include rider(s) in stated premium [ ] Children's Rider (CBR) _____________
4. Face/Specified Amount $ ________________________________________ [ ] Additional Insured Rider (AIR) _____________
5. Excess: Modal Premium $_____________________________________ [ ] Base Insured Rider (BIR) _____________
Lump Sum Premium $__________________________________ [ ] Accidental Death Benefit (ADB) _____________
6. Total Initial Life Premium $ ____________________________________ [ ] Guaranteed Insurability Rider (GIR)_____________
7. Automatic Premium Loan (APL) [ ] Yes [ ] No [ ] Other_____________________________
Automatic Premium Payment Authorization (APPA) [ ] Yes [ ] No [ ] Other_____________________________
8. If Application is approved other than as requested:
[ ] Adjust premium [ ] Adjust face
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SECTION 8. DEATH BENEFIT OPTION:
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[ ] Level benefit [ ] Increasing benefit
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SECTION 9. PREMIUMS PAYABLE:
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Planned Modal Premium: $ | | | |,| | | |. | | |
Billing Method: [ ] Checkomatic | | | Draft Date (1ST th Direct Bill ru 28TH)Complete Check-O-Matic authorization
[ ] Payroll Deduct [ ] Direct Bill [ ] Military Allot [ ] Civil Service Allot
Billing Frequency: [ ] Single Premium [ ] Semi-annual [ ] Monthly
[ ] Annual [ ] Quarterly [ ] Other________________________________________________
Billing Address: _______________________________________________________________
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SECTION 10: OTHER INSURANCE IN FORCE FOR ALL PROPOSED INSUREDS [ ] NONE
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Proposed Insured 'Name Company Amount of insurance Year issued Replacement?
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| | | | | | | | | Yes No
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| | | | | | | | | Yes No
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| | | | | | | | | Yes No
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| | | | | | | | | Yes No
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IS THIS INTENDED TO BE A 1035 EXCHANGE? [ ] Yes [ ]No Anticipated Cash Value Transfer $ | | | |, | | |.| |
1. Will the insurance applied for on any proposed insured replace or change any
existing life or annuity policy? [ ]Yes [ ]No
IT YES, COMPLETE REPLACEMENT FORMS, IF APPROPRIATE.
2. To your knowledge, will the initial and/or future premiums come from
dividends, policy loans, withdrawals or cash surrender? If yes, provide
details below. [ ] Yes [ ] No
PBL Policy number ________________________ [ ] Non-PBL
Dividends $ _______________________________ Loan $ _________________________________
Surrender: [ ] Yes [ ] No
4
LIFE APPLICATION
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SECTION 11. PERSONAL FINANCIAL STATEMENT 12. COMPLETE FOR BUSINESS COVERAGE
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A) Gross Income Current Yr $ ____ ____ ____ A) Current Eshmated Market Value $ ____ ____ ____
B) Gross Income Previous Yr $ ____ ____ ____ B)Assets $ ____ ____ ____
C) Net Worth $ ____ ____ ____ C) Liabilities $ ____ ____ ____
For over $1 million applied D) Net Worth $ ____ ____ ____
coverage complete a separate
financial questionnaire
E) Percentage of business owned
by Proposed Insured ________________%
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SECTION 13. PREMIUM ALLOCATIONS - MUST ADD UP TO 100% AND BE A WHOLE NUMBER.
5% minimum for each allocation/limit of 10 funds
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JANUS GROWTH |_|_|_|% AIM GROWTH |_|_|_|% OPPEN. HIGH INCOME |_|_|_|%
JANUS WORLDWIDE GRO. |_|_|_|% AIM INTERN. EQUITY |_|_|_|% FIDELITY INDEX 500 |_|_|_|%
JANUS BALANCED |_|_|_|% AIM GOV. SECURITIES |_|_|_|% FIDELITY MONEY MKT. |_|_|_|%
JANUS AGGR. GROWTH |_|_|_|% OPPEN. GROWTH & INC. |_|_|_|% FIDELITY GROWTH |_|_|_|%
JANUS CAPITAL APPR. |_|_|_|% OPPEN. MULTIPLE STRAT. |_|_|_|% FIDELITY CONTRAFUND |_|_|_|%
AIM VALUE |_|_|_|% OPPENHEIMER BOND |_|_|_|% FIDELITY GROWTH & INC. |_|_|_|%
AIM CAPITAL APPREC. |_|_|_|% OPPEN. STRAT. BOND |_|_|_|% FIXED ACCOUNT |_|_|_|%
OTHER _________________ |_|_|_|% OTHER_________________ |_|_|_|% OTHER_________________ |_|_|_|%
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SECTION 14. Investment Objective
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[ ] Long-Term Growth [ ] Tax Credit [ ] Short-Term Growth
[ ] Income [ ] Safety of Principal [ ] Other ____________
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SECTION 15. SUITABILITY FOR VARIABLE LIFE INSURANCE POLICY
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A) Have you, the Proposed Insured, and Purchaser, if other than the
Proposed Insured, received the current Prospectus for the policy? [ ] Yes [ ] No
B) DO YOU UNDERSTAND THAT UNDER THE POLICY APPLIED FOR (EXCLUSIVE OF ANY OPTIONAL
BENEFITS), THE AMOUNT OF DEATH BENEFIT AND THE ENTIRE AMOUNT OF THE POLICY
VALUE MAY INCREASE DR DECREASE DEPENDING UPON THE INVESTMENT EXPERIENCE? [ ] Yes [ ] No
C) With this in mind, is the policy in accord with your insurance
objectives and your anticipated financial needs? [ ] Yes [ ] No
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SECTION 16. TO BE COMPLETED BY APPLICANT/OWNER
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Telephone Transfer Auuthorization:(See Prospectus for telephone transfer
procedure) Your policy applied for, if issued, will received telephone transfer
privileges describrd in the application prospectus if instructions are indicated
below. These priveleges allow you to give the registered representative/agent of
record for this policy authority to make telephone tansfers and to change
theallocation of future payments among the Sub-Accounts on your behalf according
to your instructions.
[ ] I want telephone transfer privileges
Peoples Benefit Insurance Company will not be complying with Telephone
instructions it believes to be authentic, nor for any loss, damages, costs or
expense in acting on such telephone instruction and Policyowners will bear the
risk of any such loss. Peoples Benefit Insurance Company will employ reasonable
procedure to confirm that telephone instructions are genuine, such as requiring
forms of personal indentification prior to acting uponsuch telephone
instructions, providing written confirmation of such transactions to
Policyowners and/or tape recording of telephone transfer request instructions
received. If Peoples Benefit Insurance Company does not employ such procedurees,
it may be liable for losses due to unauthorzed or fraudulent instructions.
5
LIFE APPLICATION
SECTION 21. MEDICAL QUESTIONS - Each question must be individually asked and
answered.
Give the details of "Yes" answers below. Identify question number; state signs,
symptoms and diagnosis of each illness or injury. List the details and results
of any treatment; List the name, full address and dates of each health care
provider consulted.
To the best of your knowledge, has any Proposed Insured within the last 10 years
had or been told by a member of the medical profession that he or she had, or
has been treated for:
1) Illness, injury or disease of the eyes, ears, nose or throat? [ ] Yes [ ] No
2) Epilepsy, seizures, chronic headaches, head injury, paralysis, or other
disorder of the nervous system? [ ] Yes [ ] No
3) Anxiety, depression, affective disorder, eating disorder, psychotic
disorder, or other psychiatric treatment? [ ] Yes [ ] No
4) Asthma, emphysema, tuberculosis, shortness of breath, persistent
hoarseness or cough, or other respiratory illness or disease? [ ] Yes [ ] No
5) High blood pressure, heart attack, stroke, heart murmur, palpitation,
arrhythmia, chest pain, rheumatic fever, or other illness or disease of
the heart or circulatory system? [ ] Yes [ ] No
6) Ulcer, colitis, Crohn's disease, diverticulitis, hepatitis, intestinal
bleeding, or illness or disease of the gallbladder, stomach, intestines,
or liver? [ ] Yes [ ] No
7) Sugar, albumin, or blood in urine, or other illness or disease of the
kidneys, bladder, or urinary system? [ ] Yes [ ] No
8) Diabetes, thyroid disorder, cholesterol elevation, anemia, or other
illness or disease of the blood? [ ] Yes [ ] No
9) Arthritis, gout, lupus, illness, injury or disease of the back, spine or
joints, or other illness, injury or disease of the muscles or bones? [ ] Yes [ ] No
10) Disease or disorder of the skin, cysts, tumor, skin cancer or any other
cancer or malignancy? [ ] Yes [ ] No
11) Any illness or disease of the male or female reproductive organs,
sexually transmitted disease, prostate problems, irregular menstruation
or abnormal pap test? [ ] Yes [ ] No
12) An examination, treatment or consultation with a doctor or health care
provider other than above? [ ] Yes [ ] No
13) Had or been advised to have a check-up, consultation, lab test, EKG,
X-Ray, or other diagnostic test? [ ] Yes [ ] No
14) Received or been advised to have treatment for drug usage, whether legal
or illegal, alcoholism or been a member of AA? [ ] Yes [ ] No
15) Are you currently under the observation of a physician or taking
medication? [ ] Yes [ ] No
16) Family History: Is there a history of cardiovascular disease or cancer
in parent/siblings prior to age 60? [ ] Yes [ ] No
- ---------------------------------------------------------- FAMILY HISTORY ---------------------------------------------------------
Age if Age of Age if Age of
Insured Living? Status of Health Death? Cause of Death? Spouse Living? Status of Health Death? Cause of Death?
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Father Father
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Mother Mother
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Sibling(s) Sibling(s)
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MEDICAL QUESTION #17 continues on next page
SECTION 21A. DETAILS TO "YES" ANSWERS FOR MEDICAL QUESTIONS SECTION
Name, Address and Phone# of
Question # Proposed Insured's Name Date, Diagnosis, Treatment, Results, and Duration Attending Doctor and Hospital
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6800 R1200
6
SECTION 21B. MEDICAL QUESTIONS - CONTINUED - Provide details to "Yes" answer in
REMARKS. Include related insured.
PLEASE COMPLETE THE AIDS QUESTION FOR THE STATE THE APPLICATION IS SIGNED IN AS
INDICATED BELOW. IF THIS STATE IS NOT LISTED, ANSWER THE FIRST QUESTION.
17) Have you or any Proposed Insured EVER been diagnosed as having or been
treated for AIDS, or AIDS Related Complex (ARC) or tested positive for
the AIDS virus? [ ] Yes [ ] No
FOR APPLICANTS IN:
- ----------------
ARIZONA Have your or any Proposed Insured EVER, been diagnosed as
- ---------------- having or been treated for AIDS, or AIDS Related Complex (ARC)? [ ] Yes [ ] No
- ----------------
CALIFORNIA Have you or any Proposed Insured EVER, had or been told you/they
- ---------------- have AIDS, or AIDS Related Complex (ARC), or been tested for
HIV antibodies for the purpose of obtaining insurance? [ ] Yes [ ] No
- ----------------
CONNECTICUT Have you or any Proposed Insured EVER, been diagnosed as having
- ---------------- or been treated for Acquired Immune Deficiency Syndrome (AIDS),
AIDS Related Complex (ARC), or AIDS related conditions? [ ] Yes [ ] No
- ----------------
FLORIDA Have you or any Proposed Insured EVER, tested positive for
- ---------------- exposure to the HIV infection, or been diagnosed as having ARC,
or AIDS caused by the HIV infection? [ ] Yes [ ] No
- --------------------------------------
GEORGIA, HAWAII, ILLINOIS, NEW JERSEY Have you or any Proposed insured EVER, been
- -------------------------------------- diagnosed as having or been treated, by a member
of the medical profession for AIDS, or AIDS Related Complex (ARC)? [ ] Yes [ ] No
- ----------------
MAINE Have you or any Proposed Insured EVER, been diagnosed as having
- ---------------- or been treated for AIDS, or AIDS Related Complex (ARC)? ANSWER
THIS QUESTION NO IF YOU HAVE TESTED POSITIVE FOR HIV AND HAVE
NOT DEVELOPED SYMPTOMS OF THE DISEASE AIDS. [ ] Yes [ ] No
-------------------------------------------------------
MARYLAND, MASSACHUSETTS, NEW MEXICO, and NORTH CAROLINA Have you or any Proposed Insured
------------------------------------------------------- EVER, been diagnosed as having
or been treated for Acquired Immune Deficiency Syndrome (AIDS)
or AIDS Related Complex (ARC), or tested positive for Human
Immunodeficiency Virus (HIV)? [ ] Yes [ ] No
- ----------------
MISSOURI, OHIO Have you or any Proposed Insured EVER, been diagnosed as having or
- ---------------- been treated for AIDS, of AIDS Related Complex (ARC) or tested
positive for the HTLV-III test? [ ] Yes [ ] No
- ----------------
NORTH DAKOTA Have you been diagnosed or treated by a member of the medical
- ---------------- profession as having AIDS, ARC or the HIV infection? [ ] Yes [ ] No
- ----------------
VERMONT Have you or any Proposed Insured EVER, been diagnosed, by a
- ---------------- person licensed as a medical physician, as having or been
treated for AIDS or AIDS Related Complex (ARC)? [ ] Yes [ ] No
- ----------------
WASHINGTON Have you or any Proposed Insured EVER had or been treated or
- ---------------- diagnosed by a member of the medical profession for immune
deficiency disorder, AIDS (Acquired Immune Deficiency Syndrome)
or ARC (AIDS Related Complex) or test results indicating
exposure to the AIDS virus? [ ] Yes [ ] No
- ----------------
WISCONSIN Have you or any Proposed Insured EVER, been diagnosed, by a
- ---------------- member of the medical profession as having or been treated for
AIDS, or AIDS Related Complex (ARC) or tested positive for
the AIDS virus? Tests for HIV/AIDS must be limited to
FDA-licensed blood test. Test results received at anonymous
counseling and testing sites or from home test kits need
not be disclosed. [ ] Yes [ ] No
REMARKS
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SECTION 22. FAIR CREDIT REPORTING PRE-NOTICE
A routine investigative consumer report may possibly be made regarding your
general reputation, character, mode of living and personal characteristics. This
information may be obtained through personal interviews with your friends,
neighbors and associates. Should you desire additional information on the nature
and scope of such a report, you may write the Underwriting Department, Peoples
Benefit Life Insurance Company, 4333 Edgewood Road N.E., Cedar Rapids, Iowa
52499, (319) 398-8511.
Information regarding your insurability will be treated as confidential. Peoples
Benefit Life Insurance Company or its reinsurers may, however, make a brief
report thereon to the Medical Information Bureau, a non-profit membership
organization of life insurance companies, which operates an information exchange
on behalf of its members. If you apply to another Bureau member for life or
health insurance coverage, or a claim for benefits is submitted to such a
company, the Bureau, upon request, will supply such company with the information
in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. 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 is Post
Office Box 105, Essex Station, Boston, Massachusetts 02122, telephone number
(617) 426-3660.
Peoples Benefit Life Insurance Company or its reinsurers may also release
information in this file to other life insurance companies to whom you may apply
for life or health insurance or to whom a claim for benefits may be submitted.
6800 R1200
7
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SECTION 23. TAXPAYER ID
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TAXPAYER IDENTIFICATION NUMBER STATEMENT
Taxpayer Identification Number of Policyowner:
----------------------------------
Social Security Number or Employer
Identification Number
- --------------------------------------------------------------------------------
Check the box if you ARE NOT subject to backup withholding under the
provisions of section 3406(a)(1)(C) of the Internal Revenue Code. [ ]
- --------------------------------------------------------------------------------
Check the box if you ARE subject to backup withholding under the
provisions of section 3406(a)(1)(C) of the Internal Revenue Code. [ ]
- --------------------------------------------------------------------------------
The Internal Revenue Service does not require your consent to any provision of
this document other than the following certification required to avoid backup
withholding.
- --------------------------------------------------------------------------------
Under penalties of perjury, I hereby certify (1) that the Social Security or
Taxpayer I.D. number listed above is correct and (2) that my current status
regarding backup withholding is correct.
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SECTION 24. AUTHORIZATION TO OBTAIN INFORMATION
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I authorize any physician, medical professional, hospital, clinic, other medical
care institution, the Medical Information Bureau, Inc., insurance company,
Department of Motor Vehicle Records, consumer reporting agency, or employer
having information available as to employment, other insurance coverage, medical
care, advice or treatment with respect to any physical or mental condition
regarding me to give such information to Peoples Benefit Life Insurance Company,
its reinsurers, or any consumer reporting agency except the Medical Information
Bureau acting on Peoples Benefit Life Insurance Company's behalf.
I authorize Peoples Benefit Life Insurance Company to obtain an investigative
consumer report on me.
I understand that this information will be used by Peoples Benefit Life
Insurance Company or its reinsurers, to determine eligibility for life
insurance.
I agree that this authorization is valid for two and one-half years from the
date signed. I know that I have the right to receive a copy of this
authorization upon request. I agree that a photographic copy of this
authorization is as valid as the original.
I have received a copy of the "Notice of Information Practices" attached to this
application.
I also hereby authorize Peoples Benefit Life Insurance Company to provide its
affiliated companies any and all information provided herein and obtained
hereafter on me.
This authorization shall be valid from the date signed below until affirmatively
withdrawn in writing by myself.
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SECTION 25. REPRESENTATIONS
- --------------------------------------------------------------------------------
I represent that the statements and answers in this application are true and
complete to the best of my knowledge.
I understand that I should consult my own tax and/or legal counsel as to the
consequences of using this product in conjunction with my own particular tax or
financial plan.
It is agreed that:
(a) the statements and answers given in this application, and any
amendments or application supplements to it or statements made to the
medical examiner, will be the basis of any insurance issued;
(b) no agent or medical examiner has the authority to make or alter any
contract for the Company;
(c) if a premium deposit is given in exchange for the Conditional Receipt,
no insurance shall take effect unless all of the conditions set out in
that receipt are satisfied;
(d) IF A PREMIUM DEPOSIT IS NOT GIVEN, NO INSURANCE SHALL TAKE EFFECT
UNLESS ALL OF THE FOLLOWING CONDITIONS ARE SATISFIED;
(1) A POLICY ISSUED BY THE COMPANY IS DELIVERED TO AND ACCEPTED
BY THE OWNER DURING THE LIFETIME OF EACH PERSON TO BE COVERED BY
SUCH POLICY, (2) THE FULL FIRST PREMIUM IS PAID, AND (3) THE
HEALTH AND INSURABILITY OF EACH PERSON PROPOSED FOR INSURANCE HAS
NOT CHANGED SINCE THE DATE OF THIS APPLICATION.
- --------------------------------------------------------------------------------
Signed at on - -
---------------------- ------------------ ------ ------- ------
(city) (state) (date)
- ------------------------------------- --------------------------------------
SIGNATURE OF PROPOSED INSURED PRINT AGENT NAME
- ------------------------------------- --------------------------------------
SIGNATURE OF ADDITIONAL/JOINT INSURED SIGNATURE OF AGENT AGENT LICENSE #
- ------------------------------------- --------------------------------------
SIGNATURE OF ADDITIONAL/JOINT INSURED SIGNATURE OF AGENT AGENT LICENSE #
- ------------------------------------- --------------------------------------
SIGNATURE OF APPLICANT (OWNER) OTHER SIGNATURE OF AGENT AGENT LICENSE #
THAN THE PROPOSED INSURED (IF BUSINESS
INSURANCE, SHOW TITLE OF OFFICER AND
NAME OF FIRM)
- ------------------------------------- --------------------------------------
SIGNATURE OF PARENT OR LEGAL GUARDIAN SIGNATURE OF AGENT AGENT LICENSE #
FOR INSURED(S)
TOTAL AMOUNT PAID: $ [ ] CHECK [ ] COM [ ] OTHER
----------- -------------
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6800 R1200
8
PEOPLES BENEFIT LIFE INSURANCE COMPANY
FRAUD WARNING
The following states require that insurance applicants acknowledge a fraud
warning statement.
Please refer to the fraud warning statement for your state as indicated below.
- --------------------------------------------------------------
FOR APPLICANTS IN ARKANSAS, LOUISIANA --------------------------------
- --------------------------------------------------------------
Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
-------------------------------- --------------------------------
Applicant's Signature Date
- --------------------------------------------------------------
FOR APPLICANTS IN COLORADO --------------------------------
- --------------------------------------------------------------
It is unlawful to knowingly provide false, incomplete, or
misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the
company. Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent
of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of
Insurance within the Department of Regulatory Agencies.
-------------------------------- --------------------------------
Applicant's Signature Date
- --------------------------------------------------------------
FOR APPLICANTS IN FLORIDA --------------------------------
- --------------------------------------------------------------
Any person who knowingly and with intent to injure, defraud,
or deceive any insurer files a statement of claim or an
application containing any false, incomplete or misleading
information is guilty of a felony in the third degree.
-------------------------------- --------------------------------
Applicant's Signature Date
- --------------------------------------------------------------
FOR APPLICANTS IN KENTUCKY, OHIO, AND PENNSYLVANIA --------------------------------
- --------------------------------------------------------------
Any person who knowingly and with intent to defraud
any insurance company or other person files an
application for insurance or a statement of claim
containing any materially false information or conceals
for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal
and civil penalties.
-------------------------------- --------------------------------
Applicant's Signature Date
- --------------------------------------------------------------
FOR APPLICANTS IN MAINE, VIRGINIA AND DISTRICT OF COLUMBIA --------------------------------
- --------------------------------------------------------------
It is a crime to knowingly provide false, incomplete
or misleading information to an insurance company for
the purpose of defrauding the company. Penalties
include imprisonment, fines and denial of insurance
benefits.
-------------------------------- --------------------------------
Applicant's Signature Date
- --------------------------------------------------------------
FOR APPLICANTS IN MINNESOTA --------------------------------
- --------------------------------------------------------------
A person who files a claim with intent to defraud
or helps commit a fraud against an insurer is guilty
of a crime.
-------------------------------- --------------------------------
Applicant's Signature Date
- --------------------------------------------------------------
FOR APPLICANTS IN NEW JERSEY --------------------------------
- --------------------------------------------------------------
Any person who includes any false or misleading information
on an application for an insurance policy is subject to
criminal and civil penalties.
-------------------------------- --------------------------------
Applicant's Signature Date
- --------------------------------------------------------------
FOR APPLICANTS IN NEW MEXICO --------------------------------
- --------------------------------------------------------------
Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly
presents false information in an application for
insurance is guilty of a crime and may be subject to
fines and criminal penalties.
-------------------------------- --------------------------------
Applicant's Signature Date
6800 R1200
9
AGENT'S REPORT
1. a) How long have you known the Proposed Insured?
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b) Relationship to the Proposed Primary Insured:
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c) Are you financially responsible for the Proposed Primary Insured?
[ ] Yes [ ] No
2. Did you give the "Notice of Information Practices" to the Proposed
Insured?
[ ] Yes [ ] No
3. Are you submitting or do you plan to submit an application on any
Proposed Insured on this application to any other company?
[ ] Yes [ ] No
Company Name
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Face amount $
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Total face amount to be placed with all companies
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4. Will the policy applied for replace or change any existing life
insurance policy or annuity?
[ ] Yes [ ] No
If "Yes", explain and submit special replacement form if REQUIRED IN YOUR
STATE.
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5. Medical Examination
Are you arranging for the Medical Requirements
[ ] Yes Paramedical Service used:
----------------------------
[ ] No Request PBL order medical reqs.
6. Was the money taken with the application?
[ ] Yes [ ] No
If "Yes", was the Conditional Receipt completed and given to the
applicant?
[ ] Yes [ ] No
7. Did you ask all questions in the presence of the Proposed Insured(s)?
[ ] Yes [ ] No
8. Was a Confidential Service Sheet or some other needs analysis tool
completed during the interview?
[ ] Yes [ ] No
(If "No," explain)
-------------------------------------------
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9. Are you aware of anything about the health, habits, avocation,
environment or mode of living, except as may be related directly
or indirectly to sexual orientation, which may affect the
insurability of any person proposed for insurance?
[ ] Yes [ ] No
10. If Proposed Insured is a juvenile (ages 0 through 15):
(a) Did you personally see child? [ ] Yes [ ] No
(b) Does child live with parents? [ ] Yes [ ] No
(If "No," explain)
-------------------------------------------
(c) Life insurance in force on parent's life?
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(d) Life insurance applied for or in force on brothers and sisters?
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11. Is Proposed Insured or Owner related to any InterSercurities, Inc.
officer or employee?
[ ] Yes [ ] No
12 Is Proposed Insured or Owner a licensed Representative of any Broker/
Dealer?
[ ] Yes [ ] No
If "Yes, Name and Address of Broker/Dealer
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13. Type of Sale (check two)
[ ] Direct [ ] Pension or Profit Sharing
[ ] Personal Needs Analysis [ ] Salary Savings (EICS)
[ ] Estate Planning [ ] Gift
[ ] Business Insurance [ ] Salary Allotment
Purpose of Policy
[ ] Personal Insurance [ ] Business Insurance
[ ] Mortgage [ ] Buy-Sell
[ ] Retirement [ ] Key Employee
[ ] Education [ ] Executive Bonus
[ ] Estate Liquidity [ ] Deferred Compensation
[ ] Income to Family [ ] Split Dollar
[ ] Cash Accumulation [ ] Reserve Split Dollar
[ ] Wealth Replacement [ ] Other
14. Was this plan sold, presented or illustrated as a VEBA,
welfare benefit concept as defined under IRC Section 419,
Charitable Legacy Plan, Charitable Retirement Plan,
Charitable Remainder Life Program, or other similar
arrangement?
[ ] Yes [ ] No
If "Yes, have you completed and attached the required Disclosure,
Acknowledgment and Release Form and the accompanying Attorney's
Statement?
[ ] Yes [ ] No
15. Did you comply with all requirements relative to obtaining Informed
Consent for HIV and AIDS testing?
[ ] Yes [ ] No
Writing Agent Name
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Agent No.
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Agent's Telephone Number
------------------------------------
Agent's Social Security Number
------------------------------
Agent's Fax Number
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Percent of Agent's Split
------------------------------------
Split Agent Name
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Agent No. Percent of Agent's Split
------------- ------
Split Agent Name
--------------------------------------------
Agent No. Percent of Agent's Split
--------------- ------
REMARKS
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I submit this application assuming full responsibility for delivery of any
coverage issued and for immediate transmittal to the Company of the first
premium when collected. I know of no condition affecting the insurability of any
person proposed for insurance not fully set forth herein. I certify that a
Notice of Information Practices statement was given to the Applicant when this
application was taken. (If applicable)
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$ HAS BEEN PAID BY THE APPLICANT WITH THIS APPLICATION
-------- ------------------------------------------
SIGNATURE OF WRITING AGENT
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6800 R1200
10
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PEOPLES BENEFIT LIFE INSURANCE COMPANY
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Home Office: 4333 Edgewood Road, N. E., Cedar Rapids, Iowa 52499
NOTICE OF INFORMATION PRACTICES
(Please detach and give to the Proposed Insured)
Thank you for applying to Peoples Benefit Life Insurance Company. We appreciate
your efforts in completing each part of the application truthfully, accurately
and completely.
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UNDERWRITING
- -------------------------------------------------------------------------------
Once we receive your application, we will begin an evaluation process called
underwriting to determine whether you are eligible for insurance and, if so, the
rate you should pay for that insurance. We may find that we are unable to give
you the insurance you have applied for or that we are able to give it to you
only on a modified basis or at a rate greater than our lowest rate. For example,
if you have ever used any kind of tobacco or any other nicotine product you may
not be eligible for our lowest rate. Your application will be our primary source
of information; therefore, it must be true, complete, and accurate. You must
inform us of a change to any answer in any part of your application before
accepting delivery of a policy; in fact, you agree to do so when you sign your
application. We may seek information from other sources to help us evaluate the
information you give us on your application.
- -------------------------------------------------------------------------------
CONTESTABILITY
- -------------------------------------------------------------------------------
We strongly urge you to review the completed application closely for accuracy. A
claim may be denied or your coverage may be rescinded or contested by a lawsuit
if the application is incomplete or if it contains false statements,
misrepresentations, acts omissions, or is procured by fraud. If the policy is
rescinded or the lawsuit is successful, the policy will be void and coverage
will be lost. Any policy that is delivered to you will indicate when and under
what circumstances it may be contested as required by law. Please be aware that
if the application contains false or deceptive statements and you submitted it
with the intent to defraud or to facilitate fraud against us, you may also be
guilty of insurance fraud.
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REPLACEMENT OF EXISTING COVERAGE
- -------------------------------------------------------------------------------
If you intend to replace existing coverage, tell the agent of your intention and
answer "yes" to the replacement question in the application; state law may
require the agent to give you information that will help you compare the policy
you are applying for with the policy you intend to replace. If you are undecided
about keeping existing coverage, indicating an intention to replace existing
coverage may help you get the information you need to make a decision. If you do
replace existing coverage, the new policy may contain new suicide and
contestable periods as required by law. The following would be considered
replacement; you stop paying premiums on an existing policy or surrender an
existing policy before or shortly after applying to us or you borrow from an
existing policy to pay premiums for the insurance for which you are applying.
State law may define replacement to include other situations. Please ask your
agent if you are unsure.
- -------------------------------------------------------------------------------
INSURANCE INFORMATION PRACTICES
- -------------------------------------------------------------------------------
We will rely primarily on information provided by you. We may supplement that
information with information from other sources such as medical professionals
who have treated you. In some cases, we may ask a consumer reporting agency to
collect information and submit an investigative consumer report to us as
explained in this Notice under Federal Fair Credit Reporting Act. You may
request to be interviewed in connection with the preparation of this report. In
certain limited situations, we are allowed by law to disclose necessary items of
personal information to third parties without your specific authorization. You
have the right to be told about, and to see and copy if you wish, items of
personal information about you that appear in our files, including information
contained in investigative consumer reports. You also have the right to seek
correction of information you believe to be inaccurate. We will send you a more
detailed explanation of our information practices if you send us a written
request. You may send your request to the Director of Underwriting, Peoples
Benefit Life Insurance Company, 4333 Edgewood Road N.E., Cedar Rapids, Iowa
52499.
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FAIR CREDIT REPORTING PRE-NOTICE
- -------------------------------------------------------------------------------
A routine investigative consumer report may possibly be made regarding your
general reputation, character, mode of living, and personal characteristics.
This information may be obtained through personal interviews with your friends,
neighbors and associates. Should you desire additional information on the nature
and scope of such a report, you may write the Underwriting Department, Peoples
Benefit Life Insurance Company, 4333 Edgewood Road N.E., Cedar Rapids, Iowa
52499. You have the right to request additional information concerning the
nature and scope of the investigation to be performed. To make this request, you
must write the Underwriting Department, Peoples Benefit Life Insurance Company,
4333 Edgewood Road N.E., Cedar Rapids, Iowa 52499. You are entitled to be
interviewed in connection with any investigative consumer report and to receive
a copy of such report.
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MIB DISCLOSURE NOTICE
- -------------------------------------------------------------------------------
Information regarding your insurability will be treated as confidential. Peoples
Benefit Life Insurance Company or its reinsurers may, however, make a brief
report to the Medical Information Bureau, a non-profit membership organization
of life insurance companies, which operates an information exchange on behalf of
its members. If you apply to another Bureau member for life or health insurance
coverage, or a claim for benefits is submitted to such a Company, the Bureau,
upon request, will supply such company with the information in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. 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 is Post
Office Box 105, Essex Station, Boston, Massachusetts 02122, telephone number
(617)426-3660.
Peoples Benefit Life Insurance Company or its reinsurers may also release
information in this file to other life insurance companies to whom you may apply
for life or health insurance or to whom a claim for benefits may be submitted.
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6800 R1200
11
PAYOR'S CHECK-O-MATIC PREMIUM PAYMENT PLAN
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AUTHORIZATION TO INSURANCE COMPANY
The Premium Payor hereby authorizes Peoples Benefit Life Insurance Company to
debit his/her account or accounts by means of check or draft drawn or other
order made whether by electronic or paper means at the below named financial
institution for premiums that may become due under the policy as a result of
this application. This authorization is to remain in effect until written notice
of revocation is received at the Home Office of the Company or until the
Check-O-Matic Premium Payment Plan is terminated in a manner provided on the
reverse side. I (We) expressly agree to all conditions applicable to the
Check-O-Matic Premium Payment Plan including those appearing on the reverse
side.
Please attach a voided check or deposit slip.
- -------------------------------------------------------------------------------------
Bank Name and Address (Name, Office or Branch, Street Address, City, State, Zip Code)
- -------------------------------------------------------------------------------------
Policy Number Check-O-Matic Premium Date of First Withdrawal
- -------------------------------------------------------------------------------------
AUTHORIZATION TO FINANCIAL INSTITUTION
As a convenience to me, I hereby request and authorize you to pay and charge to
my account checks, drafts and other order's whether by electronic or paper
means, with such debits made to my account and drawn or directed by Peoples
Benefit Life Insurance Company to its own order, provided there are sufficient
collected funds in said account to pay the same upon presentation. Until you
receive written cancellation of this authorization by me (or either of us), you
are fully protected when you honor any of those orders. You may, however,
discontinue this arrangement by giving 30 days written notice to me (or either
of us) and the insurance company. Your treatment of and your rights regarding
those orders, shall be the same as if I signed or initiated them. If any of
those orders are not honored, whether with or without cause and whether
intentionally or inadvertently, you shall be under not liability if insurance is
forfeited as a result. Notice of charge for debit is hereby waived.
- ----------------------------------------------------------------------------------------
Transit Routing Number Account Number
- ----------------------------------------------------------------------------------------
Payor Name(s) Payor Signature(s) Your signature as on financial
institution's records. A copy is as valid as
the original
- ----------------------------------------------------------------------------------------
THE FINANCIAL INSTITUTION NAMED ON THE REVERSE SIDE
In consideration of your compliance with the request and authorization on the
reverse side of this form, and of your participation in the Check-O-Matic
Premium Payment Plan with Peoples Benefit Life Insurance Company, incorporated
under the laws of the State of Iowa, (hereinafter called the Company), it is
hereby agreed that:
The Company will indemnify you and hold you harmless from any loss you
may suffer as a consequence of your actions resulting from or in
connection with the execution and issuance of any debit by check, draft,
or other order, whether by electronic or paper means, whether or not
genuine, purporting to be executed and received by you in the regular
course of business for the purpose of payment, including any cost or
expenses reasonably incurred in connection therewith.
The Company will refund to you any amount you have paid to it in error
upon receipt of a claim which you may submit at any time up to twelve
months after the date of such payment.
The Company will defend, at its expense, any action which might be
brought by any depositor, beneficiary, or assignee or any other person
because of your actions taken pursuant to the depositor's or the
Company's request or in any manner arising by reason of your
participation in the Company's Check-O-Matic Premium Payment Plan.
In the event that any such debit shall be dishonored, whether with or without
cause, and whether intentionally or inadvertently, the Company will indemnify
you for any loss even though dishonor results in a forfeiture of insurance.
[SIG] [SIG]
Secretary President
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CONDITIONS APPLICABLE TO CHECK-O-MATIC PREMIUM PAYMENT PLAN
No check, draft or any other orders, either by electronic or paper
means, shall constitute payment until the Company actually receives
payment thereof within the period provided in the policy.
The Check-O-Matic Premium Payment Plan may be terminated by either party
by giving written notice to the other.
The Check-O-Matic Premium Payment Plan does not in any manner amend or
alter the terms and provisions of any policy, contract or agreement
except as may be specifically stated in a policy endorsement or properly
executed contract amendment.
For changes or questions call: Toll Free 1-800-625-4213
Or Write: Peoples Benefit Life insurance Company, 4333 Edgewood Road N.E.,
Cedar Rapids, IA 52499
6800 R1200