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Exhibit 1.10(b)
FIRST PENN-PACIFIC Executive Office: 10 North Martingale Road
LIFE INSURANCE CO. Schaumburg, Illinois 60173-2268
A member of Lincoln Financial Group (847) 466-8000
Application for Life Insurance
Part I
Please Print Using Dark Ink
SECTION 1 - PROPOSED INSURED #1 (Applicant/Owner unless otherwise noted in
Section III)
Date of
Name:_____________________ Sex: ___ Birth:___/___/___ Age:____
(First)(Middle)(Last) M D Y
State of Social
Birth: ___________ Security No.:____________
Home Address: ________________________________________________
City State Zip
Phone # (Home) (___) __________
Marital Status: __ Occupation:________________________________
Employer: _________________________________________
Business Address: ____________________________________________
City State Zip
Phone #(Business) (___) ______________________________________
SECTION II - PROPOSED INSURED #2 (Contingent Owner, unless
otherwise noted in Section III) (Complete ONLY if applying for
Second-to-Die Coverage)
Date of
Name:_____________________ Sex: ___ Birth:___/___/___ Age:____
(First)(Middle)(Last) M D Y
State of Social
Birth: ___________ Security No.:____________
Home Address: ________________________________________________
City State Zip
Phone # (Home) (___) __________
Marital Status: __ Occupation:________________________________
Employer: _________________________________________
Business Address: ____________________________________________
City State Zip
Phone #(Business) (___) ______________________________________
SECTION III - APPLICATION/OWNER (or Payor)(Applicant must sign
Page 4)
Name of Applicant/Owner (if other than Proposed Insured #1)
Date of
Name:_____________________ Birth:___/___/___
M D Y
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Social Security No.
or Taxpayer I.D. No.:_______________________
Address: _____________________________________________________
City State Zip
Relationship to
Proposed Insured(s): ________________________________
Name of Contingent Owner (if other than Proposed Insured
#2)(applicable only to Second-to-Die Coverage)
Date of
Name:_____________________ Birth:___/___/___
M D Y
Social Security No.
or Taxpayer I.D. No.:_______________________
All notices and reports will be sent to the Owner, unless otherwise specified
in Third Party Designation.
Relationship to
Proposed Insured(s): ________________________________
SECTION IV - BENEFICIARY
Primary Beneficiary: (full name and relationship to Proposed Insured(s): ______
_______________________________________________________________________________
Contingent: (full name and relationship to Proposed Insured(s): _______________
_______________________________________________________________________________
NOTE: Unless otherwise noted, death benefits will be divided equally among
multiple surviving beneficiaries.
L-3920 AAA (10/99)
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Part II
SECTION V - POLICY BENEFITS AND PREMIUMS
Plan of Insurance: _________________ Premium Frequency:
__ Single Premium $_______________
__ Annual __ Semi-Annual
Specified Amount: ________ __ Quarterly __ PAC
Death Benefit Option __ Option 1 __ Option 2 __ Other ________
Rider(s): Other ___________
Riders (if available)
Premium Payment Schedule: (if other than single)
Convalescent Care Benefits (Long-Term Care)
__ Waiver of Monthly Deduction
Planned Periodic Premium $___________________
__ 2 years and no extension __ ________________________
Additional Initial Premium $__________________
__ 2 years and 2 year extension __ ________________________
Amount submitted with App $ ______________
__ 3 years and lifetime extension __ _______________________
__ Other Combination ____________ __ ________________________
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SECTION VI - NON-MEDICAL QUESTIONS Proposed Insured #1 Proposed Insured #2
Has any Proposed Insured: (if yes, give name, date and
details in Section VII) Yes No Yes No
<S> <C> <C>
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(a) have any life insurance or annuities currently in
force which will be replaced or changed by the policy being
applied for? --- --- --- ---
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(b) smoked cigarettes in the past 12 months --- --- --- ---
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(c) used any other type of tobacco or nicotine product
within the past 12 months? --- --- --- ---
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(d) piloted an aircraft within the past 3 years, or
has any intention of becoming a pilot? --- --- --- ---
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(e) ever participated in a sport or avocation such
as vehicle racing, sky diving, hang gliding, scuba or
skin diving? --- --- --- ---
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(f) had any life or health insurance applied for ever
been declined, postponed or offered other than
applied for? --- --- --- ---
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(g) within the past 3 years had their driver's license
restricted or revoked or been cited for more than 2
moving violations or been convicted of DUI? --- --- --- ---
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(h) any intention of traveling or residing outside the
U.S. or Canada within the next two years? --- --- --- ---
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SECTION VII - DETAILS TO NON-MEDICAL QUESTIONS IN SECTIONS VI
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Proposed Insured Question # Date Details or Reason
<S> <C> <C> <C>
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(If more room needed, please use a separate sheet of paper and have the Proposed
Insured sign and date the form.)
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SECTION VIII - MEDICAL SECTION
Proposed Insured #1 Proposed Insured #2
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Height: ____ Ft. _____In. Height: ____ Ft. _____In.
Weight __________ lbs. Weight __________ lbs.
Weight Change in past year and reason? Weight Change in past year and reason?
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Personal Physician's Name Personal Physician's Name
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Address and Phone Number Address and Phone Number
<S> <C>
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</TABLE>
L-3920 AAA (10/99)
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Third Party Designation
I, the Applicant/Owner understand that I have the right to designate a third
party, in addition to myself, to receive copies of any grace period and lapse
notices of my insurance coverage. I understand that no Power of Attorney is
created by this designation and that no other policy information will be
supplied to the designated third party. I understand that the additional notice
will be mailed no later than 30 days after a premium payment is required and
unpaid. I also understand that I will be given the opportunity to change my
third party designation annually. My selection is as follows:
__ I elect NOT to designate a third party to receive any grace period or lapse
notices.
__ I designate the person listed below to receive copies of any grace
period or lapse notices.
Third Party Name: _____________________________________________________________
Address: _____________________________________________________________
Phone No. __________________________
Optional Inflation Protection Coverage (This coverage ONLY applies to the
optional Extension of Convalescent Care (Long-Term Care) Benefits Rider.)
I have reviewed the Outline of Coverage and the graphs that compare the benefits
and premiums of the optional Extension of Convalescent Care Benefits Rider with
and without inflation protection. I understand and agree that I will be issued
the rider that includes the inflation protection UNLESS I sign the rejection
statement below.
Rejection Statement: I hereby REJECT the Optional Inflation Protection.
________________________________________________________________________________
(Signature of Applicant/Owner)
______________________________________________
(Date)
Statement of Understanding
By signing the section below, I (we) understand and agree that:
All statements and answers given on all Parts of this application, when
required, are true, complete and correctly recorded to the best of my (our)
knowledge and belief. I (We) understand that all such statements and answers are
part of this application and, therefore a part of any insurance policy issued.
It is agreed that:
(1) No agent or medical examiner can accept risks or make or change contracts or
waive First Penn-Pacific's rights or requirements.
(2) No insurance shall take effect unless the Proposed Insured(s) is (are) alive
and in the same condition of health as described in this application when the
policy is delivered to the Owner and the full initial premium is paid. However,
if the full initial premium is paid as set forth in the
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attached Conditional Receipt and this Receipt is delivered to the Owner, the
terms of this Receipt shall apply.
(3) Acceptance of a policy by the Owner shall constitute ratification of any
changes made by First Penn-Pacific under Executive Office Endorsements. In
those states where it is required, changes in plan of insurance, amount, age
at issue, classification of risks or benefits will be made only with the
Owner's consent.
Fraud Notice
I understand that any person who submits an application or files a claim with
the intent to defraud or helps commit a fraud against an insurer, as determined
by a court of competent jurisdiction, is guilty of a crime.
Authorization to Obtain and Disclose Information
In conjunction with an application for insurance, the proposed insured(s) hereby
authorize(s) any licensed physician, medical practitioner, hospital, clinic,
Veterans Administration, or other medical or medically related facility,
insurance company, the Medical Information Bureau or other organization,
institution or person or consumer reporting agency who possesses information of
me (us) or my (our) children to furnish such information to First Penn-Pacific
Life Insurance Company or its reinsurers.
This authorization includes information about drugs, alcoholism or mental
illness.
First Penn-Pacific Life Insurance Company or its reinsurers may make a brief
report regarding me(us) or my(our) children to other companies to whom I(we)
have applied or may apply.
I(we) authorize First Penn-Pacific Life Insurance Company and any reinsurer
to obtain an investigative consumer report on me(us). I(we) understand that
if a consumer report is prepared, I(we) will be interviewed in connection
with this application.
I(we) elect not to have personal information disclosed to non-affiliates of
First Penn-Pacific Life Insurance Company for purposes other than the
marketing of insurance products and services.
This authorization shall be valid from the date signed for a period of two and
one-half years (30 months). I(we), or any person acting on my(our) behalf, may
obtain a copy of this authorization by writing to First Penn-Pacific Life
Insurance Company. A photographic copy of this authorization shall be as
valid as the original.
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I (We) have read the Optional Inflation Protection Coverage notice, the
Statement of Understanding, the Fraud Notice, the Authorization to Obtain and
Disclose Information and have received a copy of the Pre-Notification which
includes the Medical Information Bureau notice and the Fair Credit Reporting Act
notice. Caution: If your answers on this application are incorrect or untrue,
First Penn-Pacific may have the right to deny benefits or rescind coverage.
Signed at _____________________________________________________________________
(City/State)
this date ________________________________
(Month/Day/Year)
_______________________________________________________________________________
(Signature of Proposed Insured #1 if other than Applicant)
_______________________________________________________________________________
(Signature of Applicant/Owner if other than Proposed Insured(s))
_______________________________________________________________________________
(Signature of Proposed Insured #2 if applicable)
_______________________________________________________________________________
Signature of Witness/Agent
Executive Office Endorsement
(Not applicable in Pennsylvania or West Virginia)
Special Requests or Instructions
L-3920 AAA (10/99)
