Exhibit 1(10)(a)
PART I OF APPLICATION TO
Mutual of America Life Insurance Company
320 Park Avenue New York NY 10022-6839
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If conversion from group life insurance, only complete questions 1, 2 and 10-18
of Part I.
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1a. Proposed Insured's Name (Print) b. Sex
First Middle Last M F
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c. Date of Birth d. Place of Birth
Mo. Day Year
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e. Social Security No.
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2. Proposed Insured's Home Address
Street
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City State Zip
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Home Telephone No. ( )
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How long at above address?
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If less than 3 years, provide former residences in remarks.
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3a. Proposed Insured's Occupation b. Proposed Insured's Duties
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4. Employer's Name and Address:
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Employer Identification Number:
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Telephone No.( )
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If less than 3 years, provide information about former employer in remarks.
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5. Has the Proposed Insured smoked cigarettes in the past 12 months?
Yes [_] No [_]
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6. Has the Proposed Insured ever had a life or health insurance policy
declined, or rated, withdrawn an application, or been required to pay extra
premium or accept a policy modification? If "Yes," explain in remarks.
Yes [_] No [_]
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7. Does the Proposed Insured plan to live or travel outside the United States
and Canada within the next 12 months? If "Yes," explain in remarks.
Yes [_] No [_]
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8. Does the Proposed Insured plan to fly an aircraft, glider, balloon or like
device? Within the last 2 years has the Proposed Insured flown as a student
pilot, pilot or crew member? Has the Proposed Insured had any other duties
aboard an aircraft, gilder, balloon or like device while in flight? If
"Yes," complete Aviation Questionnaire.
Yes [_] No [_]
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9 Does the Proposed Insured engage, plan to engage, or has he or she engaged
in the last 2 years, in: (1) skin or scuba diving; (2) motor vehicle or
motorcycle racing; (3) skydiving or hang gliding? If "Yes," complete
Avocation and Sports Questionnaire.
Yes [_] No [_]
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10. Basic Coverage
[_] Variable Universal Life
[_] Face Amount Plan [_] Face Amount Plus Plan
Scheduled Premium $ Per
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[_] ____ Year Term
[_] Whole Life
[_] Automatic Premium Loan
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11. Initial Amount of Insurance 12. Amount Paid with Application
$ $
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13. Additional Benefits By Rider: (If available on policy applied for) (Check
box if desired)
[_] Waiver of Premium
[_] Accidental Death $ (amount)
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[_] Preliminary One Year Term (conversion only)
[_] Other:
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14. Mode of Premium Payment: (If available)
[_] Annual [_] Semiannual
[_] Quarterly [_] Monthly [_] PAC
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15.a. Beneficiary Type: [X] Primary
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b. Relationship: [_] Spouse [_] Child [_] Parent [_] Estate
[_] Other
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c. Full Name First Middle Last
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d. Social Security or Tax ID Number: e. Benefit Percentage:
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16.a. Beneficiary Type: [_] Primary [_] Contingent
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b. Relationship: [_] Spouse [_] Child [_] Parent [_] Estate
[_] Other
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c. Full Name First Middle Last
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d. Social Security or Tax ID Number: e. Benefit Percentage:
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If additional beneficiaries, use REMARKS section.
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17. Policy Owner: [_] Proposed Insured [_] Other(Complete below)
Full Name:
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Address:
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Telephone No. ( )
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S.S. or Tax ID Number
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Relationship to Proposed Insured
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Contingent Owner
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18. Send Premium Notices To: [_] Insured [_] Policy Owner
[_] Other (complete below)
Full Name:
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Address:
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REMARKS (Attach additional sheets, if additional room in answering questions
is necessary. Please sign and date any attachments.)
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PLEASE NOTE that the Variable Universal Life policy has an Accelerated Death
Benefit. A one-time administrative fee of $250 is charged when an
Accelerated Death Benefit is paid. RECEIPT OF ACCELERATED DEATH BENEFITS MAY
AFFECT ELIGIBILITY FOR PUBLIC ASSISTANCE PROGRAMS AND MAY BE TAXABLE.
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19. ALLOCATION OF PREMIUMS (Complete only if applying for Variable Universal
Life.)
Until the date that the policy is issued, premiums will be placed in the
Interest Accumulation Account. On the date that the policy is issued, this
amount, including interest, and all subsequent premiums, unless otherwise
elected, will be allocated according to your designation shown below.
Show the percentage of your future contributions you want to place in the
interest account and/or investment funds. Use whole numbers only, and make
sure the percentages total 100%.
Amounts you place in the interest account will be credited with the rate of
interest currently applicable to that account. Amounts allocated to any
investment fund are not guaranteed and will fluctuate to recognize
investment results.
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INTEREST ACCOUNT INVESMENT FUNDS
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MUTUAL OF AMERICA MUTUAL OF AMERICA AMERICAN CENTURY
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Interest Money Market All America Equity Index American Century
Accumulation Fund Fund Fund VP Capital
Account Appreciation Fund %
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% % % % CALVERT
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Short-Term Mid-Term Bond Calvert Social
Bond Fund Bond Fund Fund Balanced Fund %
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% % % SCUDDER
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Composite Aggressive Mid-Cap Equity
Fund Equity Fund Index Fund Scudder
Capital Growth
% % % Fund %
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FIDELITY Scudder
----------------------------------------------------------------- Bond
Fidelity VIP II Fidelity VIP Fidelity VIP II Fund %
Asset Manager Equity-Income Contrafund ------------------------
Fund Fund Scudder
International
% % % Fund %
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20. REPLACEMENT (Must be completed)
A. Does the Proposed Insured have any other life insurance in force or
applied for? [ ]Yes [ ]No If "Yes," Amount $
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B. Does the Policy Owner have any other life insurance in force or applied
for? [ ]Yes [ ]No If "Yes," Amount $
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C. Is the policy applied for intended to replace another contract/policy?
[ ]Yes [ ]No
If "Yes," Company
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Contract/Account Number Amount $
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It is represented that the statements and answers given in this application are
true, complete, and correctly recorded to the best of the Proposed Insured's and
Policy Owner's knowledge and belief.
It is agreed that: (1) This entire application shall be the basis for any policy
issued; (2) Any policy issued shall not take effect unless and until the first
full premium is paid and the policy is delivered to the Policy Owner during the
lifetime and continued insurability of the Proposed Insured as stated in this
application, except as otherwise provided in the conditional receipt with the
same number as this application; (3) No information acquired by any
representative of Mutual of America Life Insurance Company (the Company) shall
be binding upon the Company unless set out in writing in this application; (4)
No waiver or modification shall be binding upon the Company unless in writing
and signed by the President or a Vice President and the Secretary or an
Assistant Secretary.
I, the Proposed Insured, authorized 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 having any records or knowledge of me or my health to give
the Company or its reinsurers any and all information. The Company may release
information obtained to MIB, reinsuring companies, other persons or
organizations performing business or legal services in connection with my
application. The Company may release information, as required by law, or as I
may authorize. I understand and agree to the following: (1) this Authorization
is valid for two and one-half years from this application date; (2) a photocopy
is as valid as the original; and (3) a copy is available to the person to be
insured upon request.
I, the Proposed Insured, further authorize the Company to procure an
investigative consumer report if they deem it necessary to the determination of
my insurability.
I, the Proposed Insured, acknowledge receipt of the Notice of Disclosure of
Information and Investigative Consumer Report Notice.
If Variable Universal Life insurance is applied for, I, the Policy Owner,
acknowledge that: (1) I have received a copy of the current Prospectus; (2) I
have read the Prospectus and understand its terms; (3) I am familiar with the
objectives of the Investment Funds; (4) My election or authorization made under
the policy as part of this application is subject to the conditions and
limitations set forth in the Prospectus; and (5) I have determined that the
policy applied for above is suitable to my investment objectives and my
financial situation. Variable Universal Life Insurance is a flexible premium
adjustable life insurance policy. The anticipated coverage of life insurance
applied for under this form is to provide coverage for the lifetime of the
insured. The anticipated Premiums payable for life are:
Initial Premium* $ Scheduled Premium $ per
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* If the Initial Premium to be paid at issue is not shown, the source of such
payment will be:
Cash Value of other insurance policy(s) Other: Est.Amount $
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Signed at on , of the year
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City State
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Witness (Authorized Company Representative) (Proposed Insured)
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Policy Owner (if other than Proposed Insured)
NON-MEDICAL FORM (Do Not Complete This Part If Medical Examination Is Required)
PART II OF APPLICATION TO
MUTUAL OF AMERICA LIFE INSURANCE COMPANY
320 PARK AVENUE NEW YORK NY 10022-6839
NOTE: THIS PART II MUST BE COMPLETED AND SIGNED BEFORE AN AUTHORIZED COMPANY
REPRESENTATIVE
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1. PROPOSED INSURED
Print Full Name 2. Height_____ft.___in. Weight______lbs.
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CIRCLE APPLICABLE ITEMS AND GIVE DETAILS OF "YES" ANSWERS IN REMARKS.
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3. To the best of your knowledge and belief, do you, the Proposed Insured, Yes No
have, or have you ever had, or been treated for:
a. Disorder of eyes, ears, nose, or throat?................................... [_] [_]
b. Convulsions, paralysis, or mental or nervous disorder?..................... [_] [_]
c. Pleurisy, asthma, emphysema, tuberculosis, or other disorder of the
respiratory system?........................................................ [_] [_]
d. Chest pain, high blood pressure, murmur, heart attack, or other disorder
of the heart or blood vessels?............................................. [_] [_]
e. Intestinal bleeding, ulcer, hernia, colitis, diverticulitis, or other
disorder of the stomach, intestines, liver, or gallbladder?................ [_] [_]
f. Sugar, albumin, blood or pus in urine; venereal disease; stone or other
disorder of kidney, bladder, prostate, or reproductive organs?............. [_] [_]
g. Diabetes, thyroid or other endocrine disorders?............................ [_] [_]
h. Arthritis, gout, or disorder of the muscles or bones?...................... [_] [_]
i. Tumor, cancer, or disorder of skin or lymph glands?........................ [_] [_]
j. Allergies, anemia, or other disorder of the blood?......................... [_] [_]
k. Any other mental or physical disorder not listed above?.................... [_] [_]
l. Any abnormality of menstruation, pregnancy, or disorder of the
reproductive organs or breasts?............................................ [_] [_]
m. Are you now pregnant?...................................................... [_] [_]
n. Are you now under regular observation or taking treatment?................. [_] [_]
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4. Within the past 5 years, have you: Yes No
a. Had a checkup, consultation, illness, injury, or operation?................ [_] [_]
b. Been a patient in a hospital, clinic, or other medical facility?........... [_] [_]
c. Had an electrocardiogram, X-ray, or other diagnostic test?................. [_] [_]
d. Been advised to have any diagnostic test, hospitalization, or surgery which
was not completed?......................................................... [_] [_]
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5. Within the past 10 years, have you used:
a. Amphetamines, barbiturates, or sedatives except as prescribed Yes No
by a physician?............................................................ [_] [_]
b. Cocaine, heroin, morphine, LSD, marijuana, PCP, or any other hallucinogenic
or narcotic drug?.......................................................... [_] [_]
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Yes No
6. a. Has your weight changed more than 15 pounds in the past year?.............. [_] [_]
b. Have you ever received treatment or joined an organization for alcoholism
or drug addiction?......................................................... [_] [_]
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Yes No
7. Have you smoked cigarettes in the last 12 months?............................. [_] [_]
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Yes No
8. Have you ever been treated for, or been told by a physician,
that you have AIDS?........................................................... [_] [_]
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REMARKS
Details of "Yes" answers. Identify question. (Include diagnoses, dates, duration
and names and addresses of all attending physicians and medical facilities. If
more room is needed, attach additional sheets. Please sign and date any
attachments.)
I represent that the statements and answers given above are true, complete and
correctly recorded, to the best of my knowledge and belief. To the extent
permitted by law, I expressly waive all provisions of law prohibiting any
physician, hospital official or employee, or other person who has attended or
examined me, or who has been consulted by me, from disclosing any knowledge or
information thereby acquired and from testifying with reference thereto. I
expressly authorize such person to make such disclosures.
Signed at on ,of the year
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Witness
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Signature of Authorized Company Representative Signature of Proposed Insured
REPORT BY AUTHORIZED COMPANY REPRESENTATIVE
The questions in this report must be completed to permit consideration of the
application.
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ADDITIONAL QUESTIONS RELATING TO PROPOSED INSURED
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1.a. To the best of your knowledge is replacement involved? If "Yes," complete
Comparison/Disclosure Statement, as required..................[_]Yes [_]No
b. Details of life insurance to be replaced.
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Year
Insurer Amount Plan Taken
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2. Has the Proposed Insured been given the "Investigative Consumer Report
Notice" and the "Notice of Disclosure of Information"? If "No," explain
and give details in Remarks...................................[_]Yes [_]No
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3. How long have you known the Proposed Insured?
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a. Is s/he [_] single [_] married [_] divorced [_] widowed
b. Is s/he related to you or your spouse?........................[_]Yes [_]No
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4. Financial Status:
Average earned monthly income: $
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Other income: $ per month Source
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5.a. Did the Proposed Insured come to you for coverage?............[_]Yes [_]No
b. Do you know of any information not given in the application which might
affect the insurability of the person to be covered?..........[_]Yes [_]No
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6. If Proposed Insured is married:
Full maiden name, if applicable
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7. Questions Relating to Policy Owner Of Life Insurance: (Complete if Policy
Owner is other than the Proposed Insured) Policy Owner has insurable
interest in Proposed Insured because of relationship to Proposed Insured
as-
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If a corporation:
Title or position of Proposed Insured -
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If Proposed Insured is an officer, are all of the remaining officers
applying for insurance at this time? .........................[_]Yes [_]No
If "No," explain why in REMARKS.
If a Partnership:
Is Proposed Insured a partner? .............................[_]Yes [_]No
If "No," give relationship of Proposed Insured to the partnership in
REMARKS.
If Proposed Insured is a partner, are all of the remaining partners
applying for insurance at this time ..........................[_]Yes [_]No
If "No," explain why in REMARKS. If a Trustee, the Company requires a copy
of the agreement before any policy can be issued.
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8. If a Variable Universal Life policy is applied for, has the Policy Owner
completed an "Additional Information For Purchase of a Variable Contract"
form? .......................................................[_] Yes [_]No
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9. SPACE FOR CALCULATION OF PREMIUMS:
INSURING AGE
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(For Variable Universal Life use last birthday; for Term Insurance use
nearest birthday)
Total Premium $
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Be sure to include all rider premiums, if any.
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This report must be signed by each authorized company representative who has an
interest in this application. Unless otherwise indicated, each signing
authorized company representative shall have an equal interest. Each authorized
company representative must be currently licensed in the state in which the
application is signed.
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Authorized Company Representative
CONDITIONAL RECEIPT
Mutual of America Life Insurance Company (the Company) has received from
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[ ] a payment of $ __________ for the insurance applied for with the
application having the same number as this receipt.
[ ] an authorization for payment of premiums by salary deduction for the
insurance applied for with the application having the same number as this
receipt.
This receipt is not valid unless it is signed by an authorized representative of
the Company. This receipt is not valid unless the amount paid with the
application, if paid by check or draft, is honored on first presentation for
payment, or the authorization for payment of premiums remains in effect until
the first premium is transmitted to the Company.
IMPORTANT: The payment is received subject to the conditions on the other side
of this receipt. This receipt does not provide any insurance until
its conditions are met.
Dated at _________________________ on ________________, of the year ___________
Authorized Company Representative _________________________
If you do not hear from the Company regarding the proposed insurance within 30
days, notify the Company. Give the name of the company representative, date and
amount paid, and the number of this receipt. If you are not issued a policy
within 60 days, the application shall be deemed rejected, and we will refund all
premiums to you.
THIS RECEIPT IS TO BE USED ONLY IF PAYMENT IS MADE AT THE TIME THE
APPLICATION IS SIGNED; OTHERWISE IT MUST NOT BE DETACHED.
NOTICE OF DISCLOSURE OF INFORMATION
Information given in your application may be made available to other insurance
companies to which you make application for life or health insurance coverage or
to which a claim is submitted.
The information which you provide will be treated as confidential except MUTUAL
OF AMERICA LIFE INSURANCE COMPANY or its reinsurers may make a brief report
thereon to the Medical Information Bureau. The Bureau is a nonprofit membership
organization of life insurance companies which operates an information exchange
on behalf of its members. Upon request by another member insurance company to
which you have applied for life or health insurance coverage or to which a claim
is submitted, the Bureau will furnish such company with the information it may
have in its files.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. If you question the accuracy of
information in the Bureau's file, you may contact the Bureau and seek a
correction in accordance with the procedures set forth in the Federal Fair
Credit Reporting Act. The address of the Bureau's information office is Post
Office Box 105, Essex Station, Boston, Massachusetts 02112, telephone number
(617) 426-3660.
Mutual of America Life Insurance Company or its reinsurers may also release
information in its file to its reinsurers or to other life insurance companies
to which you may apply for life or health insurance, or to which a claim may be
submitted.
IMPORTANT: This conditional receipt does not provide any insurance until after
its conditions are met.
The payment or authorization for payment of premiums is received subject to the
following conditions:
(A) 1. If the first medical examination required by the Company's
published underwriting rules is completed; and
2. If the Company is satisfied that, at the time of completing the
application, each person to be covered was insurable under the
Company's rules for standard insurance on the policy in the amount and
plan applied for in the application.
Then, but only after these conditions are met, the policy applied for shall
be effective from the date of the last requirement or the date requested in
the application, whichever is the latest, regardless of any change of
insurability of each person to be covered occurring after fulfilling all
the initial requirements. If less than the full first premium has been paid
for such policy, it shall remain in effect only for the fraction of one
year that the payment made for such policy bears to the annual premium for
such policy.
The Company shall not be required to make insurance effective for an
amount, on each person to be covered, which would exceed the following
limits: (a) $150,000 of life insurance if such person is age 16 to 65,
$100,000 at all other ages; and (b) $50,000 of benefits for death by
accident.
Any insurance applied for as alternate or additional to the plan and amount
of insurance applied for in the application shall not become effective
under the conditional receipt.
(B) If the conditions of (A) are met for the insurance applied for in the
application, except that if any person to be covered is not insurable under
the Company's rules for benefits for disability or accidental death as
applied for, the life insurance, and any portion of such benefits for which
the Proposed Insured is insurable under the Company's rules, shall be
effective as provided in (A).
Except as provided in this conditional receipt, any policy issued by the Company
shall not take effect unless the full first premium is paid and the policy is
delivered to the Policy Owner during the lifetime of each person to be covered
by such policy, and all of the statements and answers given in the application
continue to be true and complete to the best of the Proposed Insured's (and
Policy Owner's) knowledge and belief as of the date of delivery of the policy.
Neither the company representative nor the medical examiner is authorized to
accept risks or pass upon insurability, to make or modify contracts, or to waive
any of the company's rights or requirements.
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INVESTIGATIVE CONSUMER REPORT NOTICE
This is to inform you that, as part of our procedure for processing your
insurance application, an investigative consumer report may be prepared.
Information is obtained through personal interviews with your 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.
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. You will be given the name and address of the consumer
reporting agency from whom you may receive and inspect a copy of such report by
contacting them.