(10) Form of Application
TA logo Home office: Administrative office:
Transamerica Occidental Variable Life Service Center
Life Insurance Company P.O. Box 8990
1150 South Olive Boston, MA 02266-8990
Los Angeles, CA 90015
Transamerica (product name)
Application for Modified
Single Premium Variable
Universal Life Insurance
Policy
Form number filename: NPag1V3.doc version as of: Monday Aug 31
Page number
Transamerica (Product Name) SPVUL
1 Owner Information if other than proposed insured.
Name (first, middle and last)
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Street Address
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City, State and Zip code
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Social Security/ Tax ID Number Date of Birth (month/day/year)
/ /
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Relationship to Proposed Insured
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1a. Joint Owner Information if applicable
Name (first, middle and last)
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Street Address
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City, State and Zip code
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Social Security Number Date of Birth (month/day/year)
/ /
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Relationship to Proposed Insured
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2 Proposed Insured Information
Name (first, middle and last)
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Street Address
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City, State and Zip code
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Years at above address Date of Birth (month/day/year)
/ /
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State of Birth Social Security Number
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Sex (check one) Driver's License (State and
|_| Female |_| Male Number)
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Daytime Telephone Number Best Time
to Call
( )
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|_| a.m. |_| p.m.
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2b. Proposed Second Insured Information if applicable Name (first, middle and
last)
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Street Address
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City, State and Zip code
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Years at above address Date of Birth (month/day/year)
/ /
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State of Birth Social Security Number
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Sex (check one) Driver's License (State and
|_| Female |_| Male Number)
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Daytime Telephone Number Best Time
to Call
( )
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|_| a.m. |_| p.m.
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Relationship to Proposed Insured
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3 Beneficiary Information
Name of Primary Beneficiary Relationship to Proposed
Insured
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Street Address, City, State and Zip Social Security/ Tax ID
code Number
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Name of Contingent Beneficiary Relationship to Proposed
Insured
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Street Address, City, State and Zip Social Security/ Tax ID
code Number
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4Investment Tool Selection (Optional)
You may elect either the Automatic Account Rebalancing (AAR) option or the
Dollar Cost Averaging (DCA) option.
4a. |_| I elect AAR
You may have value in up to 20 sub-accounts. The minimum allocation per
sub-account is 5%, and the total must equal 100%. The Fixed Account is not
included in transfers under the AAR option. Indicate allocations in Section 5b
under AAR.
Select the frequency of AAR transfers (choose one):
|_| Quarterly |_| Semi-annually |_| Annually
4b. |_| I elect DCA
For each sub-account option to which funds should be transferred, indicate the
dollar amount per transfer. You may not transfer to the "source account" or to
the Fixed Account under the DCA option.
Indicate allocations in Section 5b, under DCA. Select your DCA "source account"
(choose one):
|_| Money Market |_| Fixed Account Select the frequency of
DCA transfers (choose one):
|_| Monthly |_| Quarterly |_| Semi-annually
Amount per transfer from the "source account": $___________.
(Minimum amount $100.)
5 Allocations Whole numbers only.
5a. Payments You may allocate payments to as many as 20 sub-accounts, plus the
Fixed Account. The minimum allocation for each elected allocation is 5% and the
total must equal 100%. Indicate the allocation in Section 5b under Payment.
5bInvestment Option Percentage (%)
($)
Payment AAR DCA
AIM V.I. Capital Appreciation _______ ______ ______
AIM V.I. Growth & Income _______ ______ ______
AIM V.I. International Equity _______ ______ ______
Alger American Income & Growth _______ ______ ______
Alliance VPF Growth & Income _______ ______ ______
Alliance VPF Premier Growth _______ ______ ______
Dreyfus VIF Capital _______ ______ ______
Appreciation _______ ______ ______
Dreyfus VIF Small Cap _______ ______ ______
Janus Aspen Balanced _______ ______ ______
Janus Aspen Worldwide Growth _______ ______ ______
MFS VIT Emerging Growth _______ ______ ______
MFS VIT Growth with Income _______ ______ ______
MFS VIT Research _______ ______ ______
Morgan Stanley UF Fixed Income _______ ______ ______
Morgan Stanley UF High Yield _______ ______ ______
Morgan Stanley UF Int'l Magnum _______ ______ ______
OCC Accumulation Trust Managed _______ ______ ______
OCC Accumulation Trust Small _______ ______ ______
Cap _______ ______ ______
Transamerica VIF Aggressive _______ ______ ______
Growth _______ ______ ______
Transamerica VIF Balanced _______ ______ ______
Transamerica VIF Growth _______ ______ ______
Transamerica VIF Money Market _______ XXXXX XXXXX
----- -----
Transamerica VIF Small Company _______ _______ _______
Transamerica VIF Value _______ ______ ______
Fixed Account _______ ______ ______
_____________________________ 100% 100%
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Total
File name P2V2.DOC Created on: Monday Aug 31
6 Telephone Access
I (we) will automatically be able to transfer sub-account and/or Fixed Account
values and change the allocation of future investments by telephone or fax
unless I (we) check the box below. |_| I (we) do not accept the Telephone Access
privilege.
(Please review additional information in the Acknowledgements and
Signatures section).
7 Insurance
7a. Life insurance coverage requested $___________.
7b. Additional insurance benefits requested:
|_| Living Benefits Rider
|-| --------------------------------
7c. This application is for a standard class of risk unless
noted otherwise here: ________________________.
8 Payment Complete as applicable.
8a. Direct Payment
Enclosed is a check for the initial payment of $____________. I (we)
received a conditional receipt.
Please make check payable to:
Transamerica Occidental Life Insurance Company. Do not leave
payee blank or make payable to the representative.
8b. IRC 1035 Exchange
The initial payment will be transferred from another life insurance policy
pursuant to an IRC 1035 Exchange. The Transfer of Assets form(s) for IRC
Section 1035 Exchange is attached.
|_| Yes |_| No My existing policy has a loan and I want
to carry over that loan to this
contract.
If yes, my loan carry over amount is $__________. Approximate amount of
exchange is $__________.
(Transfer payment plus loan carry over, if applicable.)
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Name of transferring company.
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Name of transferring company.
8c. Other Transfer Payment
My initial payment will be transferred from another Financial institution
(not an IRC 1035 Exchange).
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Name of transferring company. Approx. transfer
amount ($)
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Name of transferring company. Approx. transfer
amount ($)
|_| Transfer of Assets form(s) is attached.
|_| Transfer of Assets form(s) has been sent to the
transferring company.
9 Replacement of Other Contracts
May insurance, including annuities, in any company be replaced
if the proposed policy is issued? If yes, list company name(s)
and policy number(s):
Proposed Insured
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Proposed Second Insured
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In sections 10-16 the Proposed Insured is the "Insured" and the Proposed Second
Insured is the "Second Insured".)
10 Insured and Second Insured Information 10a-10d 10a. Please provide your
employer's name, your occupation
and your general responsibilities:
Insured ______________________________
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Second Insured _________________________
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10b. Nicotine Usage
Have you used a nicotine product during the past 24 months?
Insured Second Insured
Cigarettes |_| Yes |_| No |_| Yes |_| No
Cigars |_| Yes |_| No |_| Yes |_| No
Pipes |_| Yes |_| No |_| Yes |_| No
Chewing tobacco |_| Yes |_| No |_| Yes |_| No
Other ____________ |_| Yes |_| No |_| Yes |_| No
Specify date last used: _________ _________
10c. Financial Information
Insured Second Insured
Annual earned income $ ________ $ _________
Annual unearned income $ ________ $ _________
Approximate net worth $ ________ $ _________
10d. Height/Weight Information
Insured Second Insured
Height _________ __________
Weight _________ __________
11 Simplified Underwriting - Health History During the past 10 years, have you
had, or been treated for:
Insured Second Insured
a. heart, liver or lung
disease or disorder |_| Yes |_| No |_| Yes |_| No
b. kidney disease
or disorder |_| Yes |_| No |_| Yes |_| No
c. high blood pressure
or stroke |_| Yes |_| No |_| Yes |_| No
d. diabetes or cancer |_| Yes |_| No |_| Yes |_| No
e. nervous or
psychological disorders |_| Yes |_| No |_| Yes |_| No
f. alcohol or drug abuse |_| Yes |_| No |_| Yes |_| No
12 Simplified Underwriting - Immune Disorders During the past 10 years, have you
had a diagnosis of or treatment by a member of the medical profession for:
Insured Second Insured
a. an immune system
disorder |_| Yes |_| No |_| Yes |_| No
b. acquired immune
deficiency syndrome
(AIDS) |_| Yes |_| No |_| Yes |_| No
c. AIDS related complex
(ARC) |_| Yes |_| No |_| Yes |_| No
d. a sexually transmitted
disease. |_| Yes |_| No |_| Yes |_| No
Complete this page if: a) either the Insured or the Second Insured has
answered "yes" to any response in Section 11 or 12; or b)
the payment made is outside the simplified underwriting limits.
13 Primary Physician Information
If under care of more than one physician, indicate the other
physician's information in Section 17.
Insured
I have been diagnosed for:_____________________
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I am currently being treated for: _______________
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Primary physician ____________________________ Health care provider
___________________________ Street address _______________________________ City,
state and zip code ________________________ Telephone (_____)_______________
Date of last visit _________________(MM/DD/YYYY)
Second Insured
I have been diagnosed for: __________________
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I am currently being treated for: _______________
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Primary physician ____________________________ Health care provider
___________________________ Street address _______________________________ City,
state and zip code ________________________ Telephone (_____)_______________
Date of last visit _________________(MM/DD/YYYY)
14 Avocation/Sports Information
During the past two years, have you participated in or, in the future, do you
intend to participate in:
Insured Second Insured
a. Aeronautics
(including
hang-gliding,
skydiving, ballooning, |_| Yes |_| No |_| Yes |_| No
etc.)?
b. Powered racing or competitive vehicles (including motorcycles, automobiles
and motor
boats, etc.)? |_| Yes |_| No |_| Yes |_| No
c. Recreational vehicles
over open terrain, trails, sand, snow or ice (including snowmobiles and
dirt bikes, etc.)?
|_| Yes |_| No |_| Yes |_| No
d. Skin or scuba diving, mountain climbing, competitive skiing?
|_| Yes |_| No |_| Yes |_| No
If yes to any above, complete Avocation/Sports Questionnaire.
15 Aviation Information
Insured Second Insured
a. During the past two years, have you flown as a trainee, pilot or crew
member?
|_| Yes |_| No |_| Yes |_| No
b. Do you intend to fly
in one of these
capacities in the
future? |_| Yes |_| No |_| Yes |_| No
If yes to any above, complete Aviation Questionnaire.
16 Driving History
Insured Second Insured
a. During the past ten years, have you had a motor vehicle license suspended
or revoked?
|_| Yes |_| No |_| Yes |_| No
b. During the past ten years, have you been convicted of driving while
intoxicated?
|_| Yes |_| No |_| Yes |_| No
c. During the past ten years, have you had more than one moving violation?
|_| Yes |_| No |_| Yes |_| No
17 Remarks Section
Complete section 17, if under care of more than one
Insured
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Second Insured
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Filename: ACKNOWLE.DOC version as of: Monday Aug 31
Acknowledgements and Signatures
I (or "We", as applicable) acknowledge receipt of current Prospectuses
describing the Transamerica Occidental Life Insurance Company ("Company")
contract I (we) am (are) applying
for, and the underlying portfolios.
I (we) understand that any death benefits in excess of the face amount and any
contract value of the modified single payment variable universal life insurance
contract applied for may increase or decrease to reflect the investment
experience of the sub-accounts of the variable account. The contract value
allocated to the Fixed Account will accumulate interest at a rate set by the
Company that will not be less than the minimum guaranteed rate of 4% annually.
The contract value may decrease to the point where the contract will lapse and
provide no further death benefit without additional contract payments.
It is agreed that:
a) the application consists of this application form, and the medical
questionnaire, if any; b) The representations are true and complete to the best
of my (our) knowledge and belief; c) Except as provided in the conditional
receipt if issued with the same number as this application, no liability exists
and the insurance applied for will not take effect until the contract is
delivered and the premium is paid during the lifetime of the proposed insured(s)
and then only if the proposed insured(s) has (have) not consulted or been
treated by any physician or practitioner of any healing art nor had any tests
listed in the application since its completion; but if the payment is paid prior
to delivery of the Contract and a conditional receipt is delivered by the
registered representative, insurance will be effective subject to the terms of
the conditional receipt; and d) No registered representative or broker is
authorized to amend, alter, or modify the terms of this agreement.
Unless I (we) did not accept the Telephone Access privilege in Section 6 above,
I understand that the Company is authorized to honor telephone requests by me
(us) or individuals authorized by me (us), to transfer account values among
sub-accounts and the Fixed Account, and to change the allocation of future
payments. I (We) also understand that withdrawal of funds from my (our) contract
cannot be transacted by telephone or fax instructions.
I (We) understand that omissions or misstatements in the application could cause
an otherwise valid claim to be denied under any contract issued from the
application.
I (We) understand that the amount of insurance issued, if approved, will be the
amount determined by applying my (our) payment as 100% of the Guideline Single
Premium, unless I (we) requested a higher amount of insurance and the requested
amount is within the Company's underwriting guidelines.
I (We) understand that if an investigative consumer report is ordered in
connection with this application, I (we) may elect to be interviewed in
connection with the preparation of the report and, upon request, I (we) will be
provided with a copy of the report.
I (We) elect to be interviewed if an investigative consumer report is prepared.
Yes No
Signatures
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Signature of Proposed
Insured
Date
- ----------------------------------------------
Signature of Proposed Second Insured (or name of minor
child) Date
- ----------------------------------------
Signed at
City
State
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Signature of Proposed Owner (if
applicable) Date
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Signature of Proposed Second Owner (if
applicable) Date
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Signed at
City
State
If the owner is a corporation, an authorized officer, other than
the proposed insured(s), must sign as contract owner. Please
provide corporate title and the full name of the corporation:
Corporate Title _______________________________________
Corporation Name _____________________________________
For Financial Adviser Use Only
Does the Contract applied for replace an existing annuity or
life insurance contract? |_| Yes |_| No
If yes, attach replacement forms as required.
As Registered Representative, I certify witnessing the
signature of the applicant and that the information in this
application has been accurately recorded to the best of my
knowledge and belief. Based on the information furnished by
the proposed owner(s) or proposed insured(s) in this application, I certify that
I have reasonable grounds for believing the purchase of the Contract applied for
is suitable for the owner(s). I further certify that the prospectuses were
delivered and that no written sales materials other than those furnished by the
Company were used.
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Signature of Registered
Representative
Date
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Print Name of Registered Representative
Reg Rep # Share %
(-----)-----------------(-----)------------------------
Telephone Fax
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TR Code (Indicate A, B, C or D, as applicable)
- -----------------------------------------------------
Signature of Registered
Representative
Date
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Print Name of Registered Representative Reg
Rep # Share %
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Signature of Registered Representative Date
- -----------------------------------------------------
Print Name of Registered Representative Reg
Rep # Share %
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Name of Broker/Dealer Branch #
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Branch Office Street Address City, State and Zip
Code