<PAGE>
As filed with the Securities and Exchange Commission on December 22, 1998
File No. 333-57579
File No. 811-08831
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM N-4
REGISTRATION STATEMENT UNDER THE SECURITIES ACT OF 1933 [X]
Pre-Effective Amendment No. [ ]
Post-Effective Amendment No. 1 [X]
REGISTRATION STATEMENT UNDER THE INVESTMENT COMPANY ACT OF 1940 [X]
Amendment No. 1
STATE FARM LIFE AND ACCIDENT ASSURANCE COMPANY
VARIABLE ANNUITY SEPARATE ACCOUNT
(Exact Name of Registrant)
STATE FARM LIFE AND ACCIDENT ASSURANCE COMPANY
(Name of Depositor)
One State Farm Plaza
Bloomington, Illinois 61710-0001
(Address of Depositor's Principal Executive Offices)
Depositor's Telephone Number: (309) 766-0886
Laura P. Sullivan
One State Farm Plaza
Bloomington, Illinois 61710-0001
(Name and Address of Agent for Service of Process)
Copy to:
Stephen E. Roth, Esquire
Sutherland Asbill & Brennan LLP
1275 Pennsylvania Avenue, N.W.
Washington, D.C. 20004-2415
APPROXIMATE DATE OF PROPOSED PUBLIC OFFERING:
As soon as practicable after the effective date of the Registration Statement.
It is proposed that this filing will become effective:
[X] immediately upon filing pursuant to paragraph (b) of Rule 485.
[ ] on (date) pursuant to paragraph (b) of Rule 485.
[ ] 60 days after filing pursuant to paragraph (a)(1) of Rule 485.
[ ] on (date) pursuant to paragraph (a)(1) of Rule 485.
TITLE OF SECURITIES BEING REGISTERED:
Individual variable deferred annuity policies.
<PAGE>
The registrant hereby incorporates its prospectus herein by reference to
the prospectus contained in the initial filing on Form N-4 for the registrant
(File No. 333-57579) filed with the Securities and Exchange Commission on
June 24, 1998.
The registrant hereby incorporates its statement of additional information
herein by reference to the statement of additional information contained in
the initial filing on Form N-4 for the registrant (File No. 333-57579) filed
with the Securities and Exchange Commission on June 24, 1998.
<PAGE>
PART C
OTHER INFORMATION
ITEM 24. FINANCIAL STATEMENTS AND EXHIBITS
(a) Financial Statements
All required financial statements are included in Part B.
(b) Exhibits
(1) Resolutions of the Board of Directors of State Farm Life and Accident
Assurance Company ("State Farm") establishing the State Farm Life
and Accident Assurance Company Variable Annuity Separate Account (the
"Variable Account"). (1)
(2) Not Applicable.
(3) Distribution Agreement. (1)
(4) (a) Form of Policy. (1)
(b) Riders to Form of Policy (1)
(5) Application.
(6) (a) Articles of Incorporation of State Farm. (1)
(b) By-Laws of State Farm. (1)
(7) Not Applicable.
(8) Form of Participation Agreement. (1)
(9) Opinion and Consent of Counsel. (1)
(10) (a) Consent of Sutherland Asbill & Brennan LLP. (1)
(b) Consent of Coopers & Lybrand L.L.P. (1)
(11) Not Applicable.
(12) Not Applicable.
(13) Not Applicable.
(14) Powers of Attorney (2)
- ---------------------
1. Incorporated herein by reference to the filing of this registration
statement on Form N-4 (File No. 333-57579) filed with the Securities and
Exchange Commission on June 24, 1998.
2. Incorporated herein by reference to Exhibit 12 of the registration
statement on Form S-6 (File No. 333-64345) filed with the Securities and
Exchange Commission on September 25, 1998
ITEM 25. DIRECTORS AND OFFICERS OF THE DEPOSITOR
<TABLE>
<CAPTION>
NAME AND PRINCIPAL
BUSINESS ADDRESS/*/ Position with State Farm
---------------- ------------------------
<S> <C>
Marvin D. Bower Chairman of the Board and Director
Edward B. Rust, Jr. Director; President
Roger B. Tompkins Director: Executive Vice President
Darrell W. Beernink Vice President and Actuary
Charles R. Wright Director; Agency Vice President
Bruce Callis Director
Robert S. Eckley Director
Roger S. Joslin Director
R.J. Lehman Director
Kurt G. Moser Director; Vice President - Investments
Laura P. Sullivan Director; Vice President - Counsel and Secretary
Vincent J. Trosino Director
Mary Rebecca Blakeslee Vice President - Life/Health Underwriting
James G. Fisher Vice President - Operations
James A. Malay Vice President - Policyholder Systems
William A. Montgomery Senior Vice President and General Counsel
Danny L. Scott, M.D. Vice President and Medical Director
Dale R. Egeberg Vice President and Controller - Life
Robert Myer Vice President - Life/Health Field Services
Terry L. Huff Vice President - Advanced Products
Max E. McPeek Vice President - Compliance
</TABLE>
* The principal business address of all the persons listed above is One State
Farm Plaza, Bloomington, Illinois 61710-0001.
<PAGE>
ITEM 26. PERSONS CONTROLLED BY OR UNDER COMMON CONTROL WITH THE DEPOSITOR OR
REGISTRANT
State Farm Mutual Automobile Insurance Company
State Farm County Mutual Insurance Company of Texas (Common
Management)
State Farm General Insurance Company (100% Ownership)
State Farm Fire and Casualty Company (100% Ownership)
State Farm Life Insurance Company (100% Ownership)
State Farm Annuity and Life Insurance Company (100% Ownership)
State Farm Life and Accident Assurance Company (100% Ownership)
State Farm Indemnity Company (100% Ownership)
Amberjack, Ltd. (100% Ownership)
Fiesta Jack, Ltd. (100% Ownership)
State Farm Lloyds, Inc. (100% Ownership)
State Farm Investment Management Corp. (100% Ownership)
State Farm International Services, Inc. (100% Ownership)
State Farm VP Management Corp. (100% Ownership)
Insurance Placement Services, Inc. (100% Ownership)
ITEM 27. NUMBER OF POLICY OWNERS
There are 277 policy owners as of November 30, 1998.
ITEM 28. INDEMNIFICATION
Illinois Business Corporation Act Chapter 805 Section 5/8.75 is a
comprehensive provision that defines the power of Illinois corporations to
provide for the indemnification of its officers, directors, employees and
agents. This Section also authorizes Illinois corporations to purchase and
maintain insurance on behalf of directors, officers, employees or agents of the
corporation.
The Articles of Incorporation, as amended, and the Bylaws of State
Farm Life and Accident Assurance Company do not provide for the
indemnification of officers, directors, employees or agents of the Company.
ITEM 29. PRINCIPAL UNDERWRITER
(a) State Farm VP Management Corp. ("State Farm VP") is the
registrant's principal underwriter.
<PAGE>
(b) Officers and Directors of State Farm VP.
<TABLE>
<CAPTION>
Name and Principal Positions and Offices
Business Address* With the Underwriter
- ------------------ ---------------------
<S> <C>
Edward B. Rust, Jr. Director; President, CEO
Roger S. Joslin Director; Vice President and
Treasurer; CFO
Kurt G. Moser Director
Charles R. Wright Director; Vice President,
Sales and Marketing
Roger B. Tompkins Director; Vice President,
Administration; COO
Ralph O. Bolt Assistant Vice President,
Sales and Marketing
David R. Grimes Assistant Vice President,
Financial; Secretary
Terry L. Huff Assistant Vice President,
Administration; Manager, OSJ
Max E. McPeek Assistant Vice President, Compliance;
Chief Compliance Officer
</TABLE>
* The principal business address of all of the persons listed above is One
State Farm Plaza, Bloomington, Illinois 61710-0001.
ITEM 30. LOCATION OF BOOKS AND RECORDS
All of the accounts, books, records or other documents required to be
kept by Section 31(a) of the Investment Company Act of 1940 and rules
thereunder, are maintained by State Farm at One State Farm Plaza,
Bloomington, Illinois 61710-0001.
ITEM 31. MANAGEMENT SERVICES
All management contracts are discussed in Part A or Part B of this
registration statement.
ITEM 32. UNDERTAKINGS AND REPRESENTATIONS
(a) The registrant undertakes that it will file a post-effective
amendment to this registration statement as frequently as is
necessary to ensure that the audited financial statements in the
registration statement are never more than 16 months old for as
long as purchase payments under the Policies offered herein are
being accepted.
(b) The registrant undertakes that it will include either (1) as part
of any application to purchase a Policy offered by the
prospectus, a space that an applicant can check to request a
Statement of Additional Information, or (2) a post card or
similar written communication affixed to or included in the
prospectus that the applicant can remove and send to State Farm
for a Statement of Additional Information.
(c) The registrant undertakes to deliver any Statement of Additional
Information and any financial statements required to be made
available under this Form N-4 promptly upon written or oral
request to State Farm at the address or phone number listed in
the prospectus.
(d) State Farm represents that in connection with its offering of the
Policies as funding vehicles for retirement plans meeting the
requirements of Section 403(b) of the Internal Revenue Code of
1986, it is relying on a no-action letter dated November 28,
1988, to the American Council of Life Insurance (Ref. No. IP-6-
88) regarding Sections 22(e), 27(c)(1), and 27(d) of the
Investment Company Act of 1940, and that paragraphs numbered (1)
through (4) of that letter will be complied with.
(e) State Farm represents that the fees and charges under the
Policies, in the aggregate, are reasonable in relation to the
services rendered, the expenses expected to be incurred, and the
risks assumed by State Farm.
<PAGE>
SIGNATURES
As required by the Securities Act of 1933 and the Investment Company Act
of 1940, the registrant certifies that it meets the requirements of
Securities Act of 1933 Rule 485(b) for effectiveness of this registration
statement and has caused this registration statement to be signed on its
behalf, in the City of Bloomington, and the State of Illinois, on this 22nd
day of December, 1998.
State Farm Life and Accident Assurance Company
Variable Annuity Separate Account (Registrant)
<TABLE>
<CAPTION>
<S> <C> <C>
Attest: /s/ Stephen L. Horton By: *
- ----------------------------- ------------------------------
Edward B. Rust, Jr.
President
State Farm Life and Accident Assurance Company
By: State Farm Life and Accident Assurance Company (Depositor)
Attest: /s/ Stephen L. Horton By: *
- ----------------------------- ------------------------------
Edward B. Rust, Jr.
President
State Farm Life and Accident Assurance Company
</TABLE>
<PAGE>
As required by the Securities Act of 1933, this registration statement
has been signed by the following persons in the capacities and on the dates
indicated.
Signature Title Date
- --------- ----- ----
* President and Director
- ----------------------- (Principal Executive Officer)
Edward B. Rust, Jr.
* Vice President and Actuary
- ----------------------- (Principal Financial Officer)
Darrell W. Beernink
* Vice President and Controller - Life
- ----------------------- (Principal Accounting Officer)
Dale R. Egeberg
* Director
- -----------------------
Marvin D. Bower
Director
- -----------------------
Roger B. Tompkins
* Director
- -----------------------
Robert S. Eckley
* Director
- -----------------------
Bruce Callis
* Director
- -----------------------
Roger S. Joslin
* Director
- -----------------------
Kurt G. Moser
* Director
- -----------------------
R. J. Lehman
* Director
- -----------------------
Laura P. Sullivan
* Director
- -----------------------
Vincent J. Trosino
* Director
- -----------------------
Charles R. Wright
* By /s/ Terry Huff Date: December 22, 1998
-----------------
Terry Huff
Pursuant to Power
of Attorney
<PAGE>
Exhibit Index
(5) Application.
<PAGE>
<TABLE>
<CAPTION>
<S><C>
---------------------------------------------------------------------------
[LOGO] STATE FARM LIFE AND ACCIDENT ASSURANCE COMPANY, Bloomington, Illinois
VARIABLE DEFERRED ANNUITY APPLICATION PAGE 1
- ------------------------------------------------------------------------------------------------------------------------------------
1 PROPOSED ANNUITANT (Print name in full)
- ------------------------------------------------------------------------------------------------------------------------------------
MR / / LAST NAME FIRST NAME MIDDLE INITIAL MAILING ADDRESS
a MS / /
---------------------------------------------------------------------------------------------------------------------------------
SOCIAL SECURITY OR TAX
CITY STATE ZIP CODE IN YES NO IDENTIFICATION NUMBER DRIVER'S LICENSE NUMBER STATE
b CITY? / / / /
---------------------------------------------------------------------------------------------------------------------------------
SEX BIRTH DATE MO-DAY-YR AGE MARITAL STATUS HEIGHT WEIGHT STATE OF BIRTH UNITED STATES OR YES NO
c CANADIAN CITIZEN? / / / /
---------------------------------------------------------------------------------------------------------------------------------
Do job duties fall into one of the following hazardous
OCCUPATION (GIVE EXACT DUTIES) EMPLOYER'S NAME AND ADDRESS categories? (amusement/sports; construction/explosive/ YES NO
d divers; liquor; logging/mining; gas/oil) / / / /
- ------------------------------------------------------------------------------------------------------------------------------------
2 APPLICANT/OWNER (Required for Corporate, Trusteed Keogh, AND Juvenile Non Tax-Qualified)
- ------------------------------------------------------------------------------------------------------------------------------------
MR / / LAST NAME FIRST NAME MIDDLE INITIAL SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER
a MS / /
---------------------------------------------------------------------------------------------------------------------------------
MAILING ADDRESS CITY STATE ZIP CODE IN YES NO
b CITY? / / / /
- ------------------------------------------------------------------------------------------------------------------------------------
c SUCCESSOR OWNER (REQUIRED UNLESS APPLICANT/OWNER IS A TRUST OR CORPORATION)
- ------------------------------------------------------------------------------------------------------------------------------------
LAST NAME FIRST NAME MIDDLE INITIAL
- ------------------------------------------------------------------------------------------------------------------------------------
3 COMPLETE: IF PROPOSED ANNUITANT IS UNDER AGE 16 | Is Proposed Annuitant to be Owner at and after age 21? / / YES / / NO
- ------------------------------------------------------------------------------------------------------------------------------------
4 VARIABLE DEFERRED ANNUITY
- ------------------------------------------------------------------------------------------------------------------------------------
a INITIAL ACCOUNT AND PAYMENT ALLOCATION: (During the free look period, all premiums will be allocated to the Fixed Account.)
%
(MUST BE WHOLE %
WITH 1% MINIMUM)
/ / Large Cap Equity Index Subaccount -----------------------------------------------------
------------ Check the appropriate box if you wish to have:
/ / Small Cap Equity Index Subaccount
------------ ONLY ONE MAY BE IN EFFECT AT ONE TIME.
/ / International Equity Index Subaccount / / Dollar Cost Averaging
------------
/ / Stock and Bond Balanced Subaccount -OR-
------------
/ / Bond Subaccount / / Portfolio Rebalancing
------------
/ / Money Market Subaccount COMPLETE SEPARATE FORM IF EITHER IS CHECKED.
------------ -----------------------------------------------------
/ / Fixed Account
------------
TOTAL = 100 %
--------------------
b Amount of premium to be billed: $
Mode: (Check One) --------------------
Existing Agents Payroll Employee Salary Existing Special Monthly
/ / Annual / / SFPP / / Life PAC / / Deduction / / Payroll Deduction / / Allotment Account Number:
--------------------
c Amount of premium submitted with this application: $
--------------------
--------------------
d If tax-qualified, indicate amount of premium to be applied to PRIOR tax year: (IF NONE, SO INDICATE) $
--------------------
--------------------
e If IRA, indicate amount of premium irrevocably designated as a rollover contribution: $
--------------------
- ------------------------------------------------------------------------------------------------------------------------------------
YES NO
5 Is this annuity tax-qualified? / / / / (IF YES, INDICATE TYPE) / / TSA - Issue with TSA Endorsement, with Proposed
Annuitant as Owner
/ / IRA - Issue with IRA Endorsement / / CORPORATE
/ / SEP-IRA - Issue with IRA Endorsement / / KEOGH
/ / OTHER TAX-QUALIFIED
---------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
6 Will this policy replace or change insurance or annuities you now have? / /YES / /NO (IF YES, ENTER NAME OF COMPANY AND EXPLAIN)
- ------------------------------------------------------------------------------------------------------------------------------------
7 BENEFICIARY DESIGNATION
- ------------------------------------------------------------------------------------------------------------------------------------
--PRIMARY BENEFICIARY - FULL NAME------------AGE---RELATIONSHIP-- ----SUCCESSORY BENEFICIARY - FULL NAME----AGE---RELATIONSHIP--
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | / /Interest Option or / /One Sum or / / Other-Explain |
| | | | |------------------------------------------------------------|
| | | | ----FINAL BENEFICIARY - FULL NAME----------AGE--RELATIONSHIP--
| | | | | | | |
| | | | | | | |
| / /Interest Option or / /One Sum or / /Other-Explain | | One Sum Settlement Only | | |
----------------------------------------------------------------- --------------------------------------------------------------
If a beneficiary survives the Annuitant, any payment to successor will be one sum, unless changed.
- ------------------------------------------------------------------------------------------------------------------------------------
454-616 NY Printed in U.S.A.
</TABLE>
<PAGE>
<TABLE>
<CAPTION>
<S><C> PAGE 2
VARIABLE DEFERRED ANNUITY APPLICATION
- ------------------------------------------------------------------------------------------------------------------------------------
8 SUITABILITY INFORMATION
- ------------------------------------------------------------------------------------------------------------------------------------
Applicants are urged to supply information in order that the agent may make an informed judgment as to the suitability of a
particular purchase of a Variable Deferred Annuity Policy. If the Applicant chooses not to, the agent must complete the
following items to the best of his/her knowledge.
YES NO
Did the applicant provide the suitability information? / / / / (IF NO, EXPLAIN)
- ------------------------------------------------------------------------------------------------------------------------------------
a. Annual Income from Occupation $ f. Tax g. Score from
Bracket: Risk Profiler:
- ------------------------------------------------------------------------------------------------------------------------------------
b. Annual Income from other sources $ h. Purpose for Purchasing this Policy:
Indicate other sources:
/ / Personal Retirement Planning
Years to Retirement:
--------------------
/ / Other (specify)
- ------------------------------------------------------------------------------------------------------------------------------------
c. Projected Income for next 12 months $
- ------------------------------------------------------------------------------------------------------------------------------------
d. Estimated Net Worth (excluding home) $ i. Which best approximates your experience with the following
------------ types of investments:
Liquid Assets included in Net Worth $
------------ NONE UP TO 5 YRS 5 YRS OR MORE
- ------------------------------------------------------------ Mutual Funds / / / / / /
e. No. and Age of Dependent Children: (IF NONE, SO STATE) Individual Common Stocks / / / / / /
Annuities / / / / / /
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
9 AGREEMENTS AND ACKNOWLEDGEMENTS
- ------------------------------------------------------------------------------------------------------------------------------------
YES NO
a. DO YOU BELIEVE THAT THIS POLICY WILL MEET YOUR NEEDS AND FINANCIAL OBJECTIVES? / / / /
b. DO YOU UNDERSTAND THAT THE POLICY VALUES MAY INCREASE OR DECREASE, DEPENDING ON THE INVESTMENT
EXPERIENCE OF THE SEPARATE ACCOUNT? / / / /
c. DID YOU RECEIVE THE SEPARATE ACCOUNT PROSPECTUS AND THE FUND PROSPECTUS
FOR THE POLICY APPLIED FOR? IF YES, GIVE DATE SHOWN ON THE PROSPECTUS: / / / /
-------------------------------------------
d. ARE YOU ASSOCIATED WITH AN NASD MEMBER BROKER DEALER? / / / /
Coverage will start on the policy date, provided any check received is honored for the payment when presented. By accepting
the policy, the Owner agrees to the beneficiaries named, method of payment, and corrections made. No change in plan, amount,
benefits, classification, or age at issue may be made on the application unless the Owner agrees in writing. Only an authorized
company officer may change policy provisions.
Any policy issued on this application will be owned by Proposed Annuitant or the Applicant, if other than Proposed Annuitant.
- -----------------------------------------------------------------------------------------------------------------------------------
Social Security or Tax Identification Number (TIN) Certification - By signing this application, I certify under penalties of
perjury that (1) the TIN shown above is correct, and (2) that I am not subject to backup withholding either because I have not
been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the
Internal Revenue Service has notified me that I am no longer subject to backup withholding. (IF YOU ARE SUBJECT TO BACKUP
WITHHOLDING, CROSS OUT ITEM 2.) The Internal Revenue Service does not require your consent to any provision of this document
other than the certifications required to avoid backup withholding.
- -----------------------------------------------------------------------------------------------------------------------------------
DATED ON SIGNATURE OF PROPOSED ANNUITANT X
-------------------------------- -------------------------------------------------------
MONTH DAY YEAR NOT REQUIRED IF PROPOSED ANNUITANT IS UNDER AGE 16
AT
--------------------------------------
CITY STATE
SIGNATURE OF APPLICANT X
----------------------------------------------------------------
Required for Corporate, Trusteed Keogh, TSA and Juvenile
Non Tax-Qualified. Not required unless applicant is other than
Proposed Annuitant. If a firm or corporation is to be the
owner, give its name and signature of authorized officer.
SIGNATURE OF AGENT AS X
WITNESS TO ALL SIGNATURES -----------------------------------------------
</TABLE>
<PAGE>
<TABLE>
<CAPTION>
<S><C>
- ------------------------------------------------------------------------------------------------------------------------------------
AGENT'S STATEMENT
- ------------------------------------------------------------------------------------------------------------------------------------
1 Do you know the Proposed Annuitant? 4 Is this policy a replacement or change of existing
----------------------------------------------------------------- insurance or annuities? (IF YES, EXPLAIN) / /Yes / /No
2 Check if Proposed Annuitant is now a State Farm Policyholder. ----------------------------------------------------------------
/ / Auto / / Life / / Fire / / Health 5 Did you give Proposed Agent Code Stamp
----------------------------------------------------------------- Annuitant the Premium
3 Personal History Interview Telephone Information Receipt?
DAYTIME / / Yes / / No
PHONE NO. ( ) -
-----------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
[LOGO] STATE FARM LIFE AND ACCIDENT ASSURANCE COMPANY
PREMIUM RECEIPT
State Farm Life and Accident Assurance Company has received $ . This money is part of the
-----------------------
application for an annuity on .
------------------------------------------------------
(Proposed Annuitant)
Date of Application Signature of Agent X
--------------------------------- -----------------------------------------------------
NOTICE OF INFORMATION PRACTICES
The application requests personal information about the persons proposed for coverage. Occasionally, we may need to collect
additional personal information from other sources. All such personal information is treated as confidential. In certain
cases, however, that information might be disclosed to others without authorization. A right of access and correction exists
as to the personal information we may collect. A more detailed notice, including a description of our information practices
and your rights, is available upon request.
</TABLE>
<PAGE>
STATE FARM LIFE AND ACCIDENT ASSURANCE COMPANY
100 State Farm Place, P.O. Box 8000, Ballston Spa, New York 12020-8000
Phone (518)884-5000
INSURANCE DEPARTMENT OF THE STATE OF NEW YORK
DEFINITION OF REPLACEMENT
In order to determine whether you are replacing or otherwise changing the
status of existing life insurance policies or annuity contracts, and in order
to receive the valuable information necessary to make a careful comparison if
you are contemplating replacement, the agent is required to ask you the
following questions and explain any items that you do not understand.
As part of your purchase of a new life insurance policy or a new annuity
contract, has existing coverage been, or is it likely to be:
<TABLE>
<CAPTION>
Yes No
<S> <C> <C>
(1) Lapsed, surrendered, partially surrendered, forfeited, assigned to the
insurer replacing the life insurance policy or annuity contract, or
otherwise terminated? / / / /
(2) Changed or modified into paid-up insurance; continued as extended term
insurance or under another form of nonforfeiture benefit; or otherwise
reduced in value by the use of nonforfeiture benefits, dividend
accumulations, dividend cash values or other values? / / / /
(3) Changed or modified so as to effect a reduction either in the amount of
the existing life insurance or annuity benefit or in the period of
time the existing life insurance or annuity benefit will continue in
force? / / / /
(4) Reissued with a reduction in amount such that any cash values are
released, including all transactions wherein an amount of dividend
accumulations or paid-up additions is to be released on one or more
of the existing policies? / / / /
(5) Assigned as collateral for a loan or made subject to borrowing or
withdrawal of any portion of the loan value, including all
transactions wherein any amount of dividend accumulations or paid-up
additions is to be borrowed or withdrawn on one or more existing
policies? / / / /
(6) Continued with a stoppage of premium payments or reduction in the
amount of premium paid? / / / /
</TABLE>
If you have answered yes to any of the above questions, a replacement as defined
by New York Insurance Department Regulation No. 60 has occurred or is likely to
occur and your agent is required to provide you with a completed Disclosure
Statement and the IMPORTANT Notice Regarding Replacement or Change of Life
Insurance Policies or Annuity Contracts.
DATE SIGNATURE OF APPLICANT
------------------------- ------------------------
DATE SIGNATURE OF APPLICANT
------------------------- -------------------------
To the best of my knowledge, a replacement is involved in this
transaction / / Yes / / No
DATE SIGNATURE OF AGENT
-------------------------- -----------------------------
454-626 d-26 09-1998 PRINTED IN U.S.A.
<PAGE>
STATE FARM LIFE AND ACCIDENT ASSURANCE COMPANY
100 State Farm Place, P.O. Box 8000, Ballston Spa, New York 12020-8000
Phone (518)884-5000
INSURANCE DEPARTMENT OF THE STATE OF NEW YORK
IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE INSURANCE POLICIES
OR ANNUITY CONTRACTS
THIS NOTICE IS FOR YOUR BENEFIT AND REQUIRED BY REGULATION NO. 60
You are contemplating the purchase of a life insurance policy or annuity
contract in connection with the surrender, lapse or change of existing life
insurance policies or annuity contracts. The agent is required to give you
this notice together with a signed disclosure statement containing the
summary result comparison for the new life insurance policy or annuity
contract and any life insurance policies or annuity contracts to be changed
that sets forth the facts of the transaction and its advantages and
disadvantages to you. Your decision could be a good one - or a mistake - so
make sure you understand the facts. You should:
1. Carefully study the Disclosure Statement, which includes a Summary
Result Comparison, until you are sure you understand fully the effect
of the transaction.
2. Ask the company or agent from whom you bought your existing life
insurance policies or annuity contracts to review with you the
transaction and the Disclosure Statement. You may be able to effect
the changes you desire more advantageously with them. Their customer
service telephone number is contained in the Disclosure Statement.
3. Consult your tax advisor. There may be unfavorable tax implications
associated with the contemplated changes to your existing life
insurance policies or annuity contracts.
As a general rule, it is often not advantageous to drop or change existing
coverage in favor of new coverage, whether issued by the same or a different
insurance company. Some of the reasons it may disadvantageous are:
1. The amount of the annual premium under an existing life insurance
policy may be lower than that called for by a new life insurance
policy having the same or similar benefits. Any replacement of the
same type of policy will normally be at a higher premium rate based
upon the insured's then attained age.
2. Since the initial costs of a life insurance policy are charged against
the cash value increases in the earlier life insurance policy years,
the replacement of an old life insurance policy by a new one results
in the policyholder sustaining the burden of these costs twice.
Annuity contracts usually contain provision for surrender charges,
therefore a replacement involving annuity contracts may result in the
imposition of surrender charges.
3. The incontestable and suicide clauses begin anew in a new life
insurance policy. This could result in a claim being denied under the
new life insurance policy that would have been paid under the life
insurance policy that was replaced.
4. An existing life insurance policy or annuity contract often has more
favorable provisions than a new life insurance policy or annuity
contract in areas such as loan interest rate, settlement options,
disability benefits and tax treatment.
5. There may have been changes in your health since the purchase of the
existing coverage.
6. The insurance company with which you have existing coverage can often
make a desired change on terms that would be more favorable than if
you replaced existing coverage with new coverage.
You have the right, within 60 days from the date of delivery of a new life
insurance policy or annuity contract, to return it to the insurer and receive
an unconditional full refund of all premiums or considerations paid on it, or
in the case of a variable or market value adjustment policy or contract, a
payment of the cash surrender benefits provided under the policy or contract,
plus the amount of all fees and other charges deducted from gross
considerations or imposed under the life insurance policy or annuity
contract, except that during the first 10 days from the date of delivery of
the new policy or contract return of premium or consideration, if greater,
and MAY have the right to reinstate or restore any life insurance policies
and annuity contracts that were surrendered, lapsed or changed in the
transaction to their former status to the extent possible and in accordance
with the insurer's published reinstatement rules to the extent such rules are
not inconsistent with the provisions of this part.
454-626 d-26 09-1998 PRINTED IN U.S.A.
<PAGE>
IMPORTANT: THIS RIGHT SHOULD NOT BE VIEWED AS REINSTATING OR RESTORING YOUR LIFE
INSURANCE POLICY OR ANNUITY CONTRACT TO THE SAME CONDITION AS IF IT HAD NEVER
BEEN REPLACED. THERE MAY BE CONSEQUENCES IN REINSTATING OR RESTORING YOUR LIFE
INSURANCE POLICY OR ANNUITY CONTRACT, INCLUDING BUT NOT LIMITED TO:
- The right to reinstate or restore your life insurance policy or annuity
contract applies only to companies subject to New York insurance laws;
- Your life insurance policy or annuity contract is subject to your
specific company's reinstatement rules, which may vary from company
to company. These rules may require payment of both premium and
interest; however, you will not be subject to evidence of
insurability, or a new contestable or suicide period;
- You may not receive the interest or investment performance during the
period the life insurance policy or annuity contract was replaced; and
- There may be unfavorable Federal Income Tax consequences as a result of the
reinstatement of your Life Insurance policy or annuity contract.
IMPORTANT: IN THE CASE OF A VARIABLE OR MARKET VALUE ADJUSTMENT POLICY OR
CONTRACT, THE VALUE OF THE POLICY OR CONTRACT MAY INCREASE OR DECREASE DURING
THE 60 DAY PERIOD DEPENDING ON THE PERFORMANCE OF THE UNDERLYING INVESTMENTS,
WHICH MAY AFFECT THE VALUE OF THE REFUND YOU RECEIVE.
I hereby acknowledge that I read the above "IMPORTANT NOTICE" and have received
a copy of same.
DATE SIGNATURE OF APPLICANT
------------------------- ------------------------
DATE SIGNATURE OF APPLICANT
------------------------- ------------------------
<PAGE>
STATE FARM LIFE AND ACCIDENT ASSURANCE COMPANY
100 State Farm Place, P.O. Box 8000, Ballston Spa, New York 12020-8000
Phone (518)884-5000
INSURANCE DEPARTMENT OF THE STATE OF NEW YORK
DISCLOSURE STATEMENT
IMPORTANT - IT MAY NOT BE IN YOUR BEST INTEREST TO SURRENDER, LAPSE, CHANGE OR
BORROW FROM EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS IN CONNECTION
WITH THE PURCHASE OF A NEW LIFE INSURANCE POLICY OR ANNUITY CONTRACT WHETHER
ISSUED BY THE SAME OR A DIFFERENT INSURANCE COMPANY. YOU ARE URGED TO CONTACT
YOUR EXISTING AGENT OR INSURANCE COMPANY PRIOR TO COMPLETING THE TRANSACTION.
THEY CAN HELP YOU DECIDE WHETHER THE REPLACEMENT IS IN YOUR BEST INTEREST.
FOR YOUR PROTECTION, the Insurance Department of the State of New York requires
that you be given this Disclosure Statement, the IMPORTANT Notice Regarding
Replacement or Change of Life Insurance Policies or Annuity Contracts and the
Definition of Replacement, together with policy information on all proposed and
existing coverage affected.
Name of Applicant(s) Telephone Number
----------------------- ------------------
Address
------------------------------------------------------------------------
Name of Agent Telephone Number
------------------------------ ------------------
Agent's Address
----------------------------------------------------------------
The Information On Existing Coverage On This Form Was Obtained From:
/ / The following replaced company(ies)
-----------------------------------------
/ / Approximations if replaced company(ies) failed to provide information in the
prescribed time
-----------------------------------------------------------------
454-626 b-28 10-1998 PRINTED IN U.S.A.
<PAGE>
2.
DISCLOSURE STATEMENT CONTINUED
1. DESCRIPTION OF TRANSACTION
Proposed Policy / Contract
<TABLE>
<CAPTION>
Existing Policies / Contracts Affected
(1) (2) (3)
<S> <C> <C> <C>
As of As of As of
------------- -------------- -------------
Company Name
----------------- ------------------ ------------------- ------------------
Customer Service
(800)688-0895 Phone Number
----------------- ------------------ ------------------- ------------------
Contract Number # # #
----------------- ----------------- ------------------ -----------------
Issue Date
----------------- ------------------ ------------------- ------------------
Type of Insurance
----------------- ------------------ ------------------- ------------------
Base Policy
$ Face Amount $ $ $
----------------- ----------------- ------------------ -----------------
Rider
----------------- ------------------- ----------------- ------------------- ------------------
Rider
----------------- ------------------- ----------------- ------------------- ------------------
Rider
----------------- ------------------- ----------------- ------------------- ------------------
Rider
----------------- ------------------- ----------------- ------------------- ------------------
Rider
----------------- ------------------- ----------------- ------------------- ------------------
Total Annualized
$ Premium $ $ $
----------------- ----------------- ------------------ -----------------
Current
N/A Surrender Charge $ $ $
----------------- ----------------- ------------------- ------------------
Guaranteed
% Interest Rate % % %
---------------- ----------------- ------------------ -----------------
Current Loan
% Interest Rate % % %
---------------- ----------------- ------------------ -----------------
Current Loan Balance
----------------- ------------------ ------------------- ------------------
Contestable Expiry Date
----------------- ------------------ ------------------- ------------------
Suicide Expiry Date
----------------- ------------------ ------------------- ------------------
</TABLE>
<PAGE>
3.
DISCLOSURE STATEMENT CONTINUED
Existing coverage to be changed by:
<TABLE>
<CAPTION>
<S> <C> <C> <C>
(1) (2) (3)
Lapse or Surrender / / / / / /
Amendment or Reissue / / / / / /
Loan or Withdrawal / / / / / /
Death Benefit
Reduction To $ $ $
-------------- -------------- ---------------
Reduced Paid-Up For $ $ $
-------------- -------------- ---------------
Extended Term to
-------------- -------------- ---------------
Other
-------------- -------------- ---------------
Cash released by change $ $ $
-------------- -------------- ---------------
Use of cash released
------------------------------------------------------------------------------------
</TABLE>
2. SUMMARY RESULT COMPARISON
<TABLE>
<CAPTION>
Proposed With Existing Coverage Changed Existing Coverage Unchanged
Guaranteed Non-Guaranteed Guaranteed Non-Guaranteed
<S> <C> <C> <C> <C>
Annualized Premium
$ $ Current Year $ $
---------------- --------------- -------------- -------------
$ $ 5 Years Hence $ $
---------------- --------------- -------------- -------------
$ $ 10 Years Hence $ $
---------------- --------------- -------------- -------------
Surrender Value
$ $ End of 1st Year $ $
---------------- --------------- -------------- -------------
$ $ 5 Years Hence $ $
---------------- --------------- -------------- -------------
$ $ 10 Years Hence $ $
---------------- --------------- -------------- -------------
</TABLE>
<PAGE>
4.
DISCLOSURE STATEMENT CONTINUED
<TABLE>
<CAPTION>
Proposed With Existing Coverage Changed Existing Coverage Unchanged
Guaranteed Non-Guaranteed Guaranteed Non-Guaranteed
<S> <C> <C> <C> <C>
Death Benefit
$ $ End of 1st Year $ $
---------------- ----------------- ---------------- -------------
$ $ 5 Years Hence $ $
---------------- ----------------- ---------------- -------------
$ $ 10 Years Hence $ $
---------------- ----------------- ---------------- -------------
Dividends
$ End of 1st Year $
----------------- -------------
$ 5 Years Hence $
----------------- -------------
$ 10 Years Hence $
----------------- -------------
</TABLE>
AGENT'S STATEMENT
1. The primary reasons(s) for recommending the new life insurance policy or
annuity contract is(are):
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
2. The existing life insurance policy or annuity contract cannot meet the
applicant's objectives because:
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
3. The advantages of continuing the existing life insurance policy or annuity
contract without changes are:
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
<PAGE>
5.
DISCLOSURE STATEMENT CONTINUED
REMARKS
-------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
/ / The attached proposal, including sales material, was used in this sale.
/ / No proposal or sales material was used in this sale.
If more than three existing life insurance policies or annuity contracts are
to be affected by this transaction or if more than one new life or annuity
contract is proposed, Section 1 of this Disclosure Statement must be
completed for such additional life insurance policies and annuity contracts.
In addition, a composite comparison shall be completed of all existing life
insurance policies or annuity contracts to all proposed life insurance
policies or annuity contracts. The proposal, including sales material used
in the sale of the proposed life insurance policy or annuity contract, must
accompany the submission of this form to the insurer. Copies must be given
to the applicant.
I have personally completed this form and certify that it is correct to the best
of my knowledge and ability.
Date: Signature of Agent:
------------------------ --------------------------------
I hereby acknowledge that I received and read the above Disclosure Statement
before I signed the application for the new coverage.
Date: Signature of Applicant:
------------------------ ---------------------------
Date: Signature of Applicant:
------------------------ ---------------------------
<PAGE>
STATE FARM LIFE AND ACCIDENT ASSURANCE COMPANY
100 State Farm Place, P.O. Box 8000, Ballston Spa, New York 12020-8000
Phone (518)884-5000
INSURANCE DEPARTMENT OF THE STATE OF NEW YORK
DISCLOSURE STATEMENT
(Annuity to Annuity Replacement Only)
IMPORTANT - IT MAY NOT BE IN YOUR BEST INTEREST TO SURRENDER, LAPSE, CHANGE OR
BORROW FROM EXISTING ANNUITY CONTRACTS IN CONNECTION WITH THE PURCHASE OF A NEW
ANNUITY CONTRACT WHETHER ISSUED BY THE SAME OR A DIFFERENT INSURANCE COMPANY.
YOU ARE URGED TO CONTACT YOUR EXISTING AGENT OR INSURANCE COMPANY PRIOR TO
COMPLETING THE TRANSACTION. THEY CAN HELP YOU DECIDE WHETHER THE REPLACEMENT IS
IN YOUR BEST INTEREST.
FOR YOUR PROTECTION, the Insurance Department of the State of New York requires
that you be given this Disclosure Statement, the IMPORTANT Notice Regarding
Replacement of Change of Life Insurance Policies or Annuity Contracts and the
Definition of Replacement, together with policy information on all proposed and
existing coverage affected.
PART A
Name of Applicant(s) Telephone Number
---------------------------- --------------
Address(es)
---------------------------------------------------------------------
Name of Agent Telephone Number
------------------------------------ --------------
Agent's Address
-----------------------------------------------------------------
The Information On Existing Coverage On This Form Was Obtained From:
/ / The following replaced company(ies):
----------------------------------------
/ / Approximations if replaced company(ies) failed to provide information in the
prescribed time:
---------------------------------------------------------------
<PAGE>
PART B
DESCRIPTION OF TRANSACTION:
<TABLE>
The Proposed Annuity Contract Existing Annuity Contracts Affected
<S> <C> <C> <C>
(1) (2) (3)
1. Company Name
------------------- ----------------- ---------------- ----------------
Customer Service
2. (800) 688-0895 Phone Number
------------------- ----------------- ---------------- ----------------
3. XXXXXXX Annuity Contract Number
------------------- ----------------- ---------------- ----------------
4. Type of Annuity
------------------- ----------------- ---------------- ----------------
5. XXXXXXX Annuity Issue Date
------------------- ----------------- ---------------- ----------------
6. % Current Credit Rate % % %
------------------- (If Applicable) ---------------- --------------- ---------------
Guaranteed Rate
7. % (If Applicable) % % %
------------------- --------------- --------------- ---------------
8. $ Account Value $ $ $
------------------- ----------------- ---------------- ----------------
As of Date ( ) As of Date ( ) As of Date ( )
9. N/A Minus Surrender Charge $ $ $
------------------- (if Any) ----------------- ---------------- ----------------
10. N/A Plus/Minus Market Value $ $ $
------------------- Adjustment (If Any) ----------------- ---------------- ----------------
11. N/A Equals Surrender Value $ $ $
------------------- ----------------- ---------------- ----------------
----------------------------------------------------------
Additional Information
IRS Plan Type (Check Box) Product Name (Select One)
/ / Qualified or / /
----------------------
/ / Non-Qualified / /
----------------------
----------------------------------------------------------
</TABLE>
<PAGE>
<TABLE>
<CAPTION>
PART C
SUMMARY RESULT COMPARISON*
THE PROPOSED ANNUITY IF YOU CONTINUE YOUR EXISTING ANNUITY(IES)**
1. Surrender Value to be Invested: $________________ 2. Current Value: $________________
Hypothetical Rates of Return Hypothetical Rates of Return
|--- If Fixed Annuity ---||----- If Variable Annuity -----| |--- If Fixed Annuity ---||---- If Variable Annuity ----|
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
------------------------------------------------------------------------------------------------------------------------------
| At | At | | | | | At | At | | | |
|Guaranteed | Current | @ 0% | @ 6% | @ 10% | |Guaranteed | Current | @ 0% | @ 6% | @ 10% |
| Rate | Rate*** | | | | | Rate | Rate | | | |
------------------------------------------------------------------------------------------------------------------------------
| SURRENDER |
| VALUE |
------------------------------------------------------------------------------------------------------------------------------
| | | | | | | | | | | |
| | | | | | | | | | | |
3. |$ |$ |$ |$ |$ | In 1 Year |$ |$ |$ |$ |$ |
------------------------------------------------------------------------------------------------------------------------------
| | | | | | | | | | | |
| | | | | | | | | | | |
4. |$ |$ |$ |$ |$ | In 3 Years |$ |$ |$ |$ |$ |
------------------------------------------------------------------------------------------------------------------------------
| | | | | | | | | | | |
| | | | | | | | | | | |
5. |$ |$ |$ |$ |$ | In 5 Years |$ |$ |$ |$ |$ |
------------------------------------------------------------------------------------------------------------------------------
| | | | | | | | | | | |
| | | | | | | | | | | |
6. |$ |$ |$ |$ |$ |In 10 Years |$ |$ |$ |$ |$ |
------------------------------------------------------------------------------------------------------------------------------
| DEATH |
| BENEFIT |
------------------------------------------------------------------------------------------------------------------------------
| | | | | | | | | | | |
| | | | | | | | | | | |
7. |$ |$ |$ |$ |$ | In 1 Year |$ |$ |$ |$ |$ |
------------------------------------------------------------------------------------------------------------------------------
| | | | | | | | | | | |
| | | | | | | | | | | |
8. |$ |$ |$ |$ |$ | In 3 Years |$ |$ |$ |$ |$ |
------------------------------------------------------------------------------------------------------------------------------
| | | | | | | | | | | |
| | | | | | | | | | | |
9. |$ |$ |$ |$ |$ | In 5 Years |$ |$ |$ |$ |$ |
------------------------------------------------------------------------------------------------------------------------------
| | | | | | | | | | | |
| | | | | | | | | | | |
10.|$ |$ |$ |$ |$ |In 10 Years |$ |$ |$ |$ |$ |
------------------------------------------------------------------------------------------------------------------------------
</TABLE>
* Calculations for both current and proposed policies are based on current
values and do not include possible future additional deposits or
withdrawals.
** If more than one policy is being replaced, the figures shown reflect the
aggregate total of the values for policies currently in force on the dates
shown in Part B.
*** Since the fixed rate declared is subject to change at any time, the rate
actually declared in effect on the date of issue may differ from the
current rate indicated above, and the return received on the investment may
differ from our current rate.
<PAGE>
PART D
AGENT'S STATEMENT:
1. The primary reason(s) for recommending the new annuity contract is (are):
- -------------------------------------------------------------------------------
- -------------------------------------------------------------------------------
2. The existing annuity contract cannot meet the applicant's objectives because:
- -------------------------------------------------------------------------------
- -------------------------------------------------------------------------------
3. The advantages of continuing the existing annuity contract without changes
are:
- -------------------------------------------------------------------------------
- -------------------------------------------------------------------------------
4. The surrender charge, if my client replaces his or her existing annuity
contract, is __________% or $___________________.
5. The new annuity my client is applying for imposes a new surrender charge as
follows: (Describe percentage rate of surrender charge for each year in
which a surrender charge is imposed.)
<TABLE>
<S><C>
Year: 1 2 3 4 5 6 7 ---- ---- ----
/ /% / /% / /% / /% / /% / /% / /% / /% / /% / /%
</TABLE>
Explain, if necessary:
------------------------------------------------------
- -------------------------------------------------------------------------------
REMARKS:
-----------------------------------------------------------------------
- -------------------------------------------------------------------------------
- -------------------------------------------------------------------------------
/ / The attached proposal, including sales material, was used in this sale.
/ / No proposal or sales material was used in this sale.
<PAGE>
If more than three existing annuity contracts are to be affected by this
transaction or if more than one new annuity contact is proposed, the second page
of this Disclosure Statement must be completed for such additional annuity
contracts. In addition, a composite comparison of all existing annuity
contracts to all proposed annuity contacts shall be completed. The proposal,
including sales material used in the sale of the proposed annuity contract, must
accompany the submission of this form to the insurer. Copies must be given to
the applicant.
I have personally completed this form and certify that it is correct to the best
of my knowledge and ability.
Date:__________________ Signature of Agent:____________________________________
I hereby acknowledge that I received and read the above "Disclosure
Statement" before I signed the application for the new coverage.
Date:__________________ Signature of Applicant:________________________________
Date:__________________ Signature of Applicant:________________________________
