Exhibit 1.A(10)
Application for Modified Single Premium Variable Life Insurance Policy
THE WRL FREEDOM NAVIGATOR
Western Reserve Life
Assurance Co. of Ohio
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APPLICATION FOR
LIFE INSURANCE
Western Reserve Life Assurance Co. of Ohio
Cedar Rapids, Iowa
6200VL R1198
NOTICE TO PROPOSED INSURED
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Thank you for your application. We appreciate your efforts in completing each
part of the application truthfully, accurately, and completely.
Once we receive your application, we will begin an evaluation process called
underwriting to determine whether you are eligible for insurance and, if so, the
rate you should pay for that insurance. We may find that we are unable to give
you the insurance you have applied for or that we are able to give it to you
only on a modified basis or at a rate greater than our lowest rate. For example,
if you have ever used any kind of tobacco or any other nicotine product, you may
not be eligible for our lowest rate. Your application will be our primary source
of information; therefore, it must be true, complete, and accurate. You must
inform us of a change to any answer in any part of your application before
accepting delivery of a policy; in fact, you agree to do so when you sign your
application. We may seek information from other sources to help us evaluate the
information you give us on your application.
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CONTESTABILITY
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We strongly urge you to review the completed application closely for accuracy.
During the first two policy years, a claim may be denied or your coverage may be
rescinded or contested by a lawsuit if the application is incomplete or if it
contains false statements, misrepresentations, acts, omissions, or is procured
by fraud. If the policy is rescinded or the lawsuit is successful, the policy
will be void and coverage will be lost. Any policy that is delivered to you will
indicate when and under what circumstances it may be contested. Please be aware
that if the application contains false or deceptive statements and you submitted
it with the intent to defraud or to facilitate fraud against us, you may also be
guilty of insurance fraud.
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REPLACEMENT OF EXISTING COVERAGE
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If you intend to replace existing coverage, tell the agent of your intention and
answer "yes" to the replacement question in the application; state law may
require the agent to give you information that will help you compare the policy
you are applying for with the policy you intend to replace. If you are undecided
about keeping existing coverage, indicating an intention to replace existing
coverage may help you get the information you need to make a decision. If you do
replace existing coverage, the new policy may contain new suicide and
contestable periods. The following would be considered replacement; you stop
paying premiums for the insurance for which you are applying. State laws define
replacement to include other situations. Please ask your agent if you are
unsure.
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INSURANCE INFORMATION PRACTICES
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We will rely primarily on information provided by you. We may supplement that
information with information from other sources such as medical professionals
who have treated you. In some cases, we may ask a consumer reporting agency to
collect information and submit an investigative consumer report to us as
explained in this Notice under Federal Fair Credit Reporting Act. You may
request to be interviewed in connection with the preparation of this report. You
have the right to be told about, and to see and copy if you wish, items of
personal information about you that appear in our files, including information
contained in investigate consumer reports. You also have the right to seek
correction of information you believe to be inaccurate. We will send you a more
detailed explanation of our information practices if you send us a written
request. You may send your request to the Director of Underwriting, P.O. Box
3183, Cedar Rapids, Iowa 52406-3183.
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FAIR CREDIT REPORTING PRE-NOTICE
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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, P.O. Box
3183, Cedar Rapids, Iowa 52406-3183. You have the right to request additional
information concerning the nature and scope of the investigation to be
performed. A summary of your rights is set forth on the attached signature page
of the application. To make this request, you must write the Underwriting
Department, P.O. Box 3183, Cedar Rapids, Iowa 52406-3183.
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MIB DISCLOSURE NOTICE
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Information regarding your insurability will be treated as confidential. The
Company or its reinsurers may, however, make a brief report to the Medical
Information Bureau, a non-profit membership organization of life insurance
companies, which operates an information exchange on behalf of its members. If
you apply to another Bureau member for life or health insurance coverage, or a
claim for benefits is submitted to such a Company, the Bureau, upon request,
will supply such company with the information in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. If you question the accuracy of the
information in the Bureau's file, you may contact the Bureau and seek a
correction in accordance with the procedures set forth in the Federal Fair
Credit Reporting Act. The address of the Bureau's information office is Post
Office Box 105, Essex Station, Boston, Massachusetts 02122, telephone number
(617) 426-3660.
The Company or its reinsurers may also release information in file to other life
insurance companies to whom you may apply for life or health insurance or to
whom a claim for benefits may be submitted.
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6200VL R1198 Page 2
APPLICATION FOR LIFE INSURANCE WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO
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Part I PLAN OF INSURANCE
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Plan of Insurance: Premium Amount: $ Face Amount: $
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Part II PRIMARY INSURED INFORMATION
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Name: Social Security Number: Sex: [ ] Male [ ] Female
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Street Address: Date of Birth: Age:
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City: Place of Birth (State or County):
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State: ZIP Code: Occupation:
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Beneficiary: Relationship to Insured:
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Contingent Beneficiary: Relationship to Insured:
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Will this policy replace or change any existing life insurance or annuity
policy(ies)? [ ] Yes [ ] No
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If yes, indicate policy number(s) and Company names(s)?
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Is this intended to be a 1035 Exchange? [ ] Yes [ ] No
Indicate Exchange amount:
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If this policy will replace an existing policy, complete required replacement
forms.
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Part IIA JOINT INSURED INFORMATION
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Name: Social Security Number: Sex: [ ] Male [ ] Female
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Street Address: Date of Birth: Age:
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City: Place of Birth (State or County):
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State: ZIP Code: Occupation:
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Part III CONTACT INFORMATION
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Insured's Home Telephone Business Telephone Fax:
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Preferred Place to call: [ ] Home [ ] Business
Best time to call: [ ] A.M. [ ] P.M.
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Special Comments:
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Part IV OWNER INFORMATION: (if other than proposed insured)
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Name:
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Street Address: Date of Birth:
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City: State: ZIP Code:
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Relationship To Insured: Social Security Or Tax ID Number:
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Part V BASIC HEALTH QUESTIONS
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A. Primary Insured: Height: Weight: Joint Insured: Height: Weight:
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B. Within the last 5 years, has any Proposed Insured been treated for or been
told by a member of the medical profession that you had heart disease or
circulatory problems, stroke, cancer, diabetes, kidney or liver disorder,
lung or respiratory disorder, Alzheimer's Disease, mental or psychiatric
disorder, alcohol or drug abuse? If yes, please circle the applicable
ailment(s). [ ] Yes [ ] No
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C. Within the last 10 years, has any Proposed Insured been diagnosed by a member
of the medical profession as having AIDS (Acquired Immune Deficiency
Syndrome), or have you tested positive for HIV (Human Immunodeficiency
Virus)? [ ] Yes [ ] No
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D. Within the past 12 months, has any Proposed Insured, smoked cigarettes,
cigars, pipes or used chewing tobacco? [ ] Yes [ ] No
If "yes", please circle applicable insured: Primary Insured Joint Insured
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E. Within the past 12 months, has any Proposed Insured been admitted to a
hospital or nursing home? [ ] Yes [ ] No
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F. Has any Proposed Insured ever been declined, rated or postponed for insurance
or reinstatement of life, accident or sickness insurance or has a policy ever
been cancelled or renewal refused? [ ] Yes [ ] No
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Part VI SPECIAL REQUEST
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If this life insurance cannot be issued, do you want to apply for an annuity
policy? [ ] Yes [ ] No
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6200VL R1198 Page 3
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MEDICAL QUESTIONNAIRE
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NOTE: QUESTIONS APPLY TO EACH PERSON PROPOSED FOR INSURANCE.
YES NO
A. To the best of your knowledge, has any Proposed Insured within
the last 10 years had or been told by a member of the medical
profession that he or she had:
1. Heart murmur, high blood pressure, chest pain, heart
attack, stroke, or other disorder of the heart or
circulatory system? ..........................................[ ] [ ]
2. Asthma, Emphysema, Chronic Bronchitis or any other
Respiratory disorder, colitis, ulcer, or any other
gastrointestinal disorder; hepatitis, liver or kidney
disorder? ....................................................[ ] [ ]
3. Cancer, tumor, polyp, breast, prostate or any other
reproductive disorder; or any thyroid or endocrine
disorder? ....................................................[ ] [ ]
4. Brain, mental, nervous or seizure disorder; or any paralysis
or suicide attempt? ..........................................[ ] [ ]
5. Diabetes, sugar, albumin, blood or pus in the urine?..........[ ] [ ]
B. To the best of your knowledge has any Proposed Insured within
the last 10 years had or been told by a member of the medical
profession that he or she had: ..................................[ ] [ ]
1. Used amphetamines, heroin, cocaine, marijuana or any other
illegal or controlled substance except as prescribed by a
physician? ...................................................[ ] [ ]
2. Been on or are now on prescribed medication or diet? .........[ ] [ ]
3. 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? ........................................................[ ] [ ]
4. An examination, treatment, or consultation with a doctor
other than above? ............................................[ ] [ ]
5. Have or have had a parent, brother or sister who has/had
coronary artery death or disease prior to age 60? ............[ ] [ ]
6. Sought or been advised to seek treatment, limit or discontinue
use of alcohol? ..............................................[ ] [ ]
C. To the best of your knowledge have you or any Proposed Insured
in the last 10 years:
1. Ever piloted a plane, helicopter or glider, or have any
intentions of piloting an aircraft? ..........................[ ] [ ]
2. Ever participated in any sport, avocation or hobby such as
skin-diving, skydiving, automobile or motorcycle racing,
mountain climbing, or have you any intention to do so? .......[ ] [ ]
3. Has any Proposed Insured had their driver's license restricted,
revoked, or been cited for a moving violation? ...............[ ] [ ]
Give reason, Driver's License Number and Licensed State.
D. Has any Proposed insured ever been convicted of a misdemeanor or
felony? .........................................................[ ] [ ]
E. Is there an application for life, accident or sickness insurance
now pending or contemplated on any proposed insured with this or
any other company? ..............................................[ ] [ ]
DETAILS OF "YES" ANSWERS. Include: a. Identity of person, b. Question number,
c. Diagnosis and treatment, d. Results, e. Dates and durations, f. Names and
addresses of all attending physicians and medical facilities.
I represent that the above statements and answers are full, complete and true to
the best of my knowledge and belief. I also agree that the above Medical
Questionnaire is part of the application and as such is subject to all terms and
conditions contained in the application.
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Date Signature of Proposed Insured
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Signature of Joint Insured
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6200VL R1198 Page 3A
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Part VII PERSONAL FINANCIAL STATEMENT Part VIII ADDITIONAL BENEFITS - PRIMARY INSURED ONLY
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A) Gross Income Current Yr $____ ____ ____ [ ] Asset Rebalancing
B) Gross Income Previous Yr $____ ____ ____ [ ] Dollar Cost Averaging
C) Net Worth $____ ____ ____ [ ] Guaranteed Death Benefit Rider
For over $1 million applied coverage complete
a separate financial questionnaire
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Part IX SUITABILITY FOR VARIABLE LIFE INSURANCE POLICY - COMPLETE FOR ALL VARIABLE PLANS
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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
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Part X TO BE COMPLETED BY APPLICANT/OWNER
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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 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 expenses
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 genuine. If Western Reserve Life does not employ such procedures, it may be
liable for losses due to unauthorized or fraudulent instructions. Such procedures may
include, among others, 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.
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Part XI ACCOUNT ALLOCATIONS - (FOR VARIABLE PLANS ONLY) MUST EQUAL A WHOLE NUMBER AND TOTAL 100%
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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 ______% THIRD AVENUE VALUE ______% FIXED ACCOUNT ______%
TACTICAL ASSET ALLO. ______% STRATEGIC TOTAL RETURN ______% OTHER ______%
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Part XII INVESTMENT OBJECTIVE
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[ ] Safety of Principal
[ ] Income
[ ] Long-Term Growth
[ ] Trading Profits
[ ] Other
____________________________
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6200VL R1198 Page 4
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TAXPAYER IDENTIFICATION NUMBER STATEMENT
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Taxpayer Identification Number (of) policyowner:________________________________
Social Security Number or
Taxpayer Identification Number
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Check the box if you ARE NOT subject to Check the box if you ARE subject to
backup withholding under the provisions backup withholding under the
of section 3406(a)(1)(C) of the Internal provisions of section 3406(a)(1)(C)
Revenue Code...................[ ] of the Internal Revenue Code.....[ ]
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The Internal Revenue Service does not require your consent to any provision of
this document other than the following certification required to avoid backup
withholding.
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Under penalties of perjury, I hereby certify (1) that the Social Security or
Taxpayer I.D. number listed above is correct and (2) that my current status
regarding backup withholding is correct.
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I agree that: (1) If the receipt is issued in return for the full first premium,
the Company's liability will be as set forth in such receipt. If the receipt has
not been issued, the Company shall incur liability under this application only
when a policy has been delivered and the full first premium specified in the
policy has been paid during the lifetime and continued insurability of the
Persons to be insured, as determined by the Company from this application. (2)
No modification may be made to the policy or no right of the Company waived
unless agreed to in writing and signed by: (A) The President; (B) The Vice
President; or (C) The Secretary of the Company.
The Proposed Insured acknowledges receipt of the MIB Disclosure Notice and Fair
Credit Reporting Pre-Notice.
I represent that all the statements and answers in this application are complete
and true to the best of my knowledge and belief. I agree that the statements and
answers given in this application, and any amendments or application supplements
to it will be the basis of any insurance issued.
Unless we have been notified of a community or marital property interest in this
policy, we will rely on our good faith belief that no such interest exists and
will assume no responsibility for inquiry.
AUTHORIZATION: I hereby authorize any licensed physician, medical practitioner,
hospital, clinic or medically related facility, insurance company, the Medical
Information Bureau, consumer reporting agency, or other organization, employer,
institution or person that has any records or knowledge of me or my health (or
of additional insured(s), if included in the coverage applied for), to give to
the Company, or its reinsurers, any such information. This includes information
about drugs and alcohol and about diagnosis, treatment and prognosis of any
physical or mental condition, as well as any other non-medical information. A
photographic copy of this authorization shall be as valid as the original. The
authorization will be valid from the date signed for a period of two and one
half years.
I also hereby authorize the Company 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.
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Signed at: (City and State) Date:
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Signature of Proposed Primary Insured
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Signature of Owner (if other than Proposed Insured)
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Signature of Proposed Joint Insured
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TO BE COMPLETED BY AGENT
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Do you have reason to believe the policy applied for is to replace or change any
existing annuity or insurance owned by the applicant?
[ ] Yes [ ] No (If Yes, include state replacement forms if applicable)
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If yes, indicate policy number(s) and Company name(s):
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Did you give the "MIB Disclosure Notice" to the Proposed Insured? [ ] Yes [ ] No
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Did you comply with all requirements relative to obtaining Informed Consent for
HIV and AIDS testing? [ ] Not required [ ] Yes [ ] No
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Signature of Agent Agent's State License Number:
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Agent's Social Security Number:
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Print Agent's Name: Telephone Number:
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6200VL R1198 Page 5
FRAUD WARNING
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The following states require that insurance applicants (owners) acknowledge a
fraud warning statement. If you reside in one of the states listed below, please
refer to the applicable fraud warning.
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For applicants (owners)in ARKANSAS, NEW MEXICO AND PENNSYLVANIA
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Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or 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
________________________________________________________________________________
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For applicants (owners) in COLORADO
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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 or an insurance
company who knowingly provides false, incomplete, or misleading facts or
information to the 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
________________________________________________________________________________
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For applicants (owners) in FLORIDA
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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
________________________________________________________________________________
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For applicants (owners) in KENTUCKY AND OHIO
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Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance 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.
Applicant's Signature Date
________________________________________________________________________________
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For applicants (owners) in NEW JERSEY
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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
________________________________________________________________________________
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For applicants (owners) in VIRGINIA
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Any person who, with the intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement may have violated state law.
Applicant's Signature Date
________________________________________________________________________________
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6200VL R1198 Page 6
CONDITIONAL RECEIPT (DO NOT COMPLETE AND GIVE TO APPLICANT UNLESS PAYMENT
IS MADE)
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CONDITIONS UNDER WHICH THIS PAYMENT SHALL CAUSE CONDITIONAL COVERAGE TO TAKE
EFFECT
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(1) Each and every person proposed for insurance must be insurable and
acceptable to the Company under its underwriting rules for the amount, plan and
risk classification applied for on the later of: (A) the date of application, or
(B) the date of completion of all medical tests and examinations required by the
Company. (2) Any check given for payment must be honored on first presentation.
(This receipt and all coverages applied for on the application are void if check
or draft received for payment of the initial premium is not honored for payment
on its first presentation.)
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AMOUNT OF CONDITIONAL LIFE INSURANCE COVERAGE
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If conditional coverage becomes effective under the terms of this receipt, then
the amount of conditional life insurance coverage on any person proposed for
insurance is the lesser of: (1) the amount of life insurance applied for on such
person, or (2) $300,000 reduced by the amounts payable under all other life
insurance or accidental death benefits then in force or pending with the
Company.
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WHEN CONDITIONAL COVERAGE BEGINS
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If the conditions listed above are fulfilled, then the amount of conditional
coverage specified above shall take effect on the later of (1) the date of the
application, or (2) the date of the completion of all medical tests and
examinations required by the Company. All conditional coverages for each and
every person proposed for insurance will be deemed void if the application
contains material misrepresentations or is fraudulently completed. Benefits
under this conditional receipt coverage will be denied if any person proposed
for insurance commits suicide.
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WHEN CONDITIONAL COVERAGE ENDS
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Conditional coverage shall terminate automatically, without notice, on the
earliest of the following dates: (1) the date the Company approves the policy as
applied for; (2) 10 days following any counter offer by the Company to offer
insurance to any person proposed for insurance under a different plan or at an
increased premium or on a different rate class; (3) at the end of the fraction
of a year which the payment bears to the premium required to provide one month
of insurance coverage in the amount as described above; or (4) at the beginning
of the 60th day following the date of this receipt.
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CONDITIONAL RECEIPT
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The Insurance Company has received from ________________________________________
this _____day of _____________, __________________a premium deposit of $________
in connection with an application for life insurance. Unless the conditions
stated above this receipt are fulfilled, no conditional coverage shall take
effect and this payment will be refunded. All premium checks must be made
payable to the Insurance Company indicated above. Do not make checks payable to
the agent or leave payee blank.
Date ____________________ Signature of Owner ___________________________________
Date ____________________ Signature of Agent ___________________________________
NOTE: If you do not receive a policy or refund of the amount you paid within 60
days from the date of this receipt please notify:
Western Reserve Life Assurance Co. of Ohio
Cedar Rapids, Iowa
P.O. Box 3183, Cedar Rapids 52406-3183
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6200VL R1198 Page 7
Western Reserve Life Assurance Co. of Ohio
Cedar Rapids, Iowa
P.O. Box 3183, Cedar Rapids 52406-3183