Exhibit 1.A.(10)
Application for Flexible Premium Variable Life Insurance Policy
A HISTORY OF PERFORMANCE/R/ WRL PRIORITY:
P.O. BOX 628069
ORLANDO, FL 32862-8069
STREET ADDRESS-USE FOR CARRIER
[WRL LOGO] OTHER THAN POST OFFICE:
570 CARILLON PKWY
INSURANCE /bullet/ ANNUITIES ST. PETERSBURG, FL 33716
WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO
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#:_________________
Date Faxed: (If Applicable)________________________________________________
Amount of initial premium with application $_________________________
Amount to be applied to application
$_________________________
$_________________________
$_________________________
DO: DON'T:
--- ------
[ ] Complete the entire application (front and back). [ ] Do not use pencil or whiteout.
[ ] Print application in black ink. [ ] Do not accept or send money on applications that total
more than $1,000,000.00
[ ] Have applicant initial all changes.
[ ] Do not submit an agent check as the initial premium.
[ ] Obtain all required signatures.
[ ] Do not submit starter checks or deposit slips for
[ ] Complete and sign the Agents Report. checkomatic withdrawals.
[ ] Use supplement if more than one Other Insured Rider
is required.
[ ] Include certification if a trust is owner of the policy.
U000286-WMA
WRL PRIORITY:
P.O. BOX 628069
A HISTORY OF PERFORMANCE ORLANDO, FL 32862-8069
STREET ADDRESS-USE FOR CARRIER
OTHER THAN POST OFFICE:
[WRL LOGO] 570 CARILLON PKWY
ST. PETERSBURG, FL 33716
INSURANCE /bullet/ ANNUITIES 1-800-443-9975 (X6420
WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO
APPLICATION FOR LIFE INSURANCE
Agent Name:________________________________________________________
Agent Number:______________________________________________________
Broker/Dealer______________________________________________________
Date Faxed: (If Applicable)________________________________________
Amount of initial premium with application $___________________
Amount to be applied to application
0000999999 $___________________
$___________________
$___________________
DO: DON'T:
--- ------
[ ] Complete the entire application (front and back). [ ] Do not use pencil or whiteout.
[ ] Print application in black ink. [ ] Do not accept or send money on applications that total
more than $1,000,000.00
[ ] Have applicant initial all changes.
[ ] Do not submit an agent check as the initial premium.
[ ] Obtain all required signatures.
[ ] Do not submit starter checks or deposit slips for
[ ] Complete and sign the Agents Report. checkomatic withdrawals.
[ ] Use supplement if more than one Other Insured Rider
is required.
[ ] Include certification if a trust is owner of the policy.
U000286
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 WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO
the Board of Directors of the WESTERN RESERVE LIFE ASSURANCE
CO. OF OHIO on October 29, 1991. /s/ WILLIAM H. GEIGER
---------------------
TO: WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO Secretary
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.____________________ LIST ANY OTHER POLICIES TO BE PAID
on the life of ___________________________ BY SAME CHECK, DRAFT OR DEBIT
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.
AUTHORIZATION FOR PREAUTHOFIIZED
PAYMENTS TO:
WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO
P.O. BOX 5068, CLEARWATER, FL 34618-5068
"I elect _______ day (select 1 to 27) of As a convenience to me, I hereby request and authorize you to pay and charge to
each month to have the payment of my bank checking account checks or drafts drawn by and payable to the order of
$_______ taken from my account. If no WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO or to debit my account identified below
date is indicated the draft date will be via ACH electronic fund transfers provided there are sufficient collected funds in
the policy issue date." 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.
U000286
LIFE APPLICATION - The Western Life Assurance Co. of Ohio APPLICATION#
SECTION 1. PROPOSED PRIMARY INSURED
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 8. Insurable 9. Place of Birth 10. Social Security Number
of Birth Age - State/Country
[ ] Male
[ ] Female - -
- -------------------------------------------------------------------------------
11. Height 12. Weight 13. Marital Status 14. Employer Years
ft in lbs
- -------------------------------------------------------------------------------
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 at Address/ 4. Home Phone/ 5. Driver / State
License Number
( )- -
- -------------------------------------------------------------------------------
6. Sex / 7. Date of Birth/ 8. Insurable/ 9. Place of Birth/ 10. Social Security
Age - State/ Country Number
[ ] Male
[ ] Female MM - DD - YYYY - -
- -------------------------------------------------------------------------------
11. Height/ 12. Weight/ 13. Marital/ 14. Relationship to/ 15. Employer Years
Status Proposed Insured
ft in lbs
- -------------------------------------------------------------------------------
16. Occupation & Duties
- -------------------------------------------------------------------------------
17. Employer's Address 18. Business Phone Number
( )- -
- -------------------------------------------------------------------------------
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. 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:
MM-DD-YYY
- -------------------------------------------------------------------------------
SECTION 4. CHILDREN'S INSURANCE RIDER
COVERAGE AMOUNT ($2,000 MINIMUM TO $10,000 MAXIMUM COVERAGE FOR CHILDREN 18 AND
UNDER) $__,____
NAME RELATIONSHIP DATE OF BIRTH HEIGHT WEIGHT
MM-DD-YYYY ft in lbs
MM-DD-YYYY ft in lbs
MM-DD-YYYY ft in lbs
Are all children listed? [ ] Yes [ ] No Are children living with proposed
primary insured? [ ] Yes [ ] No
If not, explain why:__________________
U000286 1
SECTION 5. PRIMARY BENEFICIARY - IF PERCENTAGE SHARES ARE NOT GIVEN THEY WILL 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:
1. [ ] FFB [ ] FEP [ ] FWP [ ] OTHER ______________
2. Specified Amount: $ , ,000
-------------
3. Primary Insured Rider $ , ,000
-------------
4. Primary Insured Rider Plus $ , ,000
-------------
5. Other Insured Rider
$ , ,000
- --------------------------------- -------------
6. ARE YOU APPLYING FOR MORE THAN ONE OTHER INSURED RIDER?
[ ] YES [ ] NO
IF YES PLEASE USE SUPPLEMENTAL APPLICATION #U000286-SUPP
FWP POLICIES ONLY
7. No Lapse Guarantee Option: [ ] A) 5YR [ ] B) 10YR
8. Wealth Protector Rider $ 000
----,---,---
9. Joint Insured Rider $ 000
----,---,---
10. INDIVIDUAL INSURED RIDER(S)
[ ] Proposed Primary Insured $ 000
----,---,---
[ ] Proposed Joint Insured $ 000
----,---,---
- -------------------------------------------------------------------------------
SECTION 8. DEATH BENEFIT OPTION
[ ] A) Level Benefit
[ ] B) Increasing Benefit
[ ] C) Option B To Age 70 Then Grading Down
(option C for FFB only)
- -------------------------------------------------------------------------------
SECTION 9. ADDITIONAL BENEFITS-PRIMARY INSURED ONLY
[ ] Disability Waiver Rider
[ ] Disability Waiver And Income Rider
($300 per month maximum) $________
[ ] Accidental Death Benefit
($150,000 maximum) $ 000
-----,---
- -------------------------------------------------------------------------------
SECTION 10. PREMIUMS PAYABLE
Planned Premium $___,___,__
[ ] Checkomatic __ Draft Date (1ST thru 27TH)
[ ] Direct Bill
[ ] Single Premium [ ] Quarterly
[ ] Annual [ ] Monthly
[ ] Semi-annual [ ] Other __________
- -------------------------------------------------------------------------------
SECTION 11. SUB-ACCOUNT ALLOCATIONS - (FOR VARIABLE PLANS ONLY) MUST EQUAL
100% AND A WHOLE NUMBER.
MONEY MARKET ____% VALUE EQUITY ____% AGGRESSIVE GROWTH ____%
GROWTH FUND ____% US EQUITY ____% GROWTH AND INCOME ____%
EMERGING GROWTH ____% REAL ESTATE SECURITIES ____% CASE GROWTH ____%
GLOBAL ACCOUNT ____% BOND FUND ____% INTERNATIONAL EQUITY ____%
BALANCED FUND ____% FIXED ACCOUNT ____% THIRD AVENUE VALUE ____%
TACTICAL ASSET ALLO. ____% STRATEGIC TOTAL RETURN ____% 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
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 insured in this or any other company? If yes,
give details in Agent's Report, Question 3. [ ] Yes [ ] No
U000286 2
LIFE APPLICATION - PART 2
SECTION 14. PERSONAL FINANCIAL STATEMENT
A) Gross Income Current Yr $___,___,___
B) Gross Income Previous Yr $___,___,___
C) Net Worth $___,___,___
For over $1 million applied coverage complete
a separate financial questionnaire
- -------------------------------------------------------------------------------
15. COMPLETE FOR CORPORATION, PARTNERSHIP, PENSION OR TRUST
A) Current Estimated Market Value $__,___,___
B) Assets LIQUID $__,___,___
NONLIQUID $__,___,___
C) Liabilities $__,___,___
D) Net Worth $__,___,___
- -------------------------------------------------------------------------------
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 diagnosis 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, hiqh 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, ulcer 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 endocrine 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 prescribe by a physcian? [ ] 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 consultation 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 OR OTHER INSURED CHILDREN
- --------------------- ------------------------------- -----------------------
- --------------------- ------------------------------- -----------------------
- --------------------- ------------------------------- -----------------------
- --------------------- ------------------------------- -----------------------
- --------------------- ------------------------------- -----------------------
DATE AND REASON LAST DATE AND REASON LAST CONSULTED DATE AND REASON LAST
CONSULTED A PHYSICIAN A PHYSICIAN CONSULTED A PHYSICIAN
- --------------------- ------------------------------- -----------------------
- --------------------- ------------------------------- -----------------------
- --------------------------------------------------------------------------------
U000286 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 driver's 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/OWNERR
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 l of page 1 or 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.)
U000286 4
LIFE APPLICATION
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 any
physical or mental condition regarding me or my children who are to be insured,
to give such information to Western Reserve Life of Ohio, its reinsurers, or any
consumer reporting agency except the Medical Information Bureau acting on
Western Reserve Life's 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 M M - D D - Y Y Y Y
--------------------- ------- --- --- -------
(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 Agent #
and under
______________________________________________
Signature of Joint Insured or OIR
U000286 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.
____________________________________ ___________________
Applicant's 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.
____________________________________ ___________________
Applicant's 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.
____________________________________ ___________________
Applicant's 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.
____________________________________ ___________________
Applicant's 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.
____________________________________ ___________________
Applicant's 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.
____________________________________ ___________________
Applicant's Signature Date
______________________________________________________________________________
FOR APPLICANTS IN VIRGINIA
______________________________________________________________________________
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.
____________________________________ ___________________
Applicant's Signature Date
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?
[ ] 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 Requirement?
[ ] 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 any affect the insureability 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 in brothers and sisters?
__________________________________________________________________________
Remarks:______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
9. Is Proposed Insured or Owner related to any InterSecurities, Inc. officer
or employee?
10. Is Proposed 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 [ ] Buy-Sell
[ ] Retirement [ ] Key Employee
[ ] Education [ ] Executive Bonus
[ ] Estate Liquidity [ ] Deferred Compensation
[ ] Income to Family [ ] Split Dollar
[ ] Cash Accumulation [ ] Reserve Split Dollar
[ ] Wealth Replacement [ ] Other
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
8
THIS PAGE IS
INTENTIONALLY BLANK
10
NOTICE OF INFORMATION PRACTICES Western Reserve Life Assurance Co. of Ohio
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:
/bullet/ ask you to have an examination, which may include special tests such
as an electrocardiogram, chest x-ray, blood studies, or urinalysis;
/bullet/ ask physicians, medical practitioners, clinics, hospitals, or other
health care providers for information about you:
/bullet/ 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 procedures;
/bullet/ 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 33768. 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 nonprofit 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 MIB 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 MIB's 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
MIB's office is: MIB, Inc.; P.O. Box 105, Essex Station; Boston, MA 02112. MIB's
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:
WESTERN RESERVE LIFE ASSURANCE CO.
ANY OTHER P.O. BOX 5068
QUESTIONS? CLEARWATER, FLORIDA 34618-5068
1-813-587-1800
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 you-such as where you work and live, if you pay your bills on time, and
whether you've been sued, arrested, or filed for bankruptcy-to 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 Commission's 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.
/bullet/ 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 you-such as denying an application for credit,
insurance, or employment-must give you the name, address, and phone
number of the consumer reporting agency that provided the report.
/bullet/ 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.
/bullet/ 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 agencies-to which it provides data-of 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 agency's 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.
/bullet/ 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.
/bullet/ You can dispute inaccurate items with the source of the information.
If you tell anyone-such 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 you've 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.
/bullet/ 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.
/bullet/ Access to your file is limited. Consumer reporting agencies may
provide information about you only to those who have a need recognized
by the FCRA-usually to consider an application you have submitted to a
creditor, insurer, employer, landlord, or other business.
/bullet/ 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.
/bullet/ 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.
/bullet/ 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.
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.
13