EX-99.APP 4 g85171a1exv99wapp.txt EX-99.APP APPLICATION FOR LIFE INSURANCE POLICY EXHIBIT 99.APP Exhibit 27(e) Application for Flexible Premium Variable Life Insurance Policy A History Of Performance(R) WRL PRIORITY: P.O. BOX 9026 [WRL(R) LOGO] CLEARWATER, FL 33758-9026 Western Reserve Life Assurance Co. of Ohio STREET ADDRESS-USE FOR CARRIER OTHER THAN POST OFFICE: 570 CARILLON PARKWAY ST. PETERSBURG, FLORIDA 33716 1-800-443-9975 APPLICATION FOR LIFE INSURANCE Agent Name:_____________________________________________________________________ Agent Number:___________________________________________________________________ Broker/Dealer:__________________________________________________________________ Date Faxed: (If Applicable)_____________________________________________________ Amount of initial premium with application $ ____ , _______ , ______ . ____ Amount to be applied to application ________________________ $ ____ , _______ , ______ . ____ ________________________ ________________________ $ ____ , _______ , ______ . ____ ________________________ Owner E-Mail:___________________________________________________________________ DO: AGENT COMMENTS [ ] Complete the entire application (front and back). [ ] Print application in black ink. _____________________________________________ [ ] Have applicant initial all changes. [ ] Obtain all required signatures. _____________________________________________ [ ] Complete and sign the Agents Report. [ ] Include certification if a trust is owner of the policy. _____________________________________________ [ ] Section 5,6 & 13, Page 2: If additional space is required firmly attach a separate page. _____________________________________________ DO NOT: [ ] Use pencil or whiteout. _____________________________________________ [ ] Accept or send money on applications that total more than $1,000,000.00 _____________________________________________ [ ] Submit an agent check as the initial premium. [ ] Submit starter checks or deposit _____________________________________________ slips for electronic (bank draft) withdrawals. _____________________________________________ (For additional space, see reverse)
ADDITIONAL COMMENTS ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ CMC__________ AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS ATTACH VOIDED SAMPLE OF YOUR PERSONAL CHECK HERE To: Banks which agree to honor charges in the form of checks, draft or debits ACH electronic fund transfers. So that you may comply with your depositor's authorization and direction as set forth below, Western Reserve Life Assurance Co. of Ohio agrees: 1. To indemnify you and hold you harmless from any loss you may suffer as a consequence of your actions resulting from or in connection with the execution and issuance of any check or draft, whether or not genuine, or payment of any preauthorized ACH electronic fund transfer debit received by you in the regular course of business for the purpose of payment to this Company, including any cost or expenses reasonably incurred in connection therewith. 2. In the event that any such check, draft or debit shall be dishonored whether with or without cause, and whether intentionally or inadvertently, to indemnify you for any loss even though dishonor results in a forfeiture of the insurance. 3. To defend at our own cost and expense any action which might be brought by any depositor or any other persons because of your actions taken pursuant to the foregoing request, or in any manner arising by reason of your participation in the foregoing plan of premium collections. WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO Authorized in a resolution adopted /s/ William H Geiger by the Executive Committee of the Secretary Board of Directors of WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO on October 29, 1991. TO: WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO As a convenience to me, I hereby request and authorize you to obtain payment of amounts becoming due you by initiating charges in the form of check, drafts or debits via ACH electronic fund transfers on my account maintained at the ___________________________________ _____________________________________ (Name of Bank) (Address of Bank) for the payment of each monthly premium under Policy LIST ANY OTHER POLICIES TO BE PAID No.________________ on the life of _________________________ BY SAME CHECK, DRAFT OR DEBIT 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 drawing any such check or draft or initiating such debit. I understand that if any such check, draft __________________________________ or debit be dishonored by my Bank and any monthly amount due to WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO is not paid within the __________________________________ time stipulated in the policy, said policy shall become null and void except as otherwise provided therein. __________________________________ AUTHORIZATION FOR PREAUTHORIZED PAYMENTS TO: WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO P.O. BOX 9026, CLEARWATER, FL 33758-9026
"I elect __________ day (select 1 to 27) of As a convenience to me, I hereby request and authorize you to pay each month to have the payment of $ _________ and charge to my bank checking account checks or drafts drawn by taken from my account. If no date is indicated and payable to the order of WESTERN RESERVE LIFE ASSURANCE CO. OF the draft date will be the policy issue date." OHIO or to debit my account identified above via ACH electronic fund transfers provided there are sufficient collected funds in said account to pay the same upon presentation. 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 check, draft or debit. I further agree that if any such draft or debit be check, dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in the forfeiture of insurance. _____________________ 1 (X)_________________________ _____________________ 2 (X)_________________________ Both Authorized Signatures Required on Joint Accts.
THIS PAGE IS INTENTIONALLY BLANK LIFE APPLICATION-PART 1 WRL - Western Reserve Life Assurance Co. of Ohio, P.O. Box 9026, Clearwater, FL 33758-9026 SECTION 1. PROPOSED PRIMARY INSURED/OWNER [ ] Check if Proposed Primary Insured is also the Owner IF PROPOSED CONTINGENT OWNER IS NAMED, PLEASE USE ADDITIONAL INFORMATION PAGES. 1. Last Name First Name M.I. 2. Address Apt# City State Zip Code 3. Years at Address 4. Home Phone ( ) 5. Driver License Number State 6. Sex [ ] Male [ ] Female 7. Date of Birth M M - D D - Y Y Y Y 8. Insurable Age 9. Place of Birth - State/Country 10. Social Security Number 11. Height ft in 12. Weight lbs 13. Marital Status 14. Employer Years 15. Occupation & Duties 16. Employer's Address 17. Business Phone Number ( ) - 18. Have you used TOBACCO or any other product containing NICOTINE in the last 5 years? [ ] Yes [ ] No Date last used _____________ 19. Rate Class Quoted: [ ] Preferred Elite [ ] Preferred Plus [ ] Preferred [ ] Non-Tobacco [ ] Preferred Tobacco [ ] Tobacco [ ] Juvenile SECTION 2. PROPOSED OTHER INSURED IF MORE THAN ONE OTHER INSURED, PLEASE USE ADDITIONAL INFORMATION PAGES 1. Last Name First Name M.I. 2. Address Apt# City State Zip Code 3. Years at Address 4. Home Phone ( ) 5. Driver License Number State 6. Sex [ ] Male [ ] Female 7. Date of Birth M M - D D - Y Y Y Y 8. Insurable Age 9. Place of Birth - State/Country 10. Social Security Number 11. Height ft in 12. Weight lbs 13. Marital Status 14. Relationship to Proposed Insured 15. Employer Years 16. Occupation & Duties 17. Employer's Address 18. Business Phone Number ( ) 19. Have you used TOBACCO or any other product containing NICOTINE in the last 5 years? [ ] Yes [ ] No Date last used _____________ 20. Rate Class Quoted: [ ] Preferred Elite [ ] Preferred Plus [ ] Preferred [ ] Non-Tobacco [ ] Preferred Tobacco [ ] Tobacco [ ] Juvenile SECTION 3. APPLICANT/OWNER IF OTHER THAN THE PROPOSED PRIMARY INSURED 1. Last Name First Name M.I. 2. Address Apt# City State Zip Code 3. Home Phone ( ) 4. Social Security Number / Tax ID # 5. Date of Birth/Trust Date M M - D D - Y Y Y Y 6. Relationship to the Proposed Primary Insured: SECTION 4. CHILDREN'S INSURANCE RIDER COVERAGE AMOUNT $ ___________, ____________
Name Relationship Date of Birth Height Weight --------------------------------------------------------------------------------- M M - D D - Y Y Y Y ft in lbs --------------------------------------------------------------------------------- M M - D D - Y Y Y Y ft in lbs --------------------------------------------------------------------------------- M M - D D - Y Y Y Y ft in lbs ---------------------------------------------------------------------------------
Are all children listed? [ ] Yes [ ] No Are children living with proposed primary insured? [ ] Yes [ ] No If not, explain why: _________________________ 1 LIFE APPLICATION SECTION 5. PRIMARY BENEFICIARY - IF PERCENTAGE SHARES ARE NOT LISTED BELOW, THEY WILL BE DIVIDED EQUALLY AMONG THE BENEFICIARIES
Name Percent Relationship Social Security Number/Tax ID# -------------------------------------------------------------------------------- - - -------------------------------------------------------------------------------- - - -------------------------------------------------------------------------------- - - -------------------------------------------------------------------------------- TOTAL 100 --------------------------------------------------------------------------------
SECTION 6. CONTINGENT BENEFICIARY - IF PERCENTAGE SHARES ARE NOT LISTED BELOW, THEY WILL BE DIVIDED EQUALLY AMONG THE BENEFICIARIES
Name Percent Relationship Social Security Number/Tax ID# -------------------------------------------------------------------------------- - - -------------------------------------------------------------------------------- - - -------------------------------------------------------------------------------- - - -------------------------------------------------------------------------------- TOTAL 100 --------------------------------------------------------------------------------
SECTION 7. PROPOSED PLAN OF INSURANCE: 1. [ ] Freedom Xcelerator [ ] Other ________________________________ 2. Specified Amount: $ _________ , _________ , __________ 3. Primary Insured Rider Plus $ _________ , _________ , __________ 4. Other Insured Rider $ _________ , _________ , __________ _________________________________ $ _________ , _________ , __________ 5. ARE YOU APPLYING FOR MORE THAN ONE OTHER INSURED RIDER? [ ] YES [ ] NO IF YES PLEASE USE ADDITIONAL INFORMATION PAGES SECTION 8. DEATH BENEFIT OPTION [ ] A) Level Benefit [ ] B) Increasing Benefit [ ] C) Option B To Age 70 Then Grading Down to Level Death Benefit SECTION 9. ADDITIONAL BENEFITS-PRIMARY INSURED ONLY [ ] Death Benefit Extension Rider [ ] Disability Waiver Rider [ ] Disability Waiver of Premium Rider ($300 per month maximum) $ __________________ [ ] Accidental Death Benefit ($150,000 maximum) $ ____________ , ____________ [ ] Inflation Death Benefit Rider (only available with Option A) SECTION 10. PREMIUMS PAYABLE Planned Premium $ ____________, ___________. ___________ [ ] Electronic (bank draft) _______ Draft Date (1st thru 27th) [ ] Direct Bill [ ] Single Premium [ ] Quarterly [ ] Annual [ ] Monthly [ ] Semi-annual [ ] Other SECTION 11. SUBACCOUNT ALLOCATIONS FOR VARIABLE PLANS ONLY USE L-APPSUPP SUBACCOUNT ALLOCATIONS FOR LIFE INSURANCE SECTION 12. LIFE INSURANCE COMPLIANCE TEST (ONLY CHOOSE ONE) [ ] Cash Value Accumulation Test (CVAT) [ ] Guideline Premium Test SECTION 13. OTHER INSURANCE IN FORCE FOR ALL PROPOSED INSUREDS Does the proposed insured have existing life insurance policies or annuity contracts? [ ] Yes [ ] No
Proposed Insured Name Company Amount of insurance Year issued Replacement? ----------------------------------------------------------------------------------------------------------- Yes No ----------------------------------------------------------------------------------------------------------- Yes No ----------------------------------------------------------------------------------------------------------- Yes No -----------------------------------------------------------------------------------------------------------
IS THIS INTENDED TO BE A 1035 EXCHANGE? [ ] Yes [ ] No Anticipated Cash Value Transfer $ ___________ , ___________ , __________ 1) Has any proposed insured ever had life, disability or health insurance declined, rated, modified, issued with an exclusion rider, canceled, or not renewed? If yes please explain in REMARKS. [ ] Yes [ ] No 2) Will the insurance applied for on any proposed insured replace or change any existing life or annuity policy? If yes, complete replacement forms, if appropriate. [ ] Yes [ ] No 3) Is there an application for life, accident or sickness insurance now pending or contemplated on any proposed insured in this or any other company? If yes, give details in Agent's Report, Question 3. [ ] Yes [ ] No 2 LIFE APPLICATION-PART 2 SECTION 14. PERSONAL FINANCIAL STATEMENT FOR PROPOSED PRIMARY INSURED A) Gross Income Current Yr $ __________ , _________ , ___________ B) Gross Income Previous Yr $ __________ , _________ , ___________ C) Source of Income [ ] Employment [ ] Retirement [ ] Inheritance [ ] 1035 Exchange [ ] Other _________________________ D) Current Net Worth $ __________ , _________ , ___________ For over $1 million applied coverage complete a separate financial questionnaire (Form #U00001 - 12/97) 15. COMPLETE FOR CORPORATION,PARTNERSHIP, OR TRUST A) Current Estimated Market Value $ __________ , _________ , ___________ B) Assets Liquid $ __________ , _________ , ___________ Nonliquid $ __________ , _________ , ___________ C) Liabilities $ __________ , _________ , ___________ D) Net Worth $ __________ , _________ , ___________ SECTION 16. MEDICAL QUESTIONS - EACH QUESTION MUST BE INDIVIDUALLY ASKED AND ANSWERED FOR EACH PROPOSED INSURED. Give the details of "Yes" answers below. Identify question number; state signs, symptoms and diagnosis of each illness or injury. List the details and results of any treatment; List the name, full address and dates of each health care provider consulted. To the best of your knowledge, has any Proposed Insured within the last 10 yrs had or been told by a member of the medical profession that he or she had, or has been treated for: 1) Heart murmur, high blood pressure, chest pain, heart attack, stroke, or other disorder of the heart or circulatory system? [ ] Yes [ ] No 2) Asthma, Emphysema, Chronic Bronchitis, Tuberculosis, or any other Respiratory disorder; colitis, ulcer or any other gastrointestinal disorder; jaundice, hepatitis, liver or kidney disorder? [ ] Yes [ ] No 3) Cancer, tumor, polyp, breast, prostate or any other reproductive disorder; or any thyroid or endocrine disorder? [ ] Yes [ ] No 4) Brain, mental, anxiety, depression, suicide attempt, or seizure disorder; or any paralysis? [ ] Yes [ ] No 5) Diabetes, anemia, or any disorder of the blood; sugar, protein, or blood in the urine? [ ] Yes [ ] No 6) Used amphetamines, heroin, cocaine, marijuana, or any other illegal or controlled substance except as prescribed by a physician? [ ] Yes [ ] No 7) Sought or been advised to seek treatment, limit or discontinue use of alcohol? [ ] Yes [ ] No 8) Been on or are now on prescribed medication or diet? [ ] Yes [ ] No 9) Has any Proposed Insured been told by a member of the medical profession that he or she had a diagnosis of AIDS (Acquired Immune Deficiency Syndrome), ARC (AIDS Related Complex), or the HIV (Human Immunodeficiency Virus) infection? [ ] Yes [ ] No 10) Had or been advised to have any hospitalization, surgery, or any diagnostic test including, but not limited to, electrocardiograms, blood studies, scans, MRI's or other test? [ ] Yes [ ] No 11) An examination, treatment or consultation with a doctor or health care provider other than above? [ ] Yes [ ] No 12) Has any parent or sibling had any occurance prior to age 60 of coronary artery disease, cardiovascular disease, intestinal cancer or melanoma? [ ] Yes [ ] No SECTION 17. DETAILS TO "YES" ANSWERS FOR MEDICAL QUESTIONS SECTION Name, Address and Phone # of Question # Proposed Insured's Name Date, Diagnosis, Treatment, Results, and Duration Attending Doctor and Hospital ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________
SECTION 18. NAME AND ADDRESS OF PERSONAL PHYSICIAN AND REASON CONSULTED (IF NONE, SO STATE) Primary Insured Other Insured Children ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________
Date and reason last consulted a physician Date and reason last consulted a physician Date and reason last consulted a physician ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________
3 LIFE APPLICATION SECTION 19. RESIDENCY A) Any Proposed Insured is a citizen of [ ] USA [ ] Other Country __________ Type of VISA ______________ B) How many years has the proposed insured resided in the USA? _________________ C) Does any proposed travel outside the USA? [ ] Yes [ ] No If yes, provide details: include destination, number of trips, duration of each trip, purpose of trip, plans for the next year. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ SECTION 20. DRIVING RECORD A) Has any Proposed Insured had their driver's license suspended, restricted, revoked, or been cited for a moving violation in the last 5 years? [ ] Yes [ ] No If yes, give reason: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ B) Has any Proposed Insured in the last ten years been convicted of a misdemeanor (other than a minor traffic violation) or felony? [ ]Yes [ ] No If yes, give reason: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ SECTION 21. SPECIAL ACTIVITIES A) Except as a passenger on a regularly scheduled flight, has any proposed insured flown within the past 3 years, or does any proposed insured have plans to fly in the future? If yes, complete Aviation Questionnaire. [ ] Yes [ ] No B) In the past 3 years has any proposed insured participated in organized racing (automobile, motorcycle, or boat), underwater or sky diving, hang gliding, mountain or rock climbing? If yes, complete an Avocation Questionnaire. [ ] Yes [ ] No SECTION 22. SUITABILITY FOR VARIABLE LIFE INSURANCE POLICY--COMPLETE FOR ALL VARIABLE PLANS A) Have you, the Proposed Primary Insured, and Applicant/Owner, if other than the Proposed Primary Insured, received the current Prospectus for the policy? [ ] Yes [ ] No B) Do you understand that the Death Benefit may be variable or fixed under specific conditions? [ ] Yes [ ] No C) DO YOU UNDERSTAND THAT UNDER THE POLICY APPLIED FOR (EXCLUSIVE OF ANY OPTIONAL BENEFITS), THE AMOUNT OF DEATH BENEFIT AND THE ENTIRE AMOUNT OF THE POLICY CASH VALUE MAY INCREASE OR DECREASE DEPENDING UPON THE INVESTMENT EXPERIENCE? [ ] Yes [ ] No D) With this in mind, is the policy in accordance with your insurance objectives and your anticipated financial needs? [ ] Yes [ ] No E) Would you like to receive a statement of additional information? [ ] Yes SECTION 23. TO BE COMPLETED BY APPLICANT/OWNER Transfer Authorization: (See Prospectus for transfer procedures.) Your policy applied for, if issued, will automatically receive transfer privileges described in the applicable prospectus unless declined below. These privileges allow the Owner to give the registered representative/agent of record for this policy authority to make transfers and to change the allocation of future payments among the Subaccounts and the Fixed Account on the Owner's behalf according to the Owner's instructions. [ ] I do NOT want transfer privileges. Western Reserve Life will not be liable for complying with transfer instructions it reasonably believes to be authentic, nor for any loss, damage, costs or expense in acting on such instructions, and Policyowners will bear the risk of any such loss. Western Reserve Life will employ reasonable procedures to confirm that transfer instructions are genuine. If Western Reserve Life does not employ such procedures, it may be liable for losses due to unauthorized or fraudulent instructions. These procedures include but are not limited to requiring forms of personal identification prior to acting upon such transfer instruction, providing written confirmation of such transactions to the owner and/or tape recording of telephone transfer request instructions received. SECTION 24. TAXPAYER IDENTIFICATION AND BACKUP WITHHOLDING CERTIFICATION Under penalties of perjury, each of the undersigned hereby certifies (1) that the Social Security or Taxpayer Identification Number set forth on this application is correct and (2) that I am currently not subject to backup withholding. [Cross out (2) if not correct.] The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. 4 LIFE APPLICATION SECTION 25. OTHER INSURANCE-TO BE COMPLETED BY THE REGISTERED REPRESENTATIVE 1. Will the policy applied for replace or change any existing life insurance policy or annuity? [ ] Yes [ ] No 2. If replacement of existing insurance is involved, have you complied with all state requirements, including any Disclosure and Comparison Statements? [ ] Yes [ ] No [ ] N/A If "No," explain _______________________________________________________________________________ SECTION 26. ACKNOWLEDGMENT OF APPLICANT AND PROPOSED INSURED Each of the undersigned hereby certifies and represents as follows: The statements and answers given on this application are true and correct. I acknowledge and agree (a) that this application and any amendments shall be the basis for any insurance issued; (b) that the agent does not have the authority to waive any question on this application, to decide if insurance will be issued, or to modify any term or provision of any insurance which may be issued based on this application, only a writing signed by an officer of the Company can change the terms of this application or the terms of any insurance issued by the Company; (c) no policy applied for shall take effect until all of the following conditions have been met: (1) the first full premium must be received by the Company; (2) during the lifetime of any proposed insured, the proposed owner must have personally received and accepted the policy which was applied for and all answers on this application must be true and correct on the date such policy is received and accepted; and (3) on the date of the later of either (1) or (2) above, all of the statements and answers given in this application must be true and complete, and there must have been no change in the insurability of any proposed insured. Unless otherwise stated the undersigned applicant is the premium payor and owner of the policy applied for. I authorize Medical Information Bureau, Inc., my employer, any consumer reporting agency or insurance company, or any other individual or entity that possesses information concerning me to provide such information about me to Western Reserve Life Assurance Co. of Ohio, its representatives or its reinsurers. The Company shall have sixty days from the date hereof within which to consider and act on this application and if within such period a policy has not been received by the applicant or if notice of approval or rejection has not been given, then this application shall be deemed to have been declined by the Company. I ACKNOWLEDGE RECEIPT OF THE (1) NOTICE TO PERSONS APPLYING FOR INSURANCE REGARDING INVESTIGATIVE REPORT, (2) NOTICE OF DISCLOSURE OF INFORMATION, AND (3) NOTICE OF INSURANCE INFORMATION PRACTICES. I UNDERSTAND THAT ANY OMISSIONS OR MISSTATEMENTS IN THIS APPLICATION COULD CAUSE AN OTHERWISE VALID CLAIM TO BE DENIED UNDER ANY INSURANCE ISSUED FROM THIS APPLICATION. Signed at ______________________ _____________________ on M M - D D - Y Y Y Y (city) (state) ---------------------- (date) __________________________________________________________________ _________________________________________________ Signature of Proposed Primary Insured/Owner Print Agent Name (Child over age 15 must sign) __________________________________________________________________ Signature of Proposed Other Insured __________________________________________________________________ _________________________________________________ Signature of Applicant/Owner if other than the Proposed Primary Signature of Licensed Agent State License # Insured (If business insurance, show title of officer and name of firm) __________________________________________________________________ Signature of Proposed Contingent Owner (if applicable) __________________________________________________________________ ______________________________ Signature of parent or legal guardian for insured(s) 15 and under Agent #
5 THIS PAGE IS INTENTIONALLY BLANK 6 ADDITIONAL INFORMATION SECTION 1. PROPOSED OTHER INSURED SPECIFIED AMOUNT $________________ 1. Last Name First Name M.I. 2. Address Apt# City State Zip Code 3. Years at Address 4. Home Phone ( ) - 5. Driver License Number State 6. Sex [ ] Male [ ] Female 7. Date of Birth M M - D D - Y Y Y Y 8. Insurable Age 9. Place of Birth - State/Country 10. Social Security Number - - 11. Height ft in 12. Weight lbs 13. Marital Status 14. Relationship to Proposed Insured 15. Employer Years 16. Occupation & Duties 17. Employer's Address 18. Business Phone Number ( ) - 19. Have you used TOBACCO or any other product containing NICOTINE in the last 5 years? [ ] Yes [ ] No Date last used________________ 20. Rate Class Quoted: [ ] Preferred Elite [ ] Preferred Plus [ ] Preferred [ ] Non-Tobacco [ ] Preferred Tobacco [ ] Tobacco [ ] Juvenile SECTION 2. PROPOSED OTHER INSURED SPECIFIED AMOUNT $________________ 1. Last Name First Name M.I. 2. Address Apt# City State Zip Code 3. Years at Address 4. Home Phone ( ) - 5. Driver License Number State 6. Sex [ ] Male [ ] Female 7. Date of Birth M M - D D - Y Y Y Y 8. Insurable Age 9. Place of Birth - State/Country 10. Social Security Number - - 11. Height ft in 12. Weight lbs 13. Marital Status 14. Relationship to Proposed Insured 15. Employer Years 16. Occupation & Duties 17. Employer's Address 18. Business Phone Number ( ) - 19. Have you used TOBACCO or any other product containing NICOTINE in the last 5 years? [ ] Yes [ ] No Date last used________________ 20. Rate Class Quoted: [ ] Preferred Elite [ ] Preferred Plus [ ] Preferred [ ] Non-Tobacco [ ] Preferred Tobacco [ ] Tobacco [ ] Juvenile SECTION 3. PROPOSED OTHER INSURED SPECIFIED AMOUNT $________________ 1. Last Name First Name M.I. 2. Address Apt# City State Zip Code 3. Years at Address 4. Home Phone ( ) - 5. Driver License Number State 6. Sex [ ] Male [ ] Female 7. Date of Birth M M - D D - Y Y Y Y 8. Insurable Age 9. Place of Birth - State/Country 10. Social Security Number - - 11. Height ft in 12. Weight lbs 13. Marital Status 14. Relationship to Proposed Insured 15. Employer Years 16. Occupation & Duties 17. Employer's Address 18. Business Phone Number ( ) - 19. Have you used TOBACCO or any other product containing NICOTINE in the last 5 years? [ ] Yes [ ] No Date last used________________ 20. Rate Class Quoted: [ ] Preferred Elite [ ] Preferred Plus [ ] Preferred [ ] Non-Tobacco [ ] Preferred Tobacco [ ] Tobacco [ ] Juvenile 7 SECTION 4. PROPOSED CONTINGENT OWNER 1. Last Name First Name M.I. 2. Address Apt# City State Zip Code 3. Years at Address 4. Home Phone ( ) - 6. Sex [ ] Male [ ] Female 7. Date of Birth M M - D D - Y Y Y Y 10. Social Security Number - - SECTION 5. CONTINUATION OF CHILDREN COVERED UNDER THE CHILDREN'S INSURANCE RIDER COVERAGE AMOUNT $______ , _____________
Name Relationship Date of Birth Height Weight ------------------------------------------------------------------------------------ MM - DD - YYYY ft in lbs ------------------------------------------------------------------------------------ MM - DD - YYYY ft in lbs ------------------------------------------------------------------------------------ MM - DD - YYYY ft in lbs ------------------------------------------------------------------------------------
Are all children listed? [ ] Yes [ ] No Are children living with proposed primary insured? [ ] Yes [ ] No If not, explain why:_____________________ SECTION 6. CONTINUATION OF OTHER INSURANCE IN FORCE
Proposed Insured Name Company Amount of insurance Year issued Replacement? -------------------------------------------------------------------------------------------------- Yes No -------------------------------------------------------------------------------------------------- Yes No -------------------------------------------------------------------------------------------------- Yes No -------------------------------------------------------------------------------------------------- Yes No --------------------------------------------------------------------------------------------------
SECTION 7. CONTINUATION OF MEDICAL EXPLANATIONS
Name, Address and Phone # of Question # Proposed Insured's Name Date, Diagnosis, Treatment, Results, and Duration Attending Doctor and Hospital ---------------------------------------------------------------------------------------------------------------------- ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________
SECTION 8. DECLARATIONS I (We) represent that all statements and answers made in this supplement are full, complete and true to the best of my (our) knowledge and belief. It is agreed that this statement shall be made part of the application, and is subject to all terms and conditions contained in the application. sec. 1 _____________________________________________________________ Signature of Proposed Other Insured (Child over 15 must sign) sec. 2 _____________________________________________________________ Signature of Proposed Other Insured (Child over 15 must sign) sec. 3 _____________________________________________________________ Signature of Proposed Other Insured (Child over 15 must sign) ________________________________________________________________________ Signature of Applicant/Owner, if other than the Proposed Primary Insured ___________________________________ _____________________ ______________________ Witness (Registered Representative) Name of Broker/Dealer Signed at (City/State) ___________________________________ _____________________ ______________________ Witness (Registered Representative) Name of Broker/Dealer Signed at (City/State)
8 WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO P.O. BOX 9026 CLEARWATER, FLORIDA 33758 FRAUD WARNING The following states require that insurance applicants acknowledge a fraud warning statement. Please refer to the fraud warning statement for your state as indicated below. FOR APPLICANTS IN ARKANSAS/LOUISIANA Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. _____________________ ___________________ Applicant's Signature Date FOR APPLICANTS IN COLORADO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. _____________________ ___________________ Applicant's Signature Date FOR APPLICANTS IN DISTRICT OF COLUMBIA It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. _____________________ ___________________ Applicant's Signature Date FOR APPLICANTS IN FLORIDA Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree. _____________________ ___________________ Applicant's Signature Date FOR APPLICANTS IN KENTUCKY, OHIO, and PENNSYLVANIA Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a 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. _____________________ ___________________ Applicant's Signature Date FOR APPLICANTS IN NEW JERSEY Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. _____________________ ___________________ Applicant's Signature Date FOR APPLICANTS IN NEW MEXICO Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and criminal penalties. _____________________ ___________________ Applicant's Signature Date FOR APPLICANTS IN OKLAHOMA Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. _____________________ ___________________ Applicant's Signature Date FOR APPLICANTS IN VIRGINIA, MAINE and TENNESSEE It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. _____________________ ___________________ Applicant's Signature Date 9 THIS PAGE IS INTENTIONALLY BLANK 10 AGENT'S REPORT 1. a) How long have you known the Proposed Insured? ___________________________________________________________________ b) Relationship to Proposed Primary Insured: ___________________________________________________________________ c) Are you financially responsible for the Proposed Primary Insured: [ ] Yes [ ] No 2. Did you give the "Notice of Information Practices" to the Proposed Insured(s)? [ ] Yes [ ] No 3. Are you submitting or do you plan to submit an application on any Proposed Insured on this application to any other company? [ ] Yes [ ] No Company Name______________________________________________________ Face amount $_____________________________________________________ Total face amount to be placed with all companies $_________________________________________________________________ 4. Medical Examination Are you arranging for the Medical Requirements? [ ] Yes Paramedical Service used: ________________________________ [ ] No Request Western Reserve Life order medical reqs. 5. Was money taken with the application? [ ] Yes [ ] No If "yes" was the Conditional Receipt completed and given to the applicant? [ ] Yes [ ] No 6. Did you ask all questions in the presence of the Proposed Insured(s)? [ ] Yes [ ] No 7. Are you aware of anything about the health, habits, avocation, environment or mode of living, except as may be related directly or indirectly to sexual orientation, which may affect the insurability of any person proposed for insurance? [ ] Yes [ ] No 8. If Proposed Insured is a juvenile (ages 0 through 15): (a) Did you personally see child? [ ] Yes [ ] No (b) Does child live with parents? [ ] Yes [ ] No (If "No," explain)________________________________________________ __________________________________________________________________ (c) Life insurance in force on parent's life? [ ] Yes [ ] No If yes, list amount_______________________________________________ (d) Life insurance applied for or in force on brothers and sisters? [ ] Yes [ ] No If yes, list amount(s)______________________________________________ ____________________________________________________________________ ____________________________________________________________________ 9. Is Proposed Primary Insured or Owner related to any InterSecurities, Inc. officer or employee? [ ] Yes [ ] No 10. Is Proposed Primary Insured or Owner a licensed Representative of any Broker/Dealer? [ ] Yes [ ] No If "Yes" Name and Address of Broker/Dealer ____________________________________________________________________ 11. Type of Sale (check two) [ ] Direct [ ] Pension or Profit Sharing [ ] Personal Needs Analysis [ ] Salary Savings (EICS) [ ] Estate Planning [ ] Gift [ ] Business Insurance [ ] Salary Allotment Purpose of Policy [ ] Personal Insurance [ ] Business Insurance [ ] Mortgage [ ] Key Employee [ ] Retirement [ ] Executive Bonus [ ] Education [ ] Deferred Compensation [ ] Estate Liquidity [ ] Split Dollar [ ] Income to Family [ ] Reverse Split Dollar [ ] Cash Accumulation [ ] Other [ ] Wealth Replacement [ ] Buy/Sell - Is Partner applying for similar amount? [ ] Yes [ ] No Name of Partner ______________________________________________________ 12. Was this plan sold, presented or illustrated as a VEBA, welfare benefit concept as defined under IRC Section 419, Charitable Legacy Plan, Charitable Retirement Plan, Charitable Remainder Life Program, or other similar arrangement? [ ] Yes [ ] No If "Yes", have you completed and attached the required Disclosure, Acknowledgement and Release Form and the accompanying Attorney's Statement? [ ] Yes [ ] No 13. Did you comply with all requirements relative to obtaining Informed Consent for HIV and AIDS testing? [ ] Yes [ ] No Writing Agent Name______________________________________________________________ Agent No.___________________________ Last 4 digits of SSN ______________________ Agent's Telephone Number________________________________________________________ Agent's Fax Number______________________________________________________________ Agent's E-Mail__________________________________________________________________ Percent of Agent's Split________________________________________________________ Split Agent Name________________________________________________________________ Agent No.____________________ Percent of Agent's Split_______________________ Split Agent Name________________________________________________________________ Agent No.____________________ Percent of Agent's Split_______________________ I submit this application assuming full responsibility for delivery of any coverage issued and for immediate transmittal to the Company of the first premium when collected. I know of no condition affecting the insurability of any person proposed for insurance not fully set forth herein.I certify that a Notice of Information Practices statement was given to the Applicant when this application was taken. (If applicable) $_____________ HAS BEEN PAID BY THE APPLICANT WITH THIS APPLICATION ______________________________________________ Signature of Writing Agent 11 THIS PAGE IS INTENTIONALLY BLANK 12 WRL CONDITIONAL RECEIPT (Detach and leave with applicant if money is submitted with application. If within the past 12 months any proposed insured has been treated for or experienced heart trouble, stroke or cancer, no payment may be accepted with the application.) PLEASE READ THIS CAREFULLY Make all checks payable to the Company. Do not make checks payable to the agent or leave the payee blank or you may jeopardize the insurance for which you have applied. Received from ______________________________, the sum of $_________________ for the insurance or annuity application dated ________, with _____________________ as the proposed insured(s) or annuitant. The policy you applied for will not become effective unless and until a policy contract is delivered to you and all other conditions of coverage are met. However, subject to the conditions and limitations of this Receipt, conditional insurance under the terms of the policy applied for may become effective as of the later of (1) the date of application and (2) the date of the last medical examination, tests, and other screenings required by the Company, if any (the "Effective Date"). Such conditional insurance will take effect as of the Effective Date, so long as all of the following requirements are met: 1. Each person proposed to be insured is found to have been insurable as of the Effective Date, exactly as applied for in accordance with the Company's underwriting rules and standards, without any modifications as to plan, amount, or premium rate; 2. As of the Effective Date, all statements and answers given in the application must be true; 3. The payment made with the application must not be less than the full initial premium for the mode of payment chosen in the application and must be received at our Home Office within the lifetime of the proposed insured; 4. All medical examinations, tests, and other screenings required of the proposed insured by the Company are completed and the results received at our Home Office within 60 days of the date the application was completed; and 5. All parts of the application, any supplemental application, questionnaires, addendum and/or amendment to the application are signed and received at our Home Office.. Any conditional coverage provided by this Receipt will terminate on the earliest of: (a) 60 days from the date the application was signed; (b) the date the Company either mails notice to the applicant of the rejection of the application and/or mails a refund of any amounts paid with the application; (c) when the insurance applied for goes into effect under the terms of the policy applied for; or (d) the date the Company offers to provide insurance on terms that differ from the insurance for which you have applied. The aggregate amount of conditional coverage provided under this Receipt, if any, and any other conditional receipt issued by the Company shall be limited to the lesser of the amount(s) applied for or $500,000 of life insurance. There is no conditional coverage for riders or any additional benefits, if any, for which you have applied. If one or more of this Receipt's conditions have not been met exactly, or if a proposed insured dies by suicide, the Company will not be liable except to return any payment made with the application. If the Company does not approve and accept the application for insurance within 60 days of the date you signed the application, the application will be deemed to be rejected by the Company and there will be no conditional insurance coverage. In that case, the Company's liability will be limited to returning any payment(s) you have made upon return of this Receipt to the Company. This Receipt is not valid unless all blanks are completed above and this Receipt is signed by an agent or authorized Company representative. This Receipt does not provide any conditional insurance until all of the conditions and requirements are met as outlined above. Dated at _____________________ on _________ _______________________________ City, State Date Agent or Authorized Company Rep 13 THIS PAGE IS INTENTIONALLY BLANK 14 DETACH AND LEAVE THIS PAGE WITH APPLICANT NOTICE TO PERSONS APPLYING FOR INSURANCE REGARDING INVESTIGATIVE REPORT To Proposed Insureds: In connection with this application, an investigative consumer report may be prepared about you. Such reports are part of the process of evaluating risks for life and health insurance. Typically, this report will contain information about your character, general reputation, personal characteristics and mode of living. The information in the report may be obtained by talking with you or members of your family, business associates, financial sources, neighbors, and others you know. You may ask to be interviewed in connection with the preparation of any such report. Also, we may have the report updated if you apply for more coverage. UPON YOUR WRITTEN REQUEST, WE WILL LET YOU KNOW WHETHER A REPORT WAS PREPARED AND WE WILL GIVE YOU THE NAME, ADDRESS, AND TELEPHONE NUMBER OF THE AGENCY PREPARING THE REPORT. BY CONTACTING THAT AGENCY AND PROVIDING PROPER IDENTIFICATION, YOU MAY OBTAIN A COPY OF THE REPORT. NOTICE OF DISCLOSURE OF INFORMATION To Proposed Insureds: Information regarding your insurability will be treated as confidential. We or our reinsurer(s) may, however, make a brief report about it to the Medical Information Bureau, Inc. ("MIB"). MIB is a non-profit membership organization of life insurance companies which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or you submit a claim for benefits to another MIB member company, then MIB, if requested, will supply such company with the information it has on file. Upon your request, MIB will disclose to you any information it has about you. If you question the accuracy of information in MIB's file, you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of MIB's information office is Post Office Box 105, Essex Station, Boston, Massachusetts 02122. MIB's telephone number is (617) 426-3660. NOTICE OF INSURANCE INFORMATION PRACTICES To Proposed Insureds: Personal information may be collected from persons other than the individual(s) proposed for coverage. Such information as well as other personal or privileged information subsequently collected by us or our agent may in certain circumstances be disclosed to third parties without authorization. Upon request, you have the right to access your personal information and ask for corrections. You may obtain a complete description of our Information Practices by writing to Western Reserve Life Assurance Co. of Ohio, Attn: Director of Underwriting, P.O. Box 9026, Clearwater, Florida 33758-9026. 15 THIS PAGE IS INTENTIONALLY BLANK 16