EXHIBIT 10.12
THE INSURED PAUL I. MANSUR
POLICY OWNER MANSUR INDUSTRIES INC
FACE AMOUNT $1,000,000
POLICY NUMBER J 96 010 417
TERM INSURANCE POLICY
THE EQUIPMENT OF COLORADO, INC.
AGREES
To pay the insurance benefits of this policy to the Beneficiary upon
receiving proof that the Insured died before the Final Term Expiry
Date; and
To provide YOU (THE POLICY OWNER) with the other rights and benefits
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/ Samuel B. Shlesinger
SAMUEL B. SHLESINGER, CHAIRMAN, PRESIDENT & CHIEF EXECUTIVE OFFICER
/s/ Linda Galasso
LINDA GALASSO, SECRETARY
Renewable Term Plan. Insurance payable upon death before Final Term Expiry Date.
Renewable until Final Term Expiry Date shown on Page 3. RENEWAL PREMIUMS AFTER
THE TENTH POLICY ANNIVERSARY MAY CHANGE SUBJECT TO GUARANTEED MAXIMUMS (SEE
"PREMIUM CHANGES" ON PAGE 4). Premiums payable to Final Term Expiry Date or
until earlier death.
Conversion Privilege. This is a non-participating policy.
CONTENTS
Insurance Benefits 2
Policy Owner and Beneficiary 4
Premiums 4
Conversion Privilege 5
General Provisions 6
Payment Options 6
Table of Guaranteed Payments 8
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 of Colorado, Inc.
"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:
- the Face Amount of this policy shown on Page 3;
- PLUS any other benefits due from riders to this policy;
- 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 on 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.
Page 2
THE INSURED PAUL I MANSUR
POLICY OWNER MANSUR INDUSTRIES INC
FACE AMOUNT $1,000,000
FINAL TERM
EXPIRY DATE MAY 3, 2046
POLICY MMBER J 96 010 417
REGISTER DATE MAY 3, 1996
DATE OF ISSUE MAY 24, 1996
ISSUE AGE,SEX 45, MALE
BENEFICIARY MANSUR INDUSTRIES
------------ BENEFITS AND PREMIUMS ------------
BENEFITS SEMI-ANNUAL PREMIUM PREMIUM PERIOD
LIFE INSURANCE $1,032.00 10 YEARS
THE FIRST PREMIUM IS $1,032.00 AND IS DUE ON OR BEFORE DELIVERY OF THE POLICY.
SUBSEQUENT PREMIUMS ARE DUE ON NOV 3, 1996 AND EVERY 6 MONTHS THEREAFTER.
----------- BENEFITS AND PREMIUMS ------------
RENEWAL SCHEDULED GUARANTEED
DATE RENEWAL MAXIMUM RENEWAL
MAY 3 PREMIUM* PREMIUM
2006 $ 3,542.00 $ 7,312.00
2007 3,732.00 8,012.00
2008 4,022.00 8,732.00
2009 4,362.00 9,502.00
2010 4,732.00 10,332.00
2011 5,172.00 11,252.00
2012 5,672.00 12,282.00
2013 6,252.00 13,442.00
2014 6,932.00 14,762.00
2015 7,742.00 16,242.00
2016 8,692.00 17,852.00
2017 9,812.00 19,022.00
2018 11,162.00 20,202.00
2019 12,742.00 21,392.00
2020 14,622.00 22,612.00
2021 16,722.00 23,942.00
2022 19,432.00 26,162.00
2023 22,492.00 30,212.00
2024 26,062.00 34,212.00
2025 30,222.00 38,602.00
2026 34,072.00 42,582.00
2027 38,932.00 48,662.00
2028 44,512.00 55,622.00
2029 50,822.00 63,522.00
2030 57,952.00 72,442.00
2031 66,262.00 82,822.00
2032 74,242.00 92,802.00
2033 83,442.00 104,302.00
2034 94,042.00 117,552.00
PAGE 3
(CONTINUED ON NEXT PAGE)
THIS PAGE 3-CONTINUED IS A PART OF POLICY NUMBER 96 010 417.
----------- SEMI-ANNUAL RENEWAL PREMIUMS ------------
RENEWAL SCHEDULED GUARANTEED
DATE RENEWAL MAXIMUM RENEWAL
MAY 3 PREMIUM* PREMIUM
2035 105,892.00 132,362.00
2036 118,852.00 148,562.00
2037 124,952.00 156,182.00
2038 146,012.00 182,512.00
2039 159,732.00 199,662.00
2040 173,832.00 217,292.00
2041 188,232.00 235,272.00
2042 206,152.00 257,692.00
2043 225,602.00 281,992.00
2044 246,762.00 308,442.00
2045 277,752.00 347,172.00
*SEE PREMIUM CHANGES-PAGE 4
PAGE 3-CONTINUED PAGE 3-CONTINUED
THIS PAGE 3 - CONTINUED IS PART OF POLICY NUMBER
--------- 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, The
Equitable of Colorado or Equitable Variable at the following address and
telephone number, The Equitable, The Equitable of Colorado or Equitable
Variable, Charlotte Service Center, 6301 Morrison Boulevard, Charlotte, North
Carolina 28211; Telephone: (800) 777-6510.
Please have your policy number available for any inquiries.
S.33-59
NOTICE TO FLORIDA RESIDENTS
If the owner or insured, this policy is age 64 or older, under Florida Law, you
may designate a secondary addressee to receive copies of notices. To request
this, please send the name and address of the person you are designating to
receive notices to our service center at the address shown above.
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 policy 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
submitting 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
sip the notice, except that it will not apply to any payment we make or other
action we take before we receive the notice in our Administrative Office. If you
change the Beneficiary, any previous arrangement you made under the Payment
Options provision on Page 6 is cancelled. You may choose a Payment Option for
the new Beneficiary in accordance with that provision.
ASSIGNMENT. You may assign this policy, if we agree, but we will not be bound by
an assignment unless we have 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 amounts and due dates of the premiums
payable until the Final Term Expiry Date. It shows scheduled renewal premiums
based on the initial rate scale; guaranteed maximum renewal premiums; and the
premium due dates for renewal periods. For the first ten policy years, the
premiums shown on Page 3 are level and guaranteed. Beginning with the eleventh
policy year, 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 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. Beginning with the eleventh policy year, we have the right to
change the scheduled renewal premiums for the policy. We will send you written
notice of any such change before the next premium payment is due. The scheduled
premium for any policy year after the tenth policy anniversary may vary, but
will never be more than the guaranteed maximum renewal premium shown on Page 3
for that 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, taxes 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 a lapse,
but not later than the Final Term if: (1) you provide evidence of insurability
satisfactory to us; and (2) you pay all overdue premiums with interest 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 fifth
policy anniversary for a new policy on the life of the Insured without evidence
of insurability: (1) if the day of the policy anniversary nearest the Insured'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 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. '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. You may
not choose a policy of term insurance, one that includes term insurance, or one
that pr6vides insurance on more than one life.
If additional benefit riders are in effect on 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.
CONVERSION DURING DISABILITY. We will issue a new policy with a Disability
Premium Waiver rider in exchange for this policy on any policy anniversary you
choose on or before the fifth policy anniversary provided (1) the date of
exchange is before the policy anniversary nearest the Insured's 65th birthday;
(2) a Disability Premium Waiver rider is in effect in this policy on the date of
exchange; and (3) the Insured is then totally disabled as defined in that rider.
The new policy will have an insurance amount equal to the amount of insurance in
effect on this policy. It will be on a life insurance plan that we then issue,
subject to our rules in effect on its Register Date as to plan. You may not
choose a policy of term insurance, one that includes term insurance, or one that
provides insurance on more than one life. 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
and after the policy anniversary nearest the Insured's 65th birthday for a total
disability that began on or after the policy anniversary of this policy nearest
the Insured'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 up 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 misstatements 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 SAREES. 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 Imured'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.
available at the time of the Insured's death.
PAGE 6
We guarantee interest 2 1/2% a year. We may raise the guaranteed rates. We
may also allow excess interest under Options 1 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 amount 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
ACCELERATED DEATH BENEFIT RIDER
DISCLOSURE. The receipt of thc Benefit Amount may be taxable. You should seek
assistance from tax advisor prior to electing the benefit.
IN THIS RIDER "WE", "OUR' AND "US" MEAN THE EQUITABLE OF COLORADO, INC. "YOU"
MEANS THE OWNER OF THE POLICY AT THE TIME AN OWNER'S RIGHT IS EXERCISED. 'THIS
POLICY' MEANS THE POLICY TO WHICH ATTACHED.
POLICY NUMBER.- 9 6 0 1 0 4 1
THIS RIDER'S BENEFIT. We will pay an accelerated death benefit in the amount
requested by the Owner, if the Insured is terminally ill, subject to the
provisions of this rider. We will pay an accelerated death benefit under this
policy only once and in one lump sum.
The maximum accelerated death benefit you may receive is the lesser of:
1. 75% of the death benefit payable under this policy, less any policy
loan and loan interest, and
2. $500,000.
The maximum aggregate amount of Accelerated Death Benefit payments that will be
paid under all policies issued by us on the life of the Insured is $500,000.
For purposes of this benefit, the death benefit does not include any accidental
death benefits, non-convertible term riders or convertible term riders not in
their conversion period or any benefits payable because of the death of any
person other than the Insured.
There is no premium or cost of insurance charge for this rider.
We reserve the right to deduct a processing charge of up to $250.00 per policy
from the accelerated death benefit payment.
We reserve the right to set a minimum of $5,000 on the amount you may receive
under this rider.
To be eligible for this benefit you must provide satisfactory evidence to us
that the Insured's life expectancy is six months or less. This evidence must
include, but is not limited to, certification by a physician licensed to
practice medicine in the United States or Canada and who is acting within the
scope of such license. A physician does not include the Owner, the Inured or a
member of either's family.
HOW THIS RIDER RELATES TO THE POLICY. This rider is a part of the policy. Its
benefits are subject to all the terms of this rider and the policy. This rider
has no cash or loan value. This rider is non-participating.
INTEREST. Interest will be charged go the amount of the Accelerated Death
Benefit and on any unpaid premium we advance after the payment of, an
Accelerated Death Benefit. The interest rate at the time the Accelerated Death
Benefit payment is made, will not exceed the greater of the following on such
date:
1. the yield on a 90-day treasury bill; or
2. the maximum adjustable policy loan interest rate permitted in the
state in which this policy is delivered.
Effect Of Accelerated Death Benefit Payment On The Policv. The Accelerated Death
Benefit payment, plus any accrued interest will be treated as a lien against the
policy values. The amount of the lien will be pro-rated against the policy's net
cash surrender value, if any, and the net amount at risk. (The net amount at
risk is defined as the death benefit of the policy minus the cash surrender
value, if any.) The amount payable at death under the policy will be reduced by
the full amount of the lien and any other indebtedness outstanding under policy.
The Owner's access to the policy's cash surrender value of the lien secured
against the cash surrender value and any other outstanding policy loans and loan
interest.
If premiums are required to be paid under the policy, they will continue to be
due after the payment of the is not paid when due, the amount of the unpaid
premium will be added to the lien.
If a Disability Premium Waiver Rider is in effect under the policy, this
policy's premiums will be waived as of the date we approve an Accelerated Death
Benefit a payment.
PAGE 8
RIDER LIMITATIONS. Your right be paid under the Accelerated Death Benefit Rider
is subject to the following conditions:
1. The policy must be in force other than as extended term insurance.
2. For term insurance policies, there must be at least one year left
before the final term expiry date.
3. You must make a claim in writing in a form that is satisfactory to
us.
4. If the policy is collaterally assigned, except to us as security
for a policy loan or an Accelerated Death Benefit lien, we must
receive a full release of this assignment for the election of this
benefit.
5. An Accelerated Death Benefit payment must be approved in writing by
any irrevocable beneficiary.
6. For joint last to die po4cles, a claim may be made under the rider
only after the death of the first of the Insureds to die.
7. You may not be eligibli6 for the Accelerated Death Benefit if we are
notified that:
a) you are required by law to elect this rider's benefit in order
to meet the claims of creditors, whether in bankruptcy or
otherwise; or
b) you are required by a government agency to elect this rider's
benefit in order to apply for, obtain. or keep a government
benefit or entitlement.
8. You may request only one Accelerated Death Benefit Amount to be paid
per policy.
9. We may require examination of the Insured by our medical
representatives at our expense as part of any proof to establish
eligibity for benefits under this rider.
WHEN THIS RIDER WILL TERMINATE. You may terminate this rider by asking us in
writing in a form satisfactory to us and by sending the rider to our
Administrative Office. The effective date of the termination will be the
beginning of the policy month which coincides with or next follows the date we
receive your request. Once this rider has been terminated, another Accelerated
Death Benefit Rider cannot be attached to the policy.
This rider will terminate when the policy terminates. If at any time the amount
of the lien equals the total death benefit the policy will terminate.
Termination will occur 31 days after we have mailed notice to the last known
address of the Owner, unless the full amount of the lien is repaid within 31
days of the notice.
THE EQUITABLE OF COLORADO., INC.
/s/ LINDA GALASSO /s/ SAMUEL B. SHLESINGER
Linda Galasso, Secretary Samuel B. Shiesinger, Chairman,
President & Chief Executive Officer
PAGE 9
Application Part I For Life Insurance
THE EQUITABLE OF.COLORAD0, INC.
1. PROPOSED INSURED a. Printe name to appear on policy.
PaulI. I. Mansur
First Middle Initial Last
_X_Mr. __Miss __Ms. __Other Title_________
a. List all current occupations - Give Title(s) and Duties
C.E.O. - Executive Duties
d. Date of Birth: Mo 01 Day 12 Yr. 51
e. Age Nearest Birthday: 45
f. Place of Birth: State of Florida
g. Residence: State of Florida
h. U.S. Citizen? _X_Yes _____No
(If "No," Country_________________)
i. _X_Male ___Female
2. PLAN AMOUNT OF INSURANCE
Term 10 $1,000,000
3. OPTIONAL BENEFITS
___Accidental Death Benefit* (Specify Amount):
___Disability Premium Waiver*
___Automatic Premium Loan (Not for Term policies)
___Increasing Term Rider
___One Time Additional Premium of $______ for Additional Death Benefit
___Recurring Additional Premium of $______ for Additional Death Benefit
*See limitations in item 9.d.
4. BENEFICIARY for Insurance on Proposed Insured. Include Full Name and
Relationship Insured. Mansur Industries, Inc. - Employer
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.
5. OWNER Owner's Soc. Sec. Or Tax No. 6 5 0 2 2 6 8 1 3
The Owner is ____Proposed Insured
___Applicant for Child (See 9.c.)
_X_Other (Give Full Name): Mansur Industries, Inc.
If "Other," complete the following:
___Mr. ___Miss ___Mrs. ___Ms. ___Other Title_______
Relationship to Insured: Employer
Specify a successor Owner if desired____________________
If the Proposed Insured or the Applicant for a Child is not the Owner and
if all persons designated die before the Insured, the Owner will be the
estate of the last of such persons to die except where the Insured is a
Child (see Note in 9.c.).
6. MAILING ADDRESS ___Business (Give Full Name) ___Residence
Mansur Industries, Inc.
(Name)
8425 SW 129 Terrace
(No.) (Street) (Apt.)
Miami FL
(City) (State)
331566519
(Zip)
7. PREMIUM PAYMENT PLAN
___Annual _X_Semi-Annual ___Quarterly
___Monthly ___System-Matic(Attach S-M Form)
8. SPECIAL INSTRUCTIONS
a. ___Preliminary Term to: Mo____Day____Yr.____
b. ___Date to save insurance age:___________________
c. Other:
9. COMPLETE IF PROPOSED INSURED IS A CHILD (ISSUE AGES 0-14).
a. Will there be more life insurance in effect on the Child than any other
child in the family?
___Yes ___No
If Yes, explain:
b. APPLICANT-COMPLETE IF OTHER THAN CHILD.
i. First Name Middle Initial Last Name
ii. ___Mr. ___Miss ___Mrs. ___Ms.
___Other Title___________________________
iii. Date of Birth ___________________________19______
Month Day Year
iv. ___Male ___Female
v. Relationship to Child:__________________
vi. Total Life Insurance now in effect:
$------------------------
c. OWNER. If the Applicant is to be the Owner, after the Applicant's death the
Child will be the owner unless otherwise designated in
Special Instructions (in any such designation include OWNER'S FULL NAME,
RELATIONSHIP to Child, and Social Security or Tax Number). NOTE: CONSIDER
DESIGNATING AN ADULT SECONDARY OWNER TO REDUCE THE CHANCE OF A MINOR CHILD
BECOMING THE OWNER. F ALL PERSONS DESIGNATED DIE BEFORE THE CHILD, THE
OWNER WILL BE THE CHILD.
d. LIMITATIONS ON CHILD'S ADB AND DPW BENEFITS. If the Accidental Death
Benefit is applied for on the Child, the benefit is payable only if the
Child dies after the Child's first birthday.
If the Disability Premium Waiver Benefit applied for on the Child, the
benefit is effective only if the Child becomes totally disabled on or after
the Child's 5th birthday.
/s/ IAN J. SCHARF IAN J. SCHARF 319-50-226
Agent's Name Agent's Signature Florida License Number
10. OTHER INFORMATION - Has the Proposed Insured:
a. Ever had a driver's license suspended or revoked or, within the last three
years, been convicted of two or more moving violations or driving under the
influence of alcohol or drugs? (Give full details - including dates, types
of violation, and reason for license suspension or violation.)
_____Yes __X_No
b. Any plan to travel or reside outside the U.S.?
_____Yes __X_No
c. Any other life insurance now in effect or application now pending?
(State companies and amounts.)
__X_Yes ____No
d. Been disabled for 2 weeks or more within the last 2 years?
_____Yes __X_No
11.
a. In the last year flown other than as a passenger or plan to do so?
_____Yes __X_No
If "Yes:" Total flying time at present_____________Hours;
Last 12mos._____Hours; Next 12 mos._____Est. Hours.
(Complete Aviation Supplement for pilot instruction; competitive, test,
stunt or military flying; or crop dusting.)
b. Engaged within the last year,
or any plan to engage in motor racing on land or water, underwater diving,
sky diving, ballooning, hang-gliding, parachuting or flying ultra-light
aircraft? (If Yes, complete Avocation Supplement.)
_____Yes __X_No
c. Ever had an application for life or health insurance declined, that
required an extra premium or was otherwise modified? (Give full details.)
_____Yes __X_No
d. Replaced or changed any existing insurance or annuity (or any plan to do
so) assuming the insurance applied for will be issued? (State companies,
plans and amounts.)
_____Yes __X_No
Answer Questions 12 through 16 only if Non-Member. 12. Proposed Insured:
Height_____ Ft.___ In.___
Weight______lbs.
Has the Proposed Insured:
13a. Ever had or been treated for heart trouble, stroke, high blood
pressure, chest pain, diabetes, tumor, cancer, respiratory or neurological
disorder? (Give full details.)
_____Yes ____No
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.)
(Give full details.)
_____Yes ____No
14. In the last 12 months:
a. Smoked cigarettes?
_____Yes __X_No
b. Used any other form to tobacco? (Give full details.)
_____Yes __X_No
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, medthdone or other narcotics; maphetamines or
other stimulants, or any other illegal or controlled substances?
_____Yes ____No
b. Received counseling or treatment regarding the use of alcohol or drugs:
_____Yes ____No
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)?
_____Yes ____No
b. Treated by a member of the medical profession for AIDS or ARC?
_____Yes ____No
17. DETAILS. For each answer give Question number and full details. FOR 13
THROUGH 16 ALSO INCLUDE CONDITIONS, DATES, DURATIONS, TREATMENTS AND
RESULTS, AND NAMES AND ADDRESSES OF PHYSICIANS AND MEDICAL FACILITIES.
No. Name of Person Affected Details 10C Paul Has Life of Virginia - $25,000
Face - Not Replacing ---- Paul Issue with Living Benefits Rider. I have
received Living Benefits Rider Brochure 94-03. Paul Mansur SS# ###-##-####
------------------------------------------------------------------------
Any Person who
knowlingly and with
intent to injure,
defraud, or deceive
any insurer files a
statement of claim or
an application
containing any false,
incomplete, or
misleading
information is guilty
of a felony of the
third degree.
18. COMPLETE IF MONEY IS PAID BEFORE THE POLICY IS DELIVERED:
Have undersigned read and do they agree to the conditions of the Temporary
Insurance Agreement of The Equitable of Colorado, Inc., including (I) the
requirement that all of the conditions in that Agreement must be met before
any temporary insurance takes effect, and (ii) the $250,000 insurance
amount limitation? __X_Yes ____No (IF "NO," OR IF ANY PERSON PROPOSED FOR
INSURANCE HAS HAD ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) OR
AIDS-RELATED COMPLEX (ARC) WITHIN THE LAST 10 YEARS OR HAD CANCER, A STROKE
OR A HEART ATTACK WITHIN THE LAST YEAR, A PREMIUM MAY NOT BE PAID BEFORE
THE POLICY IS DELIVERED.)
__X_AMOUNT PAID: $1,372.00. (DRAW CHECKS TO ORDER OF THE EQUITABLE OF
COLORADO, INC.)
19. SOCIAL SECURITY OR TAX I.D. NUMBER CERTIFICATION
I, the proposed policy owner(s), cerify under penalties of perjury that (i)
the number(s) shown in Question 5 of this form is my (our) correct taxpayer
identification number, and (ii) I ____am _X_am not subject to a backup
withholding order issued by the IRS.
In this agreement, "we" and "our" mean The Equitable of Colorado, Inc.
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 knowledge and belief. We may rely on
them in acting on this application.
(2) Our Temporary Insurance Agreement states the conditions that must be
met before any insurance takes effect, if money is paid before
the policy is delivered.
(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 while the
Proposed Insured is living; and (b) unless to the best of my 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.
(4) No agent or medical examiner has authority to modify this Agreement or the
Temporary Insurance Agreement, nor to waive any of our rights or
requirements. We shall not be bound by any information unless it is stated
in application Part 1 or Part 2.
Date at MIAMI_________FLORIDA on 04-29 1996
X_/S/__PAUL I. MANSUR
Signature of Proposed Insured or of Applicant if Proposed Insured is a Child,
Issue Age 0-14.
X_/S/__PIERRE G. MANSUR______PRESIDENT - MANSUR INDUSTRIES, INC.
Signature(s) of Purchaser/Owner if not Proposed Insured or Applicant. (If corp.,
show firm's name and signature of authorized officer.)
SIGNATURE OF AGENT /s/ IAN J. SCHARF
LARGE AMOUNT SUPPLEMENT TO:
_____THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
_____EQUITABLE VARIABLE LIFE INSURANCE COMPANY
__X__THE EQUITABLE OF COLORADO, INC.
INSTRUCTIONS: Complete Section I AND Section(s) (Personal Insurance) or III
(Business Insurance).
PROPOSED INSURED'S
NAME_____PAUL_____I._____MANSUR ASU (Alpha)/App.No.________547_________
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 $250,000 $0
Business $0 $1,000,000 - THIS ONE
Total in Force $250,000 Amount applied for elsewhere is
___competitive _X_additional.
C. FINANCIAL INFORMATION:
1. Income:
Gross Annual Compensation:
(e.g. Salary, Commissions, Bonuses,etc.) $100,000 $100,000
(Current Rate) (Current Rate)
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 $100,000
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(es) and answer all supplemental
questions.)
___Family Income ___Education Fund ___Gift ___Mortgage Protection
___Personal Loan Collateral (other than mortgage protection):
Answer supplemental questions under Business Loan Collateral in
Section III, C3.
___Estate Settlement
Taxable Estate $_______________
Estimated Settlement Costs (taxes and administration expenses)
$_____________________
Total Liquid Assets $______________________
___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 or reinstatement, as
the case may be. The Insurer may rely on them in acting on this application.
Dated____________________ on ____4/29_____ 1996
/s/ PAUL I. MANSUR
Signature of Proposed Insured, or Applicant if Proposed Insured is a Child
Witnessed by:______________________________________
Signature of Agent
1
APPLICATION PART 2 TO:
___THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
___EQUITABLE VARIABLE LIFE INSURANCE COMPANY
___THE EQUITABLE OF COLORADO, INC.
PARAMEDICAL Reason for submission of this form:
___New Policy___Policy Change ___Reinstatement
1.
a. Proposed Insured First Name Middle Initial Last Name
(PLEASE PRINT) Paul I. Mansur
b. Height: _5_ft._8_in.
c. Weight: 175 lbs.
d. Birth Date: Mo. __01__Day_12__Yr._51_
e. ____Male ____Female
2.
a. Name and address of personal physician (or medical facility instead):
(IF NONE, SO STATE):
Sharon Rodriquez, MD, 1150 Campo Sano Avenue, Suite 410,
Coral Gables, FL 33146 Telephone: 668-2181
b. Date and reason last consulted if within the last 5 years:
03-1996 Regular check-up
c. What treatment was given or recommended? (IF NONE, SO STATE):
Monopril 20 mg. And Zocot 10 mg.
(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, tubercuosis
or other chronic respiratory
disease or disorder? X
d. Chest pain, palpitation, HIGH BLOOD
PRESSURE, rheumatic fever, heart murmur,
heart attack 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, arthiritis, gout, or disease or
disorder 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 disease?
k. Disorder of protate, reproductive organs,
breasts, menstruation or pregnancy? X
4. Is Proposed Insured now under observation
or taking treatment?
X
5. Has Proposed Insured, within 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)? X
b. Treated by a member of the medical profession for
AIDS or ARC?
6. Has Proposed Insured, within 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: X
b. Received counseling or treatment
regarding the use of alcohol or drugs? X
7. Has Proposed Insured's weight changed by
more than ? 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 pracitioner? X
b. Had any illness, injury, or surgery?
c. Been a patient in or been examined or
treated at a hospital, clinic,
sanatorium, or other diagnostic test? 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?
b. used any other form of tobacco?
(Give full details.) X
10. Family History Age if Living Cause of Death Age at Death
Father Heart Attack 44
Mother Cancer 69
Brothers/Sisters 44
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.)
F. Barbara A. Monlford MD
7150 W. 20 Ave., Suite 610
Hialeah, FL 33016
Phone: 558-6518
06-1995 Blood in Urine (Mieroscopic).
4 Refer to 2C
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 rely on them in acting on the
application or making the policy change or reinstatement.
Dated at __MIAMI___FL___on__05___03___1996 /s/ PAUL I. MANSUR
City State Mo. Day Yr. Signature of Proposed Insured
Witness (MUST BE EXAMINED) /s/ illiegible
TABLE OF GUARANTEED PAYMENTS
(MINIMUM AMOUNT FOR EACH $1,000 APPLIED)
Option 2A Option 3
FIXED PERIOD INSTALLMENTS MONTHLY LIFE INCOME
Number 10 Years Certain 20 Years Certain Refund Certain
of Years' Monthly Annual
Installments Installment Installment Age Male Female Male Female Male Female
1 $84.28 $1000.00 50 $3.48 $3.19 $3.42 $3.17 $3.37 $3.14
2 42.66 506.17 51 3.54 3.23 3.47 3.21 3.42 3.17
3 28.79 341.60 52 3.59 3.28 3.51 3.25 3.46 3.21
4 21.86 259.33 53 3.65 3.32 3.56 3.29 3.51 3.25
5 17.70 210.00 54 3.70 3.37 3.61 3.33 3.56 3.29
6 14.93 177.12 55 3.77 3.42 3.66 3.37 3.61 3.34
7 12.95 153.65 56 3.83 3.47 3.72 3.42 3.67 3.38
8 11.47 136.07 57 3.90 3.58 3.83 3.52 3.78 3.48
9 9.39 122.40 58 3.97 3.58 3.83 3.52 3.78 3.48
10 9.39 111.47 59 4.04 3.64 3.88 3.57 3.84 3.53
11 8.64 102.54 60 4.12 3.70 3.94 3.62 3.90 3.58
12 8.02 95.11 61 4.20 3.76 4.00 3.68 3.97 3.64
13 7.49 88.83 62 4.29 3.83 4.06 3.74 4.04 3.69
14 7.03 83.45 63 4.38 3.90 4.12 3.79 4.11 3.75
15 6.64 78.80 64 4.48 3.98 4.18 3.85 4.19 3.82
16 6.30 74.73 65 4.58 4.06 4.25 3.92 4.26 3.88
17 6.00 71.15 66 4.68 4.14 4.31 3.98 4.35 3.95
18 5.73 67.97 67 4.79 4.23 4.37 4.04 4.43 4.02
19 5.49 65.13 68 4.90 4.32 4.43 4.11 4.52 4.10
20 5.27 62.58 69 5.02 4.42 4.50 4.18 4.62 4.18
21 5.08 60.28 70 5.14 4.52 4.56 4.25 4.71 4.26
22 4.90 58.19 71 5.26 4.63 4.62 4.31 4.82 4.35
23 4.74 56.29 72 5.39 4.75 4.67 4.38 4.92 4.44
24 4.60 54.55 73 5.52 4.87 4.73 4.45 5.03 4.53
25 4.46 52.95 74 5.66 4.99 4.78 4.51 5.14 4.63
26 4.34 51.48 75 5.80 5.12 4.83 4.58 5.27 4.74
27 4.22 50.12 76 5.95 5.26 4.88 4.64 5.39 4.84
28 4.12 48.87 77 6.10 5.40 4.93 4.70 5.53 4.96
29 4.02 47.70 78 6.25 5.55 4.97 4.75 5.66 5.08
30 3.93 46.61 79 6.40 5.70 5.01 4.80 5.80 5.20
80 6.56 5.85 5.04 4.86 5.96 5.33
81 6.72 .01 5.08 4.90 6.11 5.45
82 6.88 6.18 5.11 4.95 6.27 5.60
83 7.04 6.34 5.13 4.99 6.43 5.73
84 7.20 6.51 5.16 5.03 6.62 5.89
85 & over 7.36 6.67 5.18 5.07 6.81 6.04
If installments are paid every 3 months, they will be 25.23% of the annual
installments. If they are paid every 6 months, they will be 50.31% of the annual
installments. Amounts for Monthly Life Income are based on age nearest birthday
when income starts. Amounts for ages not shown will be furnished on request.
Page 8
TERM INSURANCE POLICY
The Equitable of Colorado, Inc.
370 17th Street, Suite 4950, Denver, CO 80202
Renewable Term Plan. Insurance payable upon death before Final Term Expiry Date.
Renewable until Final Term Expiry Date shown on Page 3. Renewal premiums after
the tenth policy anniversary may change subject to guaranteed maximums (see
"Premium Changes" on Page 4). Premiums payable to Final Term Expiry Date or
until earlier death. Conversion Privilege. This is a non-participating policy.
No. CO106-94