AGENT: THIS NOTICE MUST BE REMOVED AND LEFT WITH THE PROPOSED INURED(S)
ALPINE LIFE INSURANCE COMPANY
NATIONAL SERVICE CENTER ADDRESS:
200 HOPMEADOW STREET
SIMSBURY, CT 06089
INVESTIGATIVE CONSUMER REPORT PRE-NOTIFICATION
Federal and state laws require notification that, in connection with your
application, we may request an investigative consumer report. In addition,
such a report may be requested subsequently to update our records if you
apply for additional coverage. You may request to be interviewed in
connection with the preparation of the investigative consumer report. Within
5 business days of receiving your written request, we will inform you whether
or not an investigative consumer report was requested and, if such a report
was requested, the address and telephone number of the investigative agency
to which the request was made. By contracting the local office and providing
proper identification, you may inspect or, for the appropriate fee, receive a
copy of such report. The investigative agency may retain information they
gather and disclose it at a later date to other persons.
Typically the report will contain information as to character, general
reputation, personal characteristics and mode of living, which information is
obtained through an interview with you or an adult member of your family,
employers or business associates, financial sources, friends, neighbors or
others with whom you are acquainted. The information will consist, when
applicable, of a confirmation of your identity, age, residence, marital
status, and past and present employment including occupational duties,
financial information, driving record, sports and recreational activities,
health history, use of alcohol or drugs, if any, living conditions and type
of community. The information in the report will not be used to determine
your sexual orientation.
MEDICAL INFORMATION BUREAU (MIB) PRE-NOTIFICATION
Information regarding your insurability will be treated as confidential.
Alpine Life Insurance Company may, however, make a brief report thereon to
the Medical Information Bureau, a non-profit membership organization of life
insurance companies, which operates an information exchange on behalf of its
members. If you apply to another Bureau member company for life or health
insurance coverage, or a claim for benefits is submitted to such a company,
the Bureau, upon request will supply such a company, with the information in
its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. If you question the accuracy of
information in the bureau's file, you may contact the Bureau and seek a
correction in accordance with the procedures set forth in the Federal Fair
Credit Reporting Act. The address of the Bureau's information office is Post
Office Box 105, Essex Station, Boston, Massachusetts 02112. Telephone number
(617) 426-3660.
Alpine Life Insurance Company may also release information in their files to
other life insurance companies to whom you may apply for life of health
insurance or to whom a claim for benefits may be submitted.
PERSONAL HISTORY INTERVIEW
We may follow-up your application for insurance with a personal history
interview. This is a phone call placed to you at the request of our
underwriting office. Its purpose is to make sure that our application
information is accurate and complete.
Our interviewers are trained to conduct their calls in a friendly,
professional manner. The nature of the information discussed is always
treated as personal and confidential.
APPLICATION FOR MODIFIED SINGLE PREMIUM FIRST CLASS MAIL TO: ROYAL LIFE INSURANCE COMPANY
VARIABLE LIFE INSURANCE POLICY OF AMERICA
200 HOPMEADOW STREET
SIMSBURY, CT 06089
ALPINE LIFE INSURANCE COMPANY
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1 (a). PROPOSED INSURED INFORMATION // Owner // Joint Owner
_________________________________________ ________________________________________
First Name Middle Last Social Security Number
Address:
_________________________________________ // Male // Female DOB: ____________
Street
_________________________________________ Place of Birth: _______ Occupation:__________
City State Zip
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1. (b) PROPOSED SECOND INSUREDS INFORMATION // Owner // Joint Owner
________________________________________ _________________________________________
First Name Middle Last Social Security Number
Address:
________________________________________ // Male // Female DOB: ____________
Street
________________________________________ Place of Birth: _________ Occupation:__________
City State Zip
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2. OWNER INFORMATION (COMPLETE INFORMATION BELOW IF OWNER IS NOT THE PROPOSED INSURED, PROPOSED SECOND
INSURED OR PROPOSED INSUREDS JOINTLY. IF ADDITIONAL OWNER INFORMATION IS REQUIRED,
PLEASE NOTE IN SECTION 7 SPECIAL REMARKS.)
_______________________________________ ________________________________________
First Name Middle Last Social Security Number
Address:
_______________________________________ // Male // Female DOB: ____________
Street
_______________________________________ Place of Birth: _________ Occupation:__________
City State Zip
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3. BENEFICIARY INFORMATION (IF ADDITIONAL BENEFICIARIES, PLEASE NOTE IN SECTION 7 SPECIAL REMARKS.)
PRIMARY BENEFICIARY
_______________________________________ ________________________________________
First Name Middle Last Social Security Number or Tax ID Number
Address: ________________________________________
Relationship to Proposed Insured
_______________________________________
Street
_______________________________________ Trust Date:_______________________________
City State Zip
Contingent Beneficiary
_______________________________________ ________________________________________
First Name Middle Last Social Security Number or Tax ID Number
Address: ________________________________________
Relationship to Proposed Insured
__________________________________
Street
__________________________________ _________________ Trust Date:___________
City State Zip % of Death Benefit
APPLICATION (Continue to next page)
4. PLAN OF INSURANCE ______________ INITIAL PREMIUM $____________ INITIAL FACE AMOUNT $____________
Option 1 ______ Option 2 ______ MATURITY EXTENSION RIDER // Yes // No
Are you purchasing this insurance to replace any life insurance in force? // Yes // No
_____________________________________ ____________________________________________
If yes, Company name Estimated Transfer Amount
Is there an outstanding loan on the policy being replaced? // Yes // No Loan Amount $_______________
(IF YES, PLEASE SUBMIT EXCHANGE AGREEMENT FORM FOUND IN BACK OF THE PROSPECTUS.)
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PREMIUM ALLOCATION (MUST TOTAL 100%) (Minimum percentage allocation is 10% and must be in whole numbers.)
Small Company Fund _____% Stock Fund ______% Advisers Fund _____%
Capital Appreciation Fund _____% Index Fund ______% Bond Fund _____%
MidCap Fund _____% Dividend and Growth Fund ______% Mortgage Securities Fund _____%
International Opport. Fund _____% International Advisers Fund ______% HVA Money Market Fund _____%
Other ________________________________________________ ______%
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DOLLAR COST AVERAGING (DCA)
IS DCA ELECTED? // YES // NO
(If yes, please complete DCA Election form found in back of the prospectus.)
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6. SUITABILITY PROPOSED
PROPOSED SECOND
INSURED INSURED
------- ---------
YES NO YES NO
A. Do you believe that this policy is consistent with your insurance needs and
Financial objectives? // // // //
B. DO YOU UNDERSTAND THAT THE AMOUNT AND DURATION OF THE
DEATH BENEFIT MAY VARY, DEPENDING ON THE INVESTMENT
PERFORMANCE OF THE VARIABLE ACCOUNTS? // // // //
C. DO YOU UNDERSTAND THAT THE POLICY VALUES MAY
INCREASE OR DECREASE, POSSIBLY TO ZERO, DEPENDING
ON THE INVESTMENT PERFORMANCE OF THE
VARIABLE ACCOUNTS? // // // //
d. Did you receive the current prospectus for the life policy applied for? // // // //
e. Do you understand that the initial premium will be allocated to the Money
Market Sub-Account until the expiry of the Right to Examine Policy Period? // // // //
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7. Special Remarks (In this section, please note the question number that you are addressing.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
8. Have you in the past 12 months smoked one or more cigarettes? Proposed Insured Yes // No //
Proposed Second Insured Yes // No //
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SIMPLIFIED UNDERWRITING: If the answers to this section are "NO", Then proceed to section 13. FULL UNDERWRITING: if any of these
Questions are answered "YES", or the age or premium exceeds the simplified underwriting guidelines, please complete the entire
application. Include details Of "YES" responses under Section 11.
Proposed
Proposed Second
Insured Insured
--------- ----------
YES NO YES NO
a. Have you ever had or been treated for cancer, insulin dependent diabetes,
heart disease and/or related surgery, chest pain, stroke, disease of the nervous
system, muscular disorder, Alzheimer's disease or dementia, or any lung or
breathing disorder? // // // //
b. In the past 5 years have you had or been treated or hospitalized for a nervous or
psychological disorder, epilepsy, kidney failure, liver disorder or been advised
to have treatment for alcohol or drug abuse? // // // //
c. Has the proposed insured ever been diagnosed by a member of the medical
profession as having Acquired Deficiency Syndrome (AIDS), AIDS Related
Complex (ARC), or other immune deficiency disorder? // // // //
d. Have you ever been declined for life insurance? // // // //
APPLICATION (Continue to next page)
10. FULL UNDERWRITING PROPOSED
PROPOSED SECOND
PLEASE ANSWER ALL QUESTIONS. (EXPLAIN "YES" ANSWERS Under Section 10) INSURED INSURED
------- --------
YES NO YES NO
a. During the past 5 years have you consulted a physician or visited a clinic or
hospital as a patient? // // // //
b. Have you ever been treated for a heart murmur, high blood pressure or other heart,
blood or circulatory disorder or diabetes (whether or not on insulin)? // // // //
c. Have you ever been treated for convulsions, brain or spinal cord disorders? // // // //
d. Have you ever been treated for any disease of the bones, joints, muscles, lymph
gland, stomach, intestines or any immune disorder? // // // //
e. Have you had insurance offered with an extra premium? // // // //
f. Do you plan to travel or reside outside the United States? // // // //
(If yes, state when, where, how long).
g. Have you flown in the past 2 years as a pilot or student pilot? // // // //
h. Have you participated in the past 2 years in any type of vehicle racing, sky or
scuba diving or hang gliding? // // // //
i. Have you in the past 3 years been convicted or, pleaded guilty or no contest to: driving under
the influence of alcohol an/or drugs, speeding, reckless driving, or had your license suspended? // // // //
j. Have you in the past 12 months smoked cigarettes, cigars, pipes or used chewing tobacco? // // // //
If yes, specify substance.___________________________________________________
k. Proposed Insured Height_______ft. ________in. Weight________lbs.
l. Proposed Second Insured Height_______ft. ________in. Weight________lbs.
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11. GIVE COMPLETE DETAILS INCLUDING NAMES AND ADDRESSES OF DOCTORS, HOSPITALS AND TELEPHONE NUMBER.
Item # _______ ____________________________________________________________________________________________________
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Item # _______ ____________________________________________________________________________________________________
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Item # _______ ____________________________________________________________________________________________________
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12. OTHER INSURANCE INFORCE/APPLIED FOR: PROPOSED
PROPOSED SECOND
INSURED INSURED
-------- ---------
YES NO YES NO
Do you have life insurance in force or applied for? // // // //
(Give company, amount and year of issue)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
APPLICATION (Continue to next page)
13. AGREEMENT, ACKNOWLEDGMENT AND AUTHORIZATION
AGREEMENT AND ACKNOWLEDGMENT
Each of the undersigned declares that: the statements and answers contained
in this application are complete and true to the best of each person's
knowledge and belief: and each agrees that coverage can take effect only if
the Proposed Insured(s) is/are alive and all answers material to the risk are
still true and complete when the policy is delivered and paid for. I/We
agree that the statements and answers contained in this application shall
form the basis of any contract for life insurance that may be issued; and a
copy of his application shall be attached to and made part of the policy.
Except as provided in the Conditional Receipt with the same date as this
application, the insurance applied for will not take effect until: (a) the
policy is issued, delivered to the policyholder; and (b) the initial premium
is paid; while (c) each Proposed Insured(s) is/are living and his/her
insurability is the same as described in this application.
If the initial premium accompanies this application, I/we acknowledge
possession of the Conditional Receipt and certify that I/we have read it.
The terms and conditions of the receipt, to which I/we agree, have been
explained to me/us fully by the agent and I/we understand them.
I/We agree that only any Officer of the Company may alter the terms of the
application, the Conditional Receipt or the policy or waive any of the
Company's rights or requirements.
AUTHORIZATION TO OBTAIN, RELEASE AND DISCLOSE INFORMATION
I/We authorize: 1) any licensed physician, medical practitioner, hospital,
clinic or any other medically related facility, insurance company, the
Medical Information Bureau or other organization, institution or person that
has any records or knowledge of me/us or my/our health to give this data to
Alpine Life Insurance Company (Royal) or its reinsurers. 2) the medical,
surgical, drug or alcohol use mental health or emotional health information
requested to be used to determine my/our insurability and/or eligibility for
any benefits in the event of a claim. 3) Royal or its reinsurers to give any
information about me/us or my/our health to the Medical Information Bureau,
other insurance companies in which I/we may have policies, or to whom I/we
may apply, or to whom a claim for benefits may be submitted and as may be
required by law.
I/We understand that if I/we request details about any of the medical
information gathered about me/us or my/our children which relates to this
application; (a) the medical information; and, (b) the identity of the
medical care institution or the medical person who provided the information;
shall be released to me/us or to a licensed medical person or my/our choice.
Upon written request, I/we will receive details of the method I/we must use
to exercise my/our right to access, correct and amend any information
gathered about me/us or my/our children which relates to this application.
I/We may revoke, in writing , the right to use this consent form except to
the extent that action has already been taken.
This consent form will expire: two years from the date of the contract; or,
one year form the date below, if no contract has yet been issued. I/We know
that I/we may request to receive a copy of this authorization. A photocopy
of this consent form is as valid as the original.
SIGNED AT ____________________________ THIS ____________ DAY OF ________/________.
City State
__________________________________________ _________________________________________
SIGNATURE OF PROPOSED INSURED SIGNATURE OF PROPOSED SECOND INSURED
(PARENT OR GUARDIAN IF UNDER 15 YEARS OF AGE) (PARENT OR GUARDIAN IF UNDER 15 YEARS OF AGE)
__________________________________________ _________________________________________
SIGNATURE OF LICENSED AGENT/ SIGNATURE OF APPLICANT/OWNER
REGISTERED REPRESENTATIVE IF OTHER THAN PROPOSED INSURED(s)
__________________________________________ $________________________________________
OWNERS'S S.S. NO./TAX I.D. NO. AMOUNT RECEIVED WITH APPLICATION
APPLICATION (Continue to next page)
REGISTERED REPRESENTATIVE REPORT
PLEASE PRINT ALL INFORMATION CLEARLY
Information - Complete for all Applications
Broker/Dealer Name: _______________________________________________________________________________
________________________ ______________________ _________________________ ___________
Reg. Rep Name Reg. Rep Code Social Security Number Split %
________________________ ______________________ _________________________ ___________
Joint Reg. Rep Name Reg. Rep Code Social Security Number Split %
Reg. Representative Telephone:______________________________ Fax Number:_________________________
Proposed Insured Telephone: Home:__________________________ Business:___________________________
Best time to call Proposed Insured:_________________________________________________________________
Assistant's Name___________________________ Assistant's Telephone Number:____________________
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Do you have knowledge or reason to believe that replacement of existing life
insurance or annuities is involved in this transaction?
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COMMISSION PROGRAM - Contact your home office for program information.
// Program A // Program B // Program C // Firm/Default
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Estimated annual income, net worth and marital status or Proposed Insured(s) and
Applicant (if different)?
Give the purpose of this insurance and the nature of the Owner/Applicant's
interest.
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JUVENILE COVERAGE - If any insured is under age 19, please complete the following:
Applicant's relationship to proposed insured _______________________
Amount of insurance on each parents life _______________________________
Amount of insurance on each sibling ____________________________________
Income/Net worth of parents ____________________________________________
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PRODUCER CERTIFICATION - Complete for all Applications
1. I asked each question separately; the answers were recorded as given; and,
they are complete and accurate to the best of my knowledge and belief.
2. I am duly licensed in the state in which this application was signed.
3. I have given the Proposed Insured(s) the appropriate Disclosure documents.
4. I am a NASD Registered Representative.
5. I have compiled with state and federal laws on disclosure, cost comparison and replacement.
6. I have reviewed the purchase of this insurance policy as to suitability.
7. I have explained to the applicant that this policy is not effective until a policy is issued
by our National Service Center.
8. I have provided a compliance illustration with this application.
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X___________________________________________________
Signature(s) of Writing Registered Representative(s)
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HARTFORD LIFE USE ONLY:
F.O. #____ STAFF CODE _______ ADVANCED UND. CODE _______ MARKETING CODE ______
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CONDITIONAL RECEIPT
THIS RECEIPT IS VALID ONLY ON PROPOSED INSURED(S) AGE 80 OR LESS,
WITH AMOUNTS FOR NOT IN EXCESS OF THE INITIAL PREMIUM PLUS $500,000.
If any person proposed for coverage has answered "Yes" to any question in
Section 9, no payment may be accepted with the application.
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If the proposed insured qualifies for simplified underwriting, or answered
"no" to all the question in Section 9, an advance payment may be accepted and
the Conditional Receipt may be given ONLY under the following conditions:
1. The Proposed Insured(s) appear(s) to be standard risks, in all respects.
2. The Conditional Receipt is given and the advance premium is collected only at
the time the application is taken and signed.
3. The application does not contain a request for postdating.
4. The agent does not make an advance payment for the Proposed Insured or
Applicant. If this is done, loss of the agent's license could result.
5. For policies requiring full underwriting, the Proposed Insured(s) is/are 80
years old or less, age last birthday.
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1. NO COVERAGE WILL BECOME EFFECTIVE PRIOR TO DELIVERY OF THE POLICY APPLIED FOR
UNLESS AND UNTIL ALL THE CONDITIONS OF THIS RECEIPT HAVE BEEN FULFILLED
EXACTLY.
a) The amount of payment taken with the application must be equal to
full initial premium and for the amount of insurance, which may
become effective prior to delivery of the policy.
b) All medical examinations, test, x-rays and electrocardiograms
required by the Company must be completed and received at its
National Service Center in Minneapolis, Minnesota within 60 days
from the date of completion of this application.
c) As of the effective date, as defined below, each person proposed
for insurance in this application must be a risk insurable in
accordance with the Company's rules, limits, and standards for the
plan and the amount applied for without any modification either as
to plan, amount, riders and/or the rate of premium paid.
d) As of the effective date, the state of health and all factors
affecting the insurability of each and every person proposed for
insurance must be as stated in the application.
2. Subject to the conditions of paragraph 1 insurance, as provided by the terms
and conditions of the policy applied for and in use on the effective date,
but for an amount not exceeding that specified in paragraph 3, will become
effective as of the effective date. "Effective date", as used herein, is
the later of: (a) the date of completion of the application, or (b) the
date of completion of all medical examinations, tests, x-rays and
electrocardiograms required by the Company. The effective date is
determined separately for each person proposed for coverage.
3. The total amount of insurance which may become effective on any person
proposed for insurance shall not exceed the initial premium plus $500,000.
4. If one or more of the conditions of paragraph 1 have not been fulfilled
exactly, there shall be no liability on the part of the Company except to
return the applicable payment in exchange for this Receipt.
5. NO AGENT OR ANY OTHER PERSON IS AUTHORIZED BY THE COMPANY TO WAIVE OR
MODIFY IN ANY WAY ANY OF THE PROVISIONS OF THIS CONTINUAL RECEIPT.
If all the conditions are not fulfilled exactly, the insurance will take
effect when the policy is delivered to the owner stated in the application;
but only if at the time of such delivery there has been no change in
insurability as represented in the application.
All premium checks must be made payable to the Insurance Company. Do not
make checks payable to the agent or leave the payee blank.
Received a check totaling $___________from ______________________________ in
connection with the application for life insurance totaling $________________,
bearing the same date as this Conditional Receipt.
Dated at ______________ this ________ day of _____________/_____________.
____________________
Signature of Agent
I acknowledge possession of this receipt and certify that I have read it and
the agreement in the application. The terms and conditions of this receipt,
to which I agree, and the agreement in this application have been explained
to me fully by the agent and I understand them.
______________________
Signature of Applicant
THIS RECEIPT IS TO BE DETACHED AND GIVEN TO THE APPLICANT AT THE TIME OF
APPLICATION IF ANY MONEY IS TAKEN.