Exhibit 1.A.(10)(a)
Variable Universal
Life Insurance Application
[photograph]
[logo of Southland Life]
20-784 (4-00)
INSTRUCTIONS:
The fastest way to have new business issued is for you, as the
Agent, to fill out the application completely and legibly. Follow the
instructions below carefully.
FOR ALL APPLICATIONS:
o Use black ink.
o Do not use dashes, ditto marks, or the initials NA.
o Have the proposed insured initial all changes. Do not use correction fluid
for corrections.
o Obtain and attach special state forms such as replacement, disclosure, or
other compliance forms before the policy is issued.
o Detach and leave the Notice under the Fair Credit Reporting Act, Notice
Regarding the Medical Information Bureau, and Notice of Insurance
Information Practices with the applicant.
o Complete the Conditional Receipt only when money is accepted with the
application.
o Southland Life Insurance Company will not accept an agent or agency's
personal check, cashiers check or money order as premium payments.
SIGNATURES REQUIRED: PAGE 8 AND 10
o Your signature is required on both pages 8 and 10.
o The signature of the proper owner/applicant is required.
o The signature of the parent or legal guardian is required if proposed
insured is under age 15.
o Have all applications signed in your presence.
* ALL SIGNATURES MUST BE ON APPLICATION WHEN SUBMITTED
APPLICATION - PART ONE
SECTIONS A AND E: INSURED INFORMATION
o The names of the proposed insureds will appear in the policy as shown in
these sections.
o Carefully specify Jr., Sr., or I, II, III etc. as required.
o The age of the applicant always refers to the AGE NEAREST BIRTHDAY.
SECTIONS C AND F: BENEFICIARY INFORMATION
o The full name and relationship of the beneficiary to the insured is
required.
o USE REMARKS-SECTION 0 to explain the interest of the beneficiary if other
than the spouse or a close family member.
o If the beneficiary is a trust, include the name of the trustee, name of
the trust, and the date of the trust.
APPLICATION - PART TWO
HEALTH STATEMENT:
o Complete on ALL applications for ALL proposed insureds (include family
members if application is for Children's Rider) even in cases where
medically examined.
o Give an explanation for all "Yes" answers. Include complete details such
as the nature of the condition, date of onset, treatment and medication
recommended, and the attending physician's full name, address, and zip
code.
o Always include medical number for Kaiser, VA, etc.
o Clearly identify the proposed insured to whom the medical information
pertains.
o Indicate if the physician requires prepayment before release of medical
records.
o If medical examination is required, provide the proposed insured a medical
examination form and indicate in item 5 of the AGENT'S CERTIFICATION the
medical tests or requirements ordered.
AGENT'S CERTIFICATION:
o Indicate request for back-dating, etc. in the SPECIAL REQUEST SECTION.
Policies are dated from the 1st to the 28th of the month. Policies may be
back-dated one month prior to the date of the application if allowed by
state regulation.
o Properly complete the AGENT PRODUCTION INFORMATION SECTION.
20-784 (4-00)
PART ONE OF VARIABLE LIFE APPLICATION SOUTHLAND LIFE INSURANCE COMPANY
Customer Service Center
P. 0. Box 173789
Denver, CO 80217-3789
1-800-224-3035
SECTION A - PRIMARY INSURED
Name:______________________________________________________ SSN:___-__-____
Last Full First Middle
Address: _______________________________________________________________________
Street City County State Zip Code
Years at Address: ______ (If less than two years, Home Phone: (___)_________
show former address in SECTION O)
|_| Male |_| Married Date of Birth: ____/____/____ Age:______
(Age nearest birthday)
|_| Female |_| Single Driver's License Number and State:____________________
Place of Birth: ________________________________________________________________
Employer's Name:________________________________________________________________
Employer's Address: ____________________________________________________________
Street City County State Zip Code
Years Employed: _____ (If less than two years, Business Phone:(___)________
show former occupation in REMARKS)
All Occupations and Duties:_____________________________________________________
Primary Insured's Income: $_________ Primary Insured's Net Worth: $___________
ADDITIONAL INFORMATION FOR JUVENILE - COMPLETE THE FOLLOWING IF PRIMARY INSURED
IS UNDER AGE 15.
Father - In force $ __________ Applied for $ ___________
Mother - In force $ __________ Applied for $ ___________
- --------------------------------------------------------------------------------
SECTION B - POLICY AND RIDER BENEFITS Risk Class:
|_| Preferred
|_| Non-Tobacco
|_| Standard
Plan of Insurance:__________________ Stated Death Benefit $__________________
Death Benefit Type: |_| A (Level Death Benefit) |_| B (Increasing Death Benefit)
|_| Check here if insurance is for PENSION or similar tax-qualified ERISA plan
Riders
|_| Adjustable Term Rider $____________ |_| Other (Specify)__________________
(Attach Schedule of |_| Children's Rider -
Target Death Benefits) Number of Units ________________
|_| Waiver of Cost Insurance |_| Additional Insured
|_| Waiver of Specified Premium $______ Rider: $________________________
|_| Accidental Death $_________________ Risk Class:
|_| Guaranteed Insurability |_| Preferred
Option $__________________________ |_| Non-Tobacco
|_| Guaranteed Minimum Death Benefit: |_| Standard
|_| Later of 10 Years or Age 65 |_| Lifetime
|_| Change of Insured Option Complete "Additional Adult
Insured or Payor" Section E
for each additional adult
insured.
- --------------------------------------------------------------------------------
SECTION C - BENEFICIARY-- SHOW RELATIONSHIP OF EACH BENEFICIARY TO PRIMARY
INSURED. IF BENEFICIARY IS A TRUST, PLEASE GIVE NAME
AND DATE OF TRUST.
Primary: ____________________ Relationship to Primary Insured:________________
____________________
Contingent:__________________ Relationship to Primary Insured:________________
- --------------------------------------------------------------------------------
SECTION D - OWNER/APPLICANT |_| SSN
Name _________________________________________________ |_| Tax I.D.:___________
Last Full First Middle
Address: _______________________________________________________________________
Street City County State Zip Code
Date of Birth: ____/____/____ Age: __________ |_| Male |_| Female
Relationship to Primary Insured: __________________ Home Phone: (___)________
FLORIDA RESIDENTS ONLY: This section is to be completed only if the owner wishes
to designate a second person to receive any lapse notice sent after the owner
reaches age 64.
(May be left blank.)
Name:______________________________________________________ SSN:___-__-____
Address: _______________________________________________________________________
Street City County State Zip Code
Date of Birth: ____/____/____ |_| Male |_| Female
Relationship to Owner: _______________ Home Phone: (___)______________________
20-784 (4-00) 1
SECTION E - ADDITIONAL ADULT INSURED OR PAYOR -- Complete this section for each
Additional Adult Insured. If more than one Additional Adult Insured, attach
separate application. Complete the HEALTH STATEMENT, in all cases, on each
Additional Adult Insured.
Name:______________________________________________________ SSN:___-__-____
Last Full First Middle
Address: _______________________________________________________________________
Street City County State Zip Code
Years at Address: ______ (If less than two years, Home Phone: (___)_________
show former address in Section O)
Relationship to Primary Insured: _______________________________________________
|_| Male |_| Married Date of Birth: ____/____/____ Age:______
(Age nearest birthday)
|_| Female |_| Single Driver's License Number and State:____________________
Place of Birth: ________________________________________________________________
Employer's Name:________________________________________________________________
Employer's Address: ____________________________________________________________
Street City County State Zip Code
Years Employed: _____ (If less than two years, Business Phone:(___)________
show former occupation in Section O)
All Occupations and Duties:_____________________________________________________
- --------------------------------------------------------------------------------
SECTION F - ADDITIONAL INSURED BENEFICIARY -- Show beneficiary for additional
insured:
Primary: ____________________ Relationship to Additional Insured:_____________
____________________ ________________________________________________
Contingent:__________________ Relationship to Additional Insured:_____________
__________________ ________________________________________________
- --------------------------------------------------------------------------------
SECTION G - PREMIUM PAYMENTS
$ _____________ Cash With Application $ _____________ Collect On Delivery
PREMIUM PAYMENT METHOD AND FREQUENCY
(Check one box only) FOR FLEXIBLE PREMIUM PLANS, indicate:
$ __________ Planned Periodic Premium
(write "none", if no future billing
is desired.)
-----------------Frequency-------------
Method Annual Semi-Annual Quarterly Monthly
- ----------- ------ ----------- --------- -------
Direct Bill |_| |_| |_| N/A
PAC |_| |_| |_| |_|
INITIAL PREMIUM ALLOCATION. Your Initial Premium will be allocated to the
Guaranteed Interest Account and/or among the Variable Account Subaccounts as
specified below. Please use whole number percentages. Variable Account
allocations are limited to 18 Subaccounts. The total must equal 100%.
GUARANTEED INTEREST ACCOUNT __________%
VARIABLE ACCOUNT SUBACCOUNTS
ALGER AMERICAN FIDELITY VARIABLE INSURANCE PRODUCTS FUND (VIP) INVESCO VARIABLE INVESTMENT FUND (VIF)
___% Growth Portfolio ___% VIP Equity-Income Portfolio ___% VIF Equity Income Fund
___% Leveraged AllCap Portfolio ___% VIP Growth Portfolio ___% VIF Utilities Fund
___% MidCap Growth Portfolio ___% VIP High Income Portfolio JANUS ASPEN SERIES
___% Small Capitalization Portfolio ___% VIP Money Market Portfolio ___% Aggressive Growth Portfolio
___% VIP Overseas Portfolio ___% Balanced Portfolio
FIDELITY VARIABLE INSURANCE PRODUCTS FUND II (VIP II) ___% Growth Portfolio
___% VIP II Asset Manager Portfolio ___% International Growth Portfolio
___% VIP II Contrafund Portfolio ___% Worldwide Growth Portfolio
___% VIP II Index 500 Portfolio
___% VIP II Investment Grade Bond Portfolio
20-784 (4-00) 2
SECTION H - SPECIAL PROGRAMS -- CHECK EACH OPTION YOU WISH TO SELECT
H1 |_| Dollar Cost Averaging. (Complete Sections 2A and 7 of the Variable Life
Service Request Form attached to this application.)
H2 |_| Automatic Rebalancing (Complete Sections 2A and 5 of the Variable Life
Service Request Form.)
H3 |_| Telephone Authorization (Complete Sections 2A and 4 of the Variable Life
Service Request Form.)
20-784 (4-00) 3
SECTION I - EXISTING INSURANCE -- List all life insurance in force on all
persons proposed for insurance (including Business Insurance). Use REMARKS or
attach additional pages if additional space is needed. If NONE, write "NONE" on
the first line below.
Life Accidental Year
Insured Company Replacement Amount Death Issued
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
REGARDING ALL PERSONS PROPOSED FOR INSURANCE - If any Question is "Yes," please
explain and give complete details. Use SECTION 0 or attach additional pages if
additional space is needed.
1. Is the Policy applied for to replace or change any existing
insurance or annuities in this or any other Company? (If
"yes," check which policy in the above chart is to be
replaced or changed and follow the replacement procedures
for your state.) |_| Yes |_| No
2. Is the replacement to be handled as an IRC Section 1035
exchange? |_| Yes |_| No
3. Has any person proposed for insurance had an application(s)
pending with another Company(ies) within the past 90 days?
|_| Yes |_| No
(If "Yes," give Company(ies) and Amount(s). _________________________________
4. (THE FOLLOWING QUESTION IS NOT APPLICABLE IN THE STATE OF
MO. DO NOT ANSWER IF YOU RESIDE IN MO.) Has any person
proposed for life insurance ever applied for Life or Health
insurance which was rated, declined, postponed, withdrawn or
modified in any way? (If "Yes," state Person, Company, Dates
and Details.) |_| Yes |_| No
_____________________________________________________________________________
- --------------------------------------------------------------------------------
SECTION J - BUSINESS INSURANCE -- If application is for Business Insurance,
please complete:
1. Approximate net 2. Approximate net annual
worth of business? $____________ income of business? $____________
3. Percentage of business 4. Amount of Business
owned or controlled by Insurance in force on
Primary Insured? _______________% Primary Insured? $_______________
5. Purpose of Business Insurance on
Primary Insured (Keyman, Buy-Sell, etc.)?____________________________________
6. Information about Business Insurance carried by other Owners, Officers,
Partners, or Key Men: (Use SECTION 0 or attach additional page if additional
space is needed.)
Percentage of Insurance in Force Insurance Applied For
Full Name Ownership Amount Company Amount Company
________________________________________________________________________________
________________________________________________________________________________
- --------------------------------------------------------------------------------
SECTION K - SPECIAL ACTIVITIES -- Has any person proposed for insurance:
1. Ever had a traffic citation for driving while intoxicated,
or driving under the influence of intoxicants or drugs, or
any moving violation within the past three years? (If "Yes,"
give details in SECTION 0.) |_| Yes |_| No
2. Made in the past two years or contemplate making in the
future aerial flights of any kind other than as a passenger
on any regular scheduled airline? (If "Yes," complete and
submit the Aviation Section of an AVOCATION QUESTIONNAIRE
for each person answering "Yes.") |_| Yes |_| No
3. Engaged in the last two years or contemplate engaging in the
future in scuba/skin diving, sky diving, hang gliding, hot
air ballooning, rodeo activities, or any other organized
sport, avocation, hobby, or activity? (If "Yes," submit an
AVOCATION QUESTIONNAIRE for each person answering "Yes."
Complete each applicable section of each questionnaire
submitted for which the questions in such section(s) relate
to an activity for which the answer to question 3. is
"Yes.") |_| Yes |_| No
4. Planned to travel or reside outside the United States or
Canada within the next year? (If "Yes," give details in
SECTION 0.) |_| Yes |_| No
- --------------------------------------------------------------------------------
SECTION L - TOBACCO USAGE -- Has any person proposed for insurance in the last
twelve months:
1. Smoked or used any of the following: cigarettes, cigars,
pipe, chewing tobacco, nicotine chewing gum or patch, snuff,
or any other tobacco product? |_| Yes |_| No
For "Yes" answers, specify in SECTION 0 name of person,
product smoked or used, frequency and duration of use, and
date of last use.
20-784 (4-00) 4
SECTION M - Has any person proposed for insurance:
1. (Do not answer this question if you reside in FL or NV.)
been diagnosed by or treated by a licensed member of the
medical profession for Acquired Immune Deficiency Syndrome?. |_| Yes |_| No
2 (Answer this question ONLY if you reside in NV.) been
diagnosed by or treated by a licensed member of the medical
profession for any immune system disorder?.................. |_| Yes |_| No
3. (Do not answer this question if you reside in CA, CT, FL,
ME, MN, ND, NJ, NV, or WV.) tested **positive for antibodies
to the AIDS Virus (Human T-Cell Lymphotrophic Virus Type
III, HTLV-III) or Lymphadenopathy Virus (LAV)?.............. |_| Yes |_| No
4. (Answer this question only if you reside in WV.) tested
positive for antibodies to the AIDS Virus?.................. |_| Yes |_| No
5. (Answer this question only if you reside in FL.) tested
positive for exposure to the HIV infection or been diagnosed
as having ARC or AIDS caused by the HIV infection?.......... |_| Yes |_| No
**In Michigan such tests are limited to the ELISA-ELISA Western Blot Series.
(Give details to any "Yes" answers in the Section O. If there is not enough room
in the space provided, please attach additional pages.)
- --------------------------------------------------------------------------------
SECTION N - SUITABILITY
A. Have you, the Proposed Insured and the Owner, if other than
the Proposed Insured, received a current Prospectus,
dated__________________, for the policy applied for and for
each designated fund? |_| Yes |_| No
B. Do you understand that under the policy applied for the
amount or duration of the death benefit may vary under
specified conditions; policy values may increase or decrease
in accordance with actual future investment experience of
our Separate Account and the interest credited in the
Guaranteed Interest Account; and the amount payable on
maturity is not guaranteed but is dependent on the amount
then in the Policy?......................................... |_| Yes |_| No
C. Do you understand that any personalized illustrations
received are based on hypothetical interest assumptions
which may not be indicative of actual future investment
experience of our Separate Account or of actual interest
credited in our Guaranteed Interest Account?................ |_| Yes |_| No
D. With this in mind, is the policy in accord with your
insurance objectives and your anticipated financial needs?.. |_| Yes |_| No
- --------------------------------------------------------------------------------
SECTION 0 - REMARKS -- (If there is not enough room in the space provided,
please attach additional pages.)
- --------------------------------------------------------------------------------
SECTION P - HOME OFFICE AMENDMENTS (Not applicable in WV.)
20-784 (4-00) 5
PART TWO OF APPLICATION SOUTHLAND LIFE INSURANCE COMPANY
FOR INSURANCE TO Customer Service Center
P. 0. Box 173789, Denver, CO 80217-3789
HEALTH STATEMENT
This HEALTH STATEMENT must be completed by the Agent on ALL applications for ALL
persons proposed for insurance. (Include family members if Children's Rider is
applied for.) In addition, if a medical examination is required for any person
proposed for insurance, please provide such persons a Southland Life Insurance
Company medical examination form. Even in those cases where a medical
examination is required, please complete the Health Statement in order to
expedite the underwriting process.
Weight
Change in
Date of Birth Height Past Year Relationship to
Full Names of all to be Insured Month Day Yr. Ft. In. Weight Gain Loss Primary Insured
1. Primary Insured X X X X X X X X X X
--------------- __________ _______ ____ ____ ----------------------------
2. Additional Adult Insured X X X X __________ _______ ____ ____ X X X X X X
--------------- ----------------------------
All children to be insured under
Child rider
3. _______________________________ ______________ __________ _______ ____ ____ ____________________________
4. _______________________________ ______________ __________ _______ ____ ____ ____________________________
5. _______________________________ ______________ __________ _______ ____ ____ ____________________________
6. _______________________________ ______________ __________ _______ ____ ____ ____________________________
- --------------------------------------------------------------------------------
1. To the best of your knowledge (for MO and OR residents, in the last 10
years), has any person (Owner/Proposed Insured) proposed for insurance had or
been told by a licensed member of the medical profession that he or she had:
(For each "Yes" answer, give details in the space provided to the right of
each question. If there is not enough room in the space provided, please
attach additional pages.)
Record Question Number; Person; Condition; Diagnosis and
Dates/Duration of condition or treatment; Name and Address
of all doctors and hospitals; and medical number for
Yes No Kaiser, VA, etc.
a. Convulsions, epilepsy, paralysis, mental or nervous
disorders?................................................ |_| |_|
b. Chest pain, pulse irregularity, high "blood pressure,
rheumatic fever, heart murmur, heart attack, stroke, or
other disorder of the heart, or circulatory system, anemia
or leukemia?............................................. |_| |_|
c. Asthma, emphysema, tuberculosis, pneumonia, or chronic
respiratory disease?..................................... |_| |_|
d. Jaundice, intestinal bleeding, ulcer, colitis,
diverticulitis, or other disorder of the stomach,
intestines, liver or gall bladder?....................... |_| |_|
e. Kidney stone or other disease of kidney; disorder of the
bladder, prostate, reproductive organs, or breasts; sugar,
albumin, blood, or pus in the urine?..................... |_| |_|
f. Arthritis, gout, or disorder of the muscles, bones, or
joints, including the spine; deformity, or amputation;
blindness or deafness?................................... |_| |_|
g. Diabetes or disorder of the thyroid?..................... |_| |_|
h. Cancer or tumor, collagen disease or any other disorder not
listed above?............................................ |_| |_|
i. In the past 10 years, a disorder of the-blood*, diarrhea,
disorder of the skin, chronic cough, disorder of lymph
glands, chronic fatigue or significant weight loss?...... |_| |_|
*For residents of North Carolina, disorder of the blood
includes all conditions of the blood presently recognized as
disorders, both primary disorders of the blood (e.g. anemia,
polycythemia, leukopenia, teukocytosis, clotting disorders,
platelet disorders, immune disorders whether congenital or
acquired, disorders or gammaglobulin) and disorders that
reflect other disease processes (e.g. infections,
malignancies, sources of blood loss, biliary tract disease).
20-784 (4-00) 6
HEALTH STATEMENT (Continued)
2. To the best of your (Owner/Proposed Insured) knowledge, has any person
proposed for insurance: (For each "Yes" answer, give details in the space
provided to the right of each question. If there is not enough room in the
space provided, please attach additional pages.)
Record Question Number; Person; Condition; Diagnosis and
Dates/Duration of condition or treatment; Name and Address
of all doctors and hospitals; and medical number for
Yes No Kaiser, VA, etc.
a. Other than above, had examination, treatment, or
consultation with a physician during the past 5 years?... |_| |_|
b. Been on, or are now on, any medication or prescribed diet? |_| |_|
c. Except as prescribed by a Doctor, ever used heroin,
morphine, cocaine, or other narcotic drug?............... |_| |_|
d. Within the past two years used:
1) Barbiturates, stimulants, tranquilizers, or sedatives
except as prescribed by a physician?.................. |_| |_|
2) LSD, marijuana, PCP, or any other hallucinogenic
substance?............................................ |_| |_|
e. (DO NOT ANSWER THIS QUESTION IF YOU RESIDE IN NE.)
Ever received treatment, medical advice, joined an
organization or been arrested or convicted because of use
or possession of alcohol or drugs?....................... |_| |_|
(ANSWER THIS QUESTION ONLY IF YOU RESIDE IN NE.)
Ever received treatment, medical advice or been arrested or
convicted because of use or possession of alcohol or drugs? |_| |_|
f. Been rejected, discharged, or retired by an employer or the
military for medical or physical disability reason?...... |_| |_|
g. Been advised to have any diagnostic test, hospitalization or
surgery which has not been completed?.................... |_| |_|
- -----------------------------------------------------------------------------------------------------------------|
FAMILY RECORD OF PRIMARY INSURED | | FAMILY RECORD OF SPOUSE |
| | (If Proposed for Insurance) |
- --------------------------------------------------- --------------------------------------------------|
If Living | If Deceased | | If Living | If Deceased |
- --------------------------------------------------- --------------------------------------------------|
Age State of | Age At Cause of | | Age State of | Age At Cause of |
Health | Death Death | | Health | Death Death |
- -----------------------------------------------------------------------------------------------------------------|
| | Father | | |
- -----------------------------------------------------------------------------------------------------------------|
| | Mother | | |
- -----------------------------------------------------------------------------------------------------------------|
| | Brother(s) | | |
| | | | |
| | | | |
| | | | |
- -----------------------------------------------------------------------------------------------------------------|
| Sister(s) | | |
| | | | |
| | | | |
| | | | |
| | | | |
- -----------------------------------------------------------------------------------------------------------------|
20-784 (4-00) 7
DECLARATIONS
All statements and answers made in all parts of this application, consisting of
pages 1, 2, 3, 4, 5, 6 and 7, are full, complete and true to the best of my
knowledge and belief. It is understood and agreed that:
(a) all such statements and answers are offered to Southland Life Insurance
Company as a consideration for and shall be the basis of any insurance
issued;
(b) all such statements and answers, including the smoking status, are
considered material to the accurate assessment of the insurability of any
person proposed for insurance;
(c) a misstatement on any of the questions could result in policy rescission
and return of premiums paid; For South Carolina residents, a misstatement
on any of the questions could result in policy rescission and return of
premiums paid, subject to the incontestability provision and legal
proceedings;
(d) all information given to the Agent is contained in this application;
(e) no agent or medical examiner has the authority to make, alter, or discharge
any contract, accept risks, or waive Southland Life Insurance Company's
rights or requirements;
(f) acceptance of any policy issued pursuant hereto shall constitute
ratification of the manner in which it is written and of any corrections,
additions, or changes made by Southland Life Insurance Company and entered
in the HOME OFFICE AMENDMENTS. In those states where it is required
(Connecticut, Illinois, Iowa, Kansas, Kentucky, Maryland, Michigan,
Minnesota, Nebraska, Oregon, Pennsylvania, West Virginia and other states
as appropriate), changes as to plan, amount, age at issue, classification,
or benefits will be made only with the Owner's written consent. In West
Virginia, no change will be made without the owner's written consent;
(g) The insurance applied for in this application shall not take effect until:
1 this application has been approved by Southland Life Insurance Company,
and
2 the policy has been delivered to and accepted by the Owner, and
3 the full first premium, according to the rates stated in the policy, has
been paid while all persons proposed for insurance are alive and while
the health and insurability of such persons has not changed from that as
described in this application.
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
I hereby authorize the following to give to Southland Life Insurance Company or
its reinsurer(s) any information concerning me or my health: any licensed
physician or medical practitioner; any hospital, clinic, or other medical
facility; any insurance company or reinsurance company; employer; consumer
reporting agency; or the Medical Information Bureau, Inc. (MIB, Inc.).
I hereby authorize Southland Life Insurance Company to obtain an investigative
consumer report on me. I understand that I may request to be interviewed in
connection with such report. It is understood that I may request in writing and
receive a copy of such report.
I understand that this information will be used to determine my eligibility for
insurance and to evaluate any claim under this application. I agree that a
photocopy of this Authorization shall be as valid as the original. I agree that
this authorization will be valid for two years from the date below, if used to
determine eligibility, or for the duration of the claim, if used to evaluate any
claim under this application.
ACKNOWLEDGMENT
I acknowledge that I have received and read a copy of the "Notice Regarding
MIB," the "Notice Under the Fair Credit Reporting Act," and the "Notice of
Insurance Information Practices," and that I or my representative may request
and receive a copy of this Authorization.
Signed at_________________________________________ this___________ day of 20___.
City State
_______________________________________ ______________________________________
Signature of Proposed Insured Signature of Spouse/Additional Insured
(or Parent/Guardian if Minor)
_______________________________________ ______________________________________
*Signature of Applicant/Owner SIGNATURE OF AGENT AS WITNESS/AGENT'S
(if other than Proposed Insured) LICENSE NUMBER
______________________________________
Agent's Name (Please Print)
*If Owner is Corporation, Partnership or Trust, a Corporate Officer, Partner or
the Trustee must sign and state title.
See next page for applicable Fraud Warning.
20-784 (4-00) 8
FRAUD WARNING
Any person who with intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or files a claim containing a false
or deceptive statement of material fact may be guilty of insurance fraud (not
applicable to Arizona, Oregon or Virginia residents).
FOR COLORADO RESIDENTS, THE LAW REQUIRES THE FOLLOWING WARNING:
It is unlawful to knowingly provide false, incomplete, or misleading facts or
information to an insurance company for the purpose of defrauding or attempting
to defraud the company. Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement
or award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory Agencies.
FOR CONNECTICUT RESIDENTS, THE LAW REQUIRES THE FOLLOWING WARNING:
Any person who with intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or files a claim containing a false
or deceptive statement of material fact may be guilty of insurance fraud as
determined by a court of competent jurisdiction.
FOR FLORIDA RESIDENTS, THE LAW REQUIRES THE FOLLOWING WARNING:
Any person who knowingly 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.
FOR NEW JERSEY RESIDENTS, THE LAW REQUIRES THE FOLLOWING WARNING:
Any person who includes any false or misleading information on an application
for an insurance policy is subject to criminal and civil penalties.
20-784 (4-00) 9
SOUTHLAND LIFE INSURANCE COMPANY
P. 0. Box 173789, Denver, CO 80217-3789
AGENT'S CERTIFICATION
Name of Primary Insured_________________________________________________________
(Print)
1. Did you personally interview Primary Insured and complete
application in his or her presence? |_|Yes |_|No
2. Have you issued the "Notice of lnsurance Information
Practices"? (It must be detached and given to Primary
insured.) |_|Yes |_|No
3. Will the policy applied for replace or change any existing
insurance or annuity? |_|Yes |_|No
4. If replacement or change of existing insurance is
involved,have you complied with all relevant state
requirements, including any "Notice, Disclosure and/or
Comparisons"? |_|Yes |_|No
If no, please explain.______________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
5. Please check the medical requirements ordered:
|_| MD Exam |_| Stress EKG
|_| HOS |_| EKG
|_| Blood Profile |_| Paramedical
|_| Inspection
|_| Paramedical Company________________________
6. Is the Primary Insured a United States citizen? |_|Yes |_|No
If "no", give Visa Number:______________________________
and type of Visa:_______________________________________
7. To the best of your knowledge, are the responses to the
tobacco usage section correct? |_|Yes |_|No
8. How long have you known the Primary Insured?
________________ How well? _______________________________
Are you related to any person proposed for insurance in
this application? |_|Yes |_|No
If "Yes," give relationship.________________________________
9. Is this policy to be issued under a qualified pension,
profit sharing, or 401(k) plan? |_|Yes |_|No
10. What was the PRIMARY purpose of the insurance?
|_| Estate/Death Taxes |_| Gift
|_| Private Pension/Retirement |_| Family Income
|_| Mortgage Protection |_| Savings
|_| College Funding
|_| Other____________________________________________________
- --------------------------------------------------------------------------------
Special Requests:
- --------------------------------------------------------------------------------
I hereby certify that I have no knowledge of anything affecting the insurability
of any person proposed for insurance which is not fully set forth in these
papers.
__________________________ ______________________________ ____________________
Signature of Agent City & State Date
__________________________ ______________________________
Agent's Name (Please print) Agent's Telephone Number
AGENT PRODUCTION INFORMATION
- --------------------------------------------------------------------------------
TO BE COMPLETED BY AGENT
(Please Print)
Agent's Code:_______ Agent's Name:____________________________________________
Last Full First Middle
Broker/Dealer's Name:___________________________________________________________
- --------------------------------------------------------------------------------
Volume & Commission to be Shared With:
Agent's Code:_______ Agent's Name:______________________________ Percent:____
Last Full First Middle
20-784 (4-00) 10
Do Not Write Above This Line
Bank Copy
AUTHORIZATION TO HONOR CHECKS, DRAFTS AND OTHER INSTRUMENTS DRAWN BY
THE SOUTHLAND LIFE INSURANCE COMPANY, P 0. BOX 173789, DENVER,
CO 80217-3789
As a convenience to me, I hereby request and authorize you to charge
to my account checks, drafts and other instruments drawn on my account
by and payable to the order of the Southland Life insurance Company, I
agree that your rights in respect to each such check, draft or other
instrument shall be the same as if it were drawn on you and signed
personally by me. This authority is to remain in effect until revoked
by me in writing, and until you actually receive such notice I agree
that you shall be fully protected in honoring any such check, draft or
other instrument.
I further agree that if any such check, draft or other instrument be
dishonored, whether with or without cause and whether intentionally or
inadvertently, you shall be under no liability whatsoever even though
such dishonor results in the forfeiture of insurance.
To: Financial Institution ____________________________________________
(Branch if any)
Street Address or PO. Box_____________________________________________
City, State and Zip Code______________________________________________
Policyowner___________________________ Billing No.____________________
_____________________________________X________________________________
Date Account No. Signature EXACTLY as it appears on
Account Records
PLEASE NOTE: The size of this form is adjustable from a 4 x 6 to a
3 x 5 card for your filing convenience.
There is an indemnification Agreement on the reverse side.
- --------------------------------------------------------------------------------
PRE-AUTHORIZED CHECK AUTHORITY - HOME OFFICE RECORD - DO NOT DETACH
Subject to the conditions on the reverse side, to which I hereby agree,
Southland Life Insurance Company is hereby authorized to draw a check, draft
or other instrument on (date)___________________________________________________
for the purpose of paying premiums and/or other payments indicated hereon
against the account of
________________________________________________________________________________
Print Name EXACTLY as It appears on Account Records Account Number
with____________________________________________________________________________
Name of Financial Institution with Branch Name Transit Number
and Number, if any
________________________________________________________________________________
Address of Institution or Branch Routing Symbol
POLICY NUMBER AMOUNT PURPOSE POLICY NUMBER AMOUNT PURPOSE
_____________ ______ _______ _____________ ______ _______
_____________ ______ _______ _____________ ______ _______
_____________ ______ _______ _____________ ______ _______
_____________ ______ _______ _____________ ______ _______
X_________________________________________________ ______________ ___________
Signature EXACTLY as It appears on Account Records BILLING NUMBER DATE
Customer/Home Office Copy
A VOIDED BLANK CHECK OR DRAFT ON THE ACCOUNT TO BE DRAWN AGAINST MUST ACCOMPANY
THIS AGREEMENT
- --------------------------------------------------------------------------------
NOTICE OF INSURANCE INFORMATION PRACTICES
As a part of our normal procedure for processing an initial application for
insurance or an application for reinstatement or for a change in insurance
coverage, we may obtain personal information about an insured or a proposed
insured from persons other than the insured or proposed insured. This personal
information generally relates to health, occupation, hobbies, general
reputation, credit, mode of living (except as may be related directly or
in-directly to your sexual orientation) and other personal characteristics. In
some circumstances, this personal information and other information may be
disclosed to third parties without the specific authorization of the person to
whom the information relates. A right of access and correction exists with
respect to personal information in our files. A detailed explanation of our
insurance information practices and the right to access and correction will be
furnished to you if you make written request to: Underwriting Department,
Southland Life Insurance Company, Customer Service Center, P 0. Box 173789,
Denver, CO 80217-3789.
THIS NOTIFICATION MUST BE DETACHED AND DELIVERED TO THE APPLICANT
See Reverse Side for Notice Regarding MIB and Fair Credit Reporting Act.
11
TO: THE INSTITUTION NAMED ON THE REVERSE SIDE
In consideration of your participating in a plan which the Southland
Life Insurance Company (hereinafter known as the "Company") has put
into effect by which amounts due on policies of insurance are
collected by checks, drafts or other instruments drawn by the Company
on the accounts of persons who are responsible for these payments, the
Company does hereby agree that:
(1) It will indemnify and hold you harmless from any liability to any
person arising out of the payment by you of any check, draft or
order, whether or not genuine, drawn by the Company in the
regular course of business for the purpose of payment or arising
out of the dishonor by you, whether with or without cause, or
intentionally or inadvertently, of any such check, draft or
order, whether or not such claim or liability asserted against
you be based upon the forfeiture or alleged forfeiture of a
policy of insurance the premium on which is sought to be
collected by the Company by any such check, draft, or order, and
(2) It will defend at its cost and expense any action which may be
brought by any depositor or any other person because of any
action taken pursuant to or in any manner arising out of your
participation in the pre-authorized check plan of premium
collection, and
(3) Without limitation on the foregoing indemnities, it will refund
to you any amount erroneously paid by you on any such check,
draft, or order, if claim for the amount of such erroneous
payment is made by you within twelve months from the date of the
check, draft or order on which such erroneous payment was made,
and
(4) Your participation in the plan or that of the depositor or member
may be terminated by written notice from either party to the
other. Likewise, your participation and that of Southland Life
Insurance Company may be terminated by thirty days written notice
from either party to the other.
Southland Life Insurance Company
/s/ David Pendergrass
Treasurer
Authorized in a resolution adopted by the Board of Directors of
Southland Life Insurance Company on August 21, 1980.
- --------------------------------------------------------------------------------
Subject to the following conditions:
1. I understand that such checks, drafts or other instruments shall constitute
notice of premium due and, upon being charged to my account, by the bank or
other financial institution, shall be my receipt for payment of the premiums.
2. Should any check, draft or other instrument not be honored by said bank or
other financial institution upon presentation, then it is understood that
such premium(s) is/are to be paid to you within the time stipulated in the
policy for payment, and in default thereof, the policy(ies) shall become null
and void except as otherwise provided therein.
3. The payment of premiums under this Plan may be discontinued by the Company or
the undersigned upon 30 days written notice.
4. This agreement may be extended by mutual consent to cover additional premium
payments to the Company.
- --------------------------------------------------------------------------------
Southland Life Insurance Company o Customer Service Center
o P.O. Box 173789 o Denver, Colorado 80217-3789
NOTICE UNDER THE FAIR CREDIT REPORTING ACT
As a part of our normal procedure for processing your initial insurance
application, an investigative consumer report may be prepared whereby
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 (except as may be related directly or indirectly to your
sexual orientation). You have the right to make a written request within a
reasonable amount of time to the Southland Life Insurance Company at the above
address for additional, detailed information about the nature and scope of this
investigation.
NOTICE REGARDING M I B
Southland Life Insurance Company or its reinsurer(s) may release information
in its file, including the information in your application, to other life
insurance companies to whom you may apply for life or health insurance, or to
whom a claim for benefits may be submitted.
Information you provide will be treated as confidential except that the
Southland Life Insurance Company or its reinsurer(s) may, however, make a brief
report thereon to the Medical Information Bureau, a non-profit 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 claim
is submitted, the Bureau will supply 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.
SOUTHLAND LIFE INSURANCE COMPANY
Customer Service Center
P 0. Box 173789, Denver, CO 80217-3789
CONDITIONAL RECEIPT
IT IS HEREBY UNDERSTOOD AND AGREED THAT UNLESS EACH AND EVERY CONDITION
SPECIFIED IN THIS RECEIPT IS FULFILLED EXACTLY, NO INSURANCE WILL BECOME
EFFECTIVE PRIOR TO POLICY DELIVERY. NEITHER THE AGENT WHOSE SIGNATURE APPEARS
BELOW, NOR ANY OTHER AGENT OF THE COMPANY OR BROKER IS AUTHORIZED TO ALTER OR
WAIVE ANY SUCH CONDITION.
IT IS ALSO AGREED THAT NO PREMIUM PAYMENT IS MADE WITH RESPECT TO ANY PERSON
PROPOSED FOR COVERAGE WHO HAS, WITHIN THE PAST 12 MONTHS, BEEN TREATED FOR OR
HAD HEART DISEASE, STROKE OR CANCER.
ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO SOUTHLAND LIFE INSURANCE COMPANY (THE
"COMPANY"). DO NOT MAKE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK.
THIS RECEIPT MUST BE COMPLETED WHEN (AND ONLY WHEN) MONEY IS ACCEPTED WITH THE
APPLICATION.
Received from ________________________ the conditional deposit of $ ____________
and an application bearing the same date as this Receipt
wherein_____________________________________________ is the Primary Insured
proposed for insurance in such application.
TERMS AND CONDITIONS
NO LIFE INSURANCE MAY TAKE EFFECT EARLIER THAN THE POLICY DELIVERY DATE UNLESS
EACH CONDITION BELOW IS MET:
(1) On the latest of this application date, the last medical examination
required on any Proposed Insured, or a later date specified in the
application: All Proposed Insureds must each be insurable and eligible
under our rules and standards for the plan, the amount, and the premium
rate exactly as requested in the application;
(2) Any Medical examination (at Company expense), test, x-rays and
electrocardiograms required by Company rules must be completed within 60
days from the application date; and
(3) The conditional deposit above must equal at least one month's premium for
the coverage as applied for.
IF EACH CONDITION IS MET, part or all of the Life insurance applied for in this
application on any one life will take effect on the latest date in (1) specified
above. If the amount of all Life insurance applied for on the same life (under
this and any other Conditional Receipts issued by this Company):
-- Is $500,000 or less, the amount of Life insurance applied for on that life
will take effect;
-- Is over $500,000, a lesser amount which is a pro rata share of the $500,000
maximum will take effect. This share will be based on the total Life
insurance applied for on that life in all applications for which the
Conditional Receipts are given. The remainder of any Life insurance applied
for will not take effect unless and until the policy is delivered.
IF ANY CONDITION IS NOT MET, the Company has no liability except to return the
conditional deposit upon surrender of this Receipt.
I have received a copy of and have read this Receipt. I understand and agree to
all of its terms.
Signed at______________________________ this______day of _________________,20___
CITY STATE
______________________________________ _______________________________________
PRIMARY INSURED (OR PARENT OR GUARDIAN SPOUSE (IF PROPOSED FOR INSURANCE)
OF MINOR PRIMARY INSURED)
______________________________________ _______________________________________
*APPLICANT/OWNER WITNESSED BY AGENT
*Signature and address if other than Primary Insured or other than Premium
Payor. If Owner is a Corporation, Partnership, or Trust, a Corporate Officer,
Partner, or Trustee must sign and state title.
20-784 (4-00) 12 Home Office Copy
[Blank Page]
20-784 (4-00)
SOUTHLAND LIFE INSURANCE COMPANY
Customer Service Center
P 0. Box 173789, Denver, CO 802173789
CONDITIONAL RECEIPT
IT IS HEREBY UNDERSTOOD AND AGREED THAT UNLESS EACH AND EVERY CONDITION
SPECIFIED IN THIS RECEIPT IS FULFILLED EXACTLY, NO INSURANCE WILL BECOME
EFFECTIVE PRIOR TO POLICY DELIVERY. NEITHER THE AGENT WHOSE SIGNATURE APPEARS
BELOW, NOR ANY OTHER AGENT OF THE COMPANY OR BROKER IS AUTHORIZED TO ALTER OR
WAIVE ANY SUCH CONDITION.
IT IS ALSO AGREED THAT NO PREMIUM PAYMENT IS MADE WITH RESPECT TO ANY PERSON
PROPOSED FOR COVERAGE WHO HAS, WITHIN THE PAST 12 MONTHS, BEEN TREATED FOR OR
HAD HEART DISEASE, STROKE OR CANCER.
ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO SOUTHLAND LIFE INSURANCE COMPANY (THE
"COMPANY"). DO NOT MAKE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK.
THIS RECEIPT MUST BE COMPLETED WHEN (AND ONLY WHEN) MONEY IS ACCEPTED WITH THE
APPLICATION.
Received from ________________________ the conditional deposit of $ ____________
and an application bearing the same date as this Receipt
wherein_____________________________________________ is the Primary Insured
proposed for insurance in such application.
TERMS AND CONDITIONS
NO LIFE INSURANCE MAY TAKE EFFECT EARLIER THAN THE POLICY DELIVERY DATE UNLESS
EACH CONDITION BELOW IS MET:
(1) On the latest of this application date, the last medical examination
required on any Proposed Insured, or a later date specified in the
application: All Proposed Insureds must each be insurable and eligible
under our rules and standards for the plan, the amount, and the premium
rate exactly as requested in the application;
(2) Any Medical examination (at Company expense), test, x-rays and
electrocardiograms required by Company rules must be completed within 60
days from the application date; and
(3) The conditional deposit above must equal at least one month's premium for
the coverage as applied for.
IF EACH CONDITION IS MET, part or all of the Life insurance applied for in this
application on any one life will take effect on the latest date in (1) specified
above. If the amount of all Life insurance applied for on the same life (under
this and any other Conditional Receipts issued by this Company):
-- Is $500,000 or less, the amount of Life insurance applied for on that life
will take effect;
-- Is over $500,000, a lesser amount which is a pro rata share of the $500,000
maximum will take effect. This share will be based on the total Life
insurance applied for on that life in all applications for which the
Conditional Receipts are given. The remainder of any Life insurance applied
for will not take effect unless and until the policy is delivered.
IF ANY CONDITION IS NOT MET, the Company has no liability except to return the
conditional deposit upon surrender of this Receipt.
I have received a copy of and have read this Receipt. I understand and agree to
all of its terms.
Signed at______________________________ this______day of _________________,20___
CITY STATE
______________________________________ _______________________________________
PRIMARY INSURED (OR PARENT OR GUARDIAN SPOUSE (IF PROPOSED FOR INSURANCE)
OF MINOR PRIMARY INSURED)
______________________________________ _______________________________________
*APPLICANT/OWNER WITNESSED BY AGENT
*Signature and address if other than Primary Insured or other than Premium
Payor. If Owner is a Corporation, Partnership, or Trust, a Corporate Officer,
Partner, or Trustee must sign and state title.
20-784 (4-00) 13 Applicant Copy
[Blank Page]
20-784 (4-00)
VARIABLE
LIFE
SERVICE
REQUESTS
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20-784 (4-00)
INSTRUCTIONS FOR COMPLETING VARIABLE LIFE SERVICE REQUESTS FORM
SECTION 1 -- SECTIONS TO BE COMPLETED
- --------------------------------------------------------------------------------
A Complete each of the sections indicated for each option.
A Obtain signatures and date in Section 9.
SECTION 2-- POLICY INFORMATION:
- --------------------------------------------------------------------------------
A NEW POLICIES. If the service request is in connection with a new policy
application please enter the name of the proposed insured, the proposed
policyowner, the policy face amount and the date the application was signed
in Section 2A.
A EXISTING POLICIES. If the service request is for an existing policy, please
enter the policy number in Section 2B.
SECTION 3-- PREMIUM PAYMENT ALLOCATION CHANGE REQUEST*
- --------------------------------------------------------------------------------
o Enter your future premium allocation.
o Premium allocations must be made only in whole percentages.
o The sum of all premium allocations must equal 100%.
SECTION 4-- TELEPHONE PRIVILEGE AUTHORIZATION OR REVOCATION:
- --------------------------------------------------------------------------------
A You may give each policyowner and your Registered Representative the
authority to transfer policy values among the divisions or to request a
partial withdrawal by telephone. If you elect telephone privileges, you must
also have a PIN number. If you wish to use a specific PIN number, please
indicate that number on the request form in Section 6.
o Mark the boxes indicating the individuals for whom telephone authority is
granted.
o To revoke telephone privileges for a specific individual, mark the box
next to the persons for whom privileges are to be revoked.
o If you are revoking telephone privileges for your registered
representative, the PIN number will be changed.
SECTION 5-- AUTOMATIC REBALANCING OPTION:*
- --------------------------------------------------------------------------------
A GENERAL
o The total of all automatic rebalancing allocations must equal 100%.
o Automatic rebalancing may be done at the same time as dollar cost
averaging. If you do these simultaneously, exclude the Money Market
Subaccount from your Automatic Rebalancing Program.
o Automatic rebalancing percentages may be different from the premium
allocation percentages.
A TO INITIATE AUTOMATIC REBALANCING OPTION:
o Enter the percentage for each investment option you wish to include in
automatic rebalancing. The total of all percentages must equal 100%.
[IMPORTANT REMINDER: If you also have elected the Guaranteed Minimum
Death Benefit, you must invest your funds in at least 5 investment
options with no more than 35% in any one investment option.]
o Indicate the frequency and date with which you wish automatic rebalancing
to occur.
A TO CHANGE YOUR AUTOMATIC REBALANCING PERCENTAGES OR FREQUENCY:
o Enter the percentage for each subaccount you wish to include in automatic
rebalancing. The total of all percentages must equal 100%.
o Indicate the frequency and date with which you wish automatic rebalancing
to occur.
SECTION 6 -- PIN NUMBER CHANGE:
- --------------------------------------------------------------------------------
o You must have a PIN number if you elect the telephone privilege option.
o If you wish to use a specific PIN number, please indicate that number in
this section.
SECTION 7-- DOLLAR COST AVERAGING OPTION:*
- --------------------------------------------------------------------------------
A TO INITIATE OR CHANGE DOLLAR COST AVERAGING:
o To initiate Dollar Cost Averaging, your Money Market Subaccount
allocation must be at least $10,000.
o Changes to Dollar Cost Averaging allocations are allowed once each policy
year.
o Enter the total percentage/dollar amount you wish to have transferred
from the Money Market Subaccount.
o Enter the percentage/dollar amount you wish to have transferred into each
selected subaccount of the Variable Account.
[IMPORTANT NOTE: When transferring funds from one subaccount to another,
you may:
-- transfer dollar amounts to dollar amounts
-- transfer dollar amounts to percentages
-- transfer percentages to percentages
You may not transfer percentages to dollar amounts.]
o Percentages must add up to 100%.
o Dollar amounts must add up to the total dollar amount to be transferred.
o Indicate the frequency and date with which you wish dollar cost averaging
to occur.
o You may specify a date for Dollar Cost Averaging to terminate. You may
also specify a dollar amount so that when the Accumulation value reaches
this dollar amount, Dollar Cost Averaging will terminate.
SECTION 8-- TRANSFER REQUEST:*
- --------------------------------------------------------------------------------
A TRANSFERS AMONG INVESTMENT OPTIONS
o Enter the dollar/percentage you wish to transfer in the "Transfer From"
column. Enter the dollar/percentage you wish to transfer into an
investment option in the "Transfer To" column.
[IMPORTANT NOTE: When transferring funds from one investment option to
another, you may:
-- transfer dollar amounts to dollar amounts
-- transfer dollar amounts to percentages
-- transfer percentages to percentages
You may not transfer percentages to dollar amounts.]
o A minimum of $100 must be transferred. This minimum need not come from
any one investment option or be transferred to any one investment option
as long as the total amount requested to be transferred equals at least
$100.
o The total dollar amount shown in the "Transfer To" column must equal the
total dollar amount shown in the "Transfer From" column.
o The total percentages shown in the "Transfer To" column must equal 100%.
o Transfers to or from the Guaranteed Interest Account have specific time
and amount limitations. Please refer to your policy or prospectus for
additional information.
*You may not invest in more than 18 investment options over the life of the
policy
VARIABLE LIFE
SERVICE REQUESTS FORM
FOR NEW AND EXISTING VARIABLE LIFE POLICIES
SOUTHLAND LIFE INSURANCE COMPANY
Variable Life Customer Service Center
P. O. Box 173888, Denver, CO 80217-3888
1-800-224-3035
SECTION 1: SECTIONS TO BE COMPLETED
For Automatic Rebalancing Option -- Complete Sections 2, 5 & 9
For Dollar Cost Averaging Option -- Complete Sections 2, 7 & 9
For Premium Allocation Change Requests -- Complete Sections 2, 3 & 9
For Transfer Requests -- Complete Sections 2, 8 & 9
For Telephone Transfer Authorization/Revocation - Complete Sections 2, 4 & 9
For PIN Number Changes -- Complete Sections 2, 6 & 9
SECTION 2: POLICY INFORMATION
A. |_| FOR NEW POLICIES:
Proposed Policyowner Name:________________________________
Proposed Insured's Name:__________________________________
Policy Face Amount:_______________________________________
Policy Application Date:__________________________________
B. |_| FOR EXISTING POLICIES:
Policyowner Name:_________________________________________
Policy No.:_______________________________________________
SECTION 3: PREMIUM ALLOCATION CHANGE REQUEST
ALGER AMERICAN FIDELITY VIP& VIP II
____% Growth ____% Asset Manager
____% Leveraged AllCap ____% Contrafund
____% MidCap Growth ____% Growth
____% Small Capitalization ____% Equity-Income
____% High Income
INVESCO VIF ____% Index 500
____% Equity Income ____% Investment Grade Bond
____% Utilities ____% Money Market
____% Overseas
JANUS ASPEN
____% Aggressive Growth
____% Balanced
____% Growth
____% International Growth
____% Worldwide Growth
____% GUARANTEED INTEREST ACCOUNT
SECTION 4: TELEPHONE PRIVILEGE AUTHORIZATION OR REVOCATION
|_| TELEPHONE PRIVILEGE AUTHORIZATION: I/We authorize Southland Life Insurance
Company to accept telephone instructions from the Owners/Registered
Representative of the policy listed above.
|_| Owners Only |_| Owner and Registered Representative
|_| REVOCATION OF TELEPHONE PRIVILEGE AUTHORIZATION: I/We revoke all telephone
privilege authorization in place on the policy listed above for the
following persons:
|_| Owners and Registered Representative |_| Other_____________
|_| Registered Representative Only
By signing this form, I/We agree to hold harmless and indemnify Southland Life
Insurance Company for any losses arising from such authorization/ revocation
instructions. We further authorize Southland Life Insurance Company to record
telephone conversations with any person utilizing telephone privileges on the
policy listed in Section 2. I/We understand that Southland Life Insurance
Company reserves the right to discontinue the telephone privilege at any time.
SECTION 5: AUTOMATIC REBALANCING OPTION
|_| Initiate Automatic Rebalancing (complete below)
|_| Change Automatic Rebalancing (complete below)
AUTOMATIC REBALANCING ALLOCATION
ALGER AMERICAN FIDELITY VIP& VIP II
____% Growth ____% Asset Manager
____% Leveraged AllCap ____% Contrafund
____% MidCap Growth ____% Growth
____% Small Capitalization ____% Equity-Income
____% High Income
INVESCO VIF ____% Index 500
____% Equity Income ____% Investment Grade Bond
____% Utilities ____% Money Market
____% Overseas
JANUS ASPEN
____% Aggressive Growth
____% Balanced
____% Growth
____% International Growth
____% Worldwide Growth
____% GUARANTEED INTEREST ACCOUNT
FREQUENCY AND DATE OF AUTOMATIC REBALANCING:
(If no options are marked, frequency will be quarterly and/or date will be last
valuation date of calendar period.)
Frequency:
|_| Monthly |_| Quarterly |_| Semi-annually |_| Annually
Date:
|_| Policy Processing Date - Date on which processing will occur based on
frequency selected beginning _____________________________________________
(Month/Date)
|_| Last Valuation Date of Calendar Period
|_| Specific Date each Period beginning _______________________________________
(Specify Date)
SECTION 6: PIN NUMBER CHANGE
|_| Please issue a new Personal Identification Number (PIN #) for the policy
listed above.
|_| Use the following specific number__________________________
CAN BE ONLY 4 DIGITS
I/We understand that only individuals with telephone privilege authority will be
notified of the PIN Number change.
- --------------------------------------------------------------------------------
For Home Office use only.
- --------------------------------------------------------------------------------
SECTION 7: DOLLAR COST AVERAGING OPTION
|_| INITIATE DOLLAR COST AVERAGING (complete below)
|_| CHANGE DOLLAR COST AVERAGING (complete below)
Please transfer $_________ or _________% from:
(check one only)
|_| From Money Market Subaccount
|_| into the Variable Account Subaccount(s) selected below.
DOLLAR COST AVERAGING ALLOCATION
ALGER AMERICAN
$________or________% Growth
$________or________% Leveraged AllCap
$________or________% Midcap Growth
$________or________% Small Capitalization
INVESCO VIF
$________or________% Equity Income
$________or________% Utilities
JANUS ASPEN
$________or________% Aggressive Growth
$________or________% Balanced
$________or________% Growth
$________or________% International Growth
$________or________% Worldwide Growth
Fidelity VIP & VIP II
$________or________% Asset Manager
$________or________% Contrafund
$________or________% Growth
$________or________% Equity-Income
$________or________% High Income
$________or________% Index 500
$________or________% Investment Grade Bond
$________or________% Overseas
FREQUENCY AND DATE OF DOLLAR COST AVERAGING:
(If no options are marked, frequency will be monthly and/or date will be policy
processing date.)
FREQUENCY:
|_| Monthly |_| Quarterly |_| Semi-annually |_| Annually
DATE:
|_| Policy Processing Date - Date on which processing will occur based on
frequency selected beginning _____________________________________________
(Month/Date)
|_| Specific Date each Period beginning________________________________________
(Specify Date)
TERMINATE:
|_| Terminate Dollar Cost Averaging on (date)_________________________________
|_| Terminate Dollar Cost Averaging when account value in Money Market
Subaccount reaches $______________________
SECTION 8: TRANSFER REQUEST
|_| CHANGE PREMIUM PAYMENT ALLOCATION
|_| TRANSFER BETWEEN DIVISIONS
TRANSFER FROM INVESTMENT OPTION TRANSFER TO
ALGER AMERICAN
$_______or_______% Growth $_______or_______%
$_______or_______% Leveraged AllCap $_______or_______%
$_______or_______% Midcap Growth $_______or_______%
$_______or_______% Small Capitalization $_______or_______%
INVESCO VIF
$_______or_______% Equity Income $_______or_______%
$_______or_______% Utilities $_______or_______%
FIDELITY VIP & VIP II
$_______or_______% Asset Manager $_______or_______%
$_______or_______% Contrafund $_______or_______%
$_______or_______% Growth $_______or_______%
$_______or_______% Equity-Income $_______or_______%
$_______or_______% High Income $_______or_______%
$_______or_______% Index 500 $_______or_______%
$_______or_______% Investment Grade Bond $_______or_______%
$_______or_______% Money Market $_______or_______%
$_______or_______% Overseas $_______or_______%
JANUS ASPEN
$_______or_______% Aggressive Growth $_______or_______%
$_______or_______% Balanced $_______or_______%
$_______or_______% Growth $_______or_______%
$_______or_______% International Growth $_______or_______%
$_______or_______% Worldwide Growth $_______or_______%
$_______or_______% GUARANTEED INTEREST $_______or_______%
ACCOUNT
SECTION 9: SIGNATURES
I/We acknowledge that we have read and understand:
1. the terms and conditions listed in the instructions to this form, the
Prospectus and the Policy for each of the options or changes requested.
2. I/we can cancel or change any elections requested in Sections 5 and 7 above
by sending written notice to the Customer Service Center at least 5 days
before the next transfer date.
3. that dollar cost averaging and automatic rebalancing will begin on the date
specified only if Southland Life Insurance Company has received this signed
form at least 5 days before the date specified.
Signature of Owner(s):
______________________________________________ Date__________________________
______________________________________________ Date__________________________
______________________________________________ Date__________________________
Daytime Phone Number:___________________________________________