Pacific Life & Annuity Company [Logo of PL&A]
700 Newport Center Drive
Newport Beach, CA 92660
APPLICATION FOR LIFE INSURANCE
INSTRUCTIONS TO SOLICITING AGENT(S)
GENERAL INSTRUCTIONS
. Every appropriate section of the application must be fully completed prior to
signing the application. A blank application must never be signed.
. The following indicates who must complete the various colored sections:
Page(s) 1 and 4-8 Applicant
Page(s) 2 Applicant or Agent must complete for NON-VARIABLE
life products only
Page(s) 3 Applicant or Agent must complete for VARIABLE life
products only
Page(s) 9 and 10 Agent
. Changes noted on this application must be lined out and the new information
must be indicated and initialed by the Applicant in Sections A-E, Proposed
Insured(s) in Section F and Agent in Sections G-J. Changes made any other way
will be amended.
. The DISCLOSURE NOTICE TO APPLICANTS must be detached and given to the
Applicant. If the DISCLOSURE NOTICE TO APPLICANTS is not detached when the
application is received at Pacific Life & Annuity Company, written
verification that the Notice was given to the Applicant will be required
before the underwriting process can begin.
. For "Survivor Life" type policies, the Second Insured is considered the
Additional Insured. All Additional Insured sections must be completed.
IMPORTANT SIGNATURE REQUIREMENTS
. The party initiating the application for life insurance is considered the
Applicant. Depending on the situation, the Applicant may also be the Insured
or Owner.
. The following parties must sign page 6 of the application:
Applicant
Proposed Insured (if other than Applicant)
Other Adult Proposed Insured (if applicable)
Child of age 18 and older (required in Pennsylvania)
Owner (if other than Proposed Insured or Applicant)
Soliciting Agent
. The Authorization on page 7 must be signed and dated by the Proposed Insured
and Other Adult Proposed Insured (if applicable). Underwriting cannot begin
without a signed Authorization.
. The Soliciting Agent(s) must sign on pages 6 and 10.
. If multiple Owners, then all Owners must sign on page 6 of the application.
. For corporate signatures, the signature and title of any authorized officer
other than the Proposed Insured is required and the full name of the
corporation must be shown on page 6.
. If policy is trust owned, trustee(s) must sign on page 6 of the application
on the Signature of Applicant line indicating the title "Trustee" after the
signature. Owner designation, on page 1, must include name of trust, date of
trust, trustee(s) name, with the wording "successor or successors in trust".
UNDERWRITING REQUIREMENTS
. Underwriting requirements are based on the age of the Proposed Insured(s) and
amount applied for. Refer to the Life Underwriting Requirements Chart (not
attached) to determine the appropriate requirements.
. The Non-Medical is NOT part of this application. APPLICATION, PART II, Non-
Medical (AP9500-P2-NY) must be obtained separately. Note: Certain states will
have their own version.
AP9500-NY 85-21245-00 07/1999
INSTRUCTIONS TO SOLICITING AGENT(S)
________________________________________________________________________________
SECTION A - CLIENT INFORMATION
. Complete all questions, unless a question does not apply.
. If submitting money with the application, complete question 31A, B and C on
page 1. Also submit a Temporary Insurance Agreement (AP8112-NY) with the
application. The date on the application, check and Temporary Insurance
Agreement (TIA) must all be the same date.
. Money and the TIA must not be taken if:
(a) any health question on the TIA is answered "yes;"
(b) the proposed insured is under 15 days of age or is over 70 years old
(nearest birthday) on the date of the application.
If the face amount applied for is greater than the TIA maximum binding limit,
complete the application in the following manner:
1) Indicate the total face amount as applied for in question 31C. Also
indicate all applied for Optional Benefits here. If additional space is
needed, use Remarks section on page 2 or 3.
2) On page 2 (for non-variable products) or page 3 (for variable products),
question 3, complete with the maximum binding limit as noted on the TIA.
Leave question 5 "Optional Benefits" blank.
SECTION B - POLICY INFORMATION FOR NON-VARIABLE LIFE PRODUCTS
. Indicate product desired, base face amount, initial APB amount (if applied
for) and Total Initial Coverage in question 3. Whether APB is level or
varying, always indicate initial APB amount. This information can be found on
the Producer/Home Office Administration Worksheet page of the illustration.
. Indicate all other optional benefits in question 5.
. Complete only those questions that relate to the product (term/fixed or
flexible premium) applied for.
. If requesting an alternate or additional policy, complete the
Alternate/Additional Policy section on page 2.
SECTION C - POLICY INFORMATION FOR VARIABLE LIFE PRODUCTS
. Indicate product desired, base face amount, initial APB amount (if applied
for) and Total Initial Coverage in question 3. Whether APB is level or
varying, always indicate initial APB amount. This information can be found on
the Producer/Home Office Administration Worksheet page of the illustration.
. Indicate all other optional benefits in question 5.
. Answer all Suitability questions and include the date of the current Separate
Account Prospectus and Fund prospectus.
. If requesting an alternate or additional policy, complete the
Alternate/Additional Policy section on page 3. All suitability questions must
also be completed.
SECTION D - MEDICAL CERTIFICATION
. Complete only when submitting a medical examination from another insurance
company.
SECTION E - ADDITIONAL INSURED
. Complete if requesting an optional benefit such as APB, ART or SITR on an
Additional Insured. This section is also completed for "Survivor Life" type
policies.
SECTION F - GENERAL INFORMATION
. Complete every question of this section for the Proposed Insured and
Additional Insured (if applicable).
. If Proposed Insured or Additional Insured (if applicable) participates in a
hazardous occupation/sport, complete a General Questionnaire form (not
attached) for each Insured that participates.
SECTION G - UNI-CHECK (AUTOMATIC BANK WITHDRAWAL)
. The Uni-Check billing method is available on a monthly payment frequency for
automatic checking account deductions. Complete this section if electing Uni-
Check. Also complete Uni-Check method and monthly mode on page 1, questions
30A and 30B. A voided check must be submitted with the application.
SECTION H - BUSINESS INSURANCE
. Complete only if applying for Business Insurance.
SECTION I - FOR PROPOSED INSURED UNDER THE AGE OF 16
. Complete this section if the application is submitted on a non-medical basis
and the Proposed Insured is under age 16. If the application is submitted on
a medical basis, a medical exam is necessary. Refer to the Life Underwriting
Requirements Chart to determine the appropriate requirements.
SECTION J - AGENT INFORMATION
. Complete every question of this section.
. The signature of the Soliciting Agent(s) is required at the bottom of page
10.
. Commissions are paid in accordance with the information presented at the
bottom of page 10. The Agent listed first is the Servicing Agent, unless
indicated otherwise in the remarks section. Always include Agent Code for
prompt payment of commission.
________________________________________________________________________________
AP9500-NY 85-21245-00 07/1999
APPLICATION FOR LIFE INSURANCE, PART I NEWBSAPPLC
PACIFIC LIFE & ANNUITY COMPANY [Logo of PL&A]
700 Newport Center Drive
Newport Beach, CA 92660 NO.
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SECTION A CLIENT INFORMATION
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PROPOSED INSURED
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1. Full Name (PRINT AS TO APPEAR IN POLICY/FIRST,MIDDLE,LAST) 2. Sex: 3. State of Birth 4. Date of Birth
___ Male MO. DAY YR.
___ Female
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5. Insurance Age 6. Drivers License No. & State 7. Social Security No. or Taxpayer I.D. No. 8. Telephone No.
( )
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9. Address (STREET, CITY, COUNTY, STATE, ZIP CODE) 10. How Long
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11. Employer Name and Address (STREET, CITY, COUNTY, STATE, ZIP CODE) 12. How Long
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13. Occupation 14. Type of Business
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OWNER IF OTHER THAN PROPOSED INSURED
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15. Full Name (PRINT AS TO APPEAR IN POLICY/FIRST,MIDDLE,LAST) 16. Date of Birth 17. Relationship 18. Telephone No.
( )
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19. Address (STREET, CITY, COUNTY, STATE, ZIP CODE) 20. Social Security No. or Taxpayer I.D. No.
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BENEFICIARY
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21. Primary Beneficiary (PRINT FULL NAME/FIRST, MIDDLE, LAST) 22. Relationship
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23. Address (STREET, CITY, COUNTY, STATE, ZIP CODE)
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24. Contingent Beneficiary (PRINT FULL NAME/FIRST, MIDDLE, LAST) 25. Relationship
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26. Address (STREET, CITY, COUNTY, STATE, ZIP CODE)
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PREMIUM NOTICES
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27. Send to: ___ Insured ___ Owner at ___ Residence ___ Business or ___ Other (INDICATE BELOW)
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28. Name 29. Address (STREET, CITY, COUNTY, STATE, ZIP CODE)
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BILLING INFORMATION
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30A. Method 30B. Frequency of Premium Reminder Notice
___ Single Premium or Premium Payment
___ Direct (annual, semi-annual or quarterly only) ___ Annual
___ List Bill (3 or more lives) ___ Semi-Annual
___ Uni-Check - Attach a Voided Check and complete Uni-check Section on Page 6. ___ Quarterly
(monthly only.) ___ Monthly
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AMOUNT PAID WITH THIS APPLICATION
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31A. Is cash or check tendered with this application? ___ Yes ___ No If Yes, show amount $______________________
If No, do not complete question below
B. Do you understand, accept and agree to the terms of the Temporary Insurance Agreement (TIA)? ___ Yes ___ No
C. If Yes, and a policy face amount is applied for which is larger than that which Pacific Life & Annuity Company will
insure under the TIA, complete the following statement:
If approved, please issue a policy for a face amount of $______________________
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SPECIAL DATING REQUEST
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32.
___ Date To Save Age ___ Specific Date Month ____________________ Day _______________ Year __________
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AP9500-NY Page 1 of 10 85-21245-00 07/1999
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SECTION B POLICY INFORMATION (COMPLETE FOR NON-VARIABLE LIFE INSURANCE)
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1. Policy Name 2a. Initial Premium 2b. Planned Annual Premium
$ $
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3. Face Amount (Base only) $ _________ Plus Initial APB Amount $ _________ = Total Initial Coverage $_________
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FLEXIBLE PREMIUM LIFE INSURANCE ONLY
4A. Check one: ___ Option A (Level)
___ Option B (Increasing)
B. Dividend Option (Check one):
___ Cash ___ Increase Accumulated Value ___ Other
5. OPTIONAL BENEFITS
A. ___ ADB $________________ I. ___ Waiver of Charges
B. ___ ART/APB/SITR on Other Covered Person for $__________ J. ___ Payor Waiver of Charges (Complete Part II, Section C)
C. ___ ART on Proposed Insured for $___________ for ____ years K. ___ Owner Waiver of Charges (Complete Part II, Section C)
D. ___ Children's Term (units) _____ (Complete Part II, Section C) L. ___ Other _______________________________
E. ___ Exchange of Insured M. ___ Other _______________________________
F. ___ Guaranteed Insurability $_________________ N. ___ Other _______________________________
G. ___ Disability Benefit $____________ O. ___ Other _______________________________
H. ___ Preliminary Term ___ 1 Yr. ___ 2 Yr. ______ No. of Months
Effective Date __________________
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6. If any optional benefit applied for cannot be approved, should the policy be issued without it? ___ Yes ___ No
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COMPLETE THIS SECTION IF APPLYING FOR (Check one): ___ ADDITIONAL POLICY or ___ ALTERNATE POLICY
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7. Policy Name 8a. Initial Premium 8b. Planned Annual Premium
$ $
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9. Face amount (Base only) $ _____________ Plus Initial APB Amount $ _____________ = Total Initial Coverage $ _____________
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10. Optional Benefits:
A. __________________________________ B. _________________________________ C. ________________________________
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A. Check one:
___ Option A (Level)
___ Option B (Increasing)
B. Dividend Option: ___________________
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REMARKS
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AP9500-NY Page 2 of 10 85-21245-00 07/1999
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SECTION C POLICY INFORMATION (COMPLETE FOR VARIABLE LIFE INSURANCE)
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VARIABLE LIFE
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1. Policy Name 2a. Initial Premium 2b. Planned Annual Premium
$ $
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3. Face Amount (Base only) $ _____________ Plus Initial ART Amount $ _____________ = Total Initial Coverage $ _____________
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4. Check one: ___ Option A (Level) ___ Option B (Includes Accumulated Value) __ Option C (Includes Premiums Less Distributions)
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5. A. ___ ART on Other Covered Person for $ _____________ E. ___ Guaranteed Insurability $ _____________
B. ___ ADB $ _____________ F. ___ Waiver of Charges
C. ___ Children's Term (units) _____________ (Complete Part II, Section C) G. ___ Other ____________________
D. ___ Disability Benefit $ _____________ H. ___ Other ____________________
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6. If any optional benefit applied for cannot be approved, should the policy be issued without it? ___ Yes ___ No
PREMIUM ALLOCATIONS
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7. INDICATE ALLOCATIONS. THE TOTAL OF THE PERCENTAGES MUST BE 100%. USE WHOLE NUMBERS.
Equity: _______% Growth LT: _______% Multi-Strategy: _______% Small-Cap Index: _______%
Equity Income: _______% High Yield Bond: _______% Emerging Markets: _______% Mid-Cap Value: _______%
Equity Index: _______% International: _______% Aggressive Equity: _______% Large-Cap Value: _______%
Gov. Securities: _______% Managed Bond: _______% Bond & Income: _______% Fixed: _______%
Growth: _______% Money Market: _______% REIT: _______% Fixed LT: _______%
Other: _______% Other: _______% Other: _______% Other: _______%
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SUITABILITY
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Yes No
8. DO YOU BELIEVE THAT THIS POLICY WILL MEET YOUR INSURANCE NEEDS AND FINANCIAL OBJECTIVES?___________________ _____ _____
9. DO YOU UNDERSTAND THAT THE AMOUNT AND DURATION OF THE DEATH BENEFIT MAY VARY, DEPENDING ON THE INVESTMENT
PERFORMANCE OF THE VARIABLE ACCOUNTS IN THE SEPARATE ACCOUNT?______________________________________________ _____ _____
10. DO YOU UNDERSTAND THAT THE POLICY VALUES MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT
EXPERIENCE OF THE VARIABLE ACCOUNTS IN THE SEPARATE ACCOUNT?_______________________________________________ _____ _____
11. DID YOU RECEIVE THE SEPARATE ACCOUNT PROSPECTUS AND THE FUND PROSPECTUS FOR THE POLICY APPLIED FOR?________
If Yes, give date shown on prospectuses: Separate Account Fund
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POLICY VALUES MAY INCREASE OR DECREASE, AND MAY EVEN BE REDUCED TO ZERO, IN ACCORDANCE WITH THE EXPERIENCE OF THE VARIABLE ACCOUNTS
IN THE SEPARATE ACCOUNT (SUBJECT TO ANY SPECIFIED MINIMUM GUARANTEES). THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER SPECIFIED
CONDITIONS. CURRENT ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH BENEFITS AND CASH SURRENDER VALUES, ARE AVAILABLE UPON REQUEST.
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COMPLETE THIS SECTION IF APPLYING FOR (Check one): ___ ADDITIONAL POLICY or ___ ALTERNATE POLICY
(COMPLETE SUITABILITY QUESTIONS ABOVE)
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12. Policy Name 13a. Total Modal Premium 13b. Planned Annual Premium
$ $
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14. Face Amount (Base only) $_____________ Plus Initial ART Amount $_____________ = Total Initial Coverage $_____________
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15. Optional Benefits 16. Death Benefit Options (Check one):
A. __________________________________________ Option A (Level) __________
B. __________________________________________ Option B (Includes Accumulated Value) __________
C. __________________________________________ Option C (Includes Premiums less Distributions) __________
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REMARKS
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AP9500-NY Page 3 of 10 85-21245-00 07/1999
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SECTION D MEDICAL CERTIFICATION
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COMPLETE WHEN SUBMITTING MEDICAL EXAMINATION OF ANOTHER INSURANCE COMPANY
1. The attached examination is on the life of:
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Proposed Insured Name Name of the other Insurance Company Date of Examination
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Additional Insured Name Name of the other Insurance Company Date of Examination
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Additional Insured Name Name of the other Insurance Company Date of Examination
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Additional Insured Name Name of the other Insurance Company Date of Examination
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Proposed Insured Additional Insured
2. To the best of your knowledge and belief, are the statements in the examination
true as of today? ___ Yes ___ No ___ Yes ___ No
3. Has the person who was examined consulted a doctor or their practitioner or
received medical or surgical advice since the date of the examination?
(If yes, explain in remarks. Use additional sheet if necessary) ___ Yes ___ No ___ Yes ___ No
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SECTION E ADDITIONAL INSURED
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1. Full Name (PRINT AS TO APPEAR IN POLICY/FIRST, MIDDLE, LAST) 2. Sex: ___ Male 3. State of Birth 4. Date of Birth
___ Female MO. DAY YR.
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5. Insurance Age 6. Drivers License No. & State 7. Social Security No. or Taxpayer I.D. No. 8. Telephone No.
( )
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9. Address (STREET, CITY, COUNTY, STATE, ZIP CODE) 10. How Long
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11. Employer Name and Address (STREET, CITY, COUNTY, STATE, ZIP CODE) 12. How Long
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13. Occupation 14. Type of Business
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15. Relationship to Primary Insured
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BENEFICIARY TO ADDITIONAL INSURED
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16. Primary Beneficiary (PRINT FULL NAME/FIRST, MIDDLE, LAST) 17. Relationship
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18. Contingent Beneficiary (PRINT FULL NAME/FIRST, MIDDLE, LAST) 19. Relationship
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SECTION F GENERAL INFORMATION
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1. Give details of life insurance in force in other companies on PROPOSED INSURED. If none (or if conversion application) check
this box ___
Company Year Taken Plan Life Amount Acc. Death Amount
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1. Give details of life insurance in force in other companies on ADDITIONAL INSURED. If none (or if conversion application) check
this box ___
Company Year Taken Plan Life Amount Acc. Death Amount
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REMARKS
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AP9500-NY Page 4 of 10 85-21245-00 07/1999
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SECTION F GENERAL INFORMATION CONTINUED
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PROPOSED INSURED 3. COMPLETE EACH QUESTION BELOW FOR THE PROPOSED INSURED AND ANY ADDITIONAL INSURED
YES NO ADDITIONAL INSURED. YES NO
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A. Is the Proposed/Additional Insured married?
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$ B. Income of spouse, if any. $
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$ C. Amount of insurance in force on spouse. $
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$ D. Annual earned income from occupation (after deduction of business expenses). $
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$ E. Other Income (state source in remarks). $
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$ F. Net Worth $
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PROPOSED INSURED ADDITIONAL INSURED
YES NO 4. Does any Proposed Insured/Additional Insured contemplate leaving the U.S.A. for YES NO
___ ___ travel or residence? (If yes, explain in remarks) ___ ___
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5. Within the last 2 years has any Proposed/Additional Insured:
___ ___ A. Flown or plan to fly as a pilot, student pilot or crew member? ___ ___
B. Engaged in parachute jumping, scuba diving, auto, motor boat or motorcycle racing,
___ ___ hang gliding, mountain climbing or other hazardous sport? ___ ___
(if yes to A or B, complete a separate General Questionnaire for each Proposed/
Additional Insured)
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6. Has any Proposed/Additional Insured ever had insurance declined, rated, modified
___ ___ canceled or not renewed? (If yes, explain in remarks) ___ ___
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___ ___ 7. Has any Proposed/Additional Insured been convicted of a felony within the past 5 ___ ___
years? (If yes, explain in remarks)
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8. Has any Proposed/Additional Insured had a drivers license restricted or revoked or
___ ___ been charged with 3 or more moving violations within the past 5 years? ___ ___
(If yes, explain in remarks)
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9. Has any other insurance been applied for within the last 3 months on any Proposed/
___ ___ Additional Insured? (If yes, explain in remarks) ___ ___
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10. Will the policy applied for replace or change any existing insurance or annuity
___ ___ on any Proposed/Additional Insured? (If yes, for each give insurance company, plan, ___ ___
amount and policy number in remarks. Use an additional sheet if necessary.
Enclose all state replacement forms.)
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___ ___ A. Is this a 1035 Exchange? ___ ___
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___ ___ B. Will a loan be carried over? ___ ___
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___ ___ 11. Have you smoked a cigarette(s) in the last 12 months? ___ ___
Date: ____________ If yes, give date last smoked. Date: ____________
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___ ___ 12. Have you used tobacco in any other form within the last 24 months? ___ ___
Type: ___________ If yes, specify type and date last used. Type: ____________
Date: ___________ Date: ____________
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REMARKS
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AP9500-NY Page 5 of 10 85-21245-00 07/1999
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SECTION G UNI-CHECK
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1. ___ Bank Account No. ____________ 2. Bank Account in Name of ____________
3. ___ If other than policy date, complete day of the month you want draft to
draw from bank account.
(Must be between the 4th and 28th) ____________
As a convenience to me, I request and authorize you to pay and charge to the
above account any 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.
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REMARKS
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HOME OFFICE ENDORSEMENT
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DECLARATIONS
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I represent that the foregoing answers and statements contained in Parts I and
II are correctly recorded, complete, and true to the best of my knowledge and
belief. I agree that such answers and statements shall be attached to and made
part of the policy. I understand that:
1. EXCEPT AS OTHERWISE PROVIDED IN ANY TEMPORARY INSURANCE AGREEMENT, NO
INSURANCE WILL TAKE EFFECT BEFORE THE POLICY FOR SUCH INSURANCE IS DELIVERED
AND THE FIRST PREMIUM PAID DURING THE LIFETIME(S) AND BEFORE ANY CHANGE IN
THE HEALTH OF THE PROPOSED INSURED(S). UPON SUCH DELIVERY AND PAYMENT,
INSURANCE WILL TAKE EFFECT IF THE ANSWERS AND STATEMENTS IN THIS APPLICATION
ARE THEN TRUE.
2. Acceptance of a life insurance policy will be ratification of any
administrative change with respect to such policy made by Pacific Life
& Annuity Company, the "Company", in the space entitled "Home Office
Endorsements," where permitted by state law. All other changes, including
policy type and amount of insurance, benefits, classification or age at
issue, must be accepted in writing.
3. No agent or medical examiner is authorized to make or modify contracts or to
waive any of the Company's rights or requirements.
Signed and Dated by Applicant in:
On
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City State Mo. Day Year Signature of Applicant
-----------------------------------------
Signature of Proposed Insured (IF OTHER
THAN APPLICANT OR PARENT IF PROPOSED
INSURED IS UNDER AGE 16)
-----------------------------------------
Signature of Other Adult Proposed Insured
-----------------------------------------
Signature of Owner (IF OTHER THAN
PROPOSED INSURED OR APPLICANT)
IF OWNER IS A CORPORATION THE SIGNATURE AND TITLE OF ANY AUTHORIZED OFFICER
OTHER THAN THE PROPOSED INSURED IS REQUIRED AND THE FULL NAME OF THE CORPORATION
MUST BE SHOWN.
I certify that I have truly and accurately recorded hereon the information
supplied.
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Signature of Soliciting Agent Please Print Soliciting Agent Name
AP9500-NY Page 6 of 10 85-21245-00 07/1999
AUTHORIZATION TO OBTAIN INFORMATION
I authorize any physician, medical practitioner, hospital, clinic, other medical
or medically related facility, insurance company, the Medical Information
Bureau, consumer reporting 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 (to include an investigative consumer report)
and/or any other information of me, my spouse and my 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, 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 also
understand that 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 known as Acquired Immune Deficiency Syndrome
(AIDS). It may also include information about any history of alcohol or drug
treatment. I know that I may request to receive a copy of this authorization. I
also acknowledge receipt of Disclosure Notice to Applicants for Insurance.
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 Proposed Insured in:
On
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City State Mo. Day Year Signature of Proposed Insured (OR PARENT
IF PROPOSED INSURED IS UNDER AGE 16)
-----------------------------------------
Signature of Other Adult Proposed Insured
AP9500-NY Page 7 of 10 85-21245-00 07/1999
DISCLOSURE NOTICE TO APPLICANTS FOR INSURANCE
This brief description of our underwriting process is designed to help you to
understand how an application for insurance is handled, the types and sources of
information we may collect about you, the circumstances under which we may
disclose that information to others and your right to learn the nature and
substance of that information upon written request. The purpose of the
underwriting process is to make sure you qualify for insurance under our rules,
and assuming you do, establish the proper premium charge for that insurance.
This process - the evaluation of risks - assures that the cost of insurance is
distributed equitably among all policyowners, and that each individual pays his
or her fair share. To determine your insurability, we must consider such
factors as your medical history, physical condition, occupation and hazardous
avocations. We get this information from various sources.
SOURCES OF INFORMATION
APPLICATION AND MEDICAL RECORDS - Your application, including the medical
history, is the primary source of information in the evaluation process. In
addition, we may ask you to take a physical examination or other special test
such as an electrocardiogram. We may also ask for a report from your doctor or
hospital, another insurance company, or the Medical Information Bureau. When we
do so, we will use the authorization form you signed with your application.
MIB, INC., (Medical Information Bureau) -- MIB, Inc., is a non-profit
corporation which operates an information exchange on behalf of member life
insurance companies. As a member company, we will ask MIB if it has a record
concerning you. If you previously applied to a member company for insurance, MIB
may have information about you in its file. The purpose of the MIB is to protect
member companies and their policyowners from those who would conceal significant
facts relevant to their insurability. The information which is obtained from MIB
may be used only as an alert to the possible need for further independent
investigation. It cannot be used as a basis in making a final underwriting
decision.
Information regarding your insurability will be treated as confidential. Pacific
Life & Annuity Company, its subsidiaries or its reinsurer(s) may, however, make
a brief report to the MIB. If you later apply to another MIB member company for
life or health insurance coverage, or a claim for benefits is submitted to such
a company, the MIB, upon request, will supply the company with the information
it may have about you in its file. Pacific Life & Annuity Company, its
subsidiaries or its reinsurer(s) may also release information in its 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.
At your request, the MIB will arrange disclosure of any information it may have
about you in its file. If you question the accuracy of information on file, you
may contact the MIB and seek a correction in accordance with the procedures set
forth in the federal Fair Credit Reporting Act. The address of the information
office of MIB, Inc. is Post Office Box 105, Essex Station, Boston, Massachusetts
02112, telephone number (617) 426-3660.
INVESTIGATIVE CONSUMER REPORT - As part of our underwriting procedure, we may
request an investigative consumer report from a consumer reporting agency.
Because you may want to know more about the nature and scope of such a report,
we are providing this information below as part of this Notice.
A consumer report confirms and supplements the information of your application
pertaining to employment and residence verification, smoking habits, marital
status, occupation, hazardous avocations and general health. This report may
also cover information concerning your general reputation, personal
characteristics and mode of living (except as may be related directly or
indirectly to your sexual orientation) including drug and alcohol use, motor
vehicle driving record and any criminal activity. This information may be
obtained through personal interviews with you, your family, friends, neighbors
and business associates. If a report is required and you wish to be personally
interviewed, please let us know and we will notify the consumer reporting
agency.
The information contained in the report may be retained by the consumer
reporting agency and subsequently disclosed to other companies to the extent
permitted by the Fair Credit Reporting Act.
Investigative consumer reports are held in strict confidence and used only to
evaluate your application on a fair and equitable basis. You have a right to
inspect and obtain a copy of the report from the consumer reporting agency.
These reports may have an adverse affect on an individual's eligibility for
insurance. If it should, however, we will notify you in writing and identify
the reporting agency.
DISCLOSURE TO OTHERS
Personal information obtained about you during the underwriting process is
confidential and will not be disclosed to other persons or organizations without
your written authorization except to the extent necessary for the conduct of our
business. Examples of situations where we may share information about you are
as follows:
1. The agent may retain a copy of your application.
2. If reinsurance is required, the reinsurance company would have access to
our application file.
3. We may release information to another life insurance company to whom you
have applied for life or health insurance or to whom you have submitted
a claim for benefits, if you have authorized it to obtain such
information.
4. As stated earlier, we may report information to the Medical Information
Bureau.
5. We will disclose information to government regulatory officials, law
enforcement authorities and others where required by law.
DISCLOSURE TO YOU
In general, you have a right to learn the nature and substance of any personal
information 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 information upon which our action is based.
Medical record information, however, will normally be given only to a licensed
physician of your choice. Please refer to the section on MIB, Inc., for that
organization's disclosure procedure.
Should you feel that any information we have is inaccurate or incomplete, please
write to the Manager, Risk Selection Department, Pacific Life & Annuity Company,
700 Newport Center Drive, Newport Beach, California 92660. 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
information in the underwriting process, and the ways you can learn about this
information. We are concerned with insuring privacy as well as lives, and the
collection, use and disclosure of personal information is limited to those
specified in this Notice.
AP9500-NY Page 8 of 10 85-21245-00 07/1999
- ----------------------------------------------------------------------------------------------------------------------------------
SECTION H BUSINESS INSURANCE (COMPLETE THIS SECTION IF APPLYING FOR BUSINESS INSURANCE)
- ----------------------------------------------------------------------------------------------------------------------------------
Purpose of this Insurance:
A. ___ Buy & Sell D. ___ Split Dollar
B. ___ Employee Fringe Benefit E. ___ Key Employee
C. ___ Deferred Compensation F. ___ Other (Explain in remarks)
- ----------------------------------------------------------------------------------------------------------------------------------
2. Name of Principal Officers, Amount of Insurance
Partners or Key Employees Position % of Business Owned Owned By Business
- ----------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------------------
3. What is the current fair market value of the business? $
-------------------
4. What was the annual net profit (before taxes) of business? Last Year $ 2 Years Ago $
5. Are other officers, partners or key employees proportionately insured? ___ Yes ___ No (If no, explain in remarks)
- ----------------------------------------------------------------------------------------------------------------------------------
SECTION I COMPLETE THIS SECTION IF PROPOSED INSURED IS UNDER AGE 16
- ----------------------------------------------------------------------------------------------------------------------------------
1. Did you personally observe the Proposed Insured? ___ Yes ___ No (If no, explain in remarks)
- ----------------------------------------------------------------------------------------------------------------------------------
2. Are Proposed Insured's brothers and sisters insured for equal amounts? ___ Yes ___ No (If no, explain in remarks)
- ----------------------------------------------------------------------------------------------------------------------------------
3. Person on whom Proposed Insured depends for support:
A. Name B. Relationship
- ----------------------------------------------------------------------------------------------------------------------------------
C. Estimated annual income D. Estimated net worth E. Estimated amount of life insurance
$ $ $
- ----------------------------------------------------------------------------------------------------------------------------------
4. Information on Applicant:
A. Name B. Relationship
- ----------------------------------------------------------------------------------------------------------------------------------
C. Purpose of Insurance D. Amount of life insurance in force
$
- ----------------------------------------------------------------------------------------------------------------------------------
REMARKS
- ----------------------------------------------------------------------------------------------------------------------------------
AP9500-NY Page 9 of 10 85-21245-00 07/1999
- -----------------------------------------------------------------------------------------------------------------------------
SECTION J COMPLETE FOR ALL APPLICATIONS - AGENT INFORMATION
- -----------------------------------------------------------------------------------------------------------------------------
1. How well do you know proposed insured? 2. How well do you know Additional Insured?
(or Applicant if Proposed Insured is under age 16)
- -----------------------------------------------------------------------------------------------------------------------------
3. Have you personally asked all applicable questions in this application? Proposed Insured Additional Insured
(If no, explain in remarks) ___ Yes ___ No ___ Yes ___ No
- -----------------------------------------------------------------------------------------------------------------------------
4. Are you aware of any information not given in the application which might affect the insurability of:
Proposed Insured ___ Yes ___ No Additional Insured ___ Yes ___ No (If yes, explain in remarks)
- -----------------------------------------------------------------------------------------------------------------------------
5. Did the Proposed Insured or Applicant make the initial inquiry which led to the sale of this insurance?
___ Yes ___ No (If yes, explain in remarks)
- -----------------------------------------------------------------------------------------------------------------------------
6. Has the Proposed Insured changed name within the last 5 years? ___ Yes ___ No
7. Has the Additional Insured changed name within the last 5 years? ___ Yes ___ No (If yes, give former name in remarks)
- -----------------------------------------------------------------------------------------------------------------------------
8. To the best of your knowledge, does any policy applied for either replace, involve a change in, or involve use of value
from any existing life insurance policy or annuity?
(IF "YES" GIVE COMPANY AND POLICY NUMBER IN "REMARKS" ON PAGE 5. IF PL POLICY, Proposed Insured Additional Insured
THEN GIVE POLICY NUMBER AND HOW VALUES ARE TO BE APPLIED IN "REMARKS".) ___ Yes ___ No ___ Yes ___ No
- -----------------------------------------------------------------------------------------------------------------------------
9. If this policy is a tax qualified plan indicate type: ___ Pension/Profit sharing ___ HR-10 ___ Other
- -----------------------------------------------------------------------------------------------------------------------------
10. If application submitted on a: Proposed Insured Additional Insured
Yes No Yes No
(A) Medical Basis? ___ ___ ___ ___
(B) Non-Medical Basis? (Submit Part 2) ___ ___ ___ ___
(C) Guaranteed Issue Basis? ___ ___ ___ ___
(D) Guaranteed to Issue Basis? ___ ___ ___ ___
- -----------------------------------------------------------------------------------------------------------------------------
11. Check appropriate items which have been ordered:
Proposed Insured Additional Insured Proposed Insured Additional Insured
Yes No Yes No Yes No Yes No
Medical Exam ___ ___ ___ ___ H.O. Specimen ___ ___ ___ ___
Paramedical Exam ___ ___ ___ ___ APS ____________ ___ ___ ___ ___
EKG ___ ___ ___ ___ ________________ ___ ___ ___ ___
Blood Profile ___ ___ ___ ___ ________________ ___ ___ ___ ___
- -----------------------------------------------------------------------------------------------------------------------------
REMARKS
- -----------------------------------------------------------------------------------------------------------------------------
I certify that to the best of my knowledge and belief: Yes No
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 (or Parent for Juvenile insurance) a copy of the Fair Credit
Reporting Act and MIB 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(s) to the
Proposed Insured (or Applicant) and have given it to him/her (them)._________________________________ ___ ___
- -----------------------------------------------------------------------------------------------------------------------------
D. I have complied with state and federal laws on disclosure, cost comparison and replacement.__________ ___ ___
- -----------------------------------------------------------------------------------------------------------------------------
E. I have reviewed the purchase of this insurance policy as to suitability._____________________________ ___ ___
- -----------------------------------------------------------------------------------------------------------------------------
Signature(s) Of Soliciting Agent(s). Pay Commission as Indicated Below.
- -----------------------------------------------------------------------------------------------------------------------------
X X
- ----------------------------------------------------------------- -----------------------------------------------------
First Name Listed Below Will Be The Servicing Agent
- -----------------------------------------------------------------------------------------------------------------------------
PHONE FAX AGENCY AGENT
AGENT NAME NUMBER NUMBER NUMBER CODE COMM%
- -----------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------
Broker/Dealer Name (IF APPLICABLE): ____________________________________________
AP9500-NY Page 10 of 10 85-21245-00 07/1999
APPLICATION, PART II -- NON-MEDICAL RISK NONMED
PACIFIC LIFE & ANNUITY COMPANY [LOGO OF PL&A]
700 Newport Center Drive, Newport Beach, California 92660
SECTION A COMPLETE ON PROPOSED INSURED (AGE 16 OR OVER)
- --------------------------------------------------------------------------------
1. Full Name 2a. Date of Birth 2b. Height 2c. Weight
MO. DAY YR. FT. IN. LBS.
- --------------------------------------------------------------------------------
3.a. Name and address of personal physician, practitioner or health facility
last visited:
---------------------------------------------------------------------------
(IF NONE, SO STATE)
b. Date: _______________________ c. Reason consulted: ___________________
MO. YR.
Yes No Details of "Yes" answers. (Identify question,
and include diagnoses, dates, duration and
d. Did any symptoms prompt consultation?________________________ ___ ___ names and addresses of all attending
e. Was any treatment given or medication prescribed?____________ ___ ___ physicians and medical facilities. Use an
(IF "D" OR "E" ANSWERED "YES", GIVE DETAILS) additional sheet if necessary.)
4. To the best of your knowledge and belief, during the past
10 years, have you had, or been told that you had, or been
treated by a member of the medical profession for:
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS)
a. Disorder of the eyes, ears, nose, or throat?_________________ ___ ___
b. Dizziness, fainting, convulsions, headaches, speech defect,
paralysis or stroke, or mental or nervous condition?_________ ___ ___
c. Hoarseness or cough, blood spitting, asthma, pneumonia,
emphysema, tuberculosis, or other respiratory system
disorder? ___________________________________________________ ___ ___
d. Chest pain, high blood pressure, rheumatic fever, murmur,
heart attack or other disorder of the heart or blood
vessels? ____________________________________________________ ___ ___
e. Jaundice, intestinal bleeding, ulcer, colitis,
diverticulitis, hepatitis, or other disorder of the liver,
gallbladder, stomach or intestines? _________________________ ___ ___
f. Sugar, albumin, or blood in urine, venereal disease, stone
or other disorder of kidney, bladder, prostate, breasts or
reproductive organs? ________________________________________ ___ ___
g. Diabetes; thyroid or other endocrine disorders?______________ ___ ___
h. Neuritis, sciatica, arthritis, gout, or disorder of the
muscles or bones, including the spine, back or joints?_______ ___ ___
i. Cancer, cyst, tumor or disorder of skin, blood or lymph
glands? _____________________________________________________ ___ ___
j. Any disorder(s) of the Immune System, including AIDS
(Acquired Immune Deficiency Syndrome) and ARC (AIDS
Related Complex)? ___________________________________________ ___ ___
5.a. Have you within the past 5 years been a patient in a
hospital, clinic, sanitarium or other medical facility?______ ___ ___
b. Are you now under regular medical observation or taking
treatment? __________________________________________________ ___ ___
6.a. Except as prescribed by a physician, have you used heroin,
morphine or other narcotic drugs in the last 10 years?_______ ___ ___
b. Except as prescribed by a physician, have you used cocaine,
LSD, marijuana or other hallucinogenic agents, or
barbiturates, sedatives, tranquilizers or any amphetamines
in the last 5 years? ________________________________________ ___ ___
c. In the last 5 years have you received treatment for or
joined an organization because of alcoholism or drug
addiction? __________________________________________________ ___ ___
7. Other than as stated in answers above, have you within the
past 5 years:
a. Had a checkup, consultation, illness, injury or operation?_ ___ ___
b. Had an electrocardiogram, blood test, other test or X-ray?_ ___ ___
c. Been advised to have any diagnostic test, hospitalization
or surgery which was not completed? _______________________ ___ ___
8. Have you had any change in weight in the past year? __________ ___ ___
9. Have either of your parents, brothers or sisters had
diabetes, cancer, high blood pressure, heart disease, or
mental illness? ______________________________________________ ___ ___
(IF "YES", STATE CONDITION, GIVE RELATIONSHIP AND AGE AT ONSET)
10. Parents' Record (COMPLETE BELOW)
- ------------------------------------------------------------------------------------------------------------------------------
IF LIVING IF DECEASED
- ----------------------------------------------------------------------------------
AGE AT
AGE STATE OF HEALTH DEATH CAUSE OF DEATH
- ----------------------------------------------------------------------------------
Father
- ----------------------------------------------------------------------------------
Mother
- ----------------------------------------------------------------------------------
The above statements are true and complete to the best of my knowledge and
belief. I agree that such statements and answers shall be a part of the
application.
Dated at on X
------------------- ------------- ------------------------------
CITY STATE MO. DAY YR. SIGNATURE OF PROPOSED INSURED
- ---------------------------------------------
WITNESS
AP9500-P2-NY Page 1 of 3 85-21246-00 07/1999
APPLICATION, PART II -- NON-MEDICAL RISK NONMED
TO PACIFIC LIFE & ANNUITY COMPANY [LOGO OF PL&A]
700 Newport Center Drive, Newport Beach, California 92660
SECTION B COMPLETE ON ADDITIONAL INSURED (AGE 16 OR OVER)
- --------------------------------------------------------------------------------
1. Full Name 2a. Date of Birth 2b. Height 2c. Weight
MO. DAY YR. FT. IN. LBS.
- --------------------------------------------------------------------------------
3.a. Name and address of personal physician, practitioner or health facility
last visited:
---------------------------------------------------------------------------
(IF NONE, SO STATE)
b. Date: _______________________ c. Reason consulted: ___________________
MO. YR.
Yes No Details of "Yes" answers. (Identify question
and include diagnoses, dates, duration and
d. Did any symptoms prompt consultation?________________________ ___ ___ names and addresses of all attending
e. Was any treatment given or medication prescribed?____________ ___ ___ physicians and medical facilities. Use an
(IF "D" OR "E" ANSWERED "YES", GIVE DETAILS) additional sheet if necessary.)
4. To the best of your knowledge and belief, during the past
10 years, have you had, or been told that you had, or been
treated by a member of the medical profession for:
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS)
a. Disorder of the eyes, ears, nose, or throat?_________________ ___ ___
b. Dizziness, fainting, convulsions, headaches, speech defect,
paralysis or stroke, or mental or nervous disorder?__________ ___ ___
c. Hoarseness or cough, blood spitting, asthma, pneumonia,
emphysema, tuberculosis, or other respiratory system
disorder? ___________________________________________________ ___ ___
d. Chest pain, high blood pressure, rheumatic fever, murmur,
heart attack or other disorder of the heart or blood
vessels? ____________________________________________________ ___ ___
e. Jaundice, intestinal bleeding, ulcer, colitis,
diverticulitis, hepatitis, or other disorder of the liver,
gallbladder, stomach or intestines? _________________________ ___ ___
f. Sugar, albumin, or blood in urine, venereal disease, stone
or other disorder of kidney, bladder, prostate, breasts or
reproductive organs? ________________________________________ ___ ___
g. Diabetes; thyroid or other endocrine disorders?______________ ___ ___
h. Neuritis, sciatica, arthritis, gout, or disorder of the
muscles or bones, including the spine, back or joints?_______ ___ ___
i. Cancer, cyst, tumor or disorder of skin, blood or lymph
glands? _____________________________________________________ ___ ___
j. Any disorder(s) of the Immune System, including AIDS
(Acquired Immune Deficiency Syndrome) and ARC (AIDS
Related Complex)? ___________________________________________ ___ ___
5.a. Have you within the past 5 years been a patient in a
hospital, clinic, sanitarium or other medical facility?______ ___ ___
b. Are you now under regular medical observation or taking
treatment? __________________________________________________ ___ ___
6.a. Except as prescribed by a physician, have you used heroin,
morphine or other narcotic drugs in the last 10 years?_______ ___ ___
b. Except as prescribed by a physician, have you used cocaine,
LSD, marijuana or other hallucinogenic agents, or
barbiturates, sedatives, tranquilizers or any amphetamines
in the last 5 years? ________________________________________ ___ ___
c. In the last 5 years have you received treatment for or
joined an organization because of alcoholism or drug
addiction? __________________________________________________ ___ ___
7. Other than as stated in answers above, have you within the
past 5 years:
a. Had a checkup, consultation, illness, injury or operation?_ ___ ___
b. Had an electrocardiogram, blood test, other test or X-ray?_ ___ ___
c. Been advised to have any diagnostic test, hospitalization
or surgery which was not completed? _______________________ ___ ___
8. Have you had any change in weight in the past year? __________ ___ ___
9. Have either of your parents, brothers or sisters had
diabetes, cancer, high blood pressure, heart disease, or
mental illness? ______________________________________________ ___ ___
(IF "YES", STATE CONDITION, GIVE RELATIONSHIP AND AGE AT ONSET)
10. Parents' Record (COMPLETE BELOW)
- ------------------------------------------------------------------------------------------------------------------------------
IF LIVING IF DECEASED
- ----------------------------------------------------------------------------------
AGE AT
AGE STATE OF HEALTH DEATH CAUSE OF DEATH
- ----------------------------------------------------------------------------------
Father
- ----------------------------------------------------------------------------------
Mother
- ----------------------------------------------------------------------------------
The above statements are true and complete to the best of my knowledge and
belief. I agree that such statements and answers shall be a part of the
application.
Dated at on X
------------------- ------------- --------------------------------
CITY STATE MO. DAY YR. SIGNATURE OF ADDITIONAL INSURED
- ---------------------------------------------
WITNESS
AP9500-P2-NY Page 2 of 3 85-21246-00 07/1999
APPLICATION, PART II -- NON-MEDICAL RISK NONMED
PACIFIC LIFE & ANNUITY COMPANY [Logo of PL&A]
700 Newport Center Drive, Newport Beach, California 92660
- ------------------------------------------------------------------------------------------------------------------------------------
SECTION C COMPLETE IF APPLYING FOR OWNER PREMIUM WAIVER, PAYOR WAIVER, CHILDREN'S TERM RIDER OR IF
PROPOSED INSURED IS UNDER AGE 16.
- ------------------------------------------------------------------------------------------------------------------------------------
RELATIONSHIP AMOUNT OF AMT. OF INS.
1. NAME OF PERSON TO PROPOSED DATE OF BIRTH STATE OF HEIGHT WEIGHT INSURANCE CURRENTLY
BE COVERED INSURED (MO./DAY/YR.) BIRTH (FT/IN.) (POUNDS) NOW IN FORCE APPLIED FOR
- ---------------------------------------------------------------------------------------------------------------------------------
- ---------------------------------------------------------------------------------------------------------------------------------
- ---------------------------------------------------------------------------------------------------------------------------------
- ---------------------------------------------------------------------------------------------------------------------------------
- ---------------------------------------------------------------------------------------------------------------------------------
Note: If payor or owner waiver of charges is being applied for, please indicate the individual's occupation and the employer's
name and address:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
- ---------------------------------------------------------------------------------------------------------------------------------
2a. Name and address of your personal physician, practitioner or health facility
- ---------------------------------------------------------------------------------------------------------------------------------
b. Date: c. Reason for and results of last visit
- ------------------------------------------------------------------------------------------------------------------------------------
3. Has any person named in Question 1 during the past 10 years had or been told that he or she had, or been treated for:
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS)
Yes No
A. Diabetes, cancer or epilepsy? _____________________________________________________________ ___ ___
B. Heart murmur, high blood pressure or any heart condition? _________________________________ ___ ___
C. Any disorder(s) of the Immune System, including AIDS (Acquired Immune Deficiency Syndrome)
and ARC (AIDS Related Complex)? ___________________________________________________________ ___ ___
4. Has any person named in Question 1:
A. Been in a hospital, sanitarium or other institution for diagnosis, treatment or a surgical
operation within the past 5 years? ________________________________________________________ ___ ___
B. Had any medical consultation or treatment within the past 3 years, other than as stated in
any answer above? _________________________________________________________________________ ___ ___
GIVE DETAILS BELOW FOR EACH "YES" ANSWER IN QUESTIONS 3 and 4:
- ------------------------------------------------------------------------------------------------------------------------------------
QUESTION NO. FIRST NAME REASON FOR CONSULTATION DATE DURATION-RESULT NAME AND ADDRESS OF PHYSICIAN
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
DECLARATIONS
- ------------------------------------------------------------------------------------------------------------------------------------
I represent that the foregoing answers and statements are correctly recorded, complete, and true to the best of my knowledge
and belief. I agree that such answers and statements shall be made part of the application.
I understand that:
1. EXCEPT AS OTHERWISE PROVIDED IN ANY TEMPORARY INSURANCE AGREEMENT, NO INSURANCE WILL TAKE EFFECT BEFORE THE POLICY FOR SUCH
INSURANCE IS DELIVERED AND THE FIRST PREMIUM PAID DURING THE LIFETIME(S) AND BEFORE ANY CHANGE IN THE HEALTH OF THE PROPOSED
INSURED(S). UPON SUCH DELIVERY AND PAYMENT, INSURANCE WILL TAKE EFFECT IF THE ANSWERS AND STATEMENTS IN THIS APPLICATION ARE
THEN TRUE.
2. Acceptance of a life insurance policy will be ratification of any administrative change with respect to such policy made by the
Company in the space entitled "Home Office Endorsements," where permitted by state law. All other changes, including policy
type and amount of insurance, benefits, classification or age at issue, must be accepted in writing.
3. No agent or medical examiner is authorized to make or modify contracts or to waive any of the Company's rights or requirements.
Signed and Dated in:
On
- ------------------------------------------------------- -------------------------------------------------------------------------
City State Mo. Day Year Signature of Proposed Insured (OR PARENT, IF PROPOSED INSURED
IS UNDER AGE 16)
-------------------------------------------------------------------------
Signature of Owner/Payor
IF OWNER IS A CORPORATION THE SIGNATURE AND TITLE OF AN AUTHORIZED OFFICER OTHER THAN THE PROPOSED
INSURED IS REQUIRED AND THE FULL NAME OF THE CORPORATION MUST BE SHOWN.
I certify that I have truly and accurately recorded hereon the information supplied.
- --------------------------------------------- ---------------------------------------
Signature of Soliciting Agent Please Print Soliciting Agent Name
AP9500-P2-NY PAGE 3 of 3 85-21246-0007/1999
GENERAL QUESTIONNAIRE RISK AVOC
PACIFIC LIFE & ANNUITY COMPANY [Logo of PL&A]
700 Newport Center Drive
Newport Beach, CA 92660
- ------------------------------------------------------------------------------------------------------------------------------------
FULL NAME (Print) DATE OF BIRTH
Mo. ____________ Day ____________ Yr. _____________
- ------------------------------------------------------------------------------------------------------------------------------------
SECTION A AUTOMOBILE, MOTORCYCLE AND/OR POWER BOAT RACING
- ------------------------------------------------------------------------------------------------------------------------------------
1. Type of racing? ___ Midget ___ Go-Kart ___ Sports Car ___ Modified Stock ___ Drag Racing ___ Motorcycle
___ Powerboat ___ Other (explain) ___________________________________________________________________________________________
2. Make? ___________________________ Model ? _____________________________ Displacement? __________________________________
Class? __________________________ Engine Make & Model? _____________________________ HP? ________________________________
3. (a) Number of races 12-24 months ago? ____________________________________ (b) Past 12 months? __ ___________________________
(c) Date of last race? ______________________________ (d) Est. next 12 months? _________________________________________________
4. Type of race? ___ Midget ___ Sports Car ___ Stock Car ___ Championship ___ Drag ___ Kart ___ Hillclimb
___ Cross Country ___ Hound & Hare ___ Moto-Cross ___ Other (explain) ______________________________________________
---------------------------------------------------------------------------------------------------------------------------------
5. Type of course? ___ Paved ___ Dirt ___ Drag Strip ___ Oval ___ Other (explain) ______________________________
_________________________________________________________________________________________________________________________________
6. Where do you race? ___ Local? If not, where? ____________________________________________________________________________
7. Competition against? ___ Other Cars ___ Clock ___ Straightaway __________________________________________________
8. Average Speed? ______________________ Top Speed? _________________________ Average miles per race? ______________________
9. Is your racing? ___ Professional ___ Amateur ___ Other (explain) ____________________________________________________
- ------------------------------------------------------------------------------------------------------------------------------------
SECTION B UNDERWATER DIVING (SKIN OR SCUBA)
- ------------------------------------------------------------------------------------------------------------------------------------
1. What type of equipment do you use? ______________________________________________________________________________________________
2. Location of diving activities? _________________________ Diving for pleasure? ______________________ Pay? __________________
3. Do you belong to club or association? _____________________ Do you ever dive alone? _________________________________________
---------------------------------------------------------------------------------------------
4. Depth of Dives During Past 12 Months Expected Next 12 Months
-------------- ---------------------------------------------------------------------------------------------
No. Dives Average Time No. Dives Average Time
---------------------------------------------------------------------------------
a. Less than 40 feet
---------------------------------------------------------------------------------
b. 40 feet to 60 feet
---------------------------------------------------------------------------------
c. 60 feet & over
---------------------------------------------------------------------------------
d. Maximum depth obtained
- ------------------------------------------------------------------------------------------------------------------------------------
SECTION C PARACHUTE JUMPING AND SKY DIVING
- ------------------------------------------------------------------------------------------------------------------------------------
1. Are you now a member of any parachute or sky diving club or association? ________________________________________________________
2. Are all of your jumps made under auspices of your club or association? __________________________________________________________
3. (a) Number of jumps 12 - 24 months ago? ________________ (b) Past 12 months? _________________ (c) Next 12 months? __________
4. Do you participate in delayed chute opening competition or other stunts? ________________________________________________________
5. Location of jump areas? _______________________________________ Date of last jump? __________________________________________
- ------------------------------------------------------------------------------------------------------------------------------------
REMARKS IDENTIFY SECTION AND QUESTION
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
I represent that the foregoing answers and statements are correctly recorded, complete, and true to the best of my
knowledge and belief. I agree that such answers and statements shall be a part of the application.
Date X
---------------------------------- -----------------------------------------------------------------------------------------
Mo. Day Year Signature of Proposed Insured (or Parent if Proposed Insured is under age 15)
_______________________________________
Signature of Soliciting Agent
_______________________________________
Agency No.
AP7503-NY Page 1 of 2 85-21364-00 07/1999
GENERAL QUESTIONNAIRE RISK AVIA
PACIFIC LIFE & ANNUITY COMPANY [Logo of PL&A]
700 Newport Center Drive
Newport Beach, CA 92660
- --------------------------------------------------------------------------------
FULL NAME (Print) DATE OF BIRTH
Mo. ______ Day _____ Yr. _____
- --------------------------------------------------------------------------------
SECTION D AVIATION
- --------------------------------------------------------------------------------
FOR CIVILIAN AND MILITARY PILOTS:
1. Type of aviation activity
HOURS FLOWN 5.A. Type of license/certificate/rating
LAST 12 12-24 MO. ALL PRIOR EST. NEXT held (CHECK APPROPRIATE BOXES):
MONTHS AGO YEARS 12 MO. ___ Student ___ Private
Civilian Pilot ___ Commercial ___ ATR ___ IFR
Military Pilot ___ Instructor ___ Other
Member of Crew (SPECIFY "REMARKS")
B. Date of last renewal:
______________________________
2. Have you ever done or do C. Purpose of flights:
you intend to engage in ______________________________
flying for the purpose of
exhibition, endurance tests, ______________________________
racing, stunt flying, D. Total flying hours to date:
testing, air cargo ______________________________
operations, crop dusting or E. Date of last flight:
spraying, or instruction of Yes No ______________________________
student pilots? ____________ ___ __ FOR CREW MEMBERS:
3.A. Have you ever flown or do 6.A. Duties aboard aircraft:
you intend to fly outside ______________________________
of the United States? ____ ___ __
B. Have you ever been involved _____________________________
in any accident due to B. Purpose of flights:
flying activities? _______ ___ __ ______________________________
C. Have you ever been charged
with any violation of air _____________________________
regulations? _____________ ___ __ C. Date of last flight:
(IF "YES" TO QUESTIONS 2, 3A, 3B OR 3C, ______________________________
EXPLAIN IN "REMARKS") D. Do you plan to take instructions
FOR PILOTS AND CREW MEMBERS OF MILITARY as a pilot? ___ Yes ___ No
AIRCRAFT: (IF "YES", EXPLAIN IN "REMARKS".)
4. Describe type of aircraft flown in 7. If aviation activity does not
(including alphabetic & numeric code). permit standard unrestricted
coverage, please issue as follows:
___ Full aviation coverage, if
available, with appropriate
extra premium.
___ Aviation exclusion rider.
- --------------------------------------------------------------------------------
REMARKS IDENTIFY SECTION & AND QUESTION
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
I represent that the foregoing answers and statements are correctly recorded,
complete, and true to the best of my knowledge and belief.
Date X
-------------------------------------- ----------------------------------
Mo. Day Year Signature of Proposed Insured (or
Parent if Proposed Insured is
under age 15)
- -------------------------------------------
Signature of Soliciting Agent
- -------------------------------------------
Agency No.
AP7503-NY Page 2 of 2 85-21364-00 07/1999