EXHIBIT 1.A.(10)
PLEASE MAKE CHECK PAYABLE TO:
PROTECTIVE LIFE INSURANCE COMPANY
THE PROTECTIVE SPVL - Application P.O. BOX 830771 BIRMINGHAM, AL 35283-0771
1. PROPOSED INSURED 2. OWNER (If other than Proposed Insured)
/ / Male / / Female / / Male / / Female
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NAME NAME
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STREET ADDRESS STREET ADDRESS
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CITY STATE ZIP CITY STATE ZIP
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PHONE NUMBER TAX I.D./SOCIAL PHONE NUMBER TAX I.D./SOCIAL
SECURITY NO. SECURITY NO.
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BIRTHDATE MO./DAY/YR. BIRTHPLACE MARITAL BIRTHDATE MO./DAY/YR. RELATIONSHIP TO PROPOSED
STATUS INSURED
3. PRIMARY BENEFICIARY 4. PLAN INFORMATION
NAME, ADDRESS, RELATIONSHIP & PERCENTAGE Purchase Payment $ ---------------------
Initial Face Amount $ ---------------------
PROPOSED INSURED: Have you used tobacco or nicotine
CONTINGENT BENEFICIARY (IF ANY) of any kind over the last 12 months? / / Yes / / No
Long-Term Care Rider? / / Yes / / No
5. SIMPLIFIED UNDERWRITING: IF ALL THE ANSWERS TO QUESTION 5 ARE "NO", DO NOT COMPLETE QUESTIONS 6-8. IF ANY
ANSWERS ARE "YES", PLEASE GIVE DETAILS UNDER QUESTION 8 AND CONTINUE ANSWERING QUESTIONS 6-7. YES NO
a. Have you ever had or been treated for cancer, diabetes, cardiovascular disease, stroke, Alzheimers,
central nervous system disorders, Parkinsons, Multiple Sclerosis, paraplegia or respiratory
disorders? / / / /
b. In the past 5 years have you been diagnosed with or treated for a nervous or psychological disorder,
attempted suicide, epilepsy, emphysema, kidney disease, liver disorder or been advised to limit or
receive treatment for alcohol or drug abuse? / / / /
c. Have you ever been diagnosed as having AIDS, AIDS Related Complex or other immune deficiency
disorders? / / / /
d. Have you ever been declined for life insurance? / / / /
6. FULL UNDERWRITING:
PLEASE ANSWER ALL QUESTIONS. EXPLAIN "YES" ANSWERS UNDER QUESTION 8. YES NO
a. During the past 5 years have you consulted a physician or visited a clinic or hospital as a patient? / / / /
b. Has any life or health insurance applied for ever been declined, postponed, or offered other than
applied for? / / / /
c. Do you have any intention of traveling or residing outside the U.S. or Canada within the next two
years? (If yes, state when, where and how long.) / / / /
d. Have you participated in the past 2 years in any type of aviation other than as a passenger, vehicle
racing, sky or scuba diving or hang gliding? / / / /
e. Have you in the past 2 years had any motor vehicle moving violations or your license suspended? (If
yes, give date, violation, license number and state of license.) / / / /
7. HAVE YOU EVER BEEN TREATED FOR: YES NO
a. Heart murmur, high blood pressure or other heart, blood or circulatory disorder, or diabetes
(whether or not on Insulin)? / / / /
b. Convulsions, brain or spinal cord disorders? / / / /
c. Any disease of the bones, lymph glands, stomach, intestines or any immune disorder? / / / /
8. DETAILS OF ALL "YES" ANSWERS
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Question Date of Details, Diagnosis, Names & Addresses of Doctors, Hospitals &
Number Occurrence Treatment, Medication, Results Duration Medical Facilities Consulted
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VUL-1034-A 2/98
9. LIFE INSURANCE IN FORCE (INCLUDING BUSINESS INSURANCE): IF NONE, INSERT
"NONE"
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Year Life Accidental Death Existing Loan? To Be
Company Issued Amount Amount State Amount Replaced?
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10. COMPLETE IF APPLYING FOR LONG-TERM CARE RIDER:
Long-term care, accident and disability or health insurance inforce (IF
NONE, INSERT "NONE")
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Year
Company Issued Benefit Provisions/Amounts
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11. PURCHASE PAYMENT ALLOCATION: Select the allocation
for your purchase payments. (MAXIMUM OF 10 FUND SELECTIONS. IF NO ALLOCATION IS
SPECIFIED, ALL PROCEEDS WILL BE ALLOCATED TO THE MONEY MARKET FUND. A MINIMUM OF
10% MUST BE ALLOCATED TO AN INVESTMENT CHOICE.)
TOTAL ALLOCATION MUST EQUAL 100%
PIC/GOLDMAN SACHS CALVERT
- -----% International Equity -----% Calvert Social
- -----% Small Cap Value Small-Cap Growth
- -----% Capital Growth -----% Calvert Social Balanced
- -----% CORE U.S. Equity
- -----% Growth & Income OPPENHEIMER
- -----% Global Income -----% Aggressive Growth
- -----% Money Market -----% Growth
-----% Growth & Income
MFS -----% Strategic Bond
- -----% Emerging Growth
- -----% Research OTHER
- -----% Growth with Income -----% ---------------------
- -----% Total Return -----% ---------------------
MODEL PORTFOLIOS
- -----% Growth Portfolio
- -----% Balanced Portfolio
- -----% Aggressive Growth Portfolio
PROTECTIVE LIFE GENERAL ACCOUNT
- -----% Fixed Account
- -----% DCA Fixed Account (FOR DOLLAR COST AVERAGING AS
"SOURCE FUND" ONLY.)
12. DOLLAR COST AVERAGING
Transfer the amount indicated below (MINIMUM $100)
/ / Monthly / / Quarterly --------------------- Months (MINIMUM 12 MONTHS)
Day of Month --------------------- (1ST-28TH, PLEASE)
From Source Fund: --------------------- Amt. $ ---------------------
To Destination Fund Amount
(MAY NOT INCLUDE DCA FIXED ACCOUNT)
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- ----------------------------------------------------- $ ---------------------
- ----------------------------------------------------- $ ---------------------
- ----------------------------------------------------- $ ---------------------
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13. TELEPHONE TRANSFERS
PROTECTIVE LIFE WILL NOT BE HELD LIABLE FOR ANY LOSS, LIABILITY, COST OR EXPENSE FOR ACTING ON TELEPHONE INSTRUCTIONS.
/ / By checking this box, I authorize the Company to honor telephone instructions to transfer account values among
Sub-Accounts, subject to the conditions of the prospectus.
/ / By checking this box, I authorize the Registered Representative who signs this application to transfer account values
among Sub-Accounts, subject to the conditions of the prospectus.
Mothers Maiden Name
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14. PORTFOLIO REBALANCING
Rebalancing to begin on --------/ --------/ -------- (DATE) (REBALANCING DATE CAN ONLY BE DAYS 1-28)
Rebalancing should occur: / / Quarterly / / Semi-Annually / / Annually
THE VARIABLE POLICY VALUE WILL BE AUTOMATICALLY REBALANCED TO THE CURRENT ALLOCATIONS. THEREFORE, PURCHASES MADE TO SPECIFIC
FUNDS WILL ALSO BE REBALANCED.
REMARKS:
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HOME OFFICE ENDORSEMENT: (NOT TO BE USED IN KY, MD, MN, OR, PA, WV OR WI)
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VUL-1034-A 2/98
REGISTERED REPRESENTATIVE REPORT
COMPLETE FOR ALL APPLICATIONS AND SEND TO HOME OFFICE
1. QUESTIONS FOR REGISTERED REPRESENTATIVE TO ANSWER:
a. Is this insurance being purchased to replace any inforce life
insurance, annuities, long-term care insurance or health insurance / / / /
policies? IF YES, PLEASE INCLUDE ALL REQUIRED REPLACEMENT FORMS. Yes No
If Yes, Company(ies) ---------------------
b. I have explained to the Applicant that this policy is not effective
until a policy is issued and all of the terms of the Conditional / / / /
Receipt are satisfied. Yes No
c. Have you complied with all relevant state requirements, including any / / / /
"disclosure and comparison statements"? Yes No
d. On the basis of the Applicant's circumstances (including annual
income, net worth, marital status, dependent status and current life
insurance program) and their purpose for acquiring this insurance, is / / / /
the purchase of this insurance suitable? Yes No
2. PRINT REGISTERED REPRESENTATIVE NAME, BROKER DEALER, ADDRESS
AND AGENT NO.
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NAME
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BROKER DEALER
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STREET ADDRESS
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CITY STATE ZIP
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PHONE NUMBER AGENT
NUMBER
3. WHEN CONDITIONAL RECEIPT CAN BE USED
a. The premium is equal to the full INITIAL PREMIUM
b. The answers to Question 5 ARE ALL "NO" and maximum amount of cash
which can be submitted is for $250,000 of net amount at risk, and
maximum age 80.
c. The Conditional Receipt is given and the premium is collected ONLY AT
THE TIME THE APPLICATION IS TAKEN and signed.
d. The application does not contain a request for POSTDATING.
4. PROCESSING INSTRUCTIONS
a. Each applicant must be given the Description of Information Practices.
b. If cash is submitted with the application, complete and sign the
Conditional Receipt on the last page of this application and give to
the applicant.
c. Complete and sign any additional forms (i.e. 1035 exchange or state
replacement forms, if applicable).
d. Advise the Proposed Insured that they will be contacted by a Company
Representative to collect medical information and/or arrange a time
for a paramedical exam; if full underwriting.
e. Contact your Broker Dealer to determine where to send the completed
paperwork. There may be special processing procedures. If you are
sending the business directly to Protective, use the following
address:
REGULAR MAIL OVERNIGHT MAIL
Protective Life Insurance Co. Protective Life Insurance Co.
Variable Life Services Variable Life Services
P.O. Box 830771 2801 Highway 280 South
Birmingham, Alabama 35283-0771 Birmingham, Alabama 35223
FAX (205) 803-7065 Telephone (205) 879-9230
VUL-1034-A 2/98
DECLARATIONS: I represent that all statements and answers made in all parts of
this application are full, complete and true to the best of my knowledge and
belief. It is agreed that:
(a) All such statements and answers shall be the basis of any insurance
issued.
(b) No agent or medical examiner can make, alter or discharge any contract,
accept risks, or waive the Company's rights or requirements.
(c) No insurance shall take effect unless: (1) a policy is delivered to the
Owner; (2) the full first premium is paid while the Proposed Insured is
alive; and (3) there has been no change in health and insurability from
that described in this application. However, if the premium is paid as
set forth in the attached Conditional Receipt Agreement and that
Agreement is delivered to the Owner, the terms of Conditional Receipt
Agreement shall apply.
(d) Acceptance of a policy by the Owner shall constitute ratification of any
changes made by the Company under "Home Office Endorsements." In those
states where it is required, changes as to plan, amount, age at issue,
classification or benefits will be made only with the Owner's written
consent.
AUTHORIZATION: The Proposed Insured hereby authorizes any licensed physician,
medical practitioner, hospital, clinic, or other medically related facility,
insurance company, the Medical Information Bureau (MIB), consumer reporting
agencies (CRA) or other organization, institution or person, that has any
records or knowledge of my health, to give to Protective Life Insurance Company,
its CRA or its reinsurer any such information. A photographic copy of this
authorization shall be as valid as the original. Protective Life Insurance
Company can give information to its affiliates, MIB, consumer reporting
agencies, and its reinsurers. Protective Life Insurance Company can also give it
to persons doing services for it, or to other insurers. This is true only if it
is in connection with my application. I also hereby authorize Protective Life
Insurance Company to draw and test my blood and urine as may be necessary to
underwrite my application for insurance coverage. These tests to be performed,
may include, but are not limited to, tests for cholesterol and related blood
lipids, diabetes, liver or kidney disorders, the presence of antibodies to the
Human Immunodeficiency Virus (HIV) that has been associated with Acquired Immune
Deficiency Syndrome (AIDS). Protective Life Insurance Company can disclose
non-sensitive information to the agent representing me on this application only
when it is necessary to provide an explanation of the reasons for the Company's
decision to require special underwriting requirements or whenever my application
cannot be approved as applied.
DO YOU BELIEVE THAT THIS POLICY WILL MEET YOUR INSURANCE
NEEDS AND FINANCIAL OBJECTIVES? / / YES / / NO
DID YOU RECEIVE THE PROSPECTUS FOR THE POLICY APPLIED FOR
AND THE PROSPECTUS FOR EACH OF THE FUNDS? / / YES / / NO
DO YOU UNDERSTAND THAT THE AMOUNT AND DURATION OF THE DEATH
BENEFIT AND AMOUNT OF POLICY VALUES MAY VARY, DEPENDING ON
THE INVESTMENT EXPERIENCE OF THE VARIABLE ACCOUNTS? / / YES / / NO
ARE YOU PURCHASING THIS INSURANCE TO REPLACE ANY INFORCE
LIFE INSURANCE, ANNUITIES, LONG-TERM CARE INSURANCE OR
HEALTH INSURANCE POLICIES? / / YES / / NO
IF YES, COMPANY(IES) ---------------------
IF LIFE INSURANCE OR ANNUITIES, ESTIMATED TRANSFER
AMOUNT $ ---------------------
IF WE ARE UNABLE TO ISSUE A LIFE INSURANCE POLICY, DO YOU
WISH TO APPLY FOR A DEFERRED ANNUITY? / / YES / / NO
ANY PERSON WHO KNOWINGLY WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON, FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY
MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE
ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
YOUR POLICY IS SUBJECT TO A BINDING ARBITRATION PROVISION.
SEE YOUR POLICY FOR COMPLETE DETAILS.
Signed At (X) -----------------------------------------------------
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(City and State) Proposed Insured (Sign Name in Full)
Date ----------------------------------------------------- (X) -----------------------------------------------------
Applicant/Owner(s) (if other than Proposed Insured)
(X) ----------------------------------------------------- (X) -----------------------------------------------------
Witness to All Signatures Signature of Parent or Guardian (if applicable)
CAUTION: IF YOUR ANSWERS ON THIS APPLICATION ARE UNTRUE,
PROTECTIVE LIFE HAS THE RIGHT TO DENY BENEFITS OR RESCIND YOUR POLICY.
If the Owner is Corporation, Partnership or Trust a Corporate Officer, Partner
or the Trustee must sign and state title.
If Joint Owner(s), both Owner(s) must sign.
VUL-1034-A 2/98