EXHIBIT 10.11
THE INSURED PIERRE GERARD MANSUR
POLICY OWNER MANSUR INDUSTRIES INC
FACE AMOUNT $1,000,000
INITIAL TERM
EXPIRY DATE NOV 9 1994
POLICY NUMBER 93 04; 982
THE EQUITABLE Life Assurance Society of the United States Agrees
/bullet/ To PAY the insurance benefits of this policy to the Beneficiary
upon receiving proof that the Insured died before the Term
Expiry Date; and
/bullet/ To PROVIDE YOU (THE POLICY OWNER) with the other rights and
benefits of this policy.
These agreements are subject to the provisions of this policy.
TEN DAYS TO EXAMINE POLICY - If for any reason you are not satisfied with
your policy, you may cancel it by returning the policy to us within 10 days
after you receive it. If you do, we will refund the premium that was paid.
/s/ RICHARD H. JENRETTE
Richard H. Jenrette, Chairman and Chief Executive Officer
/s/ MOLLY K. HEINES
Molly K. Heines, Vice President and Secretary
Yearly Renewable Term Plan. Insurance payable upon death before Term Expiry
Date. Renewable annually until Final Term Expiry Date shown on Page 3.
Renewal premiums may change subject to guaranteed maximums (see "Premium
Changes" on Page 4). Premiums payable to Term Expiry Date or earlier death.
Conversion Privilege. This is a non-participating policy.
No. 133-54
Contents
Insurance Benefits 2
Term expiry date-Renewal 2
Policy owner and beneficiary 4
Premiums, grace, lapse, premium changes 4
Reinstatement 5
Conversion privilege 5
General provisions 6
Payment options 6
Any additional benefit riders and a copy of the application are at the back of
this policy.
IN THIS POLICY:-
"We ", "our" and "us" mean The Equitable Life Assurance Society of the United
States.
"You" and "your" mean the Owner of the policy at the time an Owner's right is
exercised.
INSURANCE BENEFITS
We will pay the insurance benefits of this policy to the Beneficiary when we
receive proof of the Insured's death.
These insurance benefits include the following amounts, which we will determine
as of the date of the Insured's death:
o the Face Amount of this policy shown on Page 3.
o PLUS any other ) benefits then due from riders
to this policy:
o PLUS or MINUS any adjustment for the last premium.
We will add interest to the resulting amount for the period from the date of
death to the date of payment. We will compute the interest at a rate we
determine but not less than the greater of (a) the rate we are paying on the
date of payment under the Deposit Option of Page 7: or (b) the rate required by
any applicable law.
We will pay these benefits only if premiums have been paid as called for by this
policy.
Payment of these benefits may also be affected by other provisions of this
policy. See Page 6 where we specify our right to contest the policy, what
happens if age or sex has been misstated, and the suicide exclusion. Special
exclusions or limitations (if any) are listed on Page 3.
TERM EXPIRY DATE .- RENEWAL
Term Expiry Date is the Initial Term Expiry Date shown on Page 3 unless the
policy is renewed. If it is renewed, the Term Expiry Date is the next policy
anniversary after the latest renewal. but not later than the Final Term Expiry
Date specified on Page 3.
You may renew this policy on any Term Expiry Date before the Final Term Expiry
Date. To do this you must pay the first premium for the new period on or before
the date it begins or within 31 days after that date. Scheduled and guaranteed
maximum renewal premiums are shown on Page 3. See Page 4 about changes in
scheduled renewal premiums.
THE INSURED PIERRE GERALD MANSUR REGISTER DATE NOV 9, 1993
POLICY OWNER MANSUR INSUDTRIES INC DATE OF ISSUE NOV 9, 1993
FACE AMOUNT $1,000,000 ISSUE AGE, SEX 42, MALE
INITIAL TERM FINAL TERM
EXPIRY DATE NOV 9, 1994 EXPIRY DATE NOV 9, 2051
POLICY NUMBER 93 042 982 BENEFICIARY
MANSUR INDUSTRIES INC EMPLOYER
--------- BENEFITS AND PREMIUMS ----------
BENEFITS SEMI-ANUAL PREMIUM PERIOD PERIOD
LIFE INSURANCE $1,716.00 1 YEAR
THE FIRST PREMIUM IS $1,716.00 AND IS DUE ON OR BEFORE DELIVERY OF THE POLICY.
SUBSEQUENT PREMIUMS ARE DUE ON MAY 9, 1994 IN ACCORDANCE WITH THE ABOVE
PREMIUM TABLE.
---------- SEMI-ANNUAL RENEWAL PREMIUMS ----------
GUARANTEED
RENEWAL SCHEDULED MAXIMUM
DATE RENEWAL RENEWAL
NOV. 9 PREMIUM* PREMIUM
------ ----------- -----------
1994 $ 1,836.00 $ 2,416.00
1995 1,966.00 2,826.00
1996 2,126.00 3,366.00
1997 2,316.00 3,986.00
1998 2,506.00 4,676.00
1999 2,726.00 5,386.00
2000 2,966.00 6,126.00
2001 3,216.00 6,886.00
2002 3,436.00 7,316.00
2003 3,696.00 7,756.00
2004 3,996.00 8,186.00
2005 4,336.00 8,626.00
2006 4,686.00 9,326.00
2007 5,166.00 10,426.00
2008 5,676.00 11,646.00
2009 6,216.00 12,826.00
2010 6,796.00 13,776.00
2011 7,436.00 14,606.00
2012 8,086.00 15,356.00
2013 8,816.00 16,096.00
2014 9,626.00 16,896.00
2015 10,556.00 17,786.00
2016 11,596.00 19,306.00
2017 12,846.00 21,156.00
2018 14,266.00 23,276.00
2019 15,816.00 25,536.00
2020 17,496.00 28,246.00
2021 18,786.00 30,316.00
2022 20,896.00 33,646.00
2023 22,906.00 36,796.00
2024 25,066.00 40,206.00
2025 27,376.00 43,936.00
N/YRTET3 (1) MIM-RSO
133-54-3 PAGE 3 93-11-09 93-11-09 1322
(CONTINUED ON NEXT PAGE)
THIS PAGE 3 - CONTINUED IS A PART OF POLICY NUMBER 93 042 982.
---------- SEMI-ANNUAL RENEWAL PREMIUMS ----------
GUARANTEED
RENEWAL SCHEDULED MAXIMUM
DATE RENEWAL RENEWAL
NOV. 9 PREMIUM* PREMIUM
------ ----------- -------------
2026 29,356.00 47,326.00
2027 32,796.00 53,076.00
2028 36,846.00 59,786.00
2029 40,816.00 67,496.00
2030 45,106.00 76,226.00
2031 50,036.00 86,416.00
2032 54,696.00 96,186.00
2033 59,876.00 107,476.00
2034 65,726.00 120,506.00
2035 72,196.00 135,076.00
2036 79,256.00 151,026.00
2037 82,616.00 158,406.00
2038 94,226.00 184,476.00
2039 101,936.00 201,386.00
2040 110,026.00 218,766.00
2041 118,486.00 236,506.00
2042 127,746.00 255.386.00
2043 137,526.00 274,676.00
2044 148,296.00 295,206.00
2045 163,686.00 324,276.00
2046 192,976.00 380,186.00
2047 234,046.00 456,916.00
2048 277,336.00 494,486.00
2049 323,236.00 494,486.00
2050 372,186.00 494,486.00
EE PREMIUM CHANGES - PAGE 4
________________________________
(2-2) MIM-RSO
N/YRTET3 PAGE 3-CONTINUED 93-11-09 93-11-09 1322
ENDORSEMENT
In the event you need to present inquiries, obtain information about coverage or
need assistance in resolving complaints about this policy, please contact your
Agent. If you have additional questions, you may contact The Equitable or
Equitable Variable at the following address and telephone number, The Equitable
or Equitable Variable, Charlotte Service Center, 6301 Morrison Boulevard,
Charlotte, North Carolina 28211; Telephone: (704) 362-6200.
Please have your policy number available for any inquiries.
5.33-59 PAGE 3 - Continued
POLICY OWNER AND BENEFICIARY
OWNER. The Owner of this policy is the Insured unless otherwise stated in the
application or later changed. As Owner, you can exercise all the rights in this
policy while the Insured is living. You do not need the consent of anyone who
has only a conditional or future ownership interest in this policy.
BENEFICIARY. The Beneficiary is as stated in the application, unless later
changed. If two or more persons are named, those surviving the Insured will
share equally ,unless otherwise stated.
We will pay any benefit for which there is no stated Beneficiary living at the
death of the Insured to the children of the Insured who then survive, in equal
shares. If none survive, we will pay the estate of the Insured.
CHANGES. While the Insured is living, you may change the Owner or Beneficiary by
written notice in a form satisfactory to us. You can get such a form from our
agent or by writing to us. The change will take effect on the date you sign the
notice, except that it will not apply to any payment we make or other action we
take before we receive the notice. If you change the Beneficiary, any previous
arrangement you made under the Payment Options provision on Page 7 is cancelled.
You may choose a Payment Option for the new Beneficiary in accordance with that
provision.
ASSIGNMENT. You may assign this policy, but we will not be bound by an
assignment unless we leave received it in writing. Your rights and those of any
other person referred to in this policy will be subject to the assignment. We
assume no responsibility for the validity of any assignment. An absolute
assignment will be considered as a change of ownership to the assignee.
PREMIUMS
AMOUNTS AND DUE DATES. Page 3 shows the amount and .due date of the premium for
the first policy year. It also shows scheduled renewal premiums based on the
initial rate scale; guaranteed maximum renewal premiums; and the premium due
dates for renewal periods. Scheduled renewal premiums are subject to change as
stated in the Premium Changes section. Each premium is payable on or before its
due date at our Home Office or premium collection office.
You may write and ask us to change the frequency of premium payment. If we
approve the change, the new premium will be determined on the rate scale for
this policy.
GRACE PERIOD. We allow a grace period of 31 days for payment of each premium,
after the first premium. The insurance will continue during the grace
period.
LAPSE. If a premium is not paid by the end of its grace period. the policy will
lapse as of the premium due date. If this occurs, all insurance ends at the
end of the grace period.
PREMIUM CHANGES. We have the right to change the scheduled renewal premiums for
the policy for any policy year. We will send you written notice of any such
change before the next premium payment is due. The actual premium for any policy
year may vary, but will never be more than the guaranteed maximum renewal
premium shown on Page 3 for that year. We will review the scheduled premiums
each year.
We will adjust the renewal premium only on a uniform basis for insureds of the
same insurance age, sex and class of risk, whose policies have been in force for
the same length of time. We will not change the premium or class of risk because
of an adverse change in the Insured's health, occupation or avocation. We will
base a premium change solely on future expectations as to mortality, investment
earnings, persistency and expenses. Our procedures and standards for premium
changes are on file, as required, with the insurance supervisory official of the
jurisdiction in which this policy is delivered.
PAGE 4
REINSTATEMENT. You may reinstate this policy within five years after lapse, but
not later than the Final Term Expiry Date, if: (1) you provide evidence of
insurability satisfactory to us-, and (1) you pay all overdue premiums with
interest at 6% per year compounded annually.
PREMIUM ADJUSTMENT. We will add to the insurance benefits any part of the last
premium paid that applies to a period beyond the policy month in which the
Insured dies. If the Insured dies during the grace period of an unpaid premium,
we will deduct from the benefits the part of the overdue premium for one policy
month. These are the adjustments for the last premium referred to on Page 2.
CONVERSION PRIVILEGE
You may exchange this policy on any premium due date on or before the Term
Expiry Date for a new policy on the life of the Insured without evidence of
insurability: (1) if the date of exchange is on or before the policy anniversary
nearest the lnsured's 75th birthday; and (2) if all premiums have been (duly
paid; and (3) if there is a Disability Premium Waiver rider in effect in this
policy, the Insured is not totally disabled as defined in that rider. However,
see the section "Conversion During Disability.'
The Register Date of the new policy will be the date of exchange. Premiums for
the new policy will be based our rates in effect on that date. They will be for
the lnsured's then attained insurance age and for the same class of risk as for
this policy-. The first premium for the new policy must be paid on or within 31
days before the date of exchange.
THE NEW POLICY. The new policy will have an insurance amount equal to the amount
of insurance in effect on this policy. Or, you may choose any lower amount
allowed by our rules in effect on the date of exchange.
The new policy may be on any plan of insurance we offer on the date of exchange,
subject to our rules then in effect as. to plan, age and class of risk.
If additional benefit riders are in effect in this policy on the date of
exchange, you may choose that the new policy contain similar riders subject to
our rules in effect on its Register Date.
Except as to any additional benefit riders included in the new policy, the
suicide exclusion and incontestability periods of the new policy will be
determined from the date of issue of this policy instead of from the date of
issue of the new policy. We will tell you the amount of the first premium for
the new policy upon request.
CONVERSION DURING DISABILITY. We will issue a new policy with a Disability
Premium Waiver rider in exchange for this policy on any Current Term Expiry
Date you choose that is before the policy anniversary nearest the Insured's 65th
birthday if: 1) a Disability Premium Waiver rider is in effect in this policy on
the date of exchange: and 2) the Insured is then totally disabled as defined in
that rider.
If no earlier exchange is made, we will issue a new policy with a Disability
Premium Waiver rider in exchange for this policy on the policy anniversary
nearest the Insured's 65th birthday if premiums have been waived for at least
the five preceding policy years under a Disability Premium Waiver rider in this
policy.
The new policy will have an insurance .amount equal to the amount of insurance
in effect on this policy. It will be on the level premium whole life plan with
premiums payable for life that we then issue, subject to our rules in effect on
its Register Date as to plan. Its Register Date will be the date of exchange.
Premiums for the new policy will be based on our rates in effect on that date.
They will be for the Insured's then attained insurance age and for the same
class of risk as for this policy.
We will waive premiums for the new policy as stated in its Disability Premium
Waiver rider while total disability continues. (We will not waive premiums on or
after the policy anniversary nearest the lnsured's 65th birthday for a total
disability that began on or after the policy anniversary of this policy nearest
the lnsured's 60th birthday.)
PAGE 5
GENERAL PROVISIONS
THE CONTRACT. We provide this insurance in consideration of payment of the
required premiums. This policy and the attached copy of the application for
it make LIP the entire contract.
The contract may not be modified, nor may any of our rights or requirements be
waived, except in writing signed by our President or one of our Vice Presidents.
INCONTESTABILITY. We have the right to contest the validity of this policy based
on material misstatement made in the application for this policy. However, we
will not contest the validity of this policy after it has been in effect during
the lifetime of the Insured for two years from the Date of Issue shown on Page
3. No statement shall be used to contest a claim unless contained in the
application.
All statements made in the application are representations and not warranties.
See any additional benefit riders for modifications of this provision that apply
to them.
AGE AND SEX. If the Insured's age or sex has been misstated, any benefits will
be those that the premium paid would have purchased at the correct age and sex.
SUICIDE EXCLUSION. If the Insured commits suicide, while sane or insane, within
two years after the Date of Issue shown on Page 3, our liability will be limited
to the Payment of' a single sum equal to the premiums paid.
POLICY PERIODS AND ANNIVERSARIES. Policy years, policy months, policy
anniversaries and premium periods are measured from the Register Date. Each
policy month begins on the same day in each calendar month as in the Register
Date.
POLICY CHANGES. You may change this policy to another plan of insurance or add
additional benefit riders or make other changes, subject to our rules at the
time of change.
PAYMENT OPTIONS
Instead of having the insurance benefits paid immediately in one sum, you can
choose another form of payment for all or part of the benefit. If you do not
arrange for this before the Insured dies, the Beneficiary will have this right
when the Insured dies. Arrangements you make, however, cannot be changed by the
Beneficiary after the Insured's death.
The options are:
1. DEPOSIT OPTION: The sum is left on deposit for a period mutually agreed
upon. We pay interest at the end of every month, every 3 months, every
6 months or every 12 months, as chosen.
2. INSTALLMENT OPTIONS:
A. FIXED PERIOD: We pay the sum in equal installments for a specified
number of years (not more than 30). The installments will be at least
those shown in the Table of Guaranteed Payments on Page 8.
B. FIXED AMOUNT: We pay the sum in installments as mutually agreed upon
until it, together with interest on the unpaid balance, is used up.
3. LIFE INCOME OPTIONS:
We pay the sum as a monthly income for life in an amount we determine. The
amount of the monthly payment will be at least that shown in the Table of
Guaranteed Payments on Page 8. We guarantee payments for life and in any
event for 10 years (called "10 Years Certain"), 20 years (called "20 Years
Certain"), or until the payments we make equal the amount applied (called
"Refund Certain"), according to the "certain" period chosen.
4. OTHER: We will apply the sum under any other option requested that we
make available at the time of the Insured's death.
PAGE 6
We guarantee interest under Option I at the rate of 3% a year and under
Option 2 at 31/2 % a year. We may raise these guaranteed rates. We may also
allow excess interest under Options I and 2.
The payee under an option may name and change a successor payee for any
amount we would otherwise pay the payee's estate.
Any arrangements involving more than one of the options, or a payee who is
not a natural person (for example, a corporation) or who is a fiduciary, must
have our approval. Also, details of all arrangements will be subject to our
rules at the time the arrangement takes effect. These include rules on: the
minimum amounts we will apply under an option and minimum amounts for
installment payments; withdrawal or commutation rights; naming payees and
successor payees; and proving age and survival.
Choices (or any later changes) under these options will be made and will
take effect in the same way as a change of Beneficiary. Amounts applied under
these options will not be subject to the claims of creditors or to legal
process. to the extent permitted by law.
PAGE 7
PART 1: APPLICATION FOR LIFE INSURANCE TO:
THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
(THE EQUITABLE) HOME OFFICE: 787 Seventh Avenue, New York, NY 10019
1. PROPOSED INSURED Please print in ink. (THE EQUITABLE)
Home Office: 787 Seventh Avenue, New York, NY 10019
b. Name: MR. PIERRE GERARD MANSUR
c. Date of Birth: Mo. 12 Day 29 Year 1951
d. Age Nearest Birthday 42
e. Sex X M
f. Place of Birth: Aruba Netherland
g. Soc. Sec No. 073448390
h. Previous/Other Name (If Applicable) N/A
i. U.S. Citizen X Yes
j. Current Occupation(s): (1) Title: Pres. Mansur (2) Duties: Executive
(3) How Long: 2 Yrs.
k. Residence
Care of: CIO
Current 11117 SW 79th AVENUE
MIAMI, FL 33134
Years There: 2
Previous: N/A
l. Tel. (1) Home 305-667-4849 (2) Business 305-232-6768
m. Currently empoyed? X Yes
n. Employer Name: Mansur Industries, Inc.
o. Years Employed: 2
p. Employer Address: 8425 S.W. 129 Terrace, Miami, Florida 33156
2. APPLICANT (If not proposed Insured)
a. Name: First Middle Last
b. Relationship to Proposed Insured
c. Date of Birth Mo. Day Year
d. Sex M F
e. Place of Birth:
f. Current Occupation(s): (1) Title (2) Duties If less than 1 year at
current occupation, give previous in Special Instructions
g. Address: Same as Question 1.k Residence or Question 1.p Business
Residence: No. and Street, Apt/Suite/Bldg
City, State, Zip
Business: No. and Street
City, State, Zip
3.POLICY OWNER
a. The Owner is: (1) Proposed Insured (2) Applicant (3) X Other
(a) Individual
(b) X Corporation
(c) Partnership
(d) Trust Dated Mo. Day Year
(e) Qualified (Illigible)
(f) Guardian
(g) Executor
(h) Name of Person First Middle Last
Name of Firm or Plan: MANSUR INDUSTRIES, INC.
(i) If an individual, indicate: Mr. Mrs. Ms. Miss Other
(j) Relationship to Insured EMPLOER
b. Owner's Mailing Address: Same as Current Residence (1.k) or Applicant's
Residence (2.g) Other:
Care of CIO
8425 SW 129 Terrace
Miami, FL 33156
c. Answer if Policyowner is not Proposed Insured:
(1) Soc. Sec. Or Tax I.D. Number 650226813
(2) Date of Birth: Same as 2.c or Mo. Day Year
(3) Phone: 305-232-6768
d. Successor Owner (if desired) Give full name: [section in the middle of
the page is missing so text here is omitted as it would be
fragmented]
BENEFICIARY FOR INSURANCE ON PROPOSED INSURED. Include Name and Relationship to
Proposed Insured.
a. Primary Beneficiary(ies): Name(s)
(1) MANSUR INDUSTRIES, INC. Relationship EMPLOYER
b. Contingent Beneficiary(ies)
(1) (2)
Note: Unless otherwise requested, the contingent beneficiary will be the
surviving children of the Insured in equal shares. If none survive, payment will
be made to the insured's estate. The Beneficiary(ies) under any Term Insurance
Rider on any Additional Insured or on a Child will be as stated in those riders,
unless otherwise designated in Special Instructions. In any such designation,
give full lname and relatinship of beneficiary(ies)to the Insured.
180-301N-F
5. PLAN DESCRIPTION AND PREMIUM PAYMENT METHOD
a. [TERM - EQUITABLE TERM II]
b. Amount of Insurance $ 1,000,000
c. Premium Mode: Annual X Semi-Annual Quarterly System-Matic
(Complete S-M form)
d. Loan Interest Rate Adjustable Fixed [N/A]
e. Salary Allotment
(1) Unit Name
(2) Register Date
(3) Unit/Sub Unit No.
(4) Payroll No.
(5) Allotor's Name (If other than Proposed Insured) (6) Allotor's No.
(7) Divisible by 2 4
f. Military Allotment: Branch
Register Date
6. OPTIONAL BENEFITS
___Accidental Death Benefit* (specify amount) $ ___Disability Premium
Waiver* (Not Available for Survivorship WL) ___Automatic Premium Loan (Not
for Term Policies) ___Option to Purchase Add'l Ins. (Issue ages to 37 only)
$ ___Paid-up Additional Rider: (i) Single Premium $
(ii) Recurring Premium $ paid mode
___Summplemental Insurance Rider $
Target Death Benefit $
* JUVENILLE LIMITATION: If applied for, the Accidental Death Benefit is payable
only if the Child dies as a result of an accident after the Child's first
birthday; the Disability Waiver Benefits are effective only if the Child
becomes totally disabled onor after the Child's 5th birthday.
TERM RIDERS: [ONLY ONE MAY BE ELECTED FOR INSURED. NONE AVAILABLE IF PROPOSED
INSURED AS A CHILD ISSUE AGE 0-14)]
Decreasing Term:
[ ] Family Income: Years $ Per Month
[ ] Renewable Term (1) On Insured $
(2) On Add'l Insured ** $
[ ] Children's Term** $ Unit
**If coverage is elected complete applicable parts of Question 8, and answer
Question 10 through 16 with respect to the Additional Insured and/or Children
for Term Insurance Rider.
SURVIVORSHIP WL RIDERS:
[ ] Supplemental Insurance Rider $
Target Death Benefit $
[ ] Survivorship PUA Rider (i) Single Premium $
(ii) Recurring premium $ paid mode
[ ] Yearly Renewable Term at First Death $
[ ] Option to Split Upon Divorce [ ] Estate Protector
7. DIVIDEND ELECTIONS (Not available for Term Policies) [ ] Additions (MUST
CHOOSE IF SELECTED) [ ] Accumulations [ ] Plan "AD" Term Dividend [ ] Plan "B"
Provision [ ] Premiums, Balance to Additions [ ] Cash
8. COMPLETE FOR PROPOSED ADDITIONAL INSURED, CHILDREN'S TERM RIDER, JUVENILE
INSURANCE OR SUPPLMENTAL PROTECTIVE BENEFIT Also answer Questions 10 through
16 with respect to Proposed Additional Insured, Children under Children's
Term Rider, or Applicant if electing Supplemental Protective Benefit.
a. Title: [ ] Mr. [ ] Mrs. [ ] Ms. [ ] Miss [ ] Other Title
b. Proposed Add'l Insured:
First Middle Last
Date of Birth Mo. Yr. Age Nearest Birthday Sex [ ]M [ ] F
Place of Birth:
Soc. Sec. No. Previous/ Other Name (If Applicable)
Relationship of Owner to Add'l Insured: State of Residence:
Current Occupation(s)(1)Title: (2)Duties: (3)How Long?
If less than 1 year at current occupation, give previous in Special
Instructions Children for Term Insurance Rider (Use Special Instructions if
more space is needed.)*
First Middle Last
Date of Birth M. Day Yr. Sex [ ] M [ ] Relationship to Owner
First Middle Last
Date of Birth M. Day Yr. Sex [ ] M [ ] Relationship to Owner
First Middle Last
Date of Birth M. Day Yr. Sex [ ] M [ ] Relationship to Owner
First Middle Last
*Note: To be eligible, children (including stepchildren and legally adopted
children) must not have reached their 18th birthday. Coverage does not
begin until a child is 15 days old.
d. For Juvenile Insurance (Ages 0-14)(1) Will there be more life insurance in
force on this Child than on any other child in the family? [ ] Yes [ ] No
If "Yes", explain (2) Total Life Insurance in effect on Applicant: $ e. [ ]
Supplemental Protective Benefit. Give Applicant's (i) Height Ft. In.
(ii) Weight lb.
9. OPAI. COMPLETE IF EXERCISING OPTION TO PURCHASE ADDITIONAL INSURANCE
IF OPTION IS UNDER INDIVIDUAL POLICY:
a. Regular; (2) [ ] Birth or Adoption; Child's Name ;
Date of Birth or Adoption / /; (3) [ ] Alternate
b. original policy no. .
c. Option Date / /
d. Option Amount $
e. If applying for disability Premium waiver, is Propsed Insured now totally
disabled as defined in the Disability Premium Waiver Provision of the
original policy indicated above in b.? [ ] Yes [ ] No
f. OPTION IS UNDER A GROUP POLICY: a. Existing original policy no.
b. Option Date / /
c. Employer's Name
d. Maximum Amount Available Under Option $
This application is made under a provision in the existing policy indicated in
9.b. above permitting the purchase of additional individual life insurance (the
"Option Provision"). If this application is made within the time allowed and in
accordance with the other terms in the Option Provision, including timely
payment of the full first premium for the additional insurance, then the
additional insurance shall take effect upon the terms of the policy the Insurer
would issue. Otherwise, the additional insurance shall not take effect. (ANSWER
QUESTIONS 10 THROUGH 16 ONLY IF EVIDENCE OF AVAILABILITY IS REQUIRED IN
CONNECTION WITH AN OPTIONAL BENEFIT OR ANY EXCESS OF THE INSURANCE AMOUNT
APPLIED FOR OVER THE INSURANCE AMOUNT PERMITTED BY THE OPTION PROVISION.)
OTHER INFORMATION For any "Yes" response, provide full details under Section 17
HOW MANY PERSON PROPOSED FOR INSURANCE: YES NO
10. a. Ever had a driver's license suspended or revoked, or within the
last 3 years been convicted of 2 or more moving violations or
driving under the influence of alcohol or drugs? X
b. Any plans to travel or reside outside the United States? X
c. Any other life insurance now in effect or application now
pending? X
(Give companies and amounts and policy numbers if Equitable.)
d. Been disabled for 2 or more weeks within the last 2 years? X
11. a. In the last year flown other than as a passenger or plan to
do so? X
If "Yes," enter total flying time at present hours; last
12 mos. hours; next 12 mos. est. hours.
b. Engaged within the last year or any plan to engage in motor
racing on land or water, underwater diving, skydiving,
ballooning, hang gliding, parachuting or flying ultra-
light aircraft? (If "Yes," complete Avocation Supplement.) X
c. Ever had an application for life or health insurance that
was declined, required an extra premium or other modification? X
d. Replaced or changed any existing insurance or annuity (or
plan to do so) assuming the insurance applied for will be
issued? (If "Yes", state companies, plans and amounts.) X
ANSWER QUESTIONS 12-16 ONLY IF NON-MEDICAL For any "Yes" response,
provide full details under Section 17.
12. a. Proposed insured: Height Ft. In.; Weight lb.
b. Additional insured: Height Ft. In.; Weight lb.
HAS ANY PERSON PROPOSED FOR INSURANCE:
13. a. Ever had or been treated for heart trouble, stroke, high
blood pressure, chest pain, diabetes, tumor, cancer,
respiratory or neurological disorder?
b. In the last 5 years, consulted a physician, or been examined
or treated at a hospital or other medical facility?
(Include medical check-ups in the last 2 years. Do not
include colds, minor injuries or normal pregnancy.)
14. In the last 12 months: a. Smoked cigarettes? X
b. Used any other form of tobacco? X
15. In the last 10 years:
a. Used, except as legally prescribed by a physician,
tranquilizers, barbiturates or other sedatives; marijuana,
cocaine, hallucinogens or other mood-altering drugs;
heroin, methadone or other narcotics; amphetamines or
other stimulants; or any other illegal or controlled
substances?
b. Received counseling or treatment regarding the use of
alcohol or drugs including attendance at meetings or
membership in any self-helf group or program such as
Alcoholics Anonymous or Narcotics Anonymous?
16. In the last 10 years, been:
a. Diagnosed by a member of the medical profession as having
Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related
Complex (ARC)?
b. Treated by a member of the medical profession for AIDS
or ARC?
17. DETAILS/ADDITIONAL INFORMATION For each "Yes" answer give Question
Number, name of person(s) affected, and full details. For 13-16
include conditions, dates, durations, treatment and results, and
names and addresses of physicians and medical facilities. Attach
additional sheet, if more space needed.
QUES. NO. NAME OF PERSON DETAILS
1f Pierre Pierre is a U.S. citizen
18. SPECIAL INSTRUCTIONS/ADDITIONAL INFORMATION
a. [ ] Preliminary Term to: Month Day Year
b. [ ] Date ot save insurance age:
c. [ ] Issue with Qualified Plan Riders [ ] Trusted [ ] Non-Trusted
[ ] Unisex Rates
Other: Applicant Smokes Cigarettes
Note: Insured is an owner of Mansur Industries.
19. COMPLETE IF MONEY IS PAID OR AN APPROVED PAYMENT AUTHORIZATION IS
SIGNED BEFORE THE POLICY IS DELIVERED: Have the undersigned read and do they
agree to the conditions of The Equitable's Temporary Insurance Agreement,;(I)
THE REQUIREMENT THAT ALL OF THE CONDITIONS IN THAT Agreement must be met before
any temporary insurance takes effect, and (ii) the $500,000 insurance amount
limitation? (checked Yes)
Yes No (, If "No," or if any Person Proposed for Insurance has been diagnosed
or treated for Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related
Complex (ARC) by a member of the medical profession within the last 10 years
or had cancer, a stroke or a heart attack within the last year, a premium may
not be paid nor any approved payment authorization signed before the policy is
delivered).
X Amount Paid: $1716.00.(DRAW CHECKS PAYABLE TO THE EQUITABLE.)
(initialed box) APPROVED PAYMENT AUTHORIZATION SIGNED
20.SOCIAL SECURITY OR TAX I.D. NUMBER CERTIFICATION. 1, the proposed
policyowner, by my signature below, certify under penalties of perjury
that (I) the number shown in question 3.c. (1) or 1.g. of this form
is my correct taxpayer identification number , and (ii) I am not
(checked) subject to a backup withholding order issued by the Internal
Revenue Service. I understand that failure to furnish the correct
information may subject me to Federal backup withholding.
AGREEMENT. Each signer of this application agrees that:
(1). The statements and answers in all parts of this application are true
and complete to the best of my (our) knowledge and belief, The
Equitable may rely on them in acting on this application.
(2). The Equitable's Temporary Insurance Agreement states the conditions
that must be met before any insurance takes effect it money is paid
or an approved payment authorization is signed, before the policy is
delivered. Temporary Insurance is not provided for a policy or benefit
applied for under the terms of a guaranteed insurability option or a
conversion privilege.
(3). Except as stated in the Temporary Insurance Agreement, no insurance
shall take effect on this application ' (a) until a policy is delivered
and the full initial premium for it is paid, or an approved payment
authorization is signed, while the person(s) proposed for insurance is
(are) living: (b) before any Register Date specified in this
application; and (c) unless to the best of my (our) knowledge and
belief the statements and answers in all parts of this application
continue to be true and complete, without material change, as of the
time such premium is paid or an approved payment authorization is
signed.
(4). No agent or medical examiner has authority to modify this Agreement or
the Temporary Insurance Agreement, nor to waive any of The Equitable's
rights or requirements. The Equitable shall not be bound by any
information unless it is stated in Application Part 1 or Part 2.
ACKNOWLEDGEMENT AND AUTHORIZATIONS
UNDERWRITING PRACTICES. I (We) have received a statement of the underwriting
practices of The Equitable which describes how and why The Equitable obtains
information on my insurability, to whom such information may be reported and how
I may obtain it. The statement also contains the notice required by the Fair
Credit Reporting Act.
AUTHORIZATIONS.
TO OBTAIN MEDICAL INFORMATION. I (we) authorize any physician, hospital,
medical practitioner or other facility, insurance company, and the
Medical Information Bureau to release to The Equitable and its legal
representative any and all information they may have about any
diagnosis, treatment and prognosis regarding my physical or mental condition.
TO OBTAIN NON-MEDICAL INFORMATION. I (we) authorize any employer, business
associate, government unit, financial institution, Consumer Reporting Agency.
and the Medical Information Bureau to release to The Equitable and its legal
representative any information they may have about my occupation, avocations,
finances, driving record, character and general reputation. I (we) authorize The
Equitable to obtain investigative consumer reports, as appropriate.
TO USE AND DISCLOSE INFORMATION. I (we) understand that the information that I
(we) authorize The Equitable to obtain will be used by The Equitable to help
determine my insurability or my eligibility for benefits under an existing
policy. I (we) authorize The Equitable to release information about my
insurability to its insurers, contractors and affiliates, my (our) Equitable
Agent, and to the Medical Information Bureau, all as described in the statement
of The Equitable's underwriting practices or to other persons or businesses
performing business or legal services in connection with my application or claim
of eligibility for benefits. or as may be otherwise lawfully required, or as I
(we) may further authorize. I (we) understand that I (we) have the right to
learn the contents of any report of information (generally, through my
physician, in the cabs of medical information).
COPY OF AUTHORIZATIONS. I (we) have a right to ask for and receive a true copy
of this Acknowledgment and Authorizations signed by me (us). I (we) agree that a
reproduced copy will be as valid as the original.
DURATION. I (we) agree that these authorizations will be valid for 12 months
from the date shown below.
Dated at City: Miami X /s/ Pierre G. Mansur
State: Florida Signature of Proposed Insured or of Applicant if
on 10/4/93 1993 Proposed Insured is a Child, Issue Age 0-14.
Nature of Agent X____________________________________
Signature of Proposed Additional Insured, if any
X____________________________________
Signature of Applicant if not Proposed Insured or
Owner
X /s/ Pierre G. Mansur, CEO,
MANSUR INDUSTRIES, INC
Signature(s) of Owner if not Proposed Insured or
Applicant)
(If a corporation, show firm's name and signature
of authorized officer)
No. A 31640
LARGE AMOUNT SUPPLEMENT To:
X The Equitable Life Assurance Society of the United States
0 Equitable Variable Life Insurance Company
0 The Equitable of Colorado, Inc.
Instructions: Complete Section I and applicable Section(s) 11 (Personal
Insurance ) or III (Business Insurance)
PROPOSED INSURED's
NAME Pierre Gerard Mansur ASU (Alpha)/App. No.512/A 31640
First Middle Last
Section I - General Information
(Complete in all instances)
A. Insurance In Force (All Companies) B. Insurance Applied For (All Companies)
Purpose Face Amount Face Amount
Personal $ 500k Term $ 0
Business $0 $1,000,000
Total In Force 500k Amount applied for
elsewhere is []competitive [] additional
C. Financial Information:
1. Income:
Gross Annual Compensation:
(e.g. Salary, Commissions,
Bonuses, etc.) $ 1OO,OO0 $0
(Current Rate) (Rate 1 year previously)
Gross Annual Investment
and Other Income:
(e.g. Dividends, Interest,
Net Real Estate Income, etc.) $ 0 $0
(Past 12 months) (Preceding 12 months)
Total Cash Income before taxes $100,000 $0
2. Net Personal Worth: Current
Assets: $2,000,000
Liabilities (including mortgages):$ 30,000
Net Worth: $1,970,000
SECTION II - PERSONAL INSURANCE
(Complete only when Applying for Personal Insurance)
PURPOSE (Check appropriate box(s) and answer all supplemental questions.)
0 Family Income 0 Education Fund
0 Gift 0 Mortgage Protection
0 Personal Loan Collateral (other than mortgage protection) Answer
supplemental questions under Business Loan Collateral in Section III, C3.
0 Estate Settlement
Taxable Estate $ ______________
Estimated Settlement Costs (taxes and administration expenses) $______
Total Liquid Assets $
0 Other (specify)
The above statements and answers are true and complete to the best of my
knowledge and belief I agree that such statements and answers shall be made part
of the application for insurance or request for policy change or reinstatement,
as the case may be. The Insurer may rely on them in acting on this application.
Dated at Miami FL on 10/4 1993
x Pierre G. Mansur
Signature of Proposed Insurer, or Applicant if Proposed Insured is a
Child
Witnessed by illegible
Signature of Agent
SECTION III - BUSINESS INSURANCE
(Complete only when applying for Business Insurance)
A. Type of Organization :
Sole Proprietorship Partnership X Corporation
Proposed Insured's Percentage Ownership: 80 %
B. Financial Information:
Total Business Assets: Total Liabilities:
$ 1,500.000 $500,000
Total Business Net Worth:
$1,500,000 $900,000
(Current year) (Previous Full Year)
Estimated Fair Market Value $______________
GROSS ANNUAL SALES
Last Full Calendar Year
-$0-
Previous Full Calendar Year
-$0-
Answering this question is optional; however,
if the amount applied for exceeds the appropriate
amount of insurance limit as described on card 4 of the Agent's Guide to
Financial Underwriting, this question must be answered Net Profit After Taxes
(Last 3 Years
19___$__________________
19___$__________________
19___$__________________
C. Purpose: (Check appropriate box(s) and answer all supplemental questions.)
YES NO
1.[] BUY-SELL/STOCK REDEMPTION
Is there a written buy-sell/stock redemption
Is this a section 303 Redemption? (If yes, complete Estate
Settlement portion of Section II.
Are all other parties to agreement already covered by or
applying for comparable amounts of insurance? (If no, explain
in Section D.)
2. X KEY PERSON:
Are all other key persons covered by or applying for
comparable amounts of insurance? (If no, explain in
Section D.)
Why is Proposed Insured considered "Key"?
(Provide details in Section D.)
3.Business Loan Collateral:
Is insurance required by the creditor? 0 Yes 0 NO
Name of creditor/lending institution___________________________
What is the purpose and amount of the loan?
Date loan was committed ______
If not yet committed, explain.
4.Deferred Compensation/Salary Continuation
Is there a written plan? 0 Yes X No
Are all other eligible individuals covered by or applying for
comparable amount of insurance? 0 Yes X No
5.Other (specify)
D. ADDITIONAL INFORMATION:
2 Sole Key Employee
2 He is the inventor & Designer of a newly patented
industrial machine.
The above statements and answers are true and complete to the best of my
knowledge and belief. I agree that such statements and answers shall be made
part of the application for insurance or request for policy change or
reinstatement, as the case may be. The Insurer may rely on them in acting on the
application. Or making the policy change if reinstatement.
Dated at: Miami Florida on 10-12-93 X Pierre G. Mansur Signature of Proposed
Insured
APPLICATION PART 2 TO:[ ] THE EQUITABLE LIFE ASSURANCE
SOCIETY OF THE UNITED STATES [ ] EQUITABLE
VARIABLE LIFE INSURANCE COMPANY [ ] THE EQUITABLE
OF COLORADO, INC.
REASON FOR SUBMISSION OF THIS FORM:
[ ] New Policy [ ] Policy change [ ] Reinstatement
1. a. Proposed Insured First Name Middle Initial Last Name
(PLEASE PRINT) PIERRE G. MANSUR
b. Height: 5 ft. 11 in.
c. Weight: 172 lbs.
d. Birth Date: Mo. 12 Day 29 Yr. 51
e. [x] Male [ ] Female
2. a. Name and address of personal physician (or
medical facility used instead): (If none, so state) (NONE)
b. Date and reason last consulted if within the last 5 years:
c. What treatment was given or recommended? (If none, so state)
(For all "Yes" answers to questions 3-9, circle items that apply.)
3. Has Proposed Insured ever had or been treated for: YES NO
a. Disease or disorder of eyes, ears, nose or throat? X
b. Dizziness, fainting, convulsions, paralysis or stroke;
psychiatric, psychological or emotional disturbance;
mental or nervous disease or disorder? X
c. shortness of breath; blood spitting; bronchitis, asthma,
emphysema, tuberculosis or other chronic respiratory
disease or disorder? X
d. Chest pain, palpitation, high blood pressure, rheumatic fever,
heart murmur, heart attach or other disease or disorder of the
heart or blood vessels? X
e. Ulcer, hernia, colitis, intestinal bleeding, jaundice,
hemorrhoids, or other disease or disorder of the stomach,
intestines, liver or gallbladder? X
f. Sugar, albumin, blood or pus in urine; stone or other disease or
disorder of kidney or bladder? X
g. Diabetes, cyst, tumor, or cancer; thyroid or glandular disorder;
skin disease or disorder? X
h. Neuritis, arthritis, gout, or disease of the muscles or bones,
including the back, or joints? X
i. Deformity, lameness or amputation? X
j. Allergies; anemia; other blood or lymph disease or disorder? X
k. Disorder of prostate, reproductive organs, breasts, menstruation
or pregnancy? X
4. Is Proposed Insured now under observation or taking treatment? X
a. Diagnosed by a member of the medical profession as having
Acquired Immune Deficiency syndrome (AIDS) or AIDS-Related
complex (ARC)? X
b. Treated by a member of the medical profession for AIDS or ARC? X
6. Has Proposed Insured, within the last 10 years:
a. Used, expect as legally prescribed by a physician, tranquilizers;
barbiturates or other sedatives; marijuana, cocaine, hallucinogens
or other mood-altering drugs; heroin, methadone or other narcotics;
amphetamines or other stimulants; or any other illegal or controlled
substances? X
b. Received counseling or treatment regarding the use of alcohol or
drugs? X
7. Has Proposed Insured's weight changed by more than [illegible] pounds
in the last 6 months? X
8. Other than as stated in answers to Questions 2-6, has Proposed
Insured, within the last 5 years:
a. Consulted or been examined or treated by any physician or
practitioner? X
b. Had any illness, injury, or surgery? X
c. Been a patient in or been examined or treated at a hospital, clinic,
sanatorium, or other medical facility? X
d. Had electrocardiogram, X-ray, other diagnostic test? X
e. Been advised to have any diagnostic test, hospitalization,
treatment or surgery which was not completed? X
9. Has Proposed Insured, within the last 12 months:
a. Smoked cigarettes? X
b. Used any other form of tobacco? (Give full details.) X
Age if Age at
10.Family History: Living Cause of Death Death
Father 0 Rheumatic heart disorder 44
Mother 69 -- --
Brothers/Sisters 42 -- --
DETAILS FOR "YES" ANSWERS. Include: I. Question Number.
II. Diagnosis and Treatment III. Results. IV. Dates and Duration.
V. Names and Addresses of all attending physicians and medical
facilities. (If additional space is needed, please attach a
separate sheet, dated signed and witnessed as below.)
#3D & 4 TAKES TENOVMIN FOR HIGH BLOOD PRESSURE SINCE ABOUT FIVE
OR SIX YEARS AGO. HE TAKES HALF OF A TAB A DAY. PRESERVI - DAY
BY DAY. RICHARDS MARAVA MD IN BROOKLYN, NEW YORK, NO COMPLICATIONS.
SA SMOKES CLOSE TO A PACK OF CIGARRETES DAILY.
The above statements and answers are true and complete to the best of my
knowledge and belief. I agree that such statements and answers shall be part of
the application for insurance or request for policy change or reinstatement, as
the case may be. The Insurer may relay on them in acting on the application or
making the policy change or reinstatement.
Dated at Miami, FLA 10-12-93
City State Mo. Day Yr.
X /s/ PIERRE G. MANSUR
Signature of Proposed Insured
Witness (Must be Examiner or Nurse/Technician): [ILLEGIBLE]
Table of Guaranteed Payments
(MINIMUM AMOUNT FOR EACH $1,000 APPLIED)
OPTION 2A OPTION 3
FIXED PERIOD INSTALLMENTS MONTHLY LIFE INCOME
Number Monthly Annual
of Year's
Installments Installments Installments 10 years Certain 20 Years Certain Refund Certain
Age Male Female Male Female Male Female
1 $84.70 $1000.00 50 $4.50 $3.96 $4.27 $3.89 $4.28 3.87
2 43.08 508.60 51 4.58 4.02 4.32 3.94 4.35 3.93
3 29.21 344.86 52 4.67 4.09 4.38 4.00 4.42 3.99
4 22.28 263.04 53 4.75 4.16 4.44 4.06 4.50 4.05
5 18.12 213.99 54 4.85 4.24 4.50 4.12 4.58 4.11
55 4.94 4.32 4.56 4.18 4.66 4.18
6 15.36 181.32 56 5.04 4.40 4.62 4.24 4.74 4.25
7 13.38 158.01 57 5.15 4.49 4.68 4.31 4.83 4.33
8 11.91 140.56 58 5.26 4.58 4.74 4.38 4.93 4.41
9 10.76 127.00 59 5.37 4.68 4.81 4.45 5.03 4.49
10 9.84 116.18
60 5.49 4.78 4.86 4.52 5.13 4.58
61 5.62 4.89 4.92 4.59 5.24 4.67
11 9.09 107.34 62 5.75 5.00 4.98 4.66 5.35 4.77
12 8.47 99.98 63 5.88 5.12 5.04 4.73 5.48 4.88
13 7.94 93.78 64 6.03 5.25 5.09 4.80 5.60 4.99
14 7.49 88.47
15 7.11 83.89 65 6.17 5.39 5.14 4.88 5.74 5.10
66 6.32 5.53 5.19 4.95 5.88 5.22
67 6.48 5.68 5.24 5.01 6.03 5.35
16 6.77 79.89 68 6.64 5.83 5.28 5.08 6.18 5.49
17 6.47 76.37 69 6.80 6.00 5.32 5.14 6.38 5.64
18 6.20 73.25 70 6.97 6.17 5.33 5.20 6.33 5.79
20 5.76 67.98 71 7.15 6.34 5.38 5.26 6.71 5.96
72 7.32 6.53 5.41 5.30 6.11 6.13
73 7.50 6.72 5.43 5.35 7.12 6.32
21 5.37 65.74 74 7.67 6.92 5.45 5.38 7.34 6.52
22 5.40 63.70
23 5.24 61.85 75 7.85 7.12 5.47 5.42 7.58 6.73
24 5.10 60.17 76 8.02 7.32 5.48 5.44 7.82 6.96
25 4.97 58.62 77 8.19 7.53 5.40 5.46 8.00 7.21
78 8.36 7.75 5.50 5.48 8.38 7.47
79 8.52 7.96 5.50 5.49 8.67 7.75
80 8.67 8.16 5.51 5.50 9.00 8.05
26 4.84 57.20 81 8.81 8.36 5.51 5.51 9.34 8.39
27 4.73 55.90 82 8.94 8.55 5.51 5.51 9.70 8.73
28 4.63 54.69 83 9.06 8.73 5.51 5.51 10.10 9.12
29 4.54 53.57 84 9.16 8.90 5.51 5.51 10.52 9.53
30 4.45 52.53 85 & over 9.26 9.05 5.51 5.51 10.96 9.97
If installments are paid every 3 months, they will be 25.32% of the annual
installments If they are paid every 6 months, they will be 50.43
of the annual instruments.
Amounts for Monthly Life Income are based on age nearest birthday when income
starts. Amounts for ages not shown will be furnished on request.
No. 133-54-8 PAGE 8
TERM
INSURANCE POLICY
The Equitable Life Assurance Society of the United States
787 Seventh Avenue, New York, N. Y. 10019
Yearly Renewable Term Plan. Insurance payable upon death before Term Expiry
Date. Renewable annually until Final Term Expiry Date shown on Page 3.
Renewal premiums may change subject to guaranteed maximums (see "Premium
Changes" on Page 4). Premiums payable to Term Expiry Date or until earlier
death. Conversion Privilege. This is a non-participating policy.
No. 133-54