EX-99.B(5)(B) 3 a2191292zex-99_b5b.txt EX-99.B(5)(B) Exhibit 5(b) [Lincoln Financial Group(R) LOGO] LINCOLN LIFE & ANNUITY COMPANY OF NEW YORKY SERVICE OFFICE: [350 CHURCH ST. - MEM1, HARTFORD, CT 06103-1106] (HEREINAFTER REFERRED TO AS "THE COMPANY") IMPORTANT NOTICE Since you are applying for insurance, we would like you to know more about our underwriting process and what occurs after you submit your application. THE UNDERWRITING PROCESS All forms of insurance are based on the concept of risk-sharing. Underwriters seek to determine the level of risk represented by each applicant, and then assign that person to a group with similar risk characteristics. In this way, the risk potential can be spread among all policyholders within a given risk group, assuring that each assumes his fair share of the insurance cost. Underwriters collect and review risk factors such as age, occupation, physical condition, medical history and any hazardous avocations. The level of risk and premium for the amount of coverage requested is based on this information. INVESTIGATIVE CONSUMER REPORT As a part of our routine procedure for processing your initial application, we may request an investigative consumer report. The agency making the report may keep a copy of the report and disclose its contents to others for whom it performs similar services. The report typically includes information such as identity and residence verification, character, reputation, marital status, estimate of net worth and income, occupation, avocations, medical history, habits, mode of living and other personal characteristics. Additional information is usually obtained from several different sources. Confidential interviews are conducted with neighbors, friends, business associates, and acquaintances. Public records are carefully reviewed. Past experience shows that information from investigative reports usually does not have an adverse effect on our underwriting decision. If it should, we will notify you in writing and identify the reporting agency. At that point, if you wish to do so, you may discuss the matter with the reporting agency. You have the right to be interviewed as part of any investigative consumer report that is completed. If you desire such an interview, please indicate this at the time your application is submitted. If you request it, we will supply the name, address and telephone number of the consumer reporting agency so you may obtain a copy of the report. CONTESTABILITY We strongly urge you to review the completed application closely for accuracy. During the 2 year contestability period described in the policy, a claim may be denied if the application contains material misrepresentations or fails to disclose material facts. In such a case, the policy could be void and coverage could be lost. MIB, INC. Information you provide regarding your insurability or claims will be treated as confidential except that The Company or its reinsurers, may make a brief report of it to MIB, Inc. This is a nonprofit membership organization of life insurance companies which operates an information exchange on behalf of its members. Upon request by another member insurance company to which you have applied for life or health insurance coverage or submitted a claim, MIB, Inc. will provide the information it may have in its file. Upon receipt of a request from you, MIB, Inc. will arrange disclosure of any information it may have in your file. If you question the accuracy of information in MIB, Inc.'s file, you may contact MIB at: [Box 105 Essex Station, Boston, MA 02112]. You can reach MIB by phone toll free at [(866) 692-6901. (TTY {866} 346-3642)]
[Lincoln Financial Group(R) LOGO] LINCOLN LIFE INSURANCE & ANNUITY COMPANY OF NEW YORK CORPORATE/BUSINESS OWNER APPLICATION - PART II EXECUTIVE BENEFITS, MEM1 [350 CHURCH STREET HARTFORD, CT 06103-1106] SECTION 1: INSURED INFORMATION 1. PROPOSED INSURED (First, Middle Initial, Last) 2. Place of Birth 3. Country of Citizenship ____________________________________________________________________________________________________________________________________ 4. Are you a citizen of the United States? [_] Yes [_] No (If "No", please provide country, type of visa, expiration date and green card information) ____________________________________________________________________________________________________________________________________ 5. Date of Birth (Mo-Day-Yr) 6. Social Security Number 7. Sex (CIRCLE) 8. Drivers License No. & State ___ /__ /____ _______-____ -_____ M F ____________________________________________________ 9. Current Build 9a. Has your weight changed by more than 10 pounds during the past 12 months? [_] Yes [_] No Height ______ft ______in Weight ______lb. 9b. If "Yes", by how many pounds? _________ Gain/Loss 10. Residence Address (No., Street) PO Box City, State, ZIP ____________________________________________________________________________________________________________________________________ 11. I have been notified by my employer that the maximum amount of insurance coverage that will be issued is: $_____________________ SECTION 2: MEDICAL & RELATED INFORMATION IF YOU ANSWER NO TO QUESTION 12, OR YES TO QUESTIONS 13-21, EXPLAIN IN THE SPACE PROVIDED ON PAGE 2. YES NO 12. Have you been actively at work daily on a full-time basis (30 hours/week) performing all duties of your regular occupation, at your customary place of employment for the past 3 months? (Disregard vacation days, normal non-working days and absences that total less than 4 consecutive days.) [_] [_] 13. Have you used any tobacco products in the past 12 months? IF YES, HOW MUCH AND DATE (MONTH/YEAR) LAST USED: [_] Cigarettes _______________________ [_] Cigars _______________________________ [_] Pipe _____________________________ [_] Smokeless tobacco ____________________ [_] Snuff_____________________________ [_] Nicotine Patches/Gum__________________ [_] [_] 14a. Do you now, or do you plan to fly, or have you flown during the past 2 years, as a pilot, student pilotor crew YES NO member? (IF "YES", AN AVIATION SUPPLEMENT IS REQUIRED.) [_] [_] 14b. Do you plan to participate, or have you participated within the past 2 years; in motor vehicle or boat racing, in hang gliding, sky or scuba diving, or mountain, rock or technical climbing; or in similar sports? (IF "YES", AN AVOCATION QUESTIONNAIRE IS REQUIRED.) [_] [_] 14c. Do you now, or do you plan to reside or travel outside of the United States or Canada within the next year? (IF "YES", A FOREIGN TRAVEL OR RESIDENCE QUESTIONNAIRE IS REQUIRED). [_] [_] 15 Have you ever had an indication of, or treated for: a. Chest pain, palpitations, high blood pressure, heart disease, heart murmur, heart failure or other disorders of the heart or blood vessels? [_] [_] b. Ulcers, colitis, jaundice, hepatitis, cirrhosis, gastrointestinal bleeding, or other disorder of the stomach, esophagus, liver, intestines, gallbladder, or pancreas? [_] [_] c. Seizures, fainting, dizziness, epilepsy, stroke, paralysis or other neurologic or brain disorder? [_] [_] d. Any nervous, mental, or emotional disorder, or received counseling for anxiety, depression, stress or any other emotional condition? [_] [_] e. Any tumor, cancer, cysts, melanoma, lymphoma or any disorder of the lymph nodes? [_] [_] f. Arthritis, gout or any disorder of the back, spine, muscles, nerves, bones or joints or skin? [_] [_] g. Diabetes, elevated blood sugar, thyroid, or other endocrine or glandular disorder? [_] [_] h. Anemia, leukemia, clotting disorder or any other blood disorder? [_] [_] i. Asthma, emphysema, shortness of breath, allergies, sleep apnea, tuberculosis, sarcoidosis, persistent hoarsenessor shortness of breath or any other disorder of the respiratory system? [_] [_] j. Any disorder of the eyes, ears, nose or throat? [_] [_] k. Any complication of pregnancy or disorder of the testicles, prostate, breasts, ovaries, uterus, cervix, kidney or urinary bladder? [_] [_] l. Any mental or physical disorder medically or surgically treated condition not listed above? [_] [_] 16. Have you ever been diagnosed by a medical professional as having [AIDS Related Complex (ARC)] or Acquired Immunodeficiency Syndrome (AIDS), or have you received treatment from a medical professional for AIDS or [ARC]? [_] [_]
[CORPORATE/BUSINESS OWNER] 1 [Lincoln Financial Group(R) LOGO] LINCOLN LIFE & ANNUITY COMPANY OF NEW YORK CORPORATE/BUSINESS OWNER APPLICATION - PART II EXECUTIVE BENEFITS, MEM1 [350 CHURCH STREET HARTFORD, CT 06103-1106] SECTION 2: MEDICAL & RELATED INFORMATION (CONT.) YES NO 17. Have you used or do you currently use alcoholic beverages? (IF YES, PROVIDE TYPE, FREQUENCY & AMOUNT) Type ______________ Frequency _____________ Amount ___________ [_] [_] 18. Have you ever been treated for drug or alcohol abuse or been advised by your doctor to limit your use of alcohol or any medication, prescribed or not? [_] [_] 19. Have you ever used or experimented with cocaine, marijuana, or other non-prescription stimulants (not including caffeine), depressants, or narcotics? [_] [_] 20. Have you had or been advised to have a check-up, EKG, x-ray, blood or urine test or any other diagnostic test? [_] [_] 21. Have you been a patient in a hospital, clinic, sanatorium or other medical facility, or been advised to have any hospitalization or surgery which has not been completed? [_] [_] 22. List all medication and dosages you are currently taking or have taken in the last 30 days, including prescriptions, over the counter drugs, aspirin and herbal supplements. _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ EXPLANATIONS 23. Number, nature and severity of condition, frequency of attacks, treatments received medication, dates, name, address & phone number of medical attendants and hospitals. Details (List details from "Yes" answered Medical Information; please include question number.) Use an additional sheet of paper if necessary. QUES. DETAILS ------------------------------------------------------------------------------------------------------------------------------------ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ADDITIONAL INFORMATION 24a. Name & Address of physician last consulted ____________________________________________________________________________________________________________________________________ 24b. Date and reason last consulted ____________________________________________________________________________________________________________________________________ 24c. Name & Address of primary care physician ____________________________________________________________________________________________________________________________________ 24d. Date of last complete physical examination and reason last consulted ____________________________________________________________________________________________________________________________________ 25. AGE IF LIVING & HEALTH STATUS DIABETES, CANCER, HEART DISEASE AGE AT DEATH & CAUSE ------------------------------------------------------------------------------------------------------------------------------------ a. Father ____________________________________________________________________________________________________________________________________ b. Mother ____________________________________________________________________________________________________________________________________ c. Sibling(s) ____________________________________________________________________________________________________________________________________
[CORPORATE/BUSINESS OWNER] 3 [Lincoln Financial Group(R) LOGO] LINCOLN LIFE & ANNUITY COMPANY OF NEW YORK CORPORATE/BUSINESS OWNER APPLICATION - PART II EXECUTIVE BENEFITS, MEM1 [350 CHURCH STREET HARTFORD, CT 06103-1106] GENERAL RISK INFORMATION 27. Have you had any convictions within the past 3 years for motor vehicle moving violations, or had your license YES NO suspended, revoked or restricted? [_] [_] 28. Have you ever applied for any Life or Health Insurance which was denied, required an extra premium or was issued for a reduced amount? [_] [_] 29. Currently, or within the past 10 years, have you received or applied for any disability benefits, including Worker's Compensation, Social Security Disability Insurance or any other form of disability insurance? "(IF "YES", PROVIDE DETAILS BELOW.) [_] [_] 30. Have you ever been convicted of a felony? (If "Yes", please indicate type, date and city/state of felony and if currently on probation or parole) _______________________________________________________ [_] [_] 31. Are you a member of, or applied to be a member of, or received a notice of required service in, the armed forces, reserves or National Guard? [_] [_] 32. DETAILS (LIST DETAILS FROM QUESTIONS ABOVE; PLEASE INCLUDE QUESTION NUMBER DETAILS PERTAIN TO.) Please use additional sheet of paper if needed. ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ EXISTING COVERAGE IN FORCE OR APPLIED FOR: 32a. What is the total face amount of all life insurance policies presently INFORCE on your life, if any? $____________________ 32b. What is the total amount of new life insurance coverage currently APPLIED FOR on your life with all companies? Plan Type: ___________________________ - Total $_______________ Carrier(s) __________________________ ___________________________ - Total $_______________ Carrier(s) __________________________ ___________________________ - Total $_______________ Carrier(s) __________________________ Please attach a list of any other additional insurance on a separate sheet.
[CORPORATE/BUSINESS OWNER] 4 [Lincoln Financial Group(R) LOGO] LINCOLN LIFE & ANNUITY COMPANY OF NEW YORK CORPORATE/BUSINESS OWNER APPLICATION - PART II EXECUTIVE BENEFITS, MEM1 [350 CHURCH STREET HARTFORD, CT 06103-1106]
CERTIFICATIONS I have read the questions and answers in this application and declare that they are complete and true to the best of my (our) knowledge and belief. Statements contained in this application shall be deemed representations and not warranties. I agree that this Application shall form a part of any Policy issued, and that no Agent/Representative of Lincoln Life & Annuity Company of New York shall have the authority to waive a complete answer to any question in this Application, make or alter any contract, or waive any of Lincoln Life & Annuity Company of New York's other rights or requirements. I agree that coverage can take effect only if the proposed insured is alive, and remains in the same state of health and insurability as described in each part of the application at the time the entire first premium is paid and the policy is delivered and accepted by the Owner. I agree to advise Lincoln Life & Annuity Company of New York or producer in writing of any known or suspected changes in my health, or of any changes to any answers on this application, prior to delivery of this policy. I acknowledge that I qualify as a key employee and I further acknowledge that the Policy will be used to informally fund benefit obligations. I understand and agree that the Owner may be the sole owner and beneficiary of the Policies and that neither I, my estate nor any beneficiary I may designate shall have any interest in the Policy or a right to the proceeds thereof, unless otherwise described in the Plan Document. I understand that this Policy will be acquired by the Owner for its own benefit in connection with informally funding Owner benefit liabilities. I understand that, in order to informally fund benefit obligations, the Owner may need to increase the amount of insurance under existing Policy on my life from time to time. I hereby authorize the Owner to affect such an increase or increases without providing any further notice to me. I also consent to and authorize the Owner to continue to be the owner and beneficiary of the Policy indefinitely, including after my employment terminates, whenever and for whatever reason this may occur unless otherwise described in the Plan Document. AUTHORIZATION/DECLARATION THE SIGNATURES BELOW REPRESENT THE FOLLOWING: The purpose of this authorization is to allow Lincoln Life & Annuity Company of New York, hereinafter the "Company", to determine eligibility for coverage or a claim for benefits under a life policy. I authorize any medical professional, hospital or other medical institution, insurer, MIB, Inc., or any other person or organization that has any records or knowledge of my physical or mental health or insurability to disclose that information to the Company, its reinsurers, or any other party acting on the Company's behalf. I authorize the Company to disclose medical information to MIB, Inc., and to other insurers to whom I may apply for coverage. This authorization shall be valid for two years after it is signed. A photographic copy of this authorization shall be as valid as the original. I will be given a copy of this authorization at my request. I understand that I may revoke this authorization at any time by written notification to the Company; however, any action taken prior to notification will not be affected. I ACKNOWLEDGE receipt of the Important Notice containing the Privacy Notice, Investigative Consumer Report, and MIB, Inc., information. IF AN INVESTIGATIVE CONSUMER REPORT IS OBTAINED, I [_] DO [_] DO NOT REQUEST TO BE INTERVIEWED. Signed at (City & State) ______________________________ on (Date) ______________ --------------------------------------------------- --------------------------- Signature of Proposed Insured Witness [CORPORATE/BUSINESS OWNER] 5