Exhibit 1(10)(b)
APPLICATION TO
Mutual of America Life Insurance Company
320 Park Avenue New York NY 10022-6839
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PAYROLL DEDUCTION
VARIABLE UNIVERSAL LIFE INSURANCE
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Please complete a separate application for each Proposed Insured Other than
Dependents covered under the Children's Term Rider. Items 7-15, on next page,
will only be used in connection with applications for coverage that are not
eligible for or are in excess of guaranteed issue amounts.
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1. EMPLOYEE INFORMATION
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a. Full Name: First Middle Last b. Social Security Number: c. Date of Hire: d. Annual Salary:
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2. PROPOSED INSURED'S INFORMATION 3. COVERAGE INFORMATION
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a. Proposed Insured: [_] Employee [_] Spouse [_] Dependent Child a. Policy Type: [_] Face Amount Plan [_] Face Amount Plus Plan
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b. Full Name: First Middle Last b. Initial Amount of Insurance: $ ___________________
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c. Date of Birth d. Sex e. Height f. Weight c. Scheduled Premium: $ _______________ Per Pay-Period
Month Day Year [_] Male [_] Female ft. in. lbs.
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g. Place of Birth: d. Additional Benefits by Rider: (Check box if desired)
- ---------------------------------------------------------------- [_] Children's Term per child in $1,000 [_] Accidental Death
h. Social Security Number: i. Home Phone Number: increments (max $5,000): $___________ $ ___________
( )
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j. Home Address: e. Children to be covered under Children's Term Rider:
Street __________________________________________________ (For additional children, use REMARKS section on the next
City ________________________ State ________ Zip ________ page.)
________________________________________________________________ Name Date of Birth
k. Has the proposed insured smoked _____________________________________ /_____/__________
cigarettes within the last 12 months? [_]Yes [_]No _____________________________________ /_____/__________
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l. Occupation: m. Activity at work? Beneficiary for Children's Term Rider is the Insured.
[_]Yes [_]No
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4. BENEFICIARY INFORMATION (If additional space is needed, use REMARKS section
on the next page.)
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a. Beneficiary Type: [X] Primary a. Beneficiary Type: [_] Primary [_]Contingent
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b. Relationship: [_] Spouse [_] Child [_] Parent [_] Estate b. Relationship: [_] Spouse [_] Child [_] Parent [_] Estate
[_] Other ___________________________________________________ [_] Other ________________________________________________
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c. Full Name: First Middle Last c. Full Name: First Middle Last
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d. Social Security or Tax ID Number: e. Benefit Percentage: d. Social Security or Tax ID Number: e. Benefit Percentage:
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a. Beneficiary Type: [_] Primary [_] Contingent a. Beneficiary Type: [_] Primary [_] Contingent
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b. Relationship: [_] Spouse [_] Child [_] Parent [_] Estate b. Relationship: [_] Spouse [_] Child [_] Parent [_] Estate
[_] Other _____________________________________________ [_] Other _____________________________________________
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c. Full Name: First Middle Last c. Full Name: First Middle Last
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d. Social Security or Tax ID Number: e. Benefit Percentage: d. Social Security or Tax ID Number: e. Benefit Percentage:
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5. POLICY OWNER INFORMATION (Complete only if other than the 6. EMPLOYER INFORMATION
insured)
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a. Policy Owner: [_] Employee [_] Spouse [_] Dependent Child a. Employer's Name:
[_] Other _______________________________________________ ----------------------------------------------------------------
- ---------------------------------------------------------------- b. Employer Identification No.:
b. Full Name: First Middle Last (to be obtained from employer)
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c. Address: c. Address:
Street _________________________________________________ Street __________________________________________________
City ___________________________________________________ City ___________________State_______________Zip__________
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d. Social Security or Tax ID Number: e. Home Phone Number: For Home Office Use Only
( )
- ---------------------------------------------------------------- Approved for: [_] Guaranteed Issue [_] Simplified Issue
f. Contingent Owner. Special Notes: __________________________________________
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Please answer all questions below for the Proposed Insured named in Section 2.
Give details to the "Yes" answers to items 7-15 in the REMARKS section on this
form.
Yes No
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7. Has the Proposed Insured been hospitalized at any time within the last six months? [_] [_]
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8. Has the Proposed Insured missed more than five consecutive days of work due
to accident or illness within the last six months? [_] [_]
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9. Is the Proposed Insured currently disabled? [_] [_]
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10. Has the Proposed Insured ever been treated for, or been told by a physician
that he or she has, a life-threatening illness? [_] [_]
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11. Has the Proposed Insured ever been treated for, or currently have, any of
the following:
a. Any disorder of the Heart, Circulation or Blood Pressure, or any Chest
Pain or Blood Disease? [_] [_]
b. Any disorder of the Respiratory, Nervous, Digestive, Kidney, Liver,
Urinary Tract or Reproductive Systems? [_] [_]
c. Cancer, Tumor, Diabetes, Ulcers, Epilepsy, Emotional or Mental
Disorder, any disease or abnormality of the brain, Drug Addiction or
Alcoholism? [_] [_]
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12. Has the Proposed Insured ever been treated for, or been told by a
physician that he or she has, AIDS? [_] [_]
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13. Has the Proposed Insured received any medical or surgical advice or
treatment for any ailment, injury or sickness during the last five years
other than listed above? [_] [_]
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14. Is the Proposed Insured presently taking any mediation? If "Yes," give name
of mediation, dosage, duration and the reason for taking such mediation. [_] [_]
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15. 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? [_] [_]
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REMARKS (Attach addition 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.
16. ALLOCATION OF PREMIUMS
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 INVESTMENT 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 Equity Mid-Cap Equity Scudder
Fund % Fund % Index Fund % Capital Growth Fund %
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FIDELITY Scudder Bond Fund %
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Fidelity VIP II Fidelity VIP Fidelity VIP II Scudder
Asset Manager Fund % Equity-Income Fund % Contrafund % International Fund %
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17. REPLACEMENT
a. Does the Proposed Insured have any other life insurance in force or
applied for? [_] Yes [_] No If "Yes," Amount $ ________________
b. Does the Policy Owner have any other life insurance in force or applied
for? [_] Yes [_] No If "Yes," Amount $ _________________
c. Is the policy applied for intended to replace another contract/policy?
[_] Yes [_] No
If "Yes," Company ______________________________________________________
Contract/Account Number _______________________________ Amount $________
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
areporting agency from whom you may receive and inspect a copy of such report by
contacting them.
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) 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; and (3) 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 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.
I, THE PROPOSED INSURED AND THE POLICY OWNER, UNDERSTAND that the coverage shall
be in effect only after all of the following conditions have been met: (1) this
application has been approved by the Company; (2) the policy has been issued
while all persons to be insured thereunder are alive; and (3) the answers and
statements in this application continue to be true and complete up until the
Policy Date and that coverage will not take effect if the facts have changed. If
some or all of the amount of insurance applied for with this application is
eligible for guaranteed issue, coverage on such amount shall be in effect on the
date this application is signed.
I, THE PROPOSED INSURED, AUTHORIZE any physician, medical practitioner,
hospital, clinic, medically related facility, insurance company, the Medical
Information Bureau (MIB) or other organization, institution or person that has
any information in its records concerning me to give the Company and its
reinsurers any such information to use for underwriting insurance. 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, ACKNOWLEDGE receipt of the Notice of Disclosure of
Information and Investigative Consumer Report Notice.
Date________________ City________________________________ State_________________
Employee's Signature (required) ________________________________________________
Proposed Insured's Signature (if other than Employee) __________________________
Policy Owner's Signature (if other than Insured)________________________________
CONSULTANT'S REPORT - To the best of your knowledge is the insurance applied for
intended to replace insurance or annuity in force in this or any other company?
[_] Yes [_] No If "Yes," give company name_____________________________________
Authorized Company Representative's Signature___________________________________
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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.