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EXHIBIT 1.A (10)
SPECIMEN VARIABLE LIFE INSURANCE APPLICATION
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[FIRST VARIABLE LIFE LOGO]
VARIABLE UNIVERSAL LIFE INSURANCE APPLICATION
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1 PROPOSED INSURED The person upon whose life this 3 INSURANCE How much life insurance you want.
insurance coverage is proposed.
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Name ___________________________________________ Plan Name ___________________________________
Address _________________________________________ Face Amount $________________________________
City ___________________State ________Zip _________ Check One: [ ] Preferred/Non/Smoker [ ]Smoker
Social Security Number ________-________-___________ Death Benefit (Check One):
Phone: Day ___________________Eve ________________ [ ] Option A - Death benefit is the face amount
Date of Birth _____/______/______ Male [ ] Female [ ] [ ] Option B - Death benefit is the face amount plus
Marital Status __________________ Weight ___________ the value of your investment.
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Occupation ____________________ Height ____________
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4 BENEFICIARY (Use Section 10 if needed)
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2 OWNER The person or entity exercising the PRIMARY The person or entity who will receive
policy's contractual rights. BENEFICIARY the proceeds of this policy when the
Proposed Insured dies.
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COMPLETE ONLY IF OWNER IS NOT THE PROPOSED INSURED
Name _______________________________________
Name _____________________________________________ (If split, please indicate percentages)
Address ___________________________________________ Social Security Number (if available)____-_____-_____
Relationship to Proposed Insured __________________
City _______________ State______________ Zip _________ Date of Birth ____/____/_____
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Social Security Number CONTINGENT The person or entity who will receive
or Tax ID Number _________-_____________-____________ BENEFICIARY the proceeds of this policy should
the Primary Beneficiary not survive
the Proposed Insured.
Relationship to the Proposed Insured ____________________ Name_______________________________________
(If split, please indicate percentages)
Date of Birth _____/______/_______ Social Security Number (if available)____-_____-____
Relationship to the Proposed Insured _______________
Date of Birth ___/___/___
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5 RIDERS Optional benefits you can add to your life insurance.
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[ ] Covered Insured Term Insurance $__________ Max. 6X base life insurance amount [ ] Accelerated Death Benefit
[ ] Other Insured Term Insurance $__________ Max. 6X base life insurance amount [ ] Extension of Maturity Date
[ ] Children's Term Insurance $__________ Max. $10,000 [ ] Cost of Living
[ ] Waiver of Monthly Deduction [ ] Living Care Rider
[ ] Cash Deposit Benefit $__________ [ ] Estate Protection
[ ] Accidental Death Benefit $__________ [ ] (For use in trusts only)
[ ] Guaranteed Death Benefit [ ] Other _________________
[ ] Extended Guaranteed Death Benefit [ ] 20 years [ ] to age 65 [ ] Other _________________
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Name of Birth Height/ Smoker or Social Security Relationship to Amount
Additional Insureds Date Sex Weight Preferred/Non-Smoker Number Proposed Insured Applied For
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8980-APP First Variable Service Center / P.O. Box 1317 / Des Moines, IA 50305-1317 / (800)228-1035 12/97
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This Page MUST be detached and given to the Proposed Insured
INVESTIGATIVE CONSUMER REPORT PRE-NOTIFICATION
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Thank you for applying for life insurance with First Variable Life Insurance
Company. As a part of our procedure for processing your initial insurance
application, an investigative consumer report may be prepared whereby
information is obtained through personal interviews with neighbors, friends, or
others with whom you are acquainted. This inquiry includes information as to
your character, general reputation, personal characteristics and mode of living,
except as may be related directly or indirectly to your sexual orientation. You
have the right to make a written request within a reasonable period of time to
receive additional detailed information about the nature and scope of this
investigation. For this information, you may write our Underwriting Department,
First Variable Service Center, P. O. Box 1317, Des Moines, IA 50305-1317. You
may also obtain a written summary of your rights under the Fair Credit Reporting
Act (15 USC section 1684 et seq.) from any consumer reporting agency we may use.
AUTOMATIC PAYMENT AUTHORIZATION
As a convenience to me, I request and authorize you, until revoked by written
notice, to initiate debt entries (charges), electronically, by paper means or by
any other commercially accepted method, to my account for payment of premiums
provided there are sufficient funds in my account to pay the debits. I
understand this authorization is applicable only if requested on my application.
8980-APP First Variable Service Center/P.O. Box 1317/Des Moines, IA 50305-1317
(800)228-1035 12/97
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6 PAYMENT The monetary contribution to the policy. 8 REPLACEMENT OF OTHER CONTRACTS
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I WANT TO MAKE PREMIUM PAYMENTS OF $_______________ any existing annuity or life insurance?
[ ] Annually [ ] Yes [ ] No
[ ] Quarterly
[ ] Semi-Annually If "yes", please state company name and contract
[ ] Monthly (Automatic transfer) number. (Attach any required replacement forms.)
(Please complete "Automatic Payment Authorization" below.)
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INITIAL PAYMENT: (Check one) ________________________________________
A minimum of two months premium is required as initial payment
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[ ] My initial payment is enclosed. $________________ -----------------------------------------------------
9 SERVICE OPTIONS
Make check payable to: First Variable Life Insurance Company. TELEPHONE AUTHORIZATIONS
[ ] My initial payment will be transferred from another
insurance company. Approx. amount $_________________. [ ] I authorize the Company, either directly or
I have filled out a "Transfer of Life Insurance Policy for through its agents, to act on instructions given by
1035 Tax-Free Exchange" form. telephone from the Owner of this contract or any
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Neither the Company, nor any person authorized
SEND PAYMENT NOTICES TO: by the Company, will be responsible for any
[ ] Proposed Insured [ ] Owner claim, loss, liability, or expense in connection
[ ] Other (Give name and address in Remarks.) with a telephone authorization if the Company or such
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good faith in reliance on this authorization.
AUTOMATIC PAYMENT AUTHORIZATION -----------------------------------------------------
[ ] I authorize First Variable Life Insurance Company to apply ASSET REBALANCING
monthly payments from my account on the ______ day of
each month. This is a: [ ] Please rebalance my policy value to the original
percentage allocations. (Minimum accumulation
[ ] Checking Account (include a voided check) value $5,000.) Frequency of rebalancing:
[ ] Savings Account (include a deposit slip) [ ]Quarterly
[ ] Credit Union (include a voided check/phone number [ ]Semi-Annually
of Credit Union (____)________________. [ ]Annually
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7 ALLOCATION How you want your payments allocated.
Use whole percentages to indicate to which investment options -----------------------------------------------------
or fixed accounts you would like your premium allocated. DOLLAR COST AVERAGING
Allocations must total 100%.
INVESTMENT OPTIONS [ ]I would like to enroll in the Dollar Cost
____% Small Cap Growth Averaging Program. (Please complete and attach
Pilgrim Baxter & Associates the "Dollar Cost Averaging Authorization" Form.)
____% World Equity
Keystone Investment Management Company -----------------------------------------------------
____% Growth MONTHLY DEDUCTION
Value Line, Inc. Monthly deductions will be taken
pro-rata from all investment options unless indicated
____% Matrix Equity below.
State Street Global Advisors Please make monthly deductions from:
[ ] Specific Investment Option(s) _____________
____% Growth & Income _______________ _____________
Warburg Pincus Counsellors, Inc. [ ] Best Performing Investment Option
____% Multiple Strategies -----------------------------------------------------
Value Line, Inc.
____% High Income Bond -----------------------------------------------------
Federated Investment Counseling 10 REMARKS/SPECIAL REQUESTS
____% U.S. Government Bond
Strong Capital Management, Inc.
____% Federated-Prime Money Fund II
Federated Investment Counseling
____% Other ____________________
____% Other ____________________
____% Fixed Account
First Variable Life Insurance Company
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8980-APP First Variable Service Center/P.O. Box 1317/ Des Moines, IA 503305-1317
/(800)228-1035 12/97
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This page MUST be detached and given to the Proposed Insured
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MEDICAL INFORMATION BUREAU PRE-NOTIFICATION
Information regarding your insurability will be treated as confidential. First
Variable 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 company 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
it may have in its file.
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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 Fair Credit
Reporting Act. The address of the Bureau's information office is Post Office Box
105, Essex Station, Boston, MA 02112 (Telephone (617) 426-3660). First Variable
Life Insurance Company or its reinsurers may also release information in their
files 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.
8980-APP First Variable Service Center/P.O. Box 1317/Des Moines, IA 50305-1317
/(800) 228-1035 12/97
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11 INFORMATION ABOUT THE PROPOSED INSUREDS
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(Complete the following even if exam is ordered.)
YES NO
1. Within the last 10 years, have any persons proposed for coverage been
diagnosed or treated by a member of the medical profession for high blood
pressure, heart, lung, kidney, or liver disease, diabetes, cancer or tumor,
colon problems, back or spinal disorder, nervous disorder, alcohol or drug
dependency? [ ] [ ]
2. Within the last 10 years have any persons proposed for coverage tested
positive for exposure to the HIV infection or been diagnosed as having AIDS
Related Complex (ARC) or Acquired Immune Deficiency Syndrome (AIDS) caused [ ] [ ]
by the HIV infection?
3. Within the past 5 years, have any persons proposed for coverage:
a. Been hospitalized or treated by a member of the medical profession? [ ] [ ]
b. Been advised to have any diagnostic test or hospitalization or surgery which has not
been done? (Previous AIDS testing disclosure not included.) [ ] [ ]
c. Had a weight change of more than 10 pounds? [ ] [ ]
d. Applied for life, disability or health insurance which was declined, postponed, rated
or modified? (Not applicable to Missouri residents) [ ] [ ]
e. Had a driver's license restricted or revoked, been cited for driving
under the influence of alcohol or drugs or been cited for more than
two moving violations? [ ] [ ]
f. Been convicted of a felony? [ ] [ ]
g. Traveled or resided outside the U.S. or Canada, or made plans to do so within the next
year? [ ] [ ]
h. Engaged in or intend to engage in aviation activities or sports including but not
limited to stock or sports car, drag strip or motorcycle racing, scuba or sky diving,
rock or mountain climbing? (Please complete the appropriate questionnaire) [ ] [ ]
4. In the past 12 months, have any persons proposed for coverage smoked cigarettes? (Give
details below) [ ] [ ]
5. Have any immediate family members of the Proposed Insured(s) had a history of diabetes,
cancer or heart problem? [ ] [ ]
6. Is any person proposed for coverage currently on medication or under treatment or therapy? [ ] [ ]
7. THE DATE AND REASON FOR YOUR LAST CONSULTATION WITH YOUR PERSONAL PHYSICIAN WAS ___________________________________
____________________________________________________________________________________________________________________
Please give details below if you answered "YES" to any of the above questions.
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Question Name of Details (Name of condition, date of onset, Complete Names, Addresses and Phone
Number Proposed Insured duration, current treatment and condition, etc.) Numbers of Physicians and Hospitals
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8980-APP First Variable Service Center/P.O. Box 1317/Des Moines, IA 50305-1317
/(800) 228-1035 12/97
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CONDITIONAL RECEIPT (Please detach and leave with applicant.)
Prior to the delivery of the policy, coverage will be effective only when
ALL of the following conditions are met: a) The Company receives full payment
from the proposed owner with the application. Full payment must be in good funds
in an amount not less than the required initial premium; b) The company receives
within 90 days from the date of application all medical requirements (such as
examinations, tests, x-rays and electrocardiograms) which the Company requests;
c) The Company determines that each person proposed for coverage is acceptable
to it, under its applicable underwriting standards, for the plan and amount
applied for without any modification of the premium rate paid; and d) There is
no materials misrepresentation in the application or in any medical information
furnished to the Company.
Subject to satisfactory completion of the above conditions, coverage under
the receipt will begin ON THE LATER OF a) the date the application is signed, b)
the date the last medical requirement is completed, or c) the effective date, if
any, requested on the application.
The maximum death benefit and all other supplemental benefits provided by
this receipt will be the lesser of a) the total insurance amount, including any
Accidental Death Benefit, on all pending applications with the Company or b)
$250,000. If two or more persons are proposed for coverage, this maximum applies
to all persons proposed for coverage.
If any condition under this receipt is not met, the Company's only
liability will be to refund the premium payment. Either the Company or the
proposed owner may terminate coverage under this receipt by notice to the other.
In no event will coverage under this receipt be in force after 90 days from the
date of the application. (over)
8980-APP First Variable Service Center/P.O. Box 1317/Des Moines, IA 50305-1317
/(800) 228-1035 12/97
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12 AGREEMENTS AND AUTHORIZATIONS
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I/We acknowledge receipt of current Prospectus(es) and understand that the death
benefit under the contract may increase or decrease depending on the investment
results of the contract. I/We understand that hypothetical illustrations are not
indicative of future results. The contract's cash surrender value may increase
or decrease on any day depending on the investment results. No minimum cash
surrender value is guaranteed. I/We understand that the contract represents a
long-term commitment to meet insurance needs and financial goals.
I/We represent to the best of my/our knowledge and belief that all statements
and answers contained in this application, and any supplements required by the
Company, are complete and true. I/WE EXPRESSLY AGREE THAT ANY INSURANCE APPROVED
BY FIRST VARIABLE LIFE INSURANCE COMPANY FOR ISSUANCE AS A RESULT OF THIS
APPLICATION SHALL BE CONSIDERED IN FORCE ONLY WHEN A POLICY HAS BEEN ISSUED BY
FIRST VARIABLE LIFE INSURANCE COMPANY AND SAID POLICY DELIVERED TO AND ACCEPTED
BY THE OWNER AND THE FIRST PREMIUM PAID THEREON, DURING THE LIFETIME AND
CONTINUED INSURABILITY OF THE PROPOSED INSURED, AS STATED IN THE APPLICATION.
I/We hereby authorize any licensed physician, hospital, clinic or other medical
or medically related facility, insurance company or the Medical Information
Bureau, that has any records or knowledge of me or my family or of our health,
to give First Variable Life Insurance Company, or its reinsurers any such
information and records for its use in the processing and evaluation of my
application for insurance. This agreement extends to and includes information
and records pertaining to psychiatric, drug use or alcohol use history. A copy
of this authorization shall be considered as valid as the original and either
shall be valid for a period of two years (30 months for residents of Virginia).
I/We acknowledge receipt of the Medical Information Bureau Pre-notification and
Investigative Consumer Report Pre-notification. If a premium payment is being
submitted with this application, I/we acknowledge receipt of the Conditional
Receipt. In return, I/we have read and agree to its terms.
The purpose of this form is to collect information in connection with this
application for life insurance. The Proposed Insured, or their authorized
representative, is entitled to a copy of this notice.
OWNER'S CERTIFICATION (IN LIEU OF W-9)
[ ] I am [ ]I am not subject to backup withholding under Section 3406(a)(1)(c)
of the Internal Revenue Code. Under penalties of perjury, I certify that the
information in this section is true, correct and complete. (Please be sure that
Social Security Number or Tax ID Number is provided in Section 2 of this
application.)
Signed at:______________________________ _________________________
City, State Date
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Signature of Proposed Insured Signature of Owner (if other than the Proposed Insured)
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Signature(s) of Additional Insured(s)
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13 REPRESENTATIVE'S CERTIFICATION
(1) I am a Registered Representative of a Company approved NASD member and duly
licensed in the state in which this application was signed; (2) I have asked the
questions contained in this application of the Proposed Insureds(s) and Owner
and duly recorded the answers; (3)to the best of my knowledge that there is
nothing adversely affecting the insurability of any persons proposed for
insurance except as stated in this application; (4) I have complied with the
state and federal laws on disclosure, cost comparison and replacement; (5) If
the initial premium was paid with the application, I have remitted it to the
Company and delivered a Conditional Receipt to the Owner; (6) Based on
information furnished by the Owner or Insured(s) in this application, I have
reasonable grounds for believing the purchase of the policy applied for is
suitable for the Owner; (7) The Prospectus(es) were delivered and no written
sales materials other than those furnished or approved by the Company were used.
(8) TO THE BEST OF MY KNOWLEDGE, THIS APPLICATION [ ]DOES REPLACE
[ ]DOES NOT REPLACE EXISTING LIFE INSURANCE.
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Signature of Representative Date Phone
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Name of Representative (Please print) Agent Number Social Security Number
- --------------------------------------- Commission: [ ] Trail
Name of Broker Dealer [ ] No Trail
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8980-APP First Variable Service Center/P.O. Box 1317/Des Moines, IA 50305-1317
/(800) 228-1035 12/97
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CONDITIONAL RECEIPT (conditional from previous page)
No broker, agent or medical examiner may waive a complete answer to any
question in the application, pass on insurability, make or alter any contract,
or waive any of the Company's other rights or requirements.
Company policy does not permit the acceptance of money on applications from
California if the total insurance applied for exceeds $250,000.
If there is material misrepresentation in the application or in any medical
information furnished to the Company, the Company's only liability will be
limited to refunding the premium payment.
If any person proposed for coverage commits suicide, whether sane or
insane, the Company's only liability will be limited to refunding the premium
payment. (Suicide clause not applicable in Missouri.)
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ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO FIRST VARIABLE LIFE INSURANCE
COMPANY. DO NOT MAKE CHECKS PAYABLE TO ANY AGENT OR LEAVE THE PAYEE BLANK.
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Received $_________ from _________ for an application on ______ dated __/__/__.
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Signature of Owner Signature of Representative
8980-APP First Variable Service Center/P.O. Box 1317/Des Moines, IA 50305-1317
/ (800) 228-1035 12/97
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Mail completed First Variable Service Center Overnight First Variable Service Center
application to: P.O. Box 1317 deliveries: 1206 Mulberry
Des Moines, IA 50305-1317 Des Moines, IA 50309
Phone: (800) 228-1035
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