1
EXHIBIT 1.(10)
Application for Policy
ACACIA NATIONAL LIFE INSURANCE COMPANY (ANLIC) 1010-V
7315 WISCONSIN AVENUE
BETHESDA, MD 20814
APPLICATION FOR VARIABLE
UNIVERSAL LIFE Please print clearly in black ink.
[ ]NEW POLICY [ ] INCREASE / ADDITION TO POLICY #
--------------------------
[ ]PRELIMINARY APPLICATION [ ] If increasing existing policy, enter NEW insurance
[ ]CONVERSION amount only $
[ ] POLICY# ----------------------
--------------------------------------
CONTINUE THE BALANCE? [ ] YES [ ] NO [ ] Use policy funds, no change to planned period premium
[ ]RATE REDUCTION OF POLICY# [ ] Increase planned periodic premium to $
------------------------ ---------------
If increase in premium, complete Section 10 Premium
Amount
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PART 1
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PRODUCT NAME: EXECUTIVE SELECT
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1. INSURED
Name of Insured Sex Date of Birth / / Birthplace
-------------------- ---- ---------- ------------------
(State)
Former Name (if applicable) Social Security Number
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Address
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PO Box/Address City State Zip
Occupation Employer
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Telephone - Home Best Time To Call: A.M. P.M.
------------------------------------------------- ------- ------
Telephone - Business Best Time To Call: A.M. P.M.
------------------------------------------------- ------- ------
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2. EMPLOYMENT DATA
Yes No
a. Has the insured been actively at work on a full time basis at least 30 hours
per week for the past 90 days? (If No explain) [ ] [ ]
b. Has the insured ever requested or received disability benefits in the past
ten years? [ ] [ ]
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3. TOBACCO USE
Yes No
a. Has the insured smoked one or more cigarettes in the past twelve months? [ ] [ ]
b. Has the insured used any form of tobacco or nicotine substitute in the past
twelve months? [ ] [ ]
(If yes, please indicate the type and frequency)
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4. OWNER
Full Name (Address)
---------------------------------------------- ------------------------------------------------------
Date of Birth/Trust Date / /
---------
Relationship to Insured (or all Trustees Names)
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Social Security#/TIN# / /
-----------------------
Phone Number ( ) Contact Person
----- ------------------------------------------------
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5. BENEFICIARY IF LEFT BLANK, THE BENEFICIARY WILL BE THE OWNER; OR THE ESTATE OF THE INSURED IF THE OWNER IS NOT THEN ALIVE
PAID EQUALLY TO THE SURVIVOR OR SURVIVORS.
Primary Relationship to Insured
------------------------------------------------------------------- ------------------------------
Contingent Relationship to Insured
----------------------------------------------------------------- ------------------------------
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6. DEATH BENEFIT
Amount of Insurance $
------------------
DEATH BENEFIT OPTION (select one only) OPTIONAL RIDERS:
--------------------
[ ] Option A (death benefit is the amount of [ ] Disability Benefit $ or [ ] Waiver of Monthly Deduction
insurance) ---------
[ ] Option B (death benefit is the amount of [ ] Term Coverage Rider $
insurance plus the accumulation value) -----------
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7. PREMIUM MODE Please select one.
[ ] Annual [ ] Semi-Annual [ ] Quarterly [ ] Monthly Bank Withdrawal [ ] Monthly Billing
[ ] Non-Billing [ ] Invoice Billed [ ] Payroll Deduction (Additional form required) [ ] Single $
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8. PREMIUM AMOUNT
Planned Annual Premium $ Planned Modal Premium $
--------------- ------------------
(*)Initial Premium (paid with application) $ (leave receipt with payor).
------------
(*)All premium checks must be made payable to ANLIC. Do not make check payable to the agent or leave the payee blank.
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Page 1 of 7 Pages
2
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9. INSURANCE INFORMATION
List all life insurance existing on Insured. If None, check box. [ ] None Yes No
Will the insurance now being applied for discontinue, reduce, change or replace [ ] [ ]
any life insurance or annuity in this or any other company? (If yes, attach
Replacement Notice if required by State Law.) (Specify policy number(s) below)
------------ --------------------- ---------------- ------------- -----------------------------------
YEAR Will This Policy Be Replaced?
COMPANY POLICY NUMBER AMOUNT ISSUED Yes No As a 1035?
------------ --------------------- ---------------- ------------- -----------------------------------
[ ] [ ] [ ]
------------ --------------------- ---------------- ------------- -----------------------------------
[ ] [ ] [ ]
------------ --------------------- ---------------- ------------- -----------------------------------
[ ] [ ] [ ]
------------ --------------------- ---------------- ------------- -----------------------------------
[ ] [ ] [ ]
------------ --------------------- ---------------- ------------- -----------------------------------
[ ] [ ] [ ]
------------ --------------------- ---------------- ------------- -----------------------------------
[ ] [ ] [ ]
------------ --------------------- ---------------- ------------- -----------------------------------
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10. SPECIAL INSTRUCTIONS
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11. ENDORSEMENTS/CORRECTIONS Home Office Use Only.
No change in the amount, age at issue, classification, plan of insurance or benefits shall be effective unless
agreed to in writing by me. This space will not be used in MD, PA, WV or any other state if not allowed by statute
or Insurance Department Regulations.
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12. [ ] GUARANTEED ISSUE [ ] SIMPLIFIED ISSUE [ ] REGULAR ISSUE (FULL UNDERWRITING)
(Proceed to question 14) (Complete questions 13 & 14 for Simplified and Regular Issue)
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13. OTHER INFORMATION
Yes No
a. Have you participated in any vehicle racing, parachuting, hang gliding,
scuba diving, mountain climbing or rodeos within the past 2 years or is any
such activity contemplated? (If yes, complete Avocation Form) [ ] [ ]
b. Have you, within the past 5 years, consulted a physician for any reason or
had any diagnostic tests? [ ] [ ]
c. Have you, within the past 5 years, been treated by a person licensed as a
medical physician for or had indication of:
1. Cancer, tumor, liver, kidney, lung or nervous disorder? [ ] [ ]
2. Chest pain, high blood pressure, heart disease or other circulatory
disorder, diabetes or stroke? [ ] [ ]
d. Have you ever used narcotics, barbiturates, amphetamines, cocaine, LSD,
marijuana or hallucinogenic drugs? [ ] [ ]
e. Have you ever received counseling or treatment, or been a member of any
support group for the use of alcohol or drugs? [ ] [ ]
f. Has any company declined, postponed, modified, cancelled or refused to
renew, reinstate or issue insurance? [ ] [ ]
g. Is any other life insurance application now pending or contemplated with
any other company? [ ] [ ]
h. Have you been charged with a driving violation or had your license
suspended or had a restriction placed on your license within the past 3
years? (If yes, provide:) Driver's license number State of Issue [ ] [ ]
---------------- -------
i. Do you anticipate travel or residence in a foreign country in the near
future? (If so, where and for how long?) [ ] [ ]
j. Have you within the past 3 years been prescribed medication by a physician
or practitioner? [ ] [ ]
k. Insured:
Exact Height ft. in. Exact Weight lbs. [ ] Gained [ ] Lost pounds in the past year
------ ------ ------ ------
Advise reason for change
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14. GIVE COMPLETE DETAILS OF ANY "YES" ANSWERS TO QUESTIONS IN SECTION 13.
- ------------- ------------------------------------------------- ------------- --------------------------------------------------
Question # Full details of disease, injury, activity, etc. Date Names and addresses of Physicians and hospitals
(if applicable)
- ------------- ------------------------------------------------- ------------- --------------------------------------------------
- ------------- ------------------------------------------------- ------------- --------------------------------------------------
- ------------- ------------------------------------------------- ------------- --------------------------------------------------
- ------------- ------------------------------------------------- ------------- --------------------------------------------------
- ------------- ------------------------------------------------- ------------- --------------------------------------------------
- ------------- ------------------------------------------------- ------------- --------------------------------------------------
- ------------- ------------------------------------------------- ------------- --------------------------------------------------
Page 2 of 7 Pages
3
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15. SUITABILITY INFORMATION
I, as of the (corporation, partnership, trust, etc., hereinafter "Institutional
----------------- -------------------
Customer"), hereby certify that Institutional Customer or its designated agent (corporate officer, owner, trustee, etc.)
have adequate investment experience and education to evaluate the investment risk of this investment on a basis
independent from that of the information provided to us by the Registered Representative selling this policy to
Institutional Customer. In the event Institutional Customer at any time believes that it does not have the ability to
analyze the risk of this investment it agrees to obtain the services of such consultants and/or other market
professionals as can provide the information necessary to make this decision independent of the soliciting Registered
Representative.
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Signature of Institutional Customer
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Supervisory Principal's Signature
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16. ALLOCATION
Choose either a. or b. Acacia allows you to choose either the (A) MODEL ASSET ALLOCATION PROGRAM and its options or
(B) OWNER DIRECTED ASSET ALLOCATION PROGRAM and its options.
a. I want to participate in the MODEL ASSET ALLOCATION PROGRAM (Quarterly rebalancing is automatic.)
[ ] Yes If yes, please select ONE Portfolio A-J.
Portfolio A Conservative (WITH International) [ ]
Portfolio B Conservative-Moderate (WITH International) [ ]
Portfolio C Moderate (WITH International) [ ]
Portfolio D Moderate-Aggressive (WITH International) [ ]
Portfolio E Aggressive (WITH International) [ ]
Portfolio F Conservative (WITHOUT International) [ ]
Portfolio G Conservative-Moderate (WITHOUT International) [ ]
Portfolio H Moderate (WITHOUT International) [ ]
Portfolio I Moderate-Aggressive (WITHOUT International) [ ]
Portfolio J Aggressive (WITHOUT International) [ ]
Other
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b. I want to participate in the OWNER DIRECTED ASSET ALLOCATION PROGRAM.
[ ] Yes If yes, select using whole percentages only. Must total 100%
CALVERT SOCIAL OPPENHEIMER ALGER AMERICAN
Money Market % High Income Fund/VA % Growth %
---- ---- ----
Balanced % Capital Appreciation Fund/VA % MidCap Growth %
---- ---- ----
Small CapGrowth % Aggressive Growth Fund/VA % Small Capitalization %
---- ---- ----
Mid Cap Growth % Main Street Growth & Income Fund/VA %
---- ----
International Equity % Strategic Bond Fund/VA %
---- ---- FIDELITY
Equity-Income(*) %
----
DEUTSCHE VIT FRANKLIN TEMPLETON High Income(*) %
----
Equity 500 Index % Asset Strategy % Contrafund(*) %
---- ---- ----
Small Cap Index % International Securities %
---- ----
EAFE Equity Index % ACACIA NATIONAL
----
VAN ECK General/Fixed Account %
----
NEUBERGER BERMAN Worldwide Hard Assets %
----
Limited Maturity Bond % (*)Service Class 2
----
Growth %
----
Partners % TOTAL 100 %
----
[ ] CHECK HERE FOR PORTFOLIO REBALANCING. I elect Portfolio Rebalancing (Automatic Rebalancing). Please rebalance
the values of my subaccounts to maintain the specific allocations chosen above. The first rebalancing should occur
every: [ ] 3 months, [ ] 6 months, [ ] or 1 year (check one) beginning on (date) or [ ] 3 months, [ ] 6 months, [ ]
1 year (check one) after issue date.
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Page 3 of 7 Pages
4
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17. DOLLAR COST AVERAGING Transfers totalling less than $100 are not permitted. Note: If this option is chosen, there
must be sufficient allocation to the Money Market in the Allocation Section on the application. This option will
stay in effect until the fund is depleted or until I cancel this option in writing or with an authorized telephone
instruction.
Transfer $ per month from the [ ] Money Market or from the [ ] Acacia National General Account (36 months minimum).
-----
CALVERT SOCIAL OPPENHEIMER ALGER AMERICAN
Money Market % High Income Fund/VA % Growth %
---- ---- ----
Balanced % Capital Appreciation Fund/VA % MidCap Growth %
---- ---- ----
Small CapGrowth % Aggressive Growth Fund/VA % Small Capitalization %
---- ---- ----
Mid Cap Growth % Main Street Growth & Income Fund/VA %
---- ----
International Equity % Strategic Bond Fund/VA % FIDELITY
---- ----
Equity-Income(*) %
----
DEUTSCHE VIT FRANKLIN TEMPLETON High Income(*) %
----
Equity 500 Index % Asset Strategy % Contrafund(*) %
---- ---- ----
Small Cap Index % International Securities %
---- ----
EAFE Equity Index % ACACIA NATIONAL
----
VAN ECK General/Fixed Account %
----
NEUBERGER BERMAN Worldwide Hard Assets %
----
Limited Maturity Bond % (*)Service Class 2
----
Growth %
----
Partners % Total 100 %
----
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18. EARNINGS SWEEP (Interest Sweep) Please calculate the gain on all subaccounts every [ ] 3 months, [ ] 6 months, [ ] 1 year
(check one) and deposit those gains in the subaccounts listed below:
CALVERT SOCIAL OPPENHEIMER ALGER AMERICAN
Money Market % High Income Fund/VA % Growth %
---- ---- ----
Balanced % Capital Appreciation Fund/VA % MidCap Growth %
---- ---- ----
Small CapGrowth % Aggressive Growth Fund/VA % Small Capitalization %
---- ---- ----
Mid Cap Growth % Main Street Growth & Income Fund/VA %
---- ----
International Equity % Strategic Bond Fund/VA % FIDELITY
---- ----
Equity-Income(*) %
----
DEUTSCHE VIT FRANKLIN TEMPLETON High Income(*) %
----
Equity 500 Index % Asset Strategy % Contrafund(*) %
---- ---- ----
Small Cap Index % International Securities %
---- ----
EAFE Equity Index % ACACIA NATIONAL
----
VAN ECK General/Fixed Account %
----
NEUBERGER BERMAN Worldwide Hard Assets %
----
Limited Maturity Bond % (*)Service Class 2
----
Growth %
----
Partners % Total 100 %
----
The first sweep of earnings should occur on (date) or every [ ] 3 months, [ ] 6 months, [ ] 1 year (check one)
after issue date ------------------
(Not available with Dollar Cost Averaging)
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19. CONSENT FOR ELECTRONIC DELIVERY
By initializing here the owner consents to receive the Acacia National Annual Prospectus dated May 1st of the
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Prospectus year and all subsequent prospectus amendments thereto, electronically in lieu of paper version. I would
like to receive delivery: [ ] On diskette or [ ] Via Email - My email address is
----------------------
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20. AUTOMATIC BANK DRAFT Please attach voided check. Note: If voided check is NOT attached and a personal check
accompanies this application, the account referenced on the check will be used to establish this plan unless
otherwise notified. Minimum withdrawal amount is $15.00.
Please withdraw $ from my bank account as shown below on the (day) of each month and
----------- ----------
invest as shown in Section 16. Note: Start date may be adjusted to occur on or before the policy date.
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Name of Depositor/Account Name
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Account Number Bank Phone Number
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Name of Bank, Branch and Bank Address
This authorization can be terminated upon 30 days written notice by the depositor or ANLIC to the other party.
ANLICmay terminate this authorization if any debit entry is not honored.
X
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Authorized Signature for above account
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Page 4 of 7 Pages
5
21. TELEPHONE AUTHORIZATION Unless waived, I the Owner and Agent/Registered Representative will have automatic telephone
transfer and authorization.
/ / I elect NOT to have telephone transfer authorization. / / I elect NOT to have my Registered Representative have transfer
authorization.
I hereby authorize and direct ANLIC to make allowable transfers of funds or
reallocation of net premiums among available subaccounts or to complete
other financial transactions as may be allowed by ANLIC at the time of
request, based upon instructions received by telephone from a) myself, as
Owner, b) my Agent/Registered Representative in Section 29 below; and c)
the person(s) named below. ANLIC will not be liable for following
instructions communicated by telephone that it reasonably believes to be
genuine. ANLIC will employ reasonable procedures, including requiring the
policy number to be stated, tape recording all instructions, and mailing
written confirmations. If ANLIC does not employ reasonable procedures to
confirm that instructions communicated by telephone are genuine, ANLIC may
be liable for any losses due to unauthorized or fraudulent instructions.
Name per (c) above: __________________________________________________
SS# __________________________________________________________________
Address: _____________________________________________________________
I understand: a) all telephone transactions will be recorded; and b) this
authorization will continue in force until the earlier of 1)revocation by
the Owner is received in written form or by telephone by ANLIC; or 2) ANLIC
discontinues this privilege.
22. RELEASE OF POLICY INFORMATION Authorization Agreement to release policy
information to designated individual. Policy information is automatically
sent to the policyowner, registered representative and Broker/Dealer.
As policyowner, I hereby authorize and direct the Company to send one copy
of policy information relating to the above policy to the following
designated individual.
Name _____________________________ SSN or TIN ____________________________
Address __________________________________________________________________
I understand that, as policyowner, I will continue to receive the originals
of such policy information. The designated individual is not authorized to
withdraw monies from or make any other policy changes or to act in any way
on my behalf in regard to the above policy(ies). I also understand that
monitoring policy activity is my responsibility.
TERMINATION OF AUTHORIZATION: This Authorization will continue to be in
force until the earlier of (1) written notice is received from the owner
revoking this authorization or (2) the Company terminates this agreement by
written notice to owner.
INDEMNIFICATION: Regarding the policy information released to the
individual designated above, I agree to indemnity and hold harmless the
Company, their affiliates, and their directors, officers, employees, and
agents from and against all claims, actions, costs and liabilities,
including attorney's fees, arising out of or relating to this Authorization
Agreement.
23. DISCLOSURES
I hereby acknowledge receipt of the current prospectus, and any
supplements, for this policy including any required disclosure if the
policy applied for will be in a qualified or ERISA covered non-qualified
plan. Date of Prospectus is ____________________.
/ / Check here if you wish to receive a copy of the Statement of
Additional Information
Page 5 of 7 Pages
6
24. AGREEMENTS
I AGREE AS FOLLOWS:
a. NOTE FOR ARKANSAS, KENTUCKY AND OHIO RESIDENTS: Any person who, with
intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false
or deceptive statement is guilty of insurance fraud.
b. NOTE FOR COLORADO RESIDENTS: 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 policy holder or claimant for the
purpose of defrauding or attempting to defraud the policy holder 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.
c. NOTE FOR D.C. RESIDENTS: It is a crime to provide false or misleading
information to an insurer for the purpose of defrauding the insurer or
any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant.
d. NOTE FOR LOUISIANA RESIDENTS: Any person who, with intent to defraud
or knowing that he is facilitating a fraud against an insurer, submits
an application or files a claim containing a false or deceptive
statement may be guilty of insurance fraud.
e. NOTE FOR NEW JERSEY RESIDENTS: Any person who includes any false or
misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
f. NOTE FOR NEW MEXICO RESIDENTS: 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 civil fines and criminal
penalties.
g. NOTE FOR PENNSYLVANIA RESIDENTS: Any person who knowingly and with
intent to defraud any insurance company or other person files an
application for insurance or 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.
h. NOTE FOR VIRGINIA RESIDENTS: Any person who, with intent to defraud or
knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement
may have violated state law.
i. Any policy including any endorsements issued as a result of this
application will, with this application and any supplemental
applications, be the entire insurance contract.
j. No agent, broker or medical examiner can: 1) waive the answers to any
questions in this application; 2) make or change any insurance
contract; or 3) waive any rights or rules of ANLIC.
k. EXCEPT AS SPECIFIED OTHERWISE IN A RECEIPT PROVIDED UPON A PAYMENT OF
PREMIUM AT THE TIME OF APPLICATION, INSURANCE WILL NOT BE EFFECTIVE
UNTIL ALL OF THE FOLLOWING ARE MET: A) THE POLICY ISSUED BY ANLIC IS
DELIVERED TO AND ACCEPTED BY THE APPLICANT; AND B) THE FIRST FULL
PREMIUM IS PAID.
l. ANLIC may change this application by an appropriate notation in the
space marked "Endorsements/Corrections": 1) to correct apparent errors
or omissions; and 2) to conform it with any policy rider that may be
issued. No change will be made in the following without the
applicant's written consent: 1) amount of insurance; 2) plan of
insurance; 3) classification of risks; or 4) benefits. Acceptance of
any policy issued under this application ratifies any amendments.
m. I understand that: 1) the policy I am applying for is variable and
uses a Separate Account; 2) the death benefit and policy values are
not guaranteed by ANLIC or any other insurance company. They are not
guaranteed by the U.S government or any state government. They are not
federally insured by the FDIC, the Federal Reserve Board or any other
federal or state agency; 3) I bear all risk for those funds in the
Separate Account; 4) THE AMOUNT AND DURATION OF THE DEATH BENEFIT MAY
VARY WITH INVESTMENT EXPERIENCE, LOANS AND OTHER SPECIFIED CONDITIONS;
5) POLICY VALUES NOT IN THE FIXED ACCOUNT WILL INCREASE OR DECREASE IN
ACCORDANCE WITH THE EXPERIENCE OF THE SELECTED INVESTMENT OPTIONS OF
THE SEPARATE ACCOUNT; 6) the amount of the benefit payable on
surrender is not guaranteed, but is dependent on the then surrender
value; 7) illustrations of benefits, including the death benefit, are
available upon request; and 8) this policy meets my investment
objectives and anticipated financial needs.
Page 6 of 7 Pages
7
25. AUTHORIZATION This authorization or a photocopy of it, shall remain valid
for use by Acacia National Life Insurance Company ("ANLIC") for two (2)
years from the date below. I authorize any licensed physician, medical
practitioner, hospital, clinic or other medically related facility,
insurance company, agency conducting Investigative Consumer Reports or any
information service or financial institution, family member, or associate
to release to ANLIC or any person or entity acting on its behalf, any
personal information which is on file and relates to my health or mental
condition, general character, driving records, use of alcohol and drugs,
and hobbies of a hazardous nature. I understand that any information
obtained will be used to determine my eligibility for insurance.
In addition, I authorize the Medical Information Bureau (MIB) to release to
ANLIC or its reinsurers, any personal information which is on file and
relates to me.
I also agree that I have received and read the Notice of ANLIC's Insurance
Information Practices, MIB and Investigative Consumer Reports. I also
understand that my authorized representative and I can receive a copy of
this authorization if we so desire.
NOTE FOR NEW JERSEY AND VIRGINIA RESIDENTS: I authorize ANLIC to obtain an
Investigative Consumer Report. An Investigative Consumer Report commonly
includes information regarding the consumer's character, general
reputation, personal characteristics and mode of living. It also includes
verification of residence, marital status and occupation. I understand that
I may request a copy of the report upon its completion and that I may ask
to be interviewed in conjunction with the preparation of the report by
contacting ANLIC.
NOTE FOR NEW JERSEY AND WEST VIRGINIA RESIDENTS: I also understand that
none of the information collected concerning my sexual orientation will be
used to determine my eligibility for insurance.
NOTE FOR VERMONT RESIDENTS: I do not authorize ANLIC to obtain or forward
any test result to any non-affiliated company. ANLIC will not release any
information relating to previously administered tests for HIV antibodies,
T-cell counts, AIDS or ARC. AIDS means Acquired Immune Deficiency Syndrome.
ARC means AIDS Related Complex.
26. SUBSTITUTE W-9 CERTIFICATION
I certify under penalty of perjury that: 1) the number shown on this form
is my correct taxpayer identification number (or I am waiting for a number
to be issued to me); and 2) I am not subject to backup withholding because:
a) I am exempt from backup withholding; or b) I have not been notified by
the Internal Revenue Service that I am subject to backup withholding as a
result of a failure to report all interest or dividends; or c) the IRS has
notified me that I am no longer subject to backup withholding.
You must cross out item 2 if you have been notified by the IRS that you are
currently subject to backup withholding because of underreporting interest
or dividends on your tax return.
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION
OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP
WITHHOLDING.
27. SIGNATURES
I represent to the best of my knowledge and belief that all statements and
answers to this application are complete and true.
Dated at____________________________________________ On this Date _________________________________
City State
X _____________________________ X ________________________________________________________________
Signature of Insured Signature of Owner (if corporation or trust please show full name)
X________________________________________________________________________
Signature(s) and Title or Officer or Trustee(s)
28. AGENT'S/REGISTERED REPRESENTATIVE'S STATEMENT
Do you have any knowledge or reason to believe that replacement of existing
life insurance or annuity coverage may be involved?
/ / Yes / / No
I certify that: 1) the information provided by the Owner has been
accurately recorded; 2) a current prospectus and all supplements were
delivered; and 3) I have reasonable grounds to recommend the purchase of
the policy as suitable for the Owner.
X _________________________________________________________________________
Signature of Agent/Registered Representative
___________________________________________________________________________
Print Name Here ANLIC Agent Code Agency or Broker/Dealer
Page 7 of 7 Pages
8
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29. MEDICALS Should be arranged by Agent/Registered Representative.
Indicate requirements being arranged per ANLIC published rules:
Resting Stress
Examination Urine Blood EKG EKG Inspection MVR
Insured [ ] [ ] [ ] [ ] [ ] [ ] [ ]
Give name of examiner
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Did you see Insured on the application date? [ ] Yes [ ] No
Are you applying for preferred rates? [ ] Yes [ ] No
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30. POLICY DELIVERY If not completed, policy will be mailed to Representative.
Send to: [ ] Owner [ ] Agent/Registered Representative
AGENT/REGISTERED REPRESENTATIVE REMARKS AND SPECIAL INSTRUCTIONS:
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Third Party Administrator:
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31.QUESTIONS??
If ANLIC has questions concerning this application, whom should we call at your office?
at ( )
--------------------------------------------------------------------------------------------- --------------------------
Name (Please Print)
FAX: ( )
------------------------
If you have questions completing this application or any other supporting documentation, please call: 1-888-837-6791.
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32.MAIL APPLICATION TO:
Acacia National Life Insurance Company OVERNIGHT DELIVERIES:
P.O. Box 82579 Acacia National Life Insurance Company
Lincoln, NE 68501-2579 5900 "O" Street
FAX#: 402-467-6153 Lincoln, NE 68510
Mail original to above address
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9
REGISTERED REPRESENTATIVE REPORT
1. Purpose of Insurance:
[ ] Buy/Sell [ ] Key Person [ ] Other [ ] Deferred Compensation (pure deferral)
[ ] Estate [ ] Split Dollar [ ] SERP (Supplemental Executive Retirement Plan)
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2. Business Type:
[ ] Sole Proprietorship [ ] Special Corporation [ ] Partnership [ ] Corporation
3. Fair Market Value of Business: $
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4. Is there information not given elsewhere which might affect the insurability of any person(s) intended for coverage?
[ ] Yes [ ] No
Explain Yes Answer
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5. How long have you known Proposed:
Insured?
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Applicant?
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6. Are you related to Proposed Insured or Applicant? [ ] Yes [ ] No
7. Existing TAG Account? #
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8. Is this personal business (self or immediate family) for Registered Representative(s) receiving credit? [ ] Yes [ ] No
9. Credit business to:
- ----------------------------- -------------------------- ------------------------------------ -------
AGENCY# REGISTERED REPRESENTATIVE %
- ----------------------------- -------------------------- ------------------------------------ -------
AGENT OF RECORD:
- ----------------------------- -------------------------- ------------------------------------ -------
ADDITIONAL AGENT(S):
- ----------------------------- -------------------------- ------------------------------------ -------
- ----------------------------- -------------------------- ------------------------------------ -------
- ----------------------------- -------------------------- ------------------------------------ -------
- ----------------------------- -------------------------- ------------------------------------ -------
- ----------------------------- -------------------------- ------------------------------------ -------
Broker Dealer or Name Code:
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Registered Representative's Signature
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10
**** IMPORTANT ****
THIS NOTICE MUST BE DETACHED AND LEFT WITH YOUR CLIENT IN ALL CASES.
NOTICE OF ACACIA NATIONAL LIFE INSURANCE
COMPANY'S (ANLIC) INSURANCE INFORMATION PRACTICES
To issue an insurance policy, we need to obtain information about you and any
other persons proposed for insurance. Some of that information will come from
you and some will come from other sources. That information and any subsequent
information collected by us may in certain circumstances be disclosed to third
parties without your specific authorization.
All insured persons have a right of access and correction with respect to the
information collected about himself or herself except information which relates
to a claim, or civil or criminal proceeding.
If you wish to have a more detailed explanation of our information practices,
please contact: ANLIC, Underwriting Department, P.O. Box 82579, Lincoln, NE
68501-2579.
In an effort to provide better service and products to you, ANLIC may use
information given by you to develop marketing data. Your name will not be
associated with this data in any way. If you do not want us to use information
obtained from you for these purposes, please contact us within ten (10) days. We
need to know within 10 days because once the information is separated from your
application, we will be unable to personally identify the information with you
or your application. The address at which to contact us is: ANLIC, P.O. Box
82579, Lincoln, NE 68501-2579.
Two of our sources of information about you are MIB, Inc. (Medical Information
Bureau) and Investigative Consumer Reports. The following paragraphs describe
these sources.
MIB, INC. (MEDICAL INFORMATION BUREAU)
Information regarding the Insured's insurability will be treated as
confidential. We or our reinsurers may, however, make a brief report thereon to
MIB, Inc., a non-profit membership organization of life insurance companies
which operates an information exchange on behalf of its members. If any of the
Insured(s) 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.
Upon receipt of a request from any Insured (or the Parent or Guardian, if
juvenile), the Bureau will arrange disclosure of any information it may have in
the Insured's file. If there is a question as to the accuracy of information in
the Bureau's file, the Bureau may be contacted to 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 P.O. Box 105, Essex
Station, Boston, MA 02112, telephone number (617) 426-3660.
We or our reinsurers may also release information in our file to other life
insurance companies to whom the Insured may apply for life or health insurance
or to whom a claim for benefits may be submitted.
INVESTIGATIVE CONSUMER REPORTS
Depending on the size of policy applied for, we may request that an
investigative consumer reports about the Insured be given to us. It will be
conducted by a national organization skilled in obtaining information about
people.
The kind of information we may be seeking includes such facts as residence
verification, marital status, occupation, general reputation, personal
characteristics and mode of living. It will be obtained through personal
interviews with the Insured's friends, neighbors, associates and other
acquaintances. Inquiries will not be directed toward determining the Insured's
sexual orientation. Also, no adverse underwriting decision will be made because
a report shows that an Insured has demonstrated AIDS-related concerns or has
sought AIDS-related counseling. AIDS test results received at anonymous
counseling and testing sites are confidential and need not be disclosed. Any
AIDS testing is limited to FDA-licensed blood tests and the diagnosis of AIDS
must be made by a member of the medical profession.
An Insured may ask to be interviewed in connection with the preparation of the
report by contacting us within 5 working days of applying for the insurance
requested. He or she may call us collect at the following number and ask for the
Underwriting Department: (402) 467-1122.
ADVERSE UNDERWRITING DECISION
After review of the application submitted on the Insureds, if the policy cannot
be issued as applied for, we will provide the specific reasons for this decision
upon written request from the applicant. Send your written request to the
Underwriting Department at the address above.
MEDICAL AUTHORIZATION
The medical authorization on the application, or a photocopy of it, shall remain
valid for use by ANLIC for the duration of any claim for benefits.
11
CONDITIONAL RECEIPT
1. NO COVERAGE WILL BECOME EFFECTIVE PURSUANT TO THIS CONDITIONAL RECEIPT
UNLESS AND UNTIL ALL OF THE FOLLOWING CONDITIONS HAVE BEEN SATISFIED
COMPLETELY AND EXACTLY:
a) The amount of payment received with this application must be equal to
the full initial modal premium for the amount and plan of life
insurance applied for and effective at the time of delivery of the
policy.
b) All medical examinations, tests and related data required by the
Company must be completed and received at its Service Center in
Lincoln, Nebraska within sixty (60) days from the completion of this
application.
c) As of the effective date below, each person proposed for insurance in
this application must be insurable in accordance with Company rules,
limits, and standards for the plan and the amount applied for without
any modifications either as to plan, amount, riders and/.or the rate
of premium paid.
d) As of the effective date, the state of health and all factors
affecting the insurability of each person proposed for insurance must
be as stated in this application.
2. IF THE CONDITIONS OF PARAGRAPH 1 ARE SATISFIED ON THE EFFECTIVE DATE,
INSURANCE COVERAGE WILL BE PROVIDED PURSUANT TO THIS CONDITIONAL RECEIPT ON
THE SAME TERMS AND CONDITIONS AS THE POLICY APPLIED FOR AND IN USE ON THE
EFFECTIVE DATE. HOWEVER, THE AMOUNT OF SUCH INSURANCE WILL BE IN AN AMOUNT
NOT TO EXCEED THAT SPECIFIED IN PARAGRAPH 3. "EFFECTIVE DATE" AS USED
HEREIN IS THE LATEST OF:
a) The date of the application, Part 1; or
b) The date of the completion by Insureds of all medical examinations or
tests required by the Company; or
c) The date, if any, specifically requested in the application.
3. THE MAXIMUM TOTAL AMOUNT OF INSURANCE WHICH WILL BE PAYABLE PURSUANT TO ALL
CONDITIONAL RECEIPTS RECEIVED BY THE APPLICANT AS A RESULT OF PENDING
APPLICATIONS WITH THE COMPANY AND AFFILIATED COMPANIES IS LIMITED TO THE
SMALLER OF:
a) The total amount of insurance applied for with the Company and
affiliated Companies; or
b) $250,000 minus the total amount of insurance in force with the Company
and affiliated Companies, but not less than zero.
As used above, total amount of insurance includes any amounts payable under
any Accidental Death Benefit provision.
If one or more of the conditions in paragraph 1 on any insured have not
been satisfied completely and exactly, there shall be no liability on the
part of the Company pursuant to this Conditional Receipt except to return
the applicable premium paid for coverage on that insured.
4. ANY INSURANCE IN EFFECT PURSUANT TO THIS CONDITIONAL RECEIPT WILL END AT
THE EARLIEST OF:
a) The date notice is mailed that the application is not accepted; or
b) At the end of sixty (60) days from the date of this Conditional
Receipt; or
c) The date on which coverage under the policy applied for becomes
effective.
Note: Condition 4 (b) does not apply to Connecticut residents.
NO AGENT OR ANY OTHER PERSONS IS AUTHORIZED BY THE COMPANY TO WAIVE OR
MODIFY ANY OF THE PROVISIONS OF THIS CONDITIONAL RECEIPT.
ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO THE INSURANCE COMPANY. DO NOT
MAKE CHECKS PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK.
Received the sum of $ __________________ from ________________________________
in connection with the application for life insurance bearing the same date as
this Conditional Receipt.
Dated at __________________________________ this ______ date of
______________________, 20 ____.
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Signature of Agent/Registered Representative
I acknowledge possession of this receipt. I certify that I have read it and the
terms in the Application. I also certify that the Agent/Registered
Representative has explained the provisions in paragraph 3, other terms of this
Conditional Receipt and the terms in the Application to me and that I understand
and accept them.
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Signature of Owner