Exhibit 1.A.(10)
Application for Life Insurance
GENERAL AMERICAN
Life Insurance Company
St. Louis, Missouri
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1. PROPOSED INSURED
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Name (Last, First, Middle) Gender
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[ ] Male
[ ] Female
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Social Security # Date of Birth (MM/DD/YY) Age (Nearest Birthday) Birthplace
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Home Address (Street, City, State, Zip) Email Address Home Phone
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( )
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Name and Address of Employer Years Employed Work Phone
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( )
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Occupation Annual Earned Income From Occupation Net Worth
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$ $
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2. BENEFICIARY PROVIDE FULL NAME & RELATIONSHIP OF EACH TO PROPOSED INSURED.
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Primary Contingent
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3. OWNER
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[ ] Proposed Insured (Do not designate a Contingent Owner.)
[ ] Other (Provide Full Name, Address, Phone Numbers, Email Address, Date of
Birth & Relationship of each to Proposed Insured.)
Original Contingent
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Social Security or Tax # of Original Owner (REQUIRED BY LAW)
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4. PREMIUM PAYOR
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[ ] Proposed Insured [ ] Owner [ ] Employer [ ] Other: (Provide Full Name
and Billing Address.)
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1
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5. COVERAGE APPLIED FOR INCLUDE SIGNED AND DATED ILLUSTRATION.
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SPECIAL ISSUE DATE BASE FACE AMOUNT $
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PLAN
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Contract Type (UL and VUL): Option: [ ] Level (A) [ ] Increasing (B)
[ ] Cash Value Accum Test (C)
BENEFITS AND RIDERS
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TRADITIONAL
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[ ] Waiver of Premium
[ ] Accelerated Benefits
(Complete Disclosure.)
[ ] Decreasing Specified Term II
$_________________________________________________________________________
[ ] Level Specified Term II
$_________________________________________________________________________
[ ] Premium Additions Rider (Face Amt.)
$_________________________________________________________________________
[ ] Values Plus One Units
#_________________________________________________________________________
[ ] Automatic Purchase Option
$___________________________________ Yr. _________________________________
[ ] Guaranteed Survivor Purchase Option
$___________________________________ on _________________________________
$___________________________________ on _________________________________
(Complete App. for each life.)
[ ] Other _______________________________ $ _________________________________
[ ] Other _______________________________ $ _________________________________
[ ] Other _______________________________ $ _________________________________
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UL
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[ ] Waiver of Monthly Deduction
[ ] Waiver of Specified Premium
$_________________________________________________________(Monthly Premium)
[ ] Accelerated Benefits
(Complete Disclosure.)
[ ] Anniversary Partial Withdrawal
[ ] Guaranteed Survivor Purchase Option
Plus $___________________________________ on _____________________________
$___________________________________ on _____________________________
(Complete App. for each life.)
[ ] Supplemental Coverage Term Rider/Joint Supplemental Coverage Term
Rider $___________________________________________________________________
[ ] Lifetime Coverage Rider
[ ] Secondary Guarantee Rider
[ ] Other_______________________________ $____________________________________
[ ] Other_______________________________ $____________________________________
[ ] Other_______________________________ $____________________________________
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VUL
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[ ] Waiver of Monthly Deduction
[ ] Waiver of Specified Premium
$ ________________________________________________________(Monthly Premium)
[ ] Guaranteed Survivor Purchase Option
Plus $__________________________________ on _______________________________
$__________________________________ on _______________________________
(Complete App. for each life.)
[ ] Anniversary Partial Withdrawal
[ ] Accelerated Benefits
(Complete Disclosure.)
[ ] Adjustable Benefit Term Rider
[ ] Estate Preservation Term Rider
$_________________________________________________________________________
[ ] Supplemental Coverage Term Rider/Joint Supplemental Coverage Term
Rider $____________________________________________________________________
[ ] Lifetime Coverage Rider
[ ] Secondary Guarantee Rider
[ ] Other _________________________________ $ _________________________________
[ ] Other _________________________________ $ _________________________________
[ ] Other _________________________________ $ _________________________________
Complete #7 for VUL Suitability and separate VUL Supplement to elect funds.
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6. PREMIUMS AND DIVIDENDS
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Billing
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[ ] Pre-Authorized Check Monthly
[ ] Direct [ ] Combined Direct (Traditional)
[ ] List [ ] Single Premium (UL and VUL)
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Add to Existing Bill #
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Dividend Option (if eligible)
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[ ] Pd. Up Addns. (Trad.) [ ] Cash
[ ] Reduce Prem. (Trad.) [ ] Accum. (Trad.)
[ ] Inc. Cash Value (UL and VUL)
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Mode
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[ ] Annual [ ] Semi-Annual
[ ] Quarterly [ ] Monthly (List or PAC only.)
Note: Paying your insurance premiums more often than annually (more often than
once a year) will cost more than paying them once a year. (Not applicable for
UL/VUL plans.)
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Premium Amt. (UL and VUL) $
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Automatic Premium Payment
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(Traditional)
[ ] Div. Accum. [ ] Loan
[ ] Both [ ] Neither
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2
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7. VUL SUITABILITY
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YES NO
Have you received a Prospectus/Memorandum of
Understanding for the policy applied for? [ ] [ ]
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Date of Prospectus Date of any
/Memorandum supplement
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Is a current Customer Information Statement for this owner on
file with the selling broker-dealer? [ ] [ ]
(If "No", one must be submitted with this application.)
Do you understand that:
1. THE DEATH BENEFIT AND CASH SURRENDER VALUE WILL INCREASE OR
DECREASE DEPENDING ON INVESTMENT EXPERIENCE? [ ] [ ]
2. THERE IS NO GUARANTEED MINIMUM DEATH BENEFIT OR CASH
SURRENDER VALUE? [ ] [ ]
Do you believe that the policy applied for meets your
insurance needs and your anticipated financial objectives? [ ] [ ]
[ ] I request a copy of the Statement of Additional Information for the
following Investment Company(ies):
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8. [ ] ADDITIONAL [ ] ALTERNATE INCLUDE SIGNED AND DATED ILLUSTRATION FOR EACH.
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Provide details including plan, amount and riders. If Beneficiary and Owner
other than original, indicate below.
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9. OTHER INSURANCE
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a. Total Life Insurance now in force on Proposed Insured.
If "NONE", check [ ]
Year of Personal Business Accidental Death Waiver of Prem.
Company and Policy # Issue Ins. Amt. Ins. Amt. Amt. Yes No
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If additional space is needed, provide information in
"Details" below. YES NO
b. Are you currently applying for life insurance with
any other company? [ ] [ ]
(If "Yes", provide information in "Details" below.)
c. Will the insurance being applied for replace any of
the above or any in force annuities? [ ] [ ]
d. Will the insurance being applied for receive any
values (to pay premiums or additional payments) from
another policy/contract? [ ] [ ]
If either "c" or "d" is answered "Yes", circle affected coverage above or
indicate in "Details" below. Policy/contract number MUST be provided. (Complete
and submit required replacement forms.)
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10. GENERAL INFORMATION
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Have you: (Provide explanation of "Yes" answers in
"Details" below.) YES NO
a. Ever been postponed, rated or offered a policy
different than that applied for? [ ] [ ]
b. Any intention to travel or reside outside the United
States? [ ] [ ]
c. Been a pilot or student pilot during the past 3 years
or have any intention of becoming a pilot or student
pilot in any type of aircraft?
(If "Yes", complete Aviation Supplement.) [ ] [ ]
d. Participated in, or do you contemplate participating
in: aeronautics, competitive racing, underwater or
sky diving, mountain climbing, or any other similar
avocation?
(If "Yes", complete Avocation Supplement.) [ ] [ ]
e. Ever had a traffic citation for driving while
intoxicated or driving under the influence of
intoxicants or drugs? [ ] [ ]
f. Within the past three years, had any moving vehicle
violation? [ ] [ ]
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Provide Driver's License # State
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3
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11. DETAILS TO "YES" ANSWERS ABOVE/ADDITIONAL INFORMATION
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12. HOME OFFICE ENDORSEMENTS ONLY NOT APPLICABLE IN MISSOURI.
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DECLARATIONS
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I agree that:
- - The statements and answers in this application and any amendments to it
and in any supplements are true and complete to the best of my
knowledge and belief and will be part of any policy issued.
- - No printed provision of this application will be modified or waived
except by an endorsement signed by an officer at the Home Office. No
agent has the authority to waive or change the answer to any question
in this application or has the authority to make a promise which would
have the effect of changing any portion of this application or the
policy applied for, or waiving any of its provisions.
- - My acceptance of any insurance policy means I agree to any changes
shown in #12, where state law permits Home Office endorsements.
- - If a premium payment is given in exchange for a Temporary Insurance
Agreement (TIA), the Company will be liable only as set forth in that
Agreement.
- - If a premium payment is not given, then insurance will take effect when
a policy is approved by the Company for issue as applied for, the first
full premium is paid and the health and insurability of any person
proposed for insurance have not changed since the date of this app.
- - If a policy is issued other than as applied for, insurance will take
effect under the policy only when a policy issued by the Company is
delivered to and accepted by me, the first full premium is paid, and
the health and insurability of any person proposed for insurance have
not changed since the date of this application.
The Applicant and agent certify that the Applicant has read, or had read to him
or her the completed application and that he or she realizes that any false
statement or misrepresentation therein may result in loss of coverage under the
policy.
THIS CONTRACT MAY BE SUBJECT TO TAXATION AS DESCRIBED IN THE INTERNAL REVENUE
CODE.
CERTIFICATION: UNDER PENALTIES OF PERJURY, I CERTIFY THAT:
(1) THE NUMBER SHOWN ON THIS FORM IS MY CORRECT TAXPAYER IDENTIFICATION
NUMBER (OR, IF NO NUMBER IS SHOWN, I AM WAITING FOR A NUMBER TO BE
ISSUED TO ME); AND
(2) I AM NOT SUBJECT TO BACKUP WITHHOLDING EITHER BECAUSE I HAVE NOT BEEN
NOTIFIED BY THE INTERNAL REVENUE SERVICE (IRS) THAT I AM SUBJECT TO
BACKUP WITHHOLDING AS A RESULT OF A FAILURE TO REPORT ALL INTEREST OR
DIVIDENDS, OR THE IRS HAS NOTIFIED ME THAT I AM NO LONGER SUBJECT TO
BACKUP WITHHOLDING.
**PLEASE NOTE: YOU MUST CROSS OUT AND INITIAL #(2) ABOVE IF YOU HAVE BEEN
NOTIFIED BY THE IRS THAT YOU ARE CURRENTLY SUBJECT TO BACKUP WITHHOLDING BECAUSE
OF UNDER-REPORTING INTEREST OR DIVIDENDS ON YOUR TAX RETURN.**
THE IRS DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER
THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.
_________________________________________ ___________________________________
Date (MM/DD/YY) Signed At (City, State)
_________________________________________ ___________________________________
Signature of Proposed Insured -
Parent or Guardian if Proposed ___________________________________
Insured under age 18
___________________________________
Signature, Name and Address of
Applicant/Owner if other than
Proposed Insured (If Owner is a
Corporation, Partnership or Trust,
an authorized officer, partner or
trustee must sign and state title.)
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I certify that I have truly and accurately recorded on all parts of this
application the information supplied by the Applicant. In light of the financial
need of the Proposed Insured and Owner, the purpose of this sale has been
discussed with the Owner, and I believe this application to be a suitable
recommendation.
1. ____ To the best of my knowledge, this is a replacement. (Complete and
submit required replacement forms.)
____ To the best of my knowledge, this is not a replacement
2. ____ For VUL: Did you deliver the current Prospectus/Memorandum of
Understanding and were all of the written sales materials used printed
by General American Life Insurance Company? [ ] Yes [ ] No
___________________________________
(Signature of Licensed Agent)
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4
GENERAL
AMERICAN
Life Insurance Company
St. Louis, Missouri
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MEDICAL DECLARATIONS
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1. PROPOSED INSURED'S NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH (MM/DD/YY)
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2. a. Who is the doctor who can give us the most complete and up to date
information concerning your present health?
If "None", check [ ]
Name and Address (Street, City, State, Zip) Phone
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( )
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b. When was this doctor last consulted? Why?
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c. What treatment was given or medication prescribed? If "None", check [ ]
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3. Height Weight Any Weight loss in the past year? [ ] Yes [ ] No
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If "Yes", reason
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4. a. Do you use tobacco or nicotine products?
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[ ] Current [ ] Past-date last used [ ] Never
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b. Type [ ] Cigarettes [ ] Pipe/Cigar [ ] Chew [ ] Patch/Gum
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Amount/Frequency
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5. Within the last ten years have you had, been treated
for, or diagnosed as having: YES NO
a. High blood pressure, chest pain, heart
attack, or any other disease or disorder of
the heart or circulatory system? [ ] [ ]
b. Asthma, bronchitis, emphysema, or any other
disease or disorder of the lungs or
respiratory system? [ ] [ ]
c. Seizures, stroke, headaches, or any other
disease or disorder of the brain or nervous
system? [ ] [ ]
d. Ulcer, colitis, cirrhosis, hepatitis, or any
other disease or disorder of the liver,
gallbladder, intestines or stomach? [ ] [ ]
e. Any disease or disorder of the kidney,
bladder, prostate, reproductive organs, or
breasts; sexually transmitted disease;
sugar, albumin, blood or pus in the urine? [ ] [ ]
f. Diabetes; disorder of the thyroid or lymph
glands, or other endocrine disorders? [ ] [ ]
g. Arthritis, gout or disorder of the muscles
or bones? [ ] [ ]
h. Cancer, tumor, cyst or disorder of the skin? [ ] [ ]
i. Anemia, or any other disorder of the blood? [ ] [ ]
j. Depression, stress, anxiety, or any other
psychological or emotional disorder or
symptoms? [ ] [ ]
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Details: List question number. Give dates, duration, treatment and doctors'
names and addresses.
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5
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MEDICAL DECLARATIONS (CONT.)
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YES NO
6. Are you now under observation or taking medication or
treatment? [ ] [ ]
7. Do you have any doctor's visit or medical care scheduled? [ ] [ ]
8. Have you:
a. Ever been diagnosed by a member of the
medical profession as having AIDS or AIDS
Related Complex? [ ] [ ]
b. Tested positive for antibodies to the AIDS
(HIV) virus? [ ] [ ]
9. Other than the above, during the past five years
have you had any checkup, illness, injury or
health condition; had or been recommended to have
any treatment, hospitalization, surgery, medical
test or medication? [ ] [ ]
10. Have you:
a. Used (once or more) or do you now use
barbiturates, amphetamines, hallucinogenic
drugs (including marijuana), cocaine,
heroin, narcotics, or any similar substances
or any prescription drug except in
accordance with a physician's instructions? [ ] [ ]
b. Been advised to limit or discontinue the use
of alcohol or drugs; sought or received
treatment, counseling or participated in a
group for alcohol or drug use? [ ] [ ]
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Details (Cont.):
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11. Do you exercise? [ ] Yes [ ] No Type
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How often?
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12. Are you now pregnant? [ ] Yes [ ] No
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If "Yes", estimated date of delivery?
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13. Family history:
Age if Living Age at Death Cause of Death
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Father
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Mother
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Brothers and Sisters
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# Living # Dead
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I agree that the statements and answers in this Medical Declarations are true
and complete to the best of my knowledge and belief. They, together with the
statements and answers in the application and any amendments, will become the
basis of any insurance issued and will be part of any policy issued.
Signed at (City, State) Date (MM/DD/YY)
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Signature of Proposed Insured - Parent or
Witnessed by Licensed Agent Guardian if Proposed Insured under age 18.
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6
VUL SUPPLEMENT
INFORMATION REQUIRED WHEN APPLYING FOR A VARIABLE PRODUCT
(Proposed) Insured's Name: ____________________________________________
(To be used in conjunction with application # ______________________________ .)
GENERAL AMERICAN CAPITAL COMPANY:
Money Market Fund _____________________________%
S & P 500 Index Fund _____________________________%
Bond Index Fund _____________________________%
Managed Equity Fund _____________________________%
Asset Allocation Fund _____________________________%
International Index Fund _____________________________%
Mid-Cap Equity Fund _____________________________%
Small-Cap Equity Fund _____________________________%
VAN ECK WORLDWIDE INSURANCE TRUST:
Worldwide Hard Assets Fund _____________________________%
Worldwide Emerging Markets Fund _____________________________%
J.P. MORGAN SERIES TRUST II:
Bond Portfolio _____________________________%
Small Company Portfolio _____________________________%
AMERICAN CENTURY VARIABLE PORTFOLIOS:
VP Income & Growth Fund _____________________________%
VP International Fund _____________________________%
VP Value Fund _____________________________%
METROPOLITAN SERIES FUND, INC.:
Janus Growth Portfolio _____________________________%
Janus Mid Cap Portfolio _____________________________%
T. Rowe Price Large Cap Growth
Portfolio _____________________________%
T. Rowe Price Small Cap Growth
Portfolio _____________________________%
MET INVESTORS SERIES TRUST:
PIMCO Innovation Portfolio _____________________________%
FIDELITY VARIABLE INSURANCE PRODUCTS:
VIP Equity-Income Portfolio _____________________________%
VIP Growth Portfolio _____________________________%
VIP Overseas Portfolio _____________________________%
VIP High Income Portfolio _____________________________%
VIP II Asset Manager Portfolio _____________________________%
VIP III Mid Cap Portfolio _____________________________%
SEI INSURANCE PRODUCTS TRUST:
VP Large Cap Value Fund _____________________________%
VP Large Cap Growth Fund _____________________________%
VP Small Cap Value Fund _____________________________%
VP Small Cap Growth Fund _____________________________%
VP Emerging Markets Equity
Fund _____________________________%
VP International Equity Fund _____________________________%
VP Core Fixed Income Fund _____________________________%
VP High Yield Bond Fund _____________________________%
VP International Fixed Income
Fund _____________________________%
VP Emerging Markets Debt
Fund _____________________________%
NEW ENGLAND ZENITH FUND:
Alger Equity Growth Series _____________________________%
Harris Oakmark Mid Cap Value
Series _____________________________%
OTHER _____________________________ _____________________________%
OTHER _____________________________ _____________________________%
GENERAL ACCOUNT _____________________________%
(Refer to the Prospectus for transfer rights. These are limited based on
percentage, amount, and frequency.)
TOTAL ALLOCATION ______________%
GENERAL
AMERICAN
LIFE INSURANCE COMPANY
ST. LOUIS, MISSOURI 63166
Control Number _________________________
7