Exhibit (10)
Application for Flexible Premium Variable Life Insurance Policy
______________________________
A History of Performance(R) WRL PRIORITY:
[LOGO] P.O. BOX 9009
Western Reserve Life Assurance Co. of Ohio CLEARWATER, FL 33758-9009
STREET ADDRESS-USE FOR CARRIER
OTHER THAN POST OFFICE:
8550 ULMERTON ROAD, SUITE 101
LARGO, FL 33771
1-800-443-9975 (X6582)
______________________________
Application for Life Insurance
_______________________________________________________________________________
FOR USE BY WMA REGISTERED REPRESENTATIVE
_______________________________________________________________________________
Agent Name: ___________________________________________________________________
Agent Number:___________________________________________________________________
Marketing Director:_________________________________ MD Code#:________________
Branch Manager _______________________________________ Branch#:______________
CEO:_________________________________________________ CEO Code#:______________
Amount of initial premium with application $_______________________
Amount to be applied to application
______________________________
_______________________________ $_______________________
______________________________
_______________________________ $_______________________
DO:
[ ] Complete the entire application (front and back).
[ ] Print application in black ink.
[ ] Have applicant initial all changes.
[ ] Obtain all required signatures.
[ ] Complete and sign the Agents Report.
[ ] Use supplement if more than one Other Insured Rider is required.
[ ] Include certification if a trust is owner of the policy.
[ ] Section 7, Page 2: Enter the proposed plan of insurance In #1 as shown
below.
[ ] Section 8: All Death Benefit Options are available for the FFA Death Benefit
Option C is not available for the FEP Elite.
[ ] Section 5,6 & 13, Page 2: If additional space is required firmly attach a
separate page.
DON'T:
[ ] Do not use pencil or whiteout.
[ ] Do not accept or send money on applications that total more than
$1,000,000.00
[ ] Do not submit an agent check as the initial premium.
[ ] Do not submit starter checks or deposit slips for checkomatic withdrawals.
For Non-Variable & Term Products: Do Not Complete
Section 11: Sub-Account Allocations
Section 12: Investment Objective
Section 22: Suitability
Section 23: To Be Completed by Applicant/Owner
For Term Products Only: Do Not Complete
Section 8: No Death Benefit Options are available for the Term 10 or Term 20.
________________________________________________
Freedom Elite Builder - CIR Coverage Limited to:
$5,000 Minimum and $20,000 Maximum
All Other Prodicet - CIR Coverage Limited to:
$2,000 Minimum and $10,000 Maximum
_________________________________________________
U000289 WMA
REV.301
CMC________ AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS
ATTACH VOIDED SAMPLE
OF YOUR PERSONAL
CHECK HERE
So that you may comply with your depositor's authorization and direction as set
forth on the reverse side hereof, this Company agrees:
1. To indemnify you and hold you harmless from any loss you may suffer as
a consequence of your actions resulting from or in connection with the
execution and issuance of any check or draft, whether or not genuine,
or payment of any preauthorized ACH electronic fund transfer debit
received by you in the regular course of business for the purpose of
payment to this Company, including any cost or expenses reasonably
incurred in connection therewith.
2. In the event that any such check, draft or debit shall be dishonored
whether with or without cause, and whether intentionally or
inadvertently, to indemnify you for any loss even though dishonor
results in a forfeiture of the insurance.
3. To defend at our own cost and expense any action which might be
brought by any depositor or any other persons because of your actions
taken pursuant to the foregoing request, or in any manner arising by
reason of your participation in the foregoing plan of premium
collections.
Authorized in a resolution adopted by the Executive Committee of the Board of
Directors of the Western Reserve Life Assurance Co. of Ohio on October 29, 1991.
Western Reserve Life Assurance Co. of Ohio
/signature/
Secretary
TO: WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO
As a convenience to me, I hereby request and authorize you to obtain payment of
amounts becoming due you by initiating charges in the form of check, drafts or
debits via ACH electronic fund transfers on my account maintained at the
________________________________________ _______________________________________
(Name of Bank) (Address of Bank)
for the payment of each monthly premium under Policy No.____________________ on
the life of ___________________________
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
drawing any such check or draft or initiating such debit. I understand that if
any such check, draft or debit be dishonored by my Bank and any monthly amount
due the Western Reserve Life Assurance Co. of Ohio is not paid within the time
stipulated in the policy, said policy shall become null and void except as
otherwise provided therein.
LIST ANY OTHER POLICIES TO BE PAID
BY SAME CHECK, DRAFT OR DEBIT
____________________________________________
____________________________________________
____________________________________________
I elect _______ day (select 1 to 27) of each month to have the payment of
$________ taken from my account. If no date is indicated the draft date will be
the policy issue date.
AUTHORIZATION FOR PREAUTHORIZED
PAYMENTS TO:
WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO
P.O.BOX 5068, CLEARWATER, FL 33758-5068
As a convenience to me, I hereby request and authorize you to pay and charge to
my bank checking account checks or drafts drawn by and payable to the order of
Western Reserve Life Assurance Co. of Ohio or to debit my account identified
below via ACH electronic fund transfers provided there are sufficient collected
funds in said account to pay the same upon presentation. 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 debit. I further agree that if any such check, draft or debit 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.
_______________ 1 (X)______________________________________
_______________ 2 (X)______________________________________
Both Authorized Signatures Required on Joint Accts.
PLEASE NOTE: There is an Indemnification
Agreement stated above.
U000289
LIFE APPLICATION-PART 1 WRL -- Western Reserve Life Assurance Co. of Ohio
________________________________________________________________________________
SECTION 1. PROPOSED PRIMARY INSURED
________________________________________________________________________________
1. Last Name First Name M.I.
________________________________________________________________________________
2. Address Apt# City
________________________________________________________________________________
State Zip Code 3. Years 4. Home 5. Driver State
at Phone License
Address Number
( )
________________________________________________________________________________
6. Sex 7. Date 8. Insurable 9. Place 10. Social
[ ] Male of Age of Security
[ ] Female Birth Birth - Number
State/County
________________________________________________________________________________
11. Height 12. Weight 13. Marital Status 14. Employer Years
________________________________________________________________________________
15. Occupation & Duties
________________________________________________________________________________
16. Employer's Address 17. Business Phone Number
( )
________________________________________________________________________________
18. Have you used TOBACCO or any other product containing NICOTINE in the last
12 months? [ ] Yes [ ] No
19. Rate Class Quoted: [ ] Ult Select [ ] Select [ ] Ult Standard
[ ] Standard [ ] Juvenile
________________________________________________________________________________
SECTION 2. PROPOSED OTHER/JOINT INSURED RIDER - IF MORE THAN ONE PLEASE
USE A SUPPLEMENTAL APPLICATION
________________________________________________________________________________
1. Last Name First Name M.I.
________________________________________________________________________________
2. Address Apt# City
________________________________________________________________________________
State Zip Code 3. Years 4. Home 5. Driver State
at Phone License
Address Number
( )
________________________________________________________________________________
6. Sex 7. Date 8. Insurable 9. Place 10. Social
[ ] Male of Age of Security
[ ] Female Birth Birth - Number
State/County
________________________________________________________________________________
11. Height 12. Weight 13. Marital Status 14. Employer Years
________________________________________________________________________________
15. Occupation & Duties
________________________________________________________________________________
16. Employer's Address 17. Business Phone Number
( )
________________________________________________________________________________
18. Have you used TOBACCO or any other product containing NICOTINE in the last
12 months? [ ] Yes [ ] No
19. Rate Class Quoted: [ ] Ult Select [ ] Select [ ] Ult Standard
[ ] Standard [ ] Juvenile
________________________________________________________________________________
SECTION 3. APPLICANT/OWNER IF OTHER THAN THE PROPOSED PRIMARY INSURED
________________________________________________________________________________
1. Last Name First Name M.I.
________________________________________________________________________________
2. Address Apt# City
________________________________________________________________________________
State Zip Code 3. Home Phone 4. Social Security Number/Tax ID#
( )
5. Date of Birth/Trust Date ____________________________________________________
6. Relationship to the Proposed Primary Insured:________________________________
________________________________________________________________________________
SECTION 4. CHILDREN'S INSURANCE RIDER
________________________________________________________________________________
COVERAGE AMOUNT
________________________________________________________________________________
Name Relationship Date of Birth Height Weight
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Are all children listed? [ ] Yes [ ] No
Are all children living with proposed primary insured? [ ] Yes [ ] No
If not, explain why: ___________________________________________________________
U000289
1
LIFE APPLICATION
____________________________________________________________________________________________________________________________________
SECTION 5. PRIMARY BENEFICIARY - If percentage shares are not given they wull be equal, or to the survivor
_____________________________ ________________________ _____________________________ ________________________________________
Name Percent Relationship Social Security Number/Tax ID#
_____________________________ ________________________ _____________________________ ________________________________________
-- --
_____________________________ ________________________ _____________________________ ________________________________________
-- --
_____________________________ ________________________ _____________________________ ________________________________________
____________________________________________________________________________________________________________________________________
SECTION 6. CONTINGENT BENEFICIARY - If percentage shares are not given, they will be equal, or to the survivor
_____________________________ ________________________ _____________________________ ________________________________________
Name Percent Relationship Social Security Number/Tax ID#
_____________________________ ________________________ _____________________________ ________________________________________
-- --
_____________________________ ________________________ _____________________________ ________________________________________
-- --
_____________________________ ________________________ _____________________________ ________________________________________
____________________________________________________________________________________________________________________________________
SECTION 7. PROPOSED PLAN OF INSURANCE SECTION 8. DEATH BENFIT OPTION
1. [ ] FEB [ ] FWP [ ] OTHER: _____________________________ [ ] A) Level Benefit
[ ] B) Increasing Benefit
2. Specified Amount: $______ $______ $______ [ ] C) Option B To Age 70 Then Grading Down
3. Primary Insured Rider $______ $______ $______ (Option C for FEB only)
4. Primary Insured Rider Plus $______ $______ $______ ________________________________________________________________
SECTION 9. ADDITIONAL BENEFITS-PRIMARY INSURED ONLY
5. Other Insured Rider
[ ] Disability Waiver Rider
__________________________________ $______ $______ $______ [ ] Disability Waiver and Income Rider
($300 per month maximum) $__________
6. ARE YOU APPLYING FOR MORE THAN ONE OTHER INSURED RIDER?
[ ] Accidental Death Benefit
[ ] YES [ ] NO
($150,000 maximum) $__________ __________
IF YES PLEASE USE SUPPLEMENTAL APPLICATION #U000289-supp
_________________________________________________________________
FWP POLICIES ONLY SECTION 10. PREMIUMS PAYABLE
7. No Lapse Guarantee Option: [ ] A) 5YR [ ] B) 10YR Planned Premium $___________ ___________ ___________
8. Wealth Protector Rider $ ________ $ _________ $ _________ [ ] Checkomatic ________ Draft Date (1ST thru 27TH)
9. Joint Insured Rider $ ________ $ _________ $ _________ [ ] Direct Bill
[ ] Single Premium [ ] Quarterly
10. INDIVIDUAL INSURED RIDER(S) [ ] Annual [ ] Monthly
[ ] Semi-annual [ ] Other _______________
[ ] Proposed Primary Insured $ ________ $ _________ $ _________
[ ] Proposed Joint Insured $ ________ $ _________ $ _________
____________________________________________________________________________________________________________________________________
SECTION 11. SUB-ACCOUNT ALLOCATIONS - (For Variable Plans Only) Must equal 100% and a whole number.
WRL VKAM EMERGING GROWTH ____% WRL JANUS GROWTH ____% WRL LKCM STRAT. TOTAL RET. ____%
WRL T. ROWE PRICE SMALL CAP ____% WRL LKCM CAPITAL GROWTH ____% WRL J.P. MOGAN REAL ESTATE SE. ____%
WRL MUNDER NET50 ____% WRL GOLDMAN SACHS GROWTH ____% WRL FEDERATED GROWTH & INCOME ____%
WRL PILGRIM BAXTER MID CAP GROWTH ____% WRL GE U.S. EQUITY ____% WRL AEGON BALANCED ____%
WRL ALGER AGGRESSIVE GROWTH ____% WRL GREAT COMPANIES-AMERICA(SM) ____% WRL AEGON BOND ____%
WRL THRID AVENUE VALUE ____% WRL SALOMON ALL CAP ____% WRL J.P. MORGAN MONEY MARKET ____%
WRL VALUE LINE AGGRESSIVE GROWTH ____% WRL C.A.S.E. GROWTH ____% FIDELITY VIP III GROWTH OPPORTUNITIES ____%
WRL GE INTERNATIONAL EQUITY ____% WRL DREYFUS MID CAP ____% FIDELITY VIP II CONTRAFUND ____%
WRL GABELLI GLOBAL GROWTH ____% WRL NWQ VALUE EQUITY ____% FIDELITY VIP EQUITY-INCOME ____%
WRL GREAT COMPANIES-GLOBAL(2) ____% WRL T. ROWE PRICE DIVIDEND GROWTH ____% FIXED ACCOUNT ____%
WRL GREAT COMPANIES-TECHNOLOGY(SM) ____% WRL DEAN ASSET ALLOCATION ____% OTHER ____%
____________________________________________________________________________________________________________________________________
12. INVESTMENT OBJECTIVE
[ ] Safety of Principal
[ ] Income
[ ] Long-Term Growth
[ ] Trading Profits
[ ] Other
_____________________________
____________________________________________________________________________________________________________________________________
SECTION 13. OTHER INSURANCE IN FORCE FOR ALL PROPOSED INSUREDS [ ] NONE
___________________________ ______________________ ___________________________ ________________________ ____________________
Proposed Insured Name Company Amount of Insurance Year Issued Replacement?
___________________________ ______________________ ___________________________ ________________________ ____________________
Yes No
___________________________ ______________________ ___________________________ ________________________ ____________________
Yes No
___________________________ ______________________ ___________________________ ________________________ ____________________
Yes No
___________________________ ______________________ ___________________________ ________________________ ____________________
IS THIS INTENDED TO BE A 1035 EXCHANGE? [ ] Yes [ ] No Anticipated Cash Value Transfer $________ ________ ________
1) Has any proposed insured ever had life, disability or health insurance declined, rated, modified, issued with
an exclusion rider, canceled, or not renewed? If yes please explain in REMARKS. [ ] Yes [ ] No
2) Will the insurance applied for on any proposed insured replace or change any existing life or annuity policy? [ ] Yes [ ] No
If yes, complete replacement forms, if appropriate.
3) Is there an application for life, accident or sickness insurance now pending or contemplated on any proposed
insurance in this or any other company? If yes, give details in Agent's Report, Question 3. [ ] Yes [ ] No
____________________________________________________________________________________________________________________________________
2
LIFE APPLICATION-PART 2
____________________________________________________________________________________________________________________________________
SECTION 14. PERSONAL FINANCIAL STATEMENT 15. COMPLETE FOR CORPORATION, PARTNERSHIP, PENSION OR TRUST
FOR PROPOSED PRIMARY INSURED
A) Gross Income Current Yr $______ $______ $______ A) Current Estimated Market Value $______ $______ $______
B) Gross Income Previous Yr $______ $______ $______ B) Assets LIQUID $______ $______ $______
C) Net Worth $______ $______ $______ NONLIQUID $______ $______ $______
C) Liabilities $______ $______ $______
For over $1 million applied coverage complete D) Net Worth $______ $______ $______
a separate financial questionnaire
____________________________________________________________________________________________________________________________________
SECTION 16. MEDICAL QUESTIONS - Each question must be individually asked and answered.
Give the details of "Yes" answers below. Identify question number; state signs symptoms and dianosis of each illness or injury. List
the details and results of any treatment; List the name, full address and dates of each health care provider consulted.
To the best of your knowledge, has any Proposed Insured within the last 10 yrs had or been told by a member of the medical
profession that he or she had, or has been treated for:
1) Heart murmur, high blood pressure, chest pain, heart attack, stroke, or other disorder of the heart
or circulatory system? [ ] Yes [ ] No
2) Asthma, Emphysema, Chronic Bronchitis, Tuberculosis, or any other Respiratory disorder; colitis, ulder
or any other gastrointestinal disorder, jaundice, hepatitis, liver or kidney disorder? [ ] Yes [ ] No
3) Cancer, tumor, polyp, breast, prostate or any other reproductive disorder, or any thyroid or endorcrine
disorder? [ ] Yes [ ] No
4) Brain, mental, anxiety, depression, suicide attempt, or seizure disorder; or any paralysis? [ ] Yes [ ] No
5) Diabetes, anemia, or any disorder of the blood; sugar, protein, or blood in the urine? [ ] Yes [ ] No
6) Used amphetamines, heroin, cocaine, marijuana, or any other illegal or controlled substance except as
prescribed by a physician? [ ] Yes [ ] No
7) Sought or been advised to seek treatment, limit or discontinue use of alcohol? [ ] Yes [ ] No
8) Been on or are now on prescribed medication or diet? [ ] Yes [ ] No
9) Has any Proposed Insured been told by a member of the medical profession that
he or she had a diagnosis of AIDS, ARC or the HIV infection? [ ] Yes [ ] No
10) Had or been advised to have any hospitalization, surgery, or any diagnostic test including, but not
limited to, electrocardiograms, blood studies, scans, MRI's or other test? [ ] Yes [ ] No
11) An examination, treatment or consulation with a doctor or health care provider other than above? [ ] Yes [ ] No
12) Have or have had a parent, brother or sister who has/had coronary artery death or disease prior to age 60? [ ] Yes [ ] No
____________________________________________________________________________________________________________________________________
SECTION 17. DETAILS TO "YES" ANSWERS FOR MEDICAL QUESTIONS SECTION
___________ _________________________ ______________________________________________________ ________________________________
Name, Address and Phone # of
Question # Proposed Insured's Name Date, Diagnosis, Treatment, Results, and Duration Attending Doctor and Hospital
___________ _________________________ ______________________________________________________ ________________________________
___________ _________________________ ______________________________________________________ ________________________________
___________ _________________________ ______________________________________________________ ________________________________
___________ _________________________ ______________________________________________________ ________________________________
___________ _________________________ ______________________________________________________ ________________________________
___________ _________________________ ______________________________________________________ ________________________________
___________ _________________________ ______________________________________________________ ________________________________
___________ _________________________ ______________________________________________________ ________________________________
___________ _________________________ ______________________________________________________ ________________________________
___________ _________________________ ______________________________________________________ ________________________________
____________________________________________________________________________________________________________________________________
SECTION 18. Name and address of personal physician (if none, so state)
__________________________________________ __________________________________________ __________________________________________
Primary Insured Joint of Other Insured Children
______________________________________ ______________________________________________________ ________________________________
______________________________________ ______________________________________________________ ________________________________
______________________________________ ______________________________________________________ ________________________________
______________________________________ ______________________________________________________ ________________________________
__________________________________________ __________________________________________ __________________________________________
Date and reason last consulted a physician Date and reason last consulted a physician Date and reason last consulted a physician
__________________________________________ __________________________________________ __________________________________________
__________________________________________ __________________________________________ __________________________________________
__________________________________________ __________________________________________ __________________________________________
____________________________________________________________________________________________________________________________________
3
LIFE APPLICATION
________________________________________________________________________________
SECTION 19. RESIDENCY
A) Proposed Primary Insured is a citizen of [ ] USA [ ] Other Country __________
______________ Type of VISA___________________
B) How many years has the proposed insured resided in the USA?________
C) Does any proposed insured travel outside the USA? [ ] Yes [ ] No
If yes, provide details: include destination, number of trips, duration of
each trip, purpose of trip, plans for the next year.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
SECTION 20. DRIVING RECORD
A) Has any Proposed Insured had their drivers license suspended, restricted,
revoked, or been cited for a moving violation in the last
5 years?
[ ] Yes [ ] No If yes, give reason:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
B) Has any Proposed Insured in the last ten years been convicted of a
misdemeanor (other than a minor traffic violation) or felony?
[ ] Yes [ ] No If yes, give reason:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
SECTION 21. SPECIAL ACTIVITIES
A) Except as a passenger on a regularly scheduled flight, has any
proposed insured flown within the past 3 years, or does any
proposed insured have plans to fly in the future? If yes, complete
Aviation Questionnaire. [ ] Yes [ ] No
B) In the past 3 years has any proposed insured participated in racing
(automobile, motorcycle, or boat), underwater or sky diving, hang
gliding, mountain or rock climbing? If yes, complete an Avocation
Questionnaire. [ ] Yes [ ] No
________________________________________________________________________________
SECTION 22. SUITABILITY FOR VARIABLE LIFE INSURANCE POLICY -- COMPLETE FOR ALL
VARIABLE PLANS
A) Have you, the Proposed Insured, and Purchaser, if other than the
Proposed Insured, received the current Prospectus for the policy?
[ ] Yes [ ] No
B) Do you understand that under the policy applied for (exclusive of
any optional benefits),the amount of death benefit and the entire
amount of the policy cash value may increase or decrease depending
upon the investment experience? [ ] Yes [ ] No
C) With this in mind, is the policy in accord with your insurance
objectives and your anticipated financial needs? [ ] Yes [ ] No
________________________________________________________________________________
SECTION 23. TO BE COMPLETED BY APPLICANT/OWNER
Telephone Transfer Authorization: (See Prospectus for telephone transfer
procedures.) Your policy applied for, if issued, will automatically receive
telephone transfer privileges described in the applicable prospectus unless
instructions to the contrary are indicated below. These privileges allow you to
give the registered representative/agent of record for this policy authority to
make telephone transfers and to change the allocation of future payments among
the Sub-Accounts and the Fixed Account on your behalf according to your
instructions.
[ ] I do NOT want telephone transfer privileges.
Western Reserve Life will not be liable for complying with telephone
instructions it reasonably believes to be authentic, nor for any loss, damage,
costs or expense in acting on such telephone instructions, and Policyowners will
bear the risk of any such loss. Western Reserve Life will employ reasonable
procedures to confirm that telephone instructions are genuine. If Western
Reserve Life does not employ such procedures, it may be liable for losses due to
unauthorized or fraudulent instructions. Such requiring forms of personal
identification prior to acting upon such telephone instruction, providing
written confirmation of such transactions to Policyowners and/or tape recording
of telephone transfer request instructions received.
________________________________________________________________________________
SECTION 24. CERTIFICATION
Under penalty of perjury, I (the owner) certify (1) that the number shown in
Section 1of page 1or the number shown in Section 3 on page 1 (if the owner is
other than the primary insured) is my correct Taxpayer Identification Number,
and (2) that I am not subject to backup withholding because (a) I have not been
notified by the IRS that I am subject to backup withholding as a result of a
failure to report all interest or dividends, or (b) if I ever was so notified,
the IRS has notified me that I am no longer subject to backup withholding. (If
the Internal Revenue Service has notified you that you are subject to backup
withholding and you have not received notice from the Service that backup
withholding has terminated, you should strike out the language in (2) above that
you are not subject to backup withholding due to notified payee underreporting.)
U000289
4
LIFE APPLICATION
________________________________________________________________________________
SECTION 25. AUTHORIZATION TO OBTAIN INFORMATION
________________________________________________________________________________
I authorize any physician, medical professional, hospital, clinic, other medical
care institution, the Medical Information Bureau, Inc., insurance company,
consumer reporting agency, or employer having information available as to
employment, other insurance coverage, medical care, advice or treatment with
respect to any physical or mental condition regarding me or my children who are
to be insured, to give such information to Western Reserve Life Assurance Co. of
Ohio, its reinsurers, or any consumer reporting agency including the Medical
Information Bureau acting on Western Reserve Lifes behalf.
I authorize Western Reserve Life to obtain an investigative consumer report on
me.
I understand that this information will be used by Western Reserve Life or its
reinsurers, to determine eligibility for life insurance.
I agree that this authorization is valid for two and one-half years from the
date signed. I know that I have the right to receive a copy of this
authorization upon request. I agree that a photographic copy of this
authorization is as valid as the original.
I have received a copy of this Notice of Information Practices attached to this
application.
I also hereby authorize Western Reserve Life to provide its affiliated companies
any and all information provided herein and obtained hereafter on me. This
authorization shall be valid from the date signed below until affirmatively
withdrawn in writing by myself.
[ ] I elect not to have personal information disclosed to non-affiliates of
Western Reserve Life for marketing purposes.
[ ] I elect to be interviewed if an investigative consumer report is prepared in
connection with this application.
________________________________________________________________________________
SECTION 26. OTHER INSURANCE TO BE COMPLETED BY THE REGISTERED REPRESENTATIVE
________________________________________________________________________________
1. Will the policy applied for replace or change any existing life insurance
policy or annuity? [ ] Yes [ ] No
2. If replacement of existing insurance is involved, have you complied with all
state requirements, including any Disclosure and Comparison Statements?
[ ] Yes [ ] No [ ] N/A
If No, explain
____________________________________________________________________________
________________________________________________________________________________
SECTION 27. REPRESENTATIONS
________________________________________________________________________________
I represent that the statements and answers in this application are true and
complete to the best of my knowledge.
I understand that I should consult my own tax and/or legal counsel as to the
consequences of using this product in conjunction with my own particular tax or
financial plan.
It is agreed that:
(a) the statements and answers given in this application, and any
amendments or application supplements to it or statements made to the
medical examiner, will be the basis of any insurance issued;
(b) no agent or medical examiner has the authority to make or alter any
contract for the Company;
(c) if a premium deposit is given in exchange for the Conditional Receipt,
no insurance shall take effect unless all of the conditions set out in
that receipt are satisfied;
(d) if a premium deposit is not given, no insurance shall take effect
unless all of the following conditions are satisfied; (1) a policy
issued by the Company is delivered to and accepted by the owner during
the lifetime of each person to be covered by such policy, (2) the full
first premium is paid, and (3) the health and insurability of each
person proposed for insurance has not changed since the date of this
application
Signed at _____________________________________ ______________ on_____ ________ _____________________
(city) (state) (date)
_______________________________________________________________ _____________________________________________
Signature of proposed insured (Child over age 15 must sign) Print Agent Name Social Security # of Agent
________________________________________________________________ ______________________________________________
Signature of applicant (owner) other than the Signature of Agent State License #
proposed insured (If business insurance, show
title of officer and name of firm)
__________________________________________________________________ _____________________
Signature of parent or legal guardian for insured(s) 15 and under Agent #
_____________________________________________
Signature of Joint Insured or OIR
U000289
5
This Page is
Intentionally Blank
6
WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO
P.O. BOX 5068
CLEARWATER, FLORIDA 33758
FRAUD WARNING
The following states require that insurance applicants acknowledge a fraud
warning statement. Please refer to the fraud warning statement for your state as
indicated below.
For applicants in ARKANSAS
Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
_____________________________________________ _______________
Applicants Signature Date
For applicants in COLORADO
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.
_____________________________________________ _______________
Applicants Signature Date
For applicants in FLORIDA
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 in the third degree.
_____________________________________________ _______________
Applicants Signature Date
For applicants in KENTUCKY, OHIO, and PENNSYLVANIA
Any person who knowingly and with intent to defraud any
insurance company or other person files an application for
insurance or a statement of claim containing any materially
false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
_____________________________________________ _______________
Applicants Signature Date
For applicants in NEW JERSEY
Any person who includes any false or misleading information on
an application for an insurance policy is subject to criminal
and civil penalties.
_____________________________________________ _______________
Applicants Signature Date
For applicants in NEW MEXICO
Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and criminal penalties.
_____________________________________________ _______________
Applicants Signature Date
For applicants in VIRGINIA AND MAINE
It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment,
fines and denial of insurance benefits.
_____________________________________________ _______________
Applicants Signature Date
U000289
7
AGENT'S REPORT
1. a) How long have you known the Proposed Insured?
____________________________________________________________________
____________________________________________________________________
b) Relationship to Proposed Primary Insured:
____________________________________________________________________
c) Are you financially responsible for the Proposed Primary Insured:
[ ] Yes [ ] No
2. Did you give the "Notice of Information Practices" to the Proposed
Insured(s)?
[ ] Yes [ ] No
3. Are you submitting or do you plan to submit an application on any Proposed
Insured on this application to any other company?
[ ] Yes [ ] No
Company Name___________________________________________________
Face amount $__________________________________________________
Total face amount to be placed with all companies
$______________________________________________________________
4. Medical Examination
Are you arranging for the Medical Requirements?
[ ] Yes Paramedical Service used:___________________________________
[ ] No Request Western Reserve Life order medical reqs.
5. Was money taken with the application?
[ ] Yes [ ] No
If "yes" was the Conditional Receipt completed and given to the applicant?
[ ] Yes [ ] No
6. Did you ask all questions in the presence of the Proposed Insured(s)?
[ ] Yes [ ] No
7. Are you aware of anything about the health, habits, avocation, environment or
mode of living, except as may be related directly or indirectly to sexual
orientation, which may affect the insurability of any person proposed for
insurance?
[ ] Yes [ ] No
8. If Proposed Insured is a juvenile (ages 0 through 15):
(a) Did you personally see child? [ ] Yes [ ] No
(b) Does child live with parents? [ ] Yes [ ] No
(If "No," explain)______________________________________________
________________________________________________________________
(c) Life insurance in force on parent's life?
________________________________________________________________
(d) Life insurance applied for or in force on brothers and sisters?
________________________________________________________________
Remarks:________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
9. Is Proposed Primary Insured or Owner related to any InterSecurities, Inc.
officer or employee? [ ] Yes [ ] No
10. Is Proposed Primary Insured or Owner a licensed Representative of any
Broker/Dealer? [ ] Yes [ ] No
If "Yes" Name and Address of Broker/Dealer
____________________________________________________________________
11. Type of Sale (check two)
[ ]Direct [ ]Pension or Profit Sharing
[ ]Personal Needs Analysis [ ]Salary Savings (EICS)
[ ]Estate Planning [ ]Gift
[ ]Business Insurance [ ]Salary Allotment
Purpose of Policy
[ ]Personal Insurance [ ]Business Insurance
[ ]Mortgage [ ]Key Employee
[ ]Retirement [ ]Executive Bonus
[ ]Education [ ]Deferred Compensation
[ ]Estate Liquidity [ ]Split Dollar
[ ]Income to Family [ ]Reverse Split Dollar
[ ]Cash Accumulation [ ]Other
[ ]Wealth Replacement
[ ]Buy/Sell - Is Partner applying for similar amount? [ ] Yes [ ] No
Name of Partner _______________________________________________
12. Was this plan sold, presented or illustrated as a VEBA, welfare benefit
concept as defined under IRC Section 419, Charitable Legacy Plan, Charitable
Retirement Plan, Charitable Remainder Life Program, or other similar
arrangement?
[ ] Yes [ ] No
If "Yes", have you completed and attached the required Disclosure,
Acknowledgement and Release Form and the accompanying Attorney's Statement?
[ ] Yes [ ] No
13. Did you comply with all requirements relative to obtaining Informed Consent
for HIV and AIDS testing? [ ] Yes [ ] No
Writing Agent Name ____________________________________________________
Agent No.______________________________________________________________
Agent's Telephone Number ______________________________________________
Agent's Social Security Number ________________________________________
Agent's Fax Number ____________________________________________________
Percent of Agent's Split ______________________________________________
Split Agent Name ______________________________________________________
Agent No._______________________Percent of Agent's Split____________
Split Agent Name
Agent No._______________________Percent of Agent's Split____________
I submit this application assuming full responsibility for delivery of any
coverage issued and for immediate transmittal to the Company of the first
premium when collected. I know of no condition affecting the insurability of any
person proposed for insurance not fully set forth herein. I certify that a
Notice of Information Practices statement was given to the Applicant when this
application was taken. (If applicable)
$ ___________ has been paid by the Applicant with this application __________________________
Signature of Writing Agent
U000239
8
WRL
CONDITIONAL RECEIPT
If, within the last 12 months, any person proposed for coverage has been treated
for or had heart trouble, stroke or cancer no payment may be accepted with the
application.
Received from __________________________________________ Totaling $_____________
NO COVERAGE WILL BECOME EFFECTIVE PRIOR TO DELIVERY OF THE POLICY APPLIED FOR
UNLESS AND UNTIL ALL THE CONDITIONS OF THIS RECEIPT
HAVE BEEN FULFILLED EXACTLY.
CONDITIONS:
(1) The amount of payment taken with the application must be at least the first
full premium for the mode of payment selected for the amount of insurance
stated on page 2 in the application. If the check or draft submitted as the
first mode premium is not honored by the bank, upon first presentation, this
Conditional receipt will be VOID.
(2) All medical examinations, tests, x-rays, electrocardiograms and reports
required by the company must be completed and received at its home office.
If the above requirements are not received within 60 days, from the date
this application was completed, this Conditional Receipt will be VOID.
(3) As of the effective date, as defined below, each person proposed for
insurance in this application must be a risk insurable in accordance with
the companys rules, limits and standards for the plan, amount and rate class
shown. If any modification is made by the Company to the plan, amount,
riders, and/or the premium rate class or supplemental agreements this
conditional receipt will be VOID.
(4) As of the effective date, the state of health and all factors affecting the
insurability of each person proposed for insurance must be as stated in the
application.
EFFECTIVE DATE, AS USED IN THIS CONDITIONAL RECEIPT IS THE LATER OF:
A. the date of completion of the Part I of the application having the same date
as this Receipt, or;
B. the date of completion of all medical examinations, tests, x-rays,
electrocardiograms and reports required by the Company, or;
C. the date of issue if any, requested in the application.
COVERAGE NOT TO EXCEED $300,000. MAXIMUM ALL APPLICATIONS OR RECEIPTS.
If the Company or its Authorized Agent accepts the first mode premium for this
application of life insurance and any person Proposed for insurance dies while
this Conditional Receipt is in effect, the Company will pay to the beneficiary
or the Applicant the LESSER of:
(a) the death benefit applied for on that Proposed Insured, as shown on page 2
of the Application, or:
(b) $300,000.
This total benefit limit is applicable to all insurance applied for under this
Application and any other application now pending with the Company, including
any other Conditional Receipts, for each person proposed for insurance.
DATE COVERAGE ENDS -- 60 DAY MAXIMUM
Coverage under the Conditional Receipt ends automatically on the earliest of:
(a) the date the insurance applied for under this application takes effect, or
(b) the date the company mails notice of the ending of coverage and refunds the
first mode premium to the applicant at the address shown on Part 1 of the
Application.
(c) 60 days from the date of this conditional receipt
SPECIAL LIMITATIONS
This Conditional Receipt will be void if not signed by an authorized agent of
the company.
This Conditional Receipt will be VOID in the event of fraud or material
misrepresentation in the Application
This Conditional Receipt will be VOID if, on the date of this receipt, any
person proposed for insurance is under 15 days of age or over 80 years of age.
This Conditional Receipt does not provide benefits for Disability or Accidental
Death Benefits.
This Conditional Receipt does not provide benefits if any person proposed for
insurance dies by suicide. The liability of the Company will be limited to
return of the first mode premium paid with the application.
NO AGENT IS AUTHORIZED TO WAIVE OR MODIFY ANY OF THE PROVISIONS
OF THE CONDITIONAL RECEIPT. MAKE ALL CHECKS PAYABLE TO
WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO.
I acknowledge possession of the receipt and I certify that I have read it and
the agreement in the application. The conditions and terms of this receipt have
been explained to me fully by the agent and I understand them.
Signed at ___________________________ this ___ day of _________, (year) ________
Signature of Applicant (If other than Proposed Insured) ________________________
Signature of Agent _____________________________________________________________
THIS RECEIPT IS TO BE DETACHED AND GIVEN TO THE APPLICANT
AT THE TIME OF APPLICATION ONLY IF ANY MONEY IS TAKEN
If all the conditions of this receipt are not fulfilled exactly, the insurance
will take effect only when the policy is delivered to the owner stated in the
application and there has been no change in insurability of any proposed insured
as represented in the application.
U000289
9
This Page is
Intentionally Blank
10
Western Reserve Life Assurance Co. of Ohio
NOTICE OF INFORMATION PRACTICES
IMPORTANT: THIS NOTICE MUST BE GIVEN TO THE PROPOSED INSURED(S)
WHENEVER AN APPLICATION IS COMPLETED.
SOURCES OF INFORMATION
We value your privacy. Your application is our main source of information. As a
part of this application, we may, at our expense:
o ask you to have an examination, which may include special tests such as an
electrocardiogram, chest x-ray, blood studies, or urinalysis;
o ask physicians, medical practitioners, clinics, hospitals, or other health
care providers for information about you;
o obtain information from the Medical Information Bureau and/or a consumer
reporting agency. Please refer to the lower portion of this notice for
further details about this procedure;
o obtain information from other insurance companies you have applied to in the
past. We use this information only for evaluating your insurance application.
SAFEGUARDING YOUR PRIVACY
We treat all information about you confidentially. Ordinarily, it will be
provided to third parties only if you authorize us in writing to do so. In rare
instances, we may be required to provide some or all of the information without
your consent. We may send information to state insurance departments at their
request as part of their regulatory duties, or to law enforcement facilities in
response to a summons or subpoena. We may also release information in our files
to our reinsurers and to other life insurance companies to whom you have applied
for life and health insurance or to whom a claim for benefits may be submitted.
On your written request, we will send you a summary or copy of the relevant
information obtained in connection with your application.
Confidential or detailed medical information will only be disclosed through the
physician of your choice, with whom you may discuss it. Also, on your request, a
copy of any consumer report we obtain on you will be provided to you by the
responsible agency.
We will not send you information we might collect in expectation of or in
connection with any claim or civil or criminal proceeding such as information
relating to suspected fraud or material misrepresentation.
We may gather information from you which is used for statistical purposes or
marketing research, which will not identify you individually.
CORRECTING INFORMATION
If you feel any information in our file is incorrect or incomplete, you may ask
us to review it. If we agree, we will make any necessary corrections and inform
anyone who received such information within the past two years.
If we do not agree, you may file a statement of dispute with us. We will send
that statement to anyone receiving such information in the past two years. We
will also include it in any future disclosure of the disputed information.
FAIR CREDIT REPORTING ACT
A routine investigative consumer report may possibly be made regarding your
general reputation, character, mode of living and personal characteristics. This
information may be obtained through personal interviews with your friends,
neighbors and associates. Should you desire additional information on the nature
and scope of such a report, you may write the Underwriting Department, Western
Reserve Life Assurance Co. of Ohio, PO Box 5068, Clearwater, FL 33758. You may
also request information concerning the nature and scope of the investigation to
be performed. A summary of your rights is set forth on the attached Notice to
Consumer.
THE MEDICAL INFORMATION BUREAU PRE-NOTICE
The Medical Information Bureau (MIB) is a non-profit organization of life
insurance companies which operates as an information exchange for its members.
We may make reports to the MIB regarding factors affecting your insurability.
Underwriting decisions, however, are not reported to the MIB. If you apply to
another Bureau member company for life or health insurance or submit a claim for
benefits, the MlB will, upon request, provide that company with information in
its file.
Upon your written request, the MIB will arrange for disclosure to you of any
information it has in your file. If you feel the information in the MIBs file is
incorrect, you may contact the MIB and seek a correction in accordance with
procedures outlined in the Federal Fair Credit Reporting Act. The address of the
MIBs office is: MIB, Inc.; P.O. Box 105, Essex Station; Boston, MA 02112. MIBs
telephone number: (617) 426-3660
If you would like to know more about how we collect, evaluate and control
information about you as one of our applicants for insurance, our sales
representatives will be happy to assist you or you may contact us at our office:
ANY OTHER Western Reserve Life Assurance Co. of Ohio
QUESTIONS? P.O. Box 5068
Clearwater, Florida 33758-5068
U000289 727-299-1800
11
NOTICE TO CONSUMER
A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT:
The Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness,
and privacy of information in the files of every consumer reporting agency. Most
consumer reporting agencies are credit bureaus that gather and sell information
about yousuch as where you work and live, if you pay your bills on time, and
whether youve been sued, arrested, or filed for bankruptcyto creditors,
employers, and other businesses. The FCRA gives you specific rights in dealing
with consumer reporting agencies, and requires them to provide you with a
summary of these rights as listed below. You can find the complete text of the
FCRA, 15 U.S.C. 1681 et. seq., at the Federal Trade Commissions web site
(http://www.ftc.gov). You may have additional rights under state law. You may
contact a state or local consumer protection agency or a state attorney general
to learn those rights.
o You must be told if information in your file has been used against you.
Anyone who uses information from consumer reporting agencies to take action
against yousuch as denying an application for credit, insurance, or
employmentmust give you the name, address, and phone number of the consumer
reporting agency that provided the report.
o You can find out what is in your file. A consumer reporting agency must give
you all the information in your file, and a list of everyone who has
requested it recently. However, you are not entitled to a risk score or
credit score that is based on information in your file. There is no charge
for the report if your application was denied because of information supplied
by the consumer reporting agency, and if you request the report within 60
days of receiving the denial notice. You are also entitled to one free report
a year if you certify that (1) you are unemployed and plan to seek employment
within 60 days, (2) you are on welfare, or (3) your report is inaccurate due
to fraud. Otherwise a consumer reporting agency may charge you a fee up to
$8.00 for a copy of your file.
o You can dispute inaccurate information with the credit reporting agency. If
you tell a credit reporting agency that your file contains inaccurate
information, the credit reporting agency must investigate the items (usually
within 30 days) by presenting to its information source all relevant evidence
you submit, unless your dispute is frivolous. The source must review your
evidence and report its findings to the credit reporting agency. (The source
must advise national credit reporting agenciesto which it provides dataof any
error.) The credit reporting agency must give you a written report of the
investigation and a copy of your report if the investigation results in any
change. If the credit reporting agencys investigation does not resolve the
dispute, you may add a brief statement to your file. The credit reporting
agency must normally include a summary of your statement in future reports.
If an item is deleted or a disputed statement is filed, you may ask that
anyone who has recently received your report be notified of the change.
o Inaccurate information must be corrected or deleted. A consumer reporting
agency must remove or correct inaccurate information from its files, usually
within 30 days after you dispute it. However, consumer reporting agencies are
not required to remove data from your file that is accurate unless it is
outdated or cannot be verified. If our dispute results in any change to your
report, the CRA cannot reinsert into your file a disputed item unless the
information source verifies its accuracy and completeness. In addition, the
CRA must give you a written notice telling you it has reinserted the item.
The notice must include the name, address, and phone number of the
information source.
o You can dispute inaccurate items with the source of the information. If you
tell anyonesuch as a creditor who reports to a consumer reporting agency that
you dispute the item, they may not then report the information to a consumer
reporting agency without including a notice of your dispute. In addition,
once youve been notified the source of the error in writing, they may not
continue to report it if it is in fact an error. If you have questions or
believe your file contains errors, call the toll-free number of the consumer
reporting agency.
o Outdated information may not be reported. In most cases, consumer reporting
agencies may not report negative information that is more than seven years
old; ten for bankruptcies.
o Access to your file is limited. Consumer reporting agencies may provide
information about you only to those who have a need recognized by the
FCRAusually to consider an application you have submitted to a creditor,
insurer, employer, landlord, or other business.
o Your consent is required for reports that are provided to employers or that
contain medical information. Consumer reporting agencies may not report to
your employer, or prospective employer, about you without your written
consent. Consumer reporting agencies may not divulge medical information
about you without your permission.
o You can stop a consumer reporting agency from including you on lists for
unsolicited credit and insurance offers. Creditors and insurers may use file
information as the basis for sending you unsolicited offers of credit or
insurance. Such offers must include a toll-free number for you to call and
tell the consumer reporting agency if you want your name and address excluded
from future lists or offers. If you notify the consumer reporting agency
through the toll-free number, it must keep you off the lists for two years.
If you request and complete the consumer reporting agency form provided for
this purpose, you can have your name and address removed indefinitely.
o You may have additional rights under state law. You may wish to contact a
state or local consumer protection agency or a state attorney general to
learn those rights.
U000289
12
NOTICE TO CONSUMER
The FCRA gives several different federal agencies authority to enforce the FCRA.
The agencies listed below can assist you with questions and concerns concerning
the following types of businesses:
FOR QUESTIONS OR CONCERNS REGARDING THE FOLLOWING, PLEASE CONTACT:
CRAs, creditors and others not listed below, contact the Federal Trade
Commission Bureau of Consumer Protection - FCRA Washington, DC 20580.
202-326-3761.
National Banks, federal branches/agencies of foreign banks (word "National" or
initials "N.A." appear in or after bank's name), contact the Office of the
Comptroller of the Current Compliance Management, Mail Stop 6-6 Washington, DC
20219. 800-613-6743.
Federal Reserve System member banks (except national banks, and federal
branches/agencies of foreign banks), contact the Federal Reserve Board Division
of Consumer & Community Affairs Washington, DC 20551. 202-452-3693.
Savings associations and federally chartered savings banks (word "Federal" or
initials "F.S.B." appear in federal institution's name), contact the Office of
Thrift Supervision Consumer Programs Washington, DC 20552. 800-842-6929.
Federal credit unions (words "Federal Credit Union" appear in institution's
name), contact the National Credit Union Administration, 1775 Duke Street,
Alexandria, VA 22314. 703-518-6360.
Banks that are state-chartered, or are not Federal Reserve System members,
contact the Federal Deposit Insurance Corporation Division of Compliance &
Consumer Affairs, Washington, DC 20429 . 800-934-FDIC.
Air, surface, or rail common carriers regulated by former Civil Aeronautics
Board or Interstate Commerce Commission, contact the Department of
Transportation Office of Financial Management, Washington DC 20590.
202-366-1306.
Activities subject to the Packers and Stockyards Act 1921, contact the
Department of Agriculture, Office of Deputy Administrator-GIPSA, Washington, DC
20250. 202-720-7051.
U000289
13
ON THE LIFE OF________________________________ Supplement to Application Number
This supplement amends the above captioned application _______________________________
for life insurance and becomes part of it as follows.
ADDITION OF OTHER INSURED RIDERS Dated ________________________
__________________________________________________________________________________________________________________________
SECTION 1. PROPOSED OTHER INSURED RIDER
__________________________________________________________________________________________________________________________
1. Last Name _____________________________________________ First Name ___________________________ M.I.________________
2. Address Apt# City
__________________________________________________________________________________________________________________________
State Zip Code 3. Years at Address 4. Home Phone 5. Driver License Number State
__________________________________________________________________________________________________________________________
6. Sex 7. Date of Birth 8. Insurable Age 9. Place of Birth - State/Country 10. Social Security Number
[ ] Male
[ ] Female
__________________________________________________________________________________________________________________________
11. Height 12. Weight 13. Marital Status 14. Relationship to Proposed Insured 15. Employer Years
__________________________________________________________________________________________________________________________
16. Occupation & Duties 18. Business Phone Number
______________________________________________________________________________________________
17. Employers Address
__________________________________________________________________________________________________________________________
19. Have you used tobacco or any other product containing NICOTINE in the last 12 months? [ ] Yes [ ] No
20. Rate Class Quoted: [ ] Ult Select [ ] Select [ ] Ult Standard [ ] Standard [ ] Juvenile
__________________________________________________________________________________________________________________________
SECTION 2. PROPOSED OTHER INSURED RIDER
__________________________________________________________________________________________________________________________
1. Last Name _____________________________________________ First Name ___________________________ M.I.________________
2. Address Apt# City
__________________________________________________________________________________________________________________________
State Zip Code 3. Years at Address 4. Home Phone 5. Driver License Number State
__________________________________________________________________________________________________________________________
6. Sex 7. Date of Birth 8. Insurable Age 9. Place of Birth - State/Country 10. Social Security Number
[ ] Male
[ ] Female
__________________________________________________________________________________________________________________________
11. Height 12. Weight 13. Marital Status 14. Relationship to Proposed Insured 15. Employer Years
__________________________________________________________________________________________________________________________
16. Occupation & Duties 18. Business Phone Number
______________________________________________________________________________________________
17. Employers Address
__________________________________________________________________________________________________________________________
19. Have you used tobacco or any other product containing NICOTINE in the last 12 months? [ ] Yes [ ] No
20. Rate Class Quoted: [ ] Ult Select [ ] Select [ ] Ult Standard [ ] Standard [ ] Juvenile
__________________________________________________________________________________________________________________________
SECTION 3. PROPOSED OTHER INSURED RIDER
__________________________________________________________________________________________________________________________
1. Last Name _____________________________________________ First Name ___________________________ M.I.________________
2. Address Apt# City
__________________________________________________________________________________________________________________________
State Zip Code 3. Years at Address 4. Home Phone 5. Driver License Number State
__________________________________________________________________________________________________________________________
6. Sex 7. Date of Birth 8. Insurable Age 9. Place of Birth - State/Country 10. Social Security Number
[ ] Male
[ ] Female
__________________________________________________________________________________________________________________________
11. Height 12. Weight 13. Marital Status 14. Relationship to Proposed Insured 15. Employer Years
__________________________________________________________________________________________________________________________
16. Occupation & Duties 18. Business Phone Number
______________________________________________________________________________________________
17. Employers Address
__________________________________________________________________________________________________________________________
19. Have you used tobacco or any other product containing NICOTINE in the last 12 months? [ ] Yes [ ] No
20. Rate Class Quoted: [ ] Ult Select [ ] Select [ ] Ult Standard [ ] Standard [ ] Juvenile
__________________________________________________________________________________________________________________________
U000289-Supp
1
SECTION 4. PROPOSED OTHER INSURED RIDER
________________________________________________________________________________
1. Last Name First Name M.I.
________________________________________________________________________________
2. Address Apt# City
________________________________________________________________________________
State Zip Code 3. Years 4. Home 5. Driver State
at Phone License
Address ( ) Number
________________________________________________________________________________
6. Sex 7. Date 8. Insurable 9. Place 10. Social Security
of Age of Birth Number
Birth - State/
Country
________________________________________________________________________________
11. Height 12. Weight 13. Marital 14. Relationship 15. Employer Years
Status to
Proposed
Insured
________________________________________________________________________________
16. Occupation & Duties 18. Business Phone Number
_____________________________________________________ ( )
17. Employer's Address
________________________________________________________________________________
19. Have you used tobacco or any other product containing nicotine
in the last 12 months? [ ] Yes [ ] No
20. Rate Class Quoted: [ ] Ult Select [ ] Select [ ] Ult Standard
[ ] Standard [ ] Juvenile
________________________________________________________________________________
SECTION 5. CONTINUATION OF CHILDREN COVERED UNDER THE CHILDREN'S INSURANCE RIDER
________________________________________________________________________________
COVERAGE AMOUNT
________________________________________________________________________________
Name Relationship Date of Birth Height Weight
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Are all children listed? [ ] Yes [ ] No
Are children living with proposed primary insured? [ ] Yes [ ] No
If not, explain why: ___________________________________________________________
________________________________________________________________________________
SECTION 6. CONTINUATION OF OTHER INSURANCE
________________________________________________________________________________
Proposed Amount
Insured of Year
Name Company insurance issued Replacement?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
SECTION 7. CONTINUATION OF MEDICAL EXPLANATIONS
________________________________________________________________________________
Date Name, Address and
Proposed Diagnosis, Phone # of
Insured's Treatment, Attending
Question # Name Results, and Duration Doctor and Hospital
________________________________________________________________________________
SECTION 8. DECLARATIONS
________________________________________________________________________________
I (We) represent that all statements and answers made in this supplement are
full, complete and true to the best of my (our) knowledge and belief. It is
agreed that this statement shall be made part of the application, and is subject
to all terms and conditions contained in the application.
sec. 1 _____________________________________________________________
Signature of proposed other insured (Child over 15 must sign)
sec. 2 _____________________________________________________________
Signature of proposed other insured (Child over 15 must sign)
sec. 3 _____________________________________________________________
Signature of proposed other insured (Child over 15 must sign)
sec. 4 _____________________________________________________________
Signature of proposed other insured (Child over 15 must sign)
______________________________________ _________________________________________
Witness (Registered Representative) Name of Broker/Dealer
______________________________________ _________________________________________
Witness (Registered Representative) Name of Broker/Dealer
______________________________________
Signed at (City/State)
______________________________________
Signature of Applicant/Owner, if other
than the proposed insured
U000289-Supp
2