EXHIBIT 1(10)
APPLC
PACIFIC LIFE & ANNUITY COMPANY [LOGO]
Mailing Life Insurance Operations Center
Address P.O. Box 6520 . Newport Beach, CA 92658-6520
(888) 595-6997
APPLICATION FOR LIFE INSURANCE, PART 1
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SECTION A CLIENT INFORMATION
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PROPOSED INSURED 1. Name of Proposed Insured (Print as to appear in policy: First/Middle/Last) 2. Sex
Complete for all Life [_] Male [_] Female
Insurance Policies.
3. Date of Birth 4. Age (Nearest birthday) 5. Place of Birth 6. Soc. Sec. #
7. Driver's License # & State 8. Telephone # 9. E-mail Address
10. Address (Street, City, County, State, Zip Code) 11. How Long
12. Employer Name & Address (Street, City, County, State, Zip Code) 13. How Long
14. Occupation 15. Type of Business
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PROPOSED ADDITIONAL 16. Name of Additional Proposed Insured (Print as to appear in policy: First/Middle/Last) 17. Sex
INSURED [_] Male [_] Female
Complete for a
Joint and Last 18. Date of Birth 19. Age (Nearest birthday) 20. Place of Birth 21. Soc. Sec. #
Survivor Life
Insurance Policy 22. Driver's License # & State 23. Telephone # 24. E-mail Address
or for a Term
Rider on Another 25. Address (Street, City, County, State, Zip Code) 26. How Long
Covered Person
for an Individual 27. Employer Name & Address (Street, City, County, State, Zip Code) 28. How Long
Life Insurance
Policy. 29. Occupation 30. Type of Business 31. Relationship to Insured
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OWNER 32. Name of Owner(s) (Print as to appear in policy: First/Middle/Last)
Complete only if
Owner is other than 33. Address (Street, City, County, State, Zip Code) 34. Relationship to Insured(s)
the Insured(s). If
Trust, give name of 35. Date of Birth 36. Soc. Sec. # / Tax ID # 37. Telephone # 38. E-mail Address
trust, trustee, and
date of trust.
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PRIMARY BENEFICIARY 39. Name of Beneficiary (Print as to appear in policy: First/Middle/Last)
40. Relationship to Insured(s) 41. Soc. Sec. # / Tax ID #
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CONTINGENT 42. Name of Contingent Beneficiary (Print as to appear in policy: First/Middle/Last)
BENEFICIARY
43. Relationship to Insured(s) 44. Soc. Sec. # / Tax ID #
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BENEFICIARY FOR 45. Name of Beneficiary for Individual Term Rider (Print as to appear in policy: First/Middle/Last)
INDIVIDUAL TERM
RIDER 46. Relationship to Insured 47. Soc. Sec. # / Tax ID #
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AP2001-NY Page 1 85-23808-00 01/2002
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SECTION A CLIENT INFORMATION (CONTINUED)
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PREMIUM NOTICES 48. Send Premium Notices to: [_] Insured [_] Owner [_] Other (If other, give name, relationship, and address
below)
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49A. Name B. Relationship to Insured(s)
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C. Address (Street, City, County, State, Zip Code)
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50. Method & Frequency of Payment (Select One):
A. Direct B. [ ] Electronic Funds Transfer C. List Bill (3 or more policies) D. [ ] Single
[ ] Annually (EFT) (Monthly only) Attach [ ] Annually Premium
[ ] Semi-Annually voided check and complete EFT [ ] Semi-Annually
[ ] Quarterly Authorization on page 10. [ ] Quarterly
[ ] Monthly
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AMOUNT PAID WITH 51A. Is an initial premium submitted with this application? [ ] Yes [ ] No
THIS APPLICATION (Do not submit money unless the Temporary Insurance Agreement is completed)
B. If yes, show amount of initial premium and complete the Amount $_____________________________
next question.
C. Do you understand, accept, and agree to the terms of the Temporary Insurance Agreement? [ ] Yes [ ] No
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SPECIAL POLICY 52A. [ ] Date to Save Age [ ] Specific Date
DATING If either box is checked, give policy date and complete below: Month__________ Day_________ Year_______
B. I understand that insurance charges and expenses begin on the Policy Date [ ] Yes [ ] No
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LIFE INSURANCE IN 53. Give details of all life insurance in force on any Proposed Insured. If none, check this box: [ ]
FORCE
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Will This
Year Policy Be
Insured's Name Company Policy Number Face Amount Issued Replaced?
YES NO
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[ ] [ ]
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[ ] [ ]
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[ ] [ ]
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[ ] [ ]
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REPLACEMENT & 1035 YES NO
EXCHANGE ----------------------------------------------------------------------------------------------------------------
INFORMATION 54. Will the policy applied for replace, cause a change in, or involve a cash
withdrawal or loan from any life insurance or annuity on any Proposed
Insured's life or in any life insurance or annuity owned by the Applicant?
If yes, give details in "Remarks." [ ] [ ]
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EXCHANGE
INFORMATION 55. Is this a 1035 exchange? If yes, list the policies to be exchanged in
"Remarks." [ ] [ ]
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56. If a 1035 exchange, will a loan be carried over? If yes, list in "Remarks"
the policies and the loan amount(s) to be carried over. [ ] [ ]
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2001-NY Page 2 85-23808-00 01/2002
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SECTION B GENERAL INFORMATION
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GENERAL Additional
INFORMATION Proposed Insured Insured
Complete each question 1. Annual earned income from occupation (After
for the Proposed and deduction of business expenses) $ $
Additional Insured.
2. Other income (State source in "Remarks") $ $
3. Net Worth $ $
YES NO YES NO
4. Do you contemplate leaving the USA for travel or
residence? (If yes, explain in "Remarks") [_] [_] [_] [_]
5A. Do you plan to fly, or within the last 2 years
have you flown, as a pilot, student pilot, or
crewmember? [_] [_] [_] [_]
B. Do you plan to participate in, or within the last
2 years have you participated in, parachute
jumping, scuba diving, auto/motorboat/motorcycle
racing, hang gliding, or mountain climbing? [_] [_] [_] [_]
(If yes to A or B, complete a separate General
Questionnaire for each Proposed/Additional
Insured)
6. Have you ever had insurance declined, rated, [_] [_] [_] [_]
modified, cancelled, or not renewed? (If yes,
explain in "Remarks")
7. Have you been convicted of a felony within the [_] [_] [_] [_]
past 5 years? (If yes, explain in "Remarks")
8. Have you had a driver's license restricted or
revoked or been convicted of 3 or more moving
violations within the past 5 years? (If yes,
explain in "Remarks") [_] [_] [_] [_]
9. Have you applied for any other insurance within [_] [_] [_] [_]
the last 3 months? (If yes, explain in "Remarks")
10. Have you smoked a cigarette in the last 12 months? [_] [_] [_] [_]
(If yes, give date last smoked) Date:________ Date:________
11. Have you used any other form of tobacco within the [_] [_] [_] [_]
last 2 years? (If yes, give type and date last
used) Type:________ Type:________
Date:________ Date:________
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JUVENILE INSURANCE 12A. If a child age 14 years and 6 months or younger is to be insured under this policy, answer
B & C below:
B. What is the relationship of the owner to the child? _____________________________________
C. What is the total amount of insurance on the owner, which is in force and applied for in
this and all other companies?
$___________________________________________________
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SECTION C MEDICAL CERTIFICATION
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MEDICAL 1. The attached examination is on the life of:
CERTIFICATION Proposed Additional Name of Insurance Company Date of
Complete when Insured Insured Examination
submitting a medical [_] [_]
examination of another [_] [_]
insurance company.
2. To the best of your knowledge and belief, are the statements in the examination true as of
today?
Proposed Insured [_] Yes [_] No
(If no, explain in Remarks)
Additional Insured [_] Yes [_] No
3. Has the person who was examined consulted a doctor or other medical practitioner, or received medical
or surgical advice since the date of the examination?
Proposed Insured [_] Yes [_] No
(If yes, explain in Remarks)
Additional Insured [_] Yes [_] No
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2001-NY Page 3 85-23808-00 01/2002
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SECTION D POLICY INFORMATION FOR VARIABLE LIFE INSURANCE
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PRODUCT/PREMIUM 1. Product Name 2A. Initial Premium B. Planned Annual Premium
$ $
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DEATH BENEFIT 3. Face Amount (Base Only) + Initial Annual Renewable Term Insurance = Total Initial Coverage
Rider/Joint and Last Survivor Term Insurance Rider
$ $ $
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DEATH BENEFIT 4. Check one: [_] Option A [_] Option B [_] Option C (Face amount plus [_] Option D (Face amount multiplied
OPTION (Level) (Increasing) premiums less distributions) by a death benefit factor)
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OPTIONAL BENEFITS 5. Individual Life Insurance Products Only 6. Joint and Last Survivor Life Insurance Products Only
A. [_] Annual Renewable Term Rider on Other A. [_] Individual Annual Renewable Term Rider on the
Covered Person Proposed Insured $_______________
$______________________________
B. [_] Accidental Death Rider $_______ B. [_] Individual Annual Renewable Term Rider on the
Additional Insured $_______________
C. [_] Children's Term Rider_________(units)
(Complete Application Part 2, Non-Medical)
D. [_] Disability Benefit Rider $___________
E. [_] Guaranteed Insurability Rider $______
F. [_] Waiver of Charges Rider (On Insured)
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7. If any optional benefit applied for cannot be approved, should the policy be issued without it? [_] Yes [_] No
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PREMIUM ALLOCATION 8. Indicate how premiums are to be allocated until later changed by you or your authorized representative.
The total of the percentages must be 100%. Allocation percentages must be whole numbers.
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Investment Manager Premium Investment Manager Premium
Option % Option %
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[Blue Chip] [AIM Capital Management] _______ [Capital Opportunities] [MFS Investment] _____
[Aggressive Growth] [AIM Capital Management] _______ [Mid-Cap Growth] [MFS Investment] _____
[Emerging Markets] [Alliance Capital] _______ [Global Growth] [MFS Investment] _____
[Diversified Research] [Capital Guardian] _______ [Equity Index] [Mercury Advisors] _____
[Small-Cap Equity] [Capital Guardian] _______ [Small-Cap Index] [Mercury Advisors] _____
[International Large-Cap] [Capital Guardian] _______ [REIT] [Morgan Stanley] _____
[I-Net Tollkeeper] [Goldman Sachs] _______ [Inflation Managed] [PIMCO] _____
[Financial Services] [Invesco Funds] _______ [Managed Bond] [PIMCO] _____
[Health Sciences] [Invesco Funds] _______ [Money Market] [Pacific Life] _____
[Technology] [Invesco Funds] _______ [High Yield Bond] [Pacific Life] _____
[Telecommunications] [Invesco Funds] _______ [Equity Income] [Putnam] _____
[Multi-Strategy] [JP Morgan] _______ [Research] [Putnam] _____
[Large-Cap Core] [JP Morgan] _______ [Equity] [Putnam]
[Strategic Value] [Janus] _______ [Aggressive Equity] [Putnam] _____
[Growth LT] [Janus] _______ [Large-Cap Value] [Salomon Brothers] _____
[Focused 30] [Janus] _______ Fixed Account* Pacific Life _____
[Mid-Cap Value] [Lazard] _______ Fixed LT Account* Pacific Life _____
[International Value] [Lazard] _______
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*The Fixed LT Account has less transfer liquidity and may credit a higher current rate of interest than the Fixed
Account. Both fixed account options credit a fixed minimum guaranteed interest rate. See the prospectus for details.
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ACKNOWLEDGEMENT All questions must be answered. YES NO
To be completed ------------------------------------------------------------------------------------------------------------------
by the 9. Do you understand that the amount and duration of the death benefit may vary, depending
Applicant. on the investment performance of the variable investment options? [_] [_]
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10. Do you understand that the policy values may increase or decrease, depending
on the investment experience of the variable investment options? [_] [_]
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11. Did you receive the separate account and fund prospectuses (bound together)
for the policy applied for? If yes, give date below. [_] [_]
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Date of Separate Account & Fund Prospectuses: ____________________________________________________
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POLICY VALUES MAY INCREASE OR DECREASE, AND MAY EVEN BE REDUCED TO ZERO AND CAUSE THE POLICY TO LAPSE WITHOUT
VALUE, DEPENDING ON THE EXPERIENCE OF THE VARIABLE INVESTMENT OPTIONS. THE DEATH BENEFIT MAY BE VARIABLE OR FIXED
UNDER SPECIFIED CONDITIONS. A CURRENT ILLUSTRATION OF BENEFITS, INCLUDING DEATH BENEFITS, POLICY VALUES AND
HYPOTHETICAL CASH SURRENDER VALUES, IS AVAILABLE UPON REQUEST.
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AP2001-NY Page 4 85-23808-00 01/2002
SECTION D POLICY INFORMATION FOR VARIABLE LIFE INSURANCE (CONTINUED)
REBALANCING 12. I authorize Pacific Life & Annuity Company to automatically rebalance the variable accounts to the
Optional allocation percentages shown in question 8.
Start Date: Frequency:
_____________________ ________ _____________ [_] Quarterly
Month Day Year [_] Semi-Annually
[_] Annually
FIRST YEAR TRANSFER 13. I elect First Year Transfer Program Yes [_] No [_] (if elected, submit the proper authorization form)
PROGRAM
DOLLAR COST 14. I elect Dollar Cost Averaging Yes [_] No [_] (if elected, submit the proper authorization form)
AVERAGING
REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
SECTION E POLICY INFORMATION FOR TERM LIFE INSURANCE
1. Product Name 2. Face Amount
$
REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
AP2001-NY Page 5 85-23808-00 01/2002
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SECTION F POLICY INFORMATION FOR AN ADDITIONAL OR ALTERNATE FLEXIBLE PREMIUM LIFE INSURANCE POLICY
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(SELECT ONE) VARIABLE FLEXIBLE PREMIUM LIFE INSURANCE POLICY [ ] ADDITIONAL OR [ ] ALTERNATE
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PRODUCT/PREMIUM 1. Product Name 2A. Initial Premium B. Planned Annual Premium
$ $
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DEATH BENEFIT 3. Face Amount (Base Only) + Initial Annual Renewable Term Rider/ =Total Initial Coverage
Joint and Last Survivor Added Protection Benefit Rider
$ $ $
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DEATH BENEFIT 4. Check one: [ ] Option A [ ] Option B [ ] Option C (Face amount plus [ ] Option D (Face amount times
OPTION (Level) (Increasing) premiums less distributions) the death benefit factor)
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DIVIDEND OPTION 5. Check one: [ ] Cash [ ] Increase Accumulated Value
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OPTIONAL BENEFITS 6. Individual Life Insurance Products Only 7. Joint and Last Survivor Life Insurance
A. [ ] Annual Renewable Term Rider on Other Covered Person Products Only
$__________________________________________________ A. [ ] Individual Annual Renewable Term
B. [ ] Accidental Death Rider $___________________________ Rider on the Proposed Insured $_____
C. [ ] Children's Term Rider______________(units) B. [ ] Individual Annual Renewable Term
(Complete Application Part 2, Non-Medical) Rider on the Additional Insured $___
D. [ ] Disability Benefit Rider $_________________________
E. [ ] Guaranteed Insurability Rider $____________________
F. [ ] Waiver of Charges Rider (On Insured)
8. If any optional benefit applied for cannot be approved, should the policy be issued without it?
[ ] Yes [ ] No
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PREMIUM ALLOCATION 9. Indicate how premiums are to be allocated until later changed by you or your authorized representative. The
total of the percentages must be 100%. Allocation percentages must be whole numbers.
Investment Premium Investment Premium
Option Manager % Option Manager %
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[Blue Chip] [AIM Capital Management] _______ [Capital Opportunities] [MFS Investment] ______
[Aggressive Growth] [AIM Capital Management] _______ [Mid-Cap Growth] [MFS Investment] ______
[Emerging Markets] [Alliance Capital] _______ [Global Growth] [MFS Investment] ______
[Diversified Research] [Capital Guardian] _______ [Equity Index] [Mercury Advisors] ______
[Small-Cap Equity] [Capital Guardian] _______ [Small-Cap Index] [Mercury Advisors] ______
[International Large-Cap] [Capital Guardian] _______ [REIT] [Morgan Stanley] ______
[I-Net Tollkeeper] [Goldman Sachs] _______ [Inflation Managed] [PIMCO] ______
[Financial Services] [Invesco Funds] _______ [Managed Bond] [PIMCO] ______
[Health Sciences] [Invesco Funds] _______ [Money Market] [Pacific Life] ______
[Technology] [Invesco Funds] _______ [High Yield Bond] [Pacific Life] ______
[Telecommunications] [Invesco Funds] _______ [Equity Income] [Putnam] ______
[Multi-Strategy] [JP Morgan] _______ [Research] [Putnam] ______
[Large-Cap Core] [JP Morgan] _______ [Equity] [Putnam] ______
[Strategic Value] [Janus] _______ [Aggressive Equity] [Putnam] ______
[Growth LT] [Janus] _______ [Large-Cap Value] [Salomon Brothers] ______
[Focused 30] [Janus] _______ Fixed Account* Pacific Life ______
[Mid-Cap Value] [Lazard] _______ Fixed LT Account* Pacific Life ______
[International Value] [Lazard] _______
*The Fixed LT Account has less transfer liquidity and may credit a higher current rate of interest than the
Fixed Account. Both fixed account options credit a fixed minimum guaranteed interest rate. See the prospectus
for details.
NOTE: IF APPLYING FOR AN ADDITIONAL OR ALTERNATE VARIABLE FLEXIBLE PREMIUM LIFE INSURANCE POLICY THE
ACKNOWLEDGEMENT ON PAGE 4, SECTION D, ALSO APPLIES TO THIS POLICY.
10. If any optional benefit applied for cannot be approved, should the policy be issued without it?
[ ] Yes [ ] No
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2001-NY Page 6 85-23808-00 01/2002
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SECTION G CERTIFICATION OF OWNER'S TAXPAYER ID AND APPLICANT'S DECLARATIONS
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CERTIFICATION OF OWNER'S TAXPAYER IDENTIFICATION #
Under penalty of perjury, I certify that:
1. The number shown in this application as my social security number or
taxpayer identification number is correct; and
2. I am not subject to backup withholding under Section 3406(a)(1)(c) of the
Internal Revenue Code. (If statement is false strike out and initial.) This
certification is required by the Internal Revenue Service before any taxable
distribution can be made.
GPT CVAT DISCLOSURE
(Does not apply to Last Survivor policies)
The Internal Revenue Code has two separate tests, at least one of which must be
satisfied by a policy for it to qualify as life insurance for federal tax
purposes. As applicant, you choose which of the two tests you want to use. You
may not change the test after the policy has been issued. The two tests are the
Guideline Premium Test (GPT) and the Cash Value Accumulation Test (CVAT). GPT
limits the amount of premiums that can be paid for a policy, and may require the
death benefit to increase above the specified amount if the cash value is large.
CVAT does not limit premiums, but it also requires the death benefit to increase
above the specific amount if the cash value is large. With CVAT the death
benefit may need to be increased earlier than with GPT and by a larger amount,
assuming the same cash values under both tests. Under either test, the cost of
insurance charge is based on the total death benefit in force, including any
increases resulting from your choice of GPT or CVAT. You should consider the
CVAT test if you wish to maximize premium payments over a short period. You
should consider the GPT test if you wish to maintain a higher level of cash
value in relation to death benefit protection. Your producer can supply you
with illustrations showing the effects of each test and explain how each affects
the policy. You should consult your tax advisor for any tax questions.
DECLARATIONS
The answers in this application are true and complete to the best of my
knowledge and belief. I understand and agree that:
1. Except as provided in the terms or conditions of any Temporary Insurance
Agreement that I may have received in connection with this application,
coverage will take effect when the policy is delivered and the entire first
premium is paid only if at that time the Proposed Insured(s) is alive, and
all answers in this application that are material to the risk are still true
and complete to the best of my knowledge and belief.
2. If I have given money with the application and received a Temporary Insurance
Agreement and if the coverage amount of the application exceeds the Temporary
Insurance Agreement coverage limits, I understand that if the Proposed
Insured(s) die(s) before a policy is delivered, the death benefit will be
limited to the Temporary Insurance Agreement coverage limit.
3. I must inform the Producer or Pacific Life & Annuity Company in writing of
any changes in the health of any Proposed Insured(s) or if any of the
statements or answers on this application change prior to delivery of the
policy.
4. My statements and answers in this application must continue to be true, to
the best of my knowledge and belief, as of the date I receive the policy.
5. No Producer is authorized to make or modify contracts or insurance policies
on Pacific Life & Annuity Company's behalf.
6. No Producer may alter the terms of this application, the Temporary Insurance
Agreement, or the policy, nor can the Producer waive any of Pacific Life &
Annuity Company's rights or requirements.
7. I believe that the policy(ies) applied for will meet my insurance needs
and financial objectives.
8. This application will be attached to and made part of the policy.
Signed and Dated by the Applicant:
In:______________________________ _______ __________________________
City State Month/Day/Year
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SIGNATURE OF APPLICANT
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X ____________________________________________________________________________
Applicant*
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SIGNATURE OF PROPOSED INSURED(S) - IF OTHER THAN THE APPLICANT OR SIGNATURE OF
PARENT IF PROPOSED INSURED IS 14 YEARS AND 6 MONTHS OR YOUNGER
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X ____________________________________________________________________________
Proposed Insured
X ____________________________________________________________________________
Proposed Additional Insured (if applicable)
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SIGNATURE OF OWNER - IF OTHER THAN THE APPLICANT OR THE PROPOSED INSURED
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X ____________________________________________________________________________
Owner*
*If a Corporation, the signature and title of any authorized officer other than
the Proposed Insured(s) is required and the full name of the corporation must be
shown. If a Trust, the signature of the Trustee.
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PRODUCER'S CERTIFICATION
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I certify that I have truly and accurately recorded hereon the information
supplied.
X ___________________________________ _____________________________________
Signature of Soliciting Producer Print Soliciting Producer's Name
AP2001-NY Page 7 85-23808-00 01/2002
PACIFIC LIFE & ANNUITY COMPANY
P.O. Box 6520 [LOGO] PACIFIC LIFE
Newport Beach, CA 92658-6520 & ANNUITY COMPANY
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SECTION H AUTHORIZATION OF THE PROPOSED INSURED(S) TO OBTAIN INFORMATION
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Complete for
all applications.
I authorize any physician, medical practitioner, hospital, clinic, other medical
or medically related facility, insurance company, the Medical Information
Bureau, Inc., consumer reporting agency, state motor vehicle agency, or employer
to release to Pacific Life & Annuity Company, its subsidiaries, its
reinsurer(s), or its legal representative any information they may have as to
diagnosis, treatment, and prognosis of any physical or mental condition and/or
any non-medical information, including finances, avocations, occupation, foreign
travel, alcohol, and driving record for me and any minor children.
I understand that any information obtained will be used to determine eligibility
for insurance and will not be released to any person or organization except
reinsurer(s), the Medical Information Bureau, Inc., and other persons or
organizations performing business or legal services in connection with my
application, or as may be otherwise lawfully required, or as I may further
authorize. I understand that I may revoke this authorization as it applies to
drug and/or alcohol abuse information at any time, except to the extent it will
not affect any action taken or information released prior to the revocation.
Such revocation may cause the denial of this application. I also understand the
information authorized for release may include medical information about a
communicable or venereal disease, including but not limited to diseases such as
hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus, also know
as Acquired Immune Deficiency Syndrome (AIDS). I know that I may request a copy
of this authorization. I also acknowledge receipt of the Disclosure Notice.
A photographic copy of this Authorization shall be as valid as the original and
shall be valid for two years from the date shown below.
Signed and Dated by the Proposed Insured(s):
In:____________________________ __________ _________________________________
City State Month/Day/Year
X _____________________________________________________________________________
Signature of Proposed Insured (or signature of parent if Proposed Insured is
14 years and 6 months or younger)
X _____________________________________________________________________________
Signature of Proposed Additional Insured (if applicable)
AP2001-NY Page 8 85-23808-00 01/2002
PACIFIC LIFE & ANNUITY COMPANY
P.O. Box 6520 [LOGO APPEARS HERE]
Newport Beach, CA 92658-6520
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SECTION I AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER - MONTHLY BANK DRAFT
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To be completed, by the
Authorized Account Holder,
only if Electronic Funds
Transfer Billing Method
(monthly bank drafter)
is requested.
As a convenience to me, I request and authorize you to pay and charge to the
bank account referenced below any monthly debit entries on that account by and
payable to the order of Pacific Life & Annuity Company, provided there are
sufficient collected funds in said account to pay the same upon presentation. I
agree that your rights in respect to each such debit shall be the same as if it
were a debit drawn on you and signed personally by me. This authority is to
remain in effect until revoked by me in writing, and until you actually receive
such notice I agree that you shall be fully protected in honoring any such
debit.
Pacific Life & Annuity Company will determine the monthly draft date
based upon my policy effective date. However, any special drafting requests are
indicated below.
Bank Account No. ______________________________________________________________
Bank Account in the Name(s) of: _______________________________________________
Special Drafting Request: _________________________ (All requests for special
dating will be reviewed against the policy date for eligibility)
Signed and dated at:
___________________________________ _______ ________________________________
City State Month/Day/Year
Signature of Authorized Account Holder:
X _____________________________________________________________________________
A voided check must be attached below. (A blank deposit slip will not be
accepted)
Premium payments can only be drawn from authorized U.S. financial institutions.
Some savings and money market accounts may not qualify.
PLACE VOIDED CHECK HERE
If your check does not state your financial institution's name and address,
please list below:
______________________________________________________________________________
Page 9 85-23808-00 01/2002
SECTION J PRODUCER INFORMATION
PRODUCER REPORT To be answered by the soliciting Producer YES NO
Complete for all 1. Have you personally asked all applicable questions in this application? [ ] [ ]
applications. (If no, explain in "Remarks")
2. Are you aware of any information not given in the application that might affect
the insurability of the Proposed Insured(s)? (If yes, explain in "Remarks") [ ] [ ]
3. Did the Proposed Insured/Additional Insured change his/her name during [ ] [ ]
the past 5 years? (If yes, give former name(s) in "Remarks")
4. To the best of your knowledge, is this life insurance intended to replace, or
will it cause a change in, or involve a loan from any life insurance or annuity
on any Proposed Insured's life or in any life insurance or annuity owned by
the Annuitant? (If yes, give details in "Remarks") [ ] [ ]
5A. If sales materials were used in this sale, did you use only sales materials
approved by Pacific Life & Annuity Company? [ ] [ ]
B. If sales materials were used in the sale, did you leave sales materials with
the Applicant? [ ] [ ]
6. Is application submitted on a:
[ ] Medical Basis? [ ] Guaranteed Issue Basis?
[ ] Non-Medical Basis? [ ] Guaranteed to Issue Basis?
7. Check appropriate items that have been ordered:
[ ] Medical Exam [ ] H.O. Specimen
[ ] Paramedical Exam [ ] Inspection Report
[ ] EKG [ ] APS___________________________________________
[ ] Blood Profile ___________________________________________
8. If this policy is used to fund a tax-qualified plan, indicate type:
[ ] Pension/Profit Sharing [ ] HR-10 [ ] Other (Explain In "Remarks")
BUSINESS INSURANCE 1. This life insurance policy is being purchased in conjunction with a:
Complete if applying for A. [ ] Buy/Sell D. [ ] Split Dollar
business insurance. B. [ ] Employee Fringe Benefit E. [ ] Key Employee
C. [ ] Deferred Compensation F. [ ] Other (Explain in "Remarks")
Amount of
G. Name of Principal Officers, Partners, or Key Employees Position % of Business Insurance Owned by
Owned Business
H. What is the current value of the business? $
I. What was the annual net profit (before taxes) of business? Last Year 2 Years Ago
$ $
J. Are other officers, partners, or key employees proportionately insured?
[ ] Yes [ ] No (If no, explain in "Remarks")
JUVENILE INSURANCE 1. Did you personally observe the Proposed Insured? [ ] Yes [ ] No (If no, explain in "Remarks")
Complete if the Proposed
Insured is 14 years and 6 2. Are the Proposed Insured's brothers and sisters insured for equal amounts?
months or younger. [ ] Yes [ ] No (If no, explain in "Remarks")
3A. Name of Person on whom Proposed Insured depends for support: B. Relationship to Insured
C. Estimated annual income D. Estimated net worth E. Estimated amount of life insurance
$ $ $
4A. Name of Applicant B. Relationship to Insured
C. Purpose of Insurance D. Amount of life insurance in force
$
Page 10 85-23808-00 01/2002
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SECTION K PRODUCER CERTIFICATION
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Complete for all I certify that to the best of my knowledge and belief: YES NO
applications.
A. I have presented to the Company all pertinent facts and
have correctly and completely recorded all required
answers. [ ] [ ]
B. I have given the Proposed Insured(s) (or Parent for
Juvenile insurance) a copy of the Disclosure Notice,
and any other disclosure notice or statement required by
state or federal law. [ ] [ ]
C. I have fully explained the terms and conditions of the
Temporary Insurance Agreement to the Proposed Insured(s)
(or Owner) and have given it to him/her (them). [ ] [ ]
D. I have complied with state and federal laws on cost
comparison, illustration, and replacement. [ ] [ ]
E. I have reviewed, with my Broker Dealer, as applicable,
the purchase of this insurance policy. [ ] [ ]
F. If sales activity (including solicitation, application and policy delivery)
took place in a state other than the application state, indicate the
states and associated activity. (If needed, use "Remarks" section below)
State(s)_____________________ Activity___________________________________
Signature(s) Of Soliciting Producer(s). Pay Commission as Indicated Below.
X_______________________________________________ X___________________________________
First Name Listed Below Will Be The Servicing Producer
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PHONE FAX SERVICING PRODUCER COMM
PRODUCER NAME NUMBER E-MAIL ADDRESS NUMBER OFFICE # CODE %
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Broker Dealer Name_____________________________________________________________
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
- --------------------------------------------------------------------------------
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Page 12 85-23808-00 01/2002
[LOGO OF PACIFIC LIFE]
PACIFIC LIFE & ANNUITY COMPANY
P.O. Box 6520
Newport Beach, CA 92658-6520
DISCLOSURE NOTICE
TO BE DETACHED AND LEFT WITH THE PROPOSED INSURED(S)
This is a brief description of our underwriting process ("process"). It will
help you understand how an application for insurance is handled, the types and
sources of information ("data") we may collect about you, the circumstances
under which we may disclose that data to others and your right to learn the
nature and substance of that data. The purpose of the process is to see if you
qualify for insurance under our rules, and if you do, to establish the proper
premium charge. This will assure that the cost of insurance is shared fairly
among all policy owners. To determine your insurability, we consider factors
such as your medical history, physical condition, occupation, and hazardous
avocations. We get this data from various sources.
Application and Medical Records - Your application, including the medical
history, is the primary source of data in the process. We may ask you to take a
physical exam or other special medical test. We may also ask for a report from
your doctor or hospital, another insurance company, or the Medical Information
Bureau, Inc. ("MIB"). When we do so, we will use the authorization you signed
with your application.
Medical Information Bureau, Inc. - MIB is a non-profit corporation, which
maintains a data exchange for member life insurance companies. As a member
company, we will ask MIB if it has a record for you. If you applied to a member
company for insurance, MIB may have data about you in its file. The purpose of
MIB is to protect member companies and their policy owners from those who would
conceal facts relevant to their insurability. The data, which is obtained from
MIB, may be used only as an alert to the possible need for further
investigation. It cannot be used as a basis to make a final underwriting
decision. Pacific Life & Annuity Company, its subsidiaries, or its reinsurer(s)
may make a brief report to MIB. If you later apply to another MIB member company
for life or health insurance coverage, or a claim for benefits is made to such a
company, MIB may supply the company with data it may have about you in its file.
At your request, MIB will arrange disclosure of any data it may have about you
in its file. If you question the accuracy of such data, you may contact MIB and
seek a correction in accordance with the federal Fair Credit Reporting Act
procedures. Their address is MIB, PO Box 105, Essex Station, Boston, MA 02112.
Their phone no. is (617) 426-3660.
Investigative Consumer Report - We may request an investigative consumer report
("ICR") from a consumer reporting agency ("CRA"). An ICR confirms and
supplements the data in your application having to do with employment,
residence, smoking habits, marital status, occupation, hazardous avocations, and
general health. An ICR may also cover data about your general reputation, motor
vehicle driving record, criminal activity, personal characteristics, and mode of
living, except as may be related directly or indirectly to your sexual
orientation. This data may be obtained through personal interviews with you,
your family, friends, neighbors, and business associates. If an ICR is required
and you wish to be personally interviewed, please let us know and we will notify
the CRA. The data contained in the report may be retained by the CRA and later
disclosed to other companies to the extent permitted by the Fair Credit
Reporting Act. You have a right to make a written request within a reasonable
time to receive any other details about the nature and scope this report. An ICR
may have an adverse effect on your insurability. If it should, however, we will
notify you in writing and identify the CRA.
DISCLOSURE TO OTHERS
Data obtained about you during the process and at other times is private and
will not be disclosed to others without your written authorization except to the
extent necessary for the conduct of our business. Examples of situations where
we may share data about you are as follows:
1. The Producer may keep a copy of your application, and after a policy is
issued will have access to ongoing policy data to better serve you.
2. If reinsurance were required, the reinsurance company would have access
to our application file.
3. We may release data to another life insurance company to whom you have
applied for insurance or to whom you have submitted a claim for benefits, if
you have authorized it to obtain such data.
4. We may report data to MIB.
5. We will disclose data to government, law enforcement, and others where
required by law.
DISCLOSURE TO YOU
In general, you have a right to learn the nature and substance of any personal
data about you in our file upon written request. Whenever an adverse
underwriting decision is made, we will notify you of the reason(s) for the
decision and the source of the data on which our action is based. Medical record
data, however, will normally be given only to a licensed physician of your
choice. Please refer to the section on MIB for their disclosure procedures.
Should you feel that any data we have is not correct or complete, please write
to: Manager, Risk Selection Department, Pacific Life & Annuity Co., P.O. Box
6520 Newport Beach, CA 92658-6520. Your comments will be carefully considered
and corrections made where justified. We hope this Notice will help you to
understand how we obtain and use personal data in the underwriting process, and
the ways you can learn about this data. We are concerned with insuring privacy
as well as lives, and the collection, use, and disclosure of personal data is
limited to those specified in this Notice.
AP2001-DISC-NY Page 13 85-23808-00 01/2002