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EXHIBIT (10)(a)
[NATIONAL LIFE OF VERMONT LOGO]
NATIONAL LIFE OF VERMONT
National Life Insurance Company
Montpelier, VT 05604 LIFE INSURANCE
Tel: 802 229-3333 APPLICATION - PART A (1)
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Check the appropriate use
of this application: [ ] Registered [ ] Private Placement
Underwriting Method: [ ] Guaranteed Issue [ ] Simplified Issue
[ ] Full Underwriting
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A. EMPLOYER DATA:
1. Name:
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2. Business Address: (Street, City, State, Zip Code.)
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3. Taxpayer ID No.: 4. Plan Account No.: (if available.)
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B. PROPOSED INSURED DATA:
For each Proposed Insured, the attached Schedule of Insureds lists: Full
Name, Social Security Number, Date of Birth, Sex and, for the first Policy
Year, Face Amount of Insurance and any Supplemental Term Insurance.
1. Is every Proposed Insured now working a minimum of 20 hours per week
continuously for the prior 6 months? No work absences for prior 3 months
other than minor illness or accident of no more than 5 days total.
(If 'No,' give detailed explanation in 13. Remarks.) [ ] Yes [ ] No
2. a. Is every Proposed Insured a citizen of and
resident in the USA? [ ] Yes [ ] No
b. If 'No,' is citizenship and residence of each
Proposed Insured indicated on the Schedule of
Insureds? [ ] Yes [ ] No
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C. LIFE INSURANCE DATA:
1. Permanent Plan: (Check only one.)
[ ] Sentinel Benefit Provider (A Registered Variable Universal Life
Policy.)
[ ] Sentinel Benefit Provider (A Private Placement Variable Universal
Life Policy.)
[ ] Other:
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2. Death Benefit Compliance Test:
[ ] Cash Value Accumulation Test
[ ] Guideline Premium Test
3. Death Benefit Option:
[ ] Option A - Face Amount
[ ] Option B - Face Amount plus Account Value (Not available for Cash
Value Accumulation Test.)
4. [ ] Supplemental Term Insurance Rider (Not applicable for Private
Placement.)
5. Policy Date: (For all policies on Proposed Insureds listed in Schedule of
Insureds.)
(mm/dd/yyyy)
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6. Automatic Premium Loan: (If applicable.) [ ] Yes [ ] No
7. Premium Amounts: (If applicable.)
a. Initial Premium (Total for all policies.) $
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b. Planned Annual Premium (Total for all policies.) $
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8. The policies applied for will be used in conjunction with an
employer-sponsored plan involving both males and females. All policies
will be issued on a unisex basis unless checked here for sex-distinct
basis:
[ ] Sex-Distinct Basis
9. The policies applied for will be used in conjunction with an
employer-sponsored plan involving both smokers and nonsmokers. All
policies will be issued on a uni-smoke basis unless checked here for
smoker-distinct basis:
[ ] Smoker-Distinct Basis
10. Owner: (Check one.)
[ ] Employer
[ ] Proposed Insured
[ ] Other: (Give full name, address and Taxpayer ID No.)
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9000(0888) Page 1 of 4
Cat. No. 45719
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LIFE INSURANCE APPLICATION - PART A (1) Continued
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C. Life Insurance Data: Continued
11. Beneficiary: (Check one.)
[ ] Employer
If the Employer is the beneficiary, the Employer certifies,
represents and warrants that:
a. The Employer has a lawful and substantial economic interest
in the life, health and bodily safety of each Proposed
Insured; and
b. The Services of each such Proposed Insured are such that the
Employer expects to realize either:
- A substantial pecuniary gain through the continued life of
the Proposed Insured; or
- A substantial pecuniary loss in the event of the Proposed
Insured's death.
[ ] Trust (If Trust, describe.)
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[ ] As designated by Proposed Insured on Application (Part A (2))
[ ] Owner (If other than Proposed Insured.)
[ ] See memo attached
If two or more persons are the beneficiaries in any class, payment
shall be made to them equally or to the survivor(s), unless otherwise
requested. If payment is made in one sum and there is no beneficiary
entitled to payment when the Proposed Insured dies and the Proposed
Insured is the Owner at that time, payment shall be made to the estate
of the Proposed Insured. But if the Proposed Insured is not the Owner,
payment shall be made to the Owner.
12. Has there been or will there be a lapse, surrender, replacement,
reissue, conversion, or change to reduce amount, premium or period of
coverage of any existing life, disability or annuity contract if the
applied for policy or rider is issued? (If 'Yes,' give Company Name,
Policy Number, Amount and Plan in 13. Remarks.) [ ] Yes [ ] No
Will there be any substantial borrowing on any life insurance policy if
the applied for policy or rider is issued? (If 'Yes,' give Company Name,
Policy Number, Amount and Plan in 13. Remarks.) [ ] Yes [ ] No
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13. Remarks:
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9000(0898) Page 2 of 4
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LIFE INSURANCE APPLICATION - PART A (1) Continued
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D. PAYMENT DATA:
Premium paid with this Application: $
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Premium and Other Notices will be sent to the Owner, unless otherwise
notified. (Provide proper authorization.)
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E. TEMPORARY INSURANCE AGREEMENT:
1. The Owner applies for temporary life insurance on the life of
each Proposed Insured listed in the attached Schedule of
Insureds: [ ] Yes [ ] No
(If 'No,' the following provisions of this section do not apply.)
2. The effective date of the temporary insurance is the latest of:
a. The date we receive from the Owner an amount of premium not less
than one-fourth of the sum of the initial premiums for the policies
applied for;
b. The date this Application (Part A (1)) is signed by one of our
Officers; and
c. The date (mm/dd/yyyy) chosen by the Owner (optional).
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3. The amount of temporary insurance on the life of each Proposed Insured
is:
[ ] The Face Amount and any Supplemental Term Insurance Amount for the
first Policy Year, as shown in the Schedule of Insureds.
[ ] Other:
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4. Any temporary insurance on the life of a Proposed Insured will
terminate on the earliest of:
a. The date the permanent life insurance applied for in this
application takes effect on the life of that Proposed Insured;
b. The date that the Proposed Insured fails to meet any requirements to
qualify for the permanent life insurance applied for;
c. The date 90 days after the effective date of the temporary insurance
(in this case, we will give the Owner notice prior to termination);
and
d. The date the Owner's written notice of termination of the insurance
is received by us at our Home Office.
If the temporary insurance on the life of a Proposed Insured terminates for
the reason specified above in 4(a), the amount of premium paid with this
Application that was allocated to the policy on the life of the Proposed
Insured will be applied as premiums under that permanent life insurance
policy. If the temporary insurance on the life of a Proposed Insured
terminates for any other reason, we will refund the amount of premium paid
with this Application that was allocated to the policy on the life of that
Proposed Insured, less a mortality charge. This mortality charge will be for
the period from the effective date of the temporary insurance to, but not
including, the termination date. The mortality charge for that Proposed
Insured will be based on the amount of temporary insurance on the Proposed
Insured's life, and the term rate from the Table of Temporary Insurance
Rates for the Proposed Insured's age.
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9000(0898) Page 3 of 4
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LIFE INSURANCE APPLICATION - PART A (1) Continued
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F. ACKNOWLEDGMENT AND SIGNATURE:
The person(s) signing below acknowledge and agree that:
THE AMOUNT AND DURATION OF THE DEATH BENEFIT MAY INCREASE OR DECREASE DAILY,
AS DESCRIBED IN THE DEATH BENEFIT AND POLICY CHANGES SECTION OF THIS POLICY.
THE DOLLAR AMOUNT OF THE DEATH BENEFIT IS NOT GUARANTEED.
THE CASH SURRENDER VALUE OF THIS POLICY IS DEPENDENT ON THE ACCOUNT VALUE IN
THE SEPARATE ACCOUNT, WHICH FLUCTUATES ACCORDING TO THE INVESTMENT
EXPERIENCE OF THE SUB-ACCOUNTS OF THE SEPARATE ACCOUNT CHOSEN BY THE OWNER.
THE CASH SURRENDER VALUE MAY INCREASE OR DECREASE DAILY, AND IS NOT
GUARANTEED AS TO DOLLAR AMOUNT.
THE APPLICATION - This is part of an application for permanent life
insurance. The application includes this Part A (1) and its attached
Schedule of Insureds and Table of Temporary Insurance Rates (if applicable),
the Part A (2), if applicable, (which has been or which will be completed by
the Proposed Insured), and Part B that may be required, and any amendments
or supplements to either Part. To the best of the knowledge and belief of
the person(s) signing below, all statements in this application are complete
and true and were correctly recorded. Each person signing below adopts all
the statements made in the application and agrees to be bound by them. This
Application (Part A (1)) is valid until withdrawn by the Owner by written
notice to us at our Home Office. Withdrawal of this Application (Part A (1))
shall not necessarily affect its use with applications submitted prior to
the date we receive such notice.
OUR LIABILITY - A minimum amount of premium may be paid to the agent in
exchange for temporary life insurance as discussed above in the Temporary
Insurance Agreement section. If this is done, we shall be liable only as set
forth in that Agreement. If that amount of premium is not paid, we shall
have no liability unless and until:
- The application has been approved by us at our Home Office; and
- The first premium has been paid during the lifetime of the Proposed
Insured; and
- The Proposed Insured is actively working a minimum of 20 hours per
week continuously for the prior 6 months. No work absences for prior
3 months other than minor illness or accident of no more than 5 days
total; and
- The policy, contract or certificate of coverage has been delivered
to the person named as Owner in the policy; and
- At the time of payment and delivery, all statements in the
application which are material to the risk are complete and true as
though they were made at that time.
If any of these conditions are not met, the policy, contract or certificate
of coverage and rider(s) applied for shall not take effect.
AUTHORITY OF AGENTS - No agent can change the terms of this application or
any policy/contract issued by us. No agent can waive any of our rights or
requirements, or extend the time for any payment.
CHANGES AND CORRECTIONS - Any change or correction of the application will
be shown on an Amendment of Application attached to the policy/contract.
Acceptance of any policy, contract or certificate of coverage issued shall
be acceptance of any change or correction of the application we made.
However, unless otherwise indicated in this application, any correction or
change of amount, classification, plan of insurance or riders must be agreed
to in writing.
TAXPAYER IDENTIFICATION (APPLIES ONLY IF THE EMPLOYER IS THE OWNER) - The
Employer certifies, under penalties of perjury, that the number referred to
in 3 of this application (Part A (1)) is the correct Taxpayer Identification
Number (or the Employer is waiting for a number to be issued).
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NOTICE: Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil
penalties.
Signed at: (City & State) on this day of:
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(mm/dd/yyyy)
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NAME & TITLE OF PERSON AUTHORIZED SIGNATURE OF AUTHORIZED PERSON:
TO SIGN FOR THE OWNER: (Print)
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SIGNATURE OF GENERAL AGENT SIGNATURE OF SOLICITING AGENT:
SUBMITTING APPLICATION:
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If temporary insurance applied for:
NAME & TITLE OF PERSON AUTHORIZED
TO SIGN FOR THE INSURER: (PRINT) SIGNATURE OF OFFICER:
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9000(0898) Page 4 of 4
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[NATIONAL LIFE OF VERMONT LOGO]
NATIONAL LIFE OF VERMONT
National Life Insurance Company
Montpelier, VT 05604 LIFE INSURANCE
Tel; 802 229-3333 APPLICATION - PART A (2)
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The Application consists of this Part A (2) and Part A (1)
No.:
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Employer:
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A. PROPOSED INSURED DATA:
[ ] See attached Schedule of Insureds (If this box is checked, do not
complete questions 3 through 8.)
1. Name and Address of Proposed Insured: (Hereinafter, "you" and "your"
refer to the Proposed Insured.)
Name: (Print Last, First, Middle Initial.)
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Address: (Street, City, State, Zip Code.)
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2. Tax Identification no.: 3. Date of Birth: 4. [ ] Male [ ] Female
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5. Citizenship, if not USA: Type of Visa: [ ] Permanent [ ] Temporary
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6. Business Address: (Street, City, State, Zip Code.)
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7. Beneficiary: (If to be named by Proposed Insured, as indicated in
Application Part A (1).)
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If two or more persons are the beneficiaries in any class, payment shall
be made to them equally or to the survivor(s), unless otherwise
requested. If payment is made in one sum and there is no beneficiary
entitled to payment, payment shall be made to the Owner, if living, or
to the Owner's estate.
If the Beneficiary is other than the Employer or any Trust established
by the Employer, do NOT complete question #8.
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8. I consent to insurance being purchased on my life by:
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I reserve the right to revoke my consent in the future by properly
notifying National Life Insurance Company.
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B. UNDERWRITING DATA:
1. Are you now actively working a minimum of 20 hours [ ] Yes [ ] No
per week, and have you been so working continuously
during the past 6 months? Continuously means that
you have had no work absences during the most recent
three months other than for minor illness or
accident, and you have not been absent more than 5
days total during the past 6 months.
2. Do you now use nicotine products in any form [ ] Yes [ ] No
(including cigarettes, cigars, chewing tobacco,
smokeless tobacco, pipe, "the patch", snuff or
nicotine gum) or have you used nicotine products in
any form within the last 12 months? (If 'Yes,'
details:)
3. Have you applied for life insurance and been rated, [ ] Yes [ ] No
declined or postponed in the past 5 years?
(If 'Yes,' details:)
4. Do you have, or have you been treated for, heart [ ] Yes [ ] No
disease or cancer?
5. Have you been treated for or diagnosed as having [ ] Yes [ ] No
deficiency of the immune system, such as Acquired
Immune Deficiency Syndrome (AIDS), or AIDS Related
Complex (ARC), or the AIDS Virus?
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9001(0898) Page 1 of 2
Cat. No. 45720
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LIFE INSURANCE APPLICATION - PART A (2) Continued
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C. AUTHORIZATION TO RELEASE INFORMATION:
I, the Proposed Insured, hereby authorize any licensed physician, medical
practitioner, hospital, clinic or other medical or medically related
facility, insurance company, the Medical Information Bureau or other
organization, institution or person, that has any records or knowledge of
me or my health, to give to the National Life Insurance Company or its
reinsurers any such information. I authorize National Life to request a
copy of my driving record from the state motor vehicle department.
In addition, I authorize the National Life Insurance Company to obtain an
investigative consumer report. I also acknowledge receipt of copies of the
Prenotifications relating to investigative consumer reports and the Medical
Information Bureau.
A photographic copy of this authorization shall be as valid as the
original.
NOTICE: Any person who includes any false or misleading
information on an application for an insurance
policy is subject to criminal and civil penalties.
To the best of my knowledge and belief, all answers and statements are
full, complete and true and were correctly recorded before I signed my name
below.
TAXPAYER IDENTIFICATION (APPLIES ONLY IF PROPOSED INSURED IS OWNER) - The
Proposed Insured herein certifies, under penalties of perjury, that the
number referred to in 2 of this application (Part A (2)) is his/her correct
Taxpayer Identification Number (Or he/she is waiting for a number to be
issued).
Signed at: (City, & State) _____________________________________ on this day of: (mm/dd/yy) ________________
PROPOSED SOLICITING
INSURED: AGENT:
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9001(0898) Page 2 of 2
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[NATIONAL LIFE National Life Insurance Company SUPPLEMENT TO
OF VERMONT LOGO] Montpelier, VT 05604 APPLICATION
Tel: 802 229-3333
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This Supplement is part of Application Part A (1) No.: dated: (mm/dd/yy)
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A. Owner's Name: (The Owner's Taxpayer Identification No. and address are shown
on Part A (1) of the Application.)
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B. Premium Amounts:
1. Initial Premium: $______________________ 2. Planned Annual Premium: $______________________
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C. Net Premium Allocation: (If applicable.)
SENTINEL/MARKET STREET FUNDS: NEUBERGER & BERMAN FUND:
%_______ Money Market %_______ Partners
%_______ Growth
%_______ Aggressive Growth
%_______ Managed GOLDMAN Sachs Funds:
%_______ Bond %_______ International Equity
%_______ International %_______ Global Income
%_______ Sentinel Growth %_______ CORE Small Cap Equity
%_______ Mid Cap Equity
AMERICAN CENTURY FUNDS: THE ALGER AMERICAN FUND:
%_______ Value %_______ Growth
%_______ Income & Growth %_______ Small Capitalization
OTHER: (As available.)
J.P. MORGAN FUNDS:
%_______ International Opportunities %_______ _____________________________
%_______ Small Company
%_______ _____________________________
STRONG FUNDS: %_______ _____________________________
%_______ Opportunity Fund II
%_______ Growth Fund II % 100 TOTAL
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D. Pace Amount (FA)
1. Initial: $ _______________
2. Subsequent - A pattern of FA's may be elected here subject to current
issue limits. The FA for the last Policy Year shown will apply to all
later Policy Years. If no FA is elected here, the initial FA will apply
to all Policy Years.
POLICY YEAR to and POLICY YEAR ALTERNATIVES
including
________ _________ [ ] Increase by __________ % of Face Amount
________ _________ [ ] Increase by the premium accumulated at __________ % per year.
________ _________ [ ] Increase by $ __________ % per year
________ _________ [ ] Increase by __________ % of Face Amount
________ _________ [ ] Increase by the premium accumulated at __________ % per year.
________ _________ [ ] Increase by $ __________ % per year
________ _________ [ ] Increase by __________ % of Face Amount
________ _________ [ ] Increase by the premium accumulated at __________ % per year.
________ _________ [ ] Increase by $ __________ % per year
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E. Term Insurance Amount (TIA): (If applicable.)
1. Initial: $ ____________________
2. Subsequent - A pattern of TIA's may be elected here subject to current
issue limits. The TIA for the last Policy Year shown will apply to all
later Policy Years. If no TIA is elected here, the Initial TIA will apply
to all Policy Years.
POLICY YEAR to and POLICY YEAR ALTERNATIVES
including
________ _________ [ ] Increase by __________ % of Face Amount
________ _________ [ ] Increase by __________ % of Face Amount
________ _________ [ ] Increase by __________ % of Face Amount
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9002(0898) Page 1 of 3
Cat. No. 45755
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SUPPLEMENT TO APPLICATION - Continued
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F. COMPLETE THE FOLLOWING IF APPLICABLE.
1. Has the Owner received an Offering Memorandum or a Prospectus for the policy(ies) being applied for? [ ] Yes [ ] No
If 'Yes,' give date shown on the Offering Memorandum or Prospectus: (mm/dd/yy) _______________
2. Does the Owner understand that:
- The death benefit and the duration of insurance may be variable or fixed under specified conditions? [ ] Yes [ ] No
- The cash surrender value of the policy may increase or decrease in accordance with the experience of
the Separate Account (there are no minimum guarantees as to the variable account value)? [ ] Yes [ ] No
- The fixed account value of the policy earns interest at a rate no less than a minimum specified rate? [ ] Yes [ ] No
3. In view of the above, does the Owner believe that this policy will meet his/her insurance needs and
financial objectives? [ ] Yes [ ] No
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THE FOLLOWING INFORMATION IS REQUIRED TO DETERMINE IF THIS PRODUCT IS SUITABLE FOR THE OWNER (AS INDICATED IN
ITEM A ON PAGE 1).
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G.1a.If the Owner is not an individual, a copy of the Authorization Document (i.e., Corporate, Resolution, Trust
Instrument, or Partnership Agreement) must be supplied. Have you attached or previously provided us with
this? [ ] Yes [ ] No
b. Is the Owner:
(i) a bank, savings and loan association, insurance company, or registered investment company? [ ] Yes [ ] No
(ii) an investment advisor registered under Section 203 of the Investment Advisers Act of 1940? [ ] Yes [ ] No
(iii) any other entity (whether a natural person, corporation, partnership, trust, or otherwise) with
total assets of at least $5 million? [ ] Yes [ ] No
IF THE OWNER ANSWERED 'YES,' TO G 1b (i), (ii), or (iii), do not complete 2 through 12.
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2. Number of Owner's Dependents: 7. Owner's Estimated Earned Annual Income:
_______________________________________ __$____________________________________
3. Age of Owner's Dependents: 6. Owner's Estimated Earned Annual Income:
_______________________________________ __$____________________________________
4. Owner's Occupation: 7. Owner's Estimated Earned Annual Income:
_______________________________________ __$____________________________________
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H.1 INVESTMENT OBJECTIVES: (Check all that apply.)
[ ] Growth [ ] Capital Preservation [ ] Income
[ ] Growth with Income [ ] Tax Advantage [ ] Other: ____________________________________
2. RISK TOLERANCE: (Check only one.) [ ] High [ ] Medium [ ] Low
3. INVESTMENT STRATEGY: (Check only one.)
[ ] Growth without Risk
[ ] Growth with Risk
[ ] Other: ________________________
4. SOURCES OF PAYMENT: (Check all that apply.)
[ ] Current Income [ ] Surrender or Loan on Life Insurance or Annuity
[ ] Plan Sponsor Contribution [ ] Sale of Personal Property or Real Estate
[ ] Savings [ ] Sale of Mutual Funds Presently Held
[ ] Other: ___________________ [ ] Sale of Other Securities Presently Held
5. Is Owner or Owner's Employer a member of the National Association of Securities Dealers (NASD)? [ ] Yes [ ] No
6. Owner's estimated Federal Income Tax Bracket: [ ]15% [ ]28% [ ]31% [ ]_____%
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9002(0898) Page 2 of 3
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SUPPLEMENT TO APPLICATION - Continued
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I. REMARKS:
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J. AGREEMENT AND SIGNATURE'S:
To the best of my knowledge, the above answers are true and correctly
recorded. I believe the policy(ies) applied for to be suitable for my
objectives.
SIGNATURE OF OWNER: DATE: (mm/dd/yy)
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ATTESTATION OF AGENT/REGISTERED REPRESENTATIVE:
The Owner of the policy(ies) applied for has been informed of the risks involved
in this investment, and I certify that I have reasonable grounds for believing
the policy(ies) to be suitable for the Owner's objectives.
SIGNATURE OF AGENT/REGISTERED REPRESENTATIVE: DATE:(mm/dd/yy)
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AUTHORIZED BROKER-DEALER PRINCIPAL: DATE: (mm/dd/yy)
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9002(0898) Page 3 of 3