EXHIBIT 1. (10) Application for Policy
1010-V
First Ameritas Life Insurance Corp. of New York (First Ameritas)
400 Rella Boulevard, Suite 304 / Suffern, NY 10901-4253
APPLICATION FOR
VARIABLE UNIVERSAL LIFE Please print clearly in black ink.
PRODUCT NAME: ENCORE! II
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1. PROPOSED INSURED
Name________________________________________________
Sex ____ Date of Birth ___________________________
Birthplace__________________________________________
Former Name (if applicable)_________________________
Social Security Number______________________________
Address_____________________________________________
City/State/ZIP______________________________________
Occupation__________________________________________
Employer____________________________________________
Telephone - Home_________________________ Best Time To Call:____ A.M. ____ P.M.
Telephone - Business_____________________ Best Time To Call:____ A.M. ____ P.M.
E-mail Address:_____________________________________
2. OWNER Owner of the policy is to be (choose one): ___Proposed Insured __Other
(please complete below)
Full Name_______________________________________________________
Date of Birth___________________ Trust Date___________________
Address_________________________________________________________
City/State/ZIP__________________________________________________
Relationship to Proposed Insured (or all Trustee's Names)__________________
Social Security#/TIN#_______________________________________
3. BENEFICIARY If left blank, the beneficiary will be the estate of the Owner.
Unless otherwise indicated, multiple beneficiaries of the same class shall be
paid equally to the survivor or survivors.
Primary_______________________ Relationship to Proposed Insured_________________
Contingent____________________ Relationship to Proposed Insured_________________
4. ENCORE! II
Amount of Insurance $ _________________
Death Benefit Option (select one only)
____Option A (death benefit is the amount of insurance)
____Option B (death benefit is the amount of insurance plus the accumulation
value)
OPTIONAL RIDERS:
____Accidental Death Benefit $ _________________
____Disability Benefit $ _________________ or ____Waiver of Monthly Deduction
____Payor Disability $ __________________ or ____Payor of Monthly Deduction
(Applicant under age 37, Proposed Insured up through age 14 -
Complete L-5)
____Children's Protection ($10,000 coverage per child) (Complete L-5)
____Guaranteed Insurability $ _________________(only if insured is under
age 37)
____Covered Proposed Insured Rider
____Self Amount $ ____________
____Other Person (Complete L-6)
5. PREMIUM MODE Please select one.
____Annual ____Semi-Annual ____Quarterly ____Monthly Bank Withdrawal
(Complete Optional Program form) ____Monthly Billing ____Non-Billing
____Invoice Billed ____Payroll Deduction (Additional form required)
____Single $___________________
6. PREMIUM AMOUNT
Planned Annual Premium $ __________________ Planned Modal Premium $
__________________ *Initial Premium (paid with application) $ __________________
(leave receipt with payor). *All premium checks must be made payable to First
Ameritas. Do not make check payable to the agent or leave the payee blank.
7. INSURANCE INFORMATION Proposed Insured
____None
List all life insurance existing on Proposed Insured. If None, check box.
Will the insurance now being applied for discontinue, reduce, change or replace
any life insurance or annuity in this or any other company? Yes____ No____
(Specify policy number(s) below)
NAME OF COMPANY POLICY NUMBER AMOUNT YEAR WILL THIS POLICY
PROPOSED INSURED ISSUED BE REPLACED?
----------------- ------- ------------- ------ ------ ------------------------
___Yes ___No __As a 1035?
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8. OTHER INFORMATION
With regard to the Proposed Insured: (If yes, please explain) Proposed Insured
a. Has any company declined, postponed, modified, cancelled
or refused to renew, reinstate or issue insurance? ____Yes ____No
b. Is any other life insurance application now pending
or contemplated with any other company? ____Yes ____No
c. Have you been convicted of a driving violation or
had your license suspended or had a restriction
placed on your license within the past 3 years?
(If yes, provide:) Driver's license number
____________________ State of Issue___________ ____Yes ____No
d. Have you participated in any vehicle racing,
parachuting, hang gliding, scuba diving, mountain
climbing or rodeos within the past 2 years or
is any such activity contemplated? ___Yes ____No
e. Have you flown within the past 3 years as a pilot,
student pilot, crew member, or had any flying duties,
or is any such activity contemplated? ____Yes ____No
f. Do you anticipate travel or residence in a foreign
country in the near future? (If so, where and for how
long?) ____Yes ____No
Details of "yes" answers. Identify question number:
_______________________________________________________________________________
_______________________________________________________________________________
9. TOBACCO USE Proposed Insured
a. Have you smoked one or more cigarettes in
the past twelve months? ____Yes ____No
b. Have you used any form of tobacco or nicotine
substitute in the past twelve months? ____Yes ____No
(If yes, please indicate the type and frequency)
10. SPECIAL INSTRUCTIONS
_______________________________________________________________________________
_______________________________________________________________________________
11. ALLOCATION
Whole percentages only, must total 100%.
Funds listed by Advisor/Subadvisor.
*Service class 2
FIDELITY
______% Equity-Income*
______% Growth*
______% High Income*
______% Overseas*
______% Asset Manager*
______% Investment Grade Bond*
______% Asset Manager: Growth *
______% Contrafund*
CALVERT
Socially Responsible Funds
______% Balanced
______% Small Cap Growth
______% Mid Cap Growth
______% International Equity
Ameritas Portfolio (Subadvised)
______% Money Market
ALGER MANAGEMENT
Alger American Fund
______% Balanced
______% Leveraged AllCap
Ameritas Portfolio (Subadvised)
______% Growth
______% Income & Growth
______% Small Capitalization
______% MidCap Growth
MSDW INVESTMENT MANAGEMENT
______% Emerging Markets Equity
______% Global Equity
______% International Magnum
______% U.S. Real Estate
MFS Co.
MFS Trust
______% Utilities
______% Global Governments
______% New Discovery
Ameritas Portfolio (Subadvised)
______% Emerging Growth
______% Research
______% Growth With Income
STATE STREET
Ameritas Portfolio (Subadvised)
______% Index 500
FIRST AMERITAS
______% Fixed Account
100 % TOTAL
12. DOLLAR COST AVERAGING
Transfers totalling less than
$250 are not permitted.
Note: If this option is chosen, there must be sufficient allocation to the Money
Market in the Allocation Section. This option will stay in effect until the fund
is depleted or until I cancel this option in writing. Whole percentages only,
must total 100%.
*Service class 2 Funds listed by Advisor/Subadvisor.
If you elect Dollor Cost Averaging and Portfolio, Dollar Cost Averaging will be
performed prior to Portfolio Balancing. Transfer$____________per month from the
___Money Market or from the ___First Ameritas Fixed Account (36 months Minimum).
FIDELITY
______% Equity-Income*
______% Growth*
______% High Income*
______% Overseas*
______% Asset Manager*
______% Investment Grade Bond*
______% Asset Manager: Growth *
______% Contrafund*
CALVERT
Socially Responsible Funds
______% Balanced
______% Small Cap Growth
______% Mid Cap Growth
______% International Equity
Ameritas Portfolio (Subadvised)
______% Money Market
ALGER MANAGEMENT
Alger American Fund
______% Balanced
______% Leveraged AllCap Ameritas Portfolio (Subadvised)
______% Growth
______% Income & Growth
______% Small Capitalization
______% MidCap Growth
MSDW INVESTMENT MANAGEMENT
______% Emerging Markets Equity
______% Global Equity
______% International Magnum
______% U.S. Real Estate MFS Co.
MFS Trust
______% Utilities
______% Global Governments
______% New Discovery
Ameritas Portfolio (Subadvised)
______% Emerging Growth
______% Research
______% Growth With Income
STATE STREET
Ameritas Portfolio (Subadvised)
______% Index 500
FIRST AMERITAS
______% Fixed Account
100 % TOTAL
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13. PORTFOLIO BALANCING
Please rebalance the values in my subaccounts to result in a portfolio
allocation of:
____Check here to change current and future allocations.
Rebalancing should occur every:
____3 months, ____6 months or ____1 year (check one),
beginning on (date) _________ , or after issue date.
Whole percentages only, must total 100%.
*Service class 2
Funds listed by Advisor/Subadvisor.
If you elect Dollor Cost Averaging and Portfolio, Dollar Cost Averaging will be
performed prior to Portfolio Balancing. Transfer$____________per month from the
___Money Market or from the ___First Ameritas Fixed Account (36 months Minimum).
FIDELITY
______% Equity-Income*
______% Growth*
______% High Income*
______% Overseas*
______% Asset Manager*
______% Investment Grade Bond*
______% Asset Manager: Growth *
______% Contrafund*
CALVERT
Socially Responsible Funds
______% Balanced
______% Small Cap Growth
______% Mid Cap Growth
______% International Equity
Ameritas Portfolio (Subadvised)
______% Money Market
ALGER MANAGEMENT
Alger American Fund
______% Balanced
______% Leveraged AllCap
Ameritas Portfolio (Subadvised)
______% Growth
______% Income & Growth
______% Small Capitalization
______% MidCap Growth
MSDW INVESTMENT MANAGEMENT
______% Emerging Markets Equity
______% Global Equity
______% International Magnum
______% U.S. Real Estate MFS Co.
MFS Trust
______% Utilities
______% Global Governments
______% New Discovery
Ameritas Portfolio (Subadvised)
______% Emerging Growth
______% Research
______% Growth With Income
STATE STREET
Ameritas Portfolio (Subadvised)
______% Index 500
FIRST AMERITAS
______% Fixed Account
100 % TOTAL
14. EARNINGS SWEEP
Please calculate the gain on all subaccounts and deposit those gains in the
subaccounts listed: Earnings sweep should occur every:
Rebalancing should occur every:
____3 months, ____6 months or ____1 year (check one),
beginning on (date) _________ , or after issue date.
Whole percentages only, must total 100%.
*Service class 2
Funds listed by Advisor/Subadvisor.
FIDELITY
______% Equity-Income*
______% Growth*
______% High Income*
______% Overseas*
______% Asset Manager*
______% Investment Grade Bond*
______% Asset Manager: Growth *
______% Contrafund*
CALVERT
Socially Responsible Funds
______% Balanced
______% Small Cap Growth
______% Mid Cap Growth
______% International Equity
Ameritas Portfolio (Subadvised)
______% Money Market
ALGER MANAGEMENT
Alger American Fund
______% Balanced
______% Leveraged AllCap
Ameritas Portfolio (Subadvised)
______% Growth
______% Income & Growth
______% Small Capitalization
______% MidCap Growth
MSDW INVESTMENT MANAGEMENT
______%
Emerging Markets Equity
______% Global Equity
______% International Magnum
______% U.S. Real Estate MFS Co.
MFS Trust
______% Utilities
______% Global Governments
______% New Discovery
Ameritas Portfolio (Subadvised)
______% Emerging Growth
______% Research
______% Growth With Income
STATE STREET
Ameritas Portfolio (Subadvised)
______% Index 500
FIRST AMERITAS
______% Fixed Account
100 % TOTAL
15. HEALTH HISTORY
(Answer the following questions regarding Proposed Insured)
Name of personal physician
Address ____________________________
Phone ____________________________
Reason last consulted ____________________________
Date ____________________________
What treatment was given or medication prescribed? ____________________________
For following questions "HIV" means Human Immunodeficiency Virus, "AIDS" means
Acquired Immune Deficiency Syndrome and "ARC" means AIDS Related Complex.
Proposed Insured
a. Has the Proposed Insured within the past 10 years ever been
treated or had any:
(1) Disorder of eyes, ears, nose or throat? ____Yes ____No
(2) Dizziness, fainting, convulsions, epilepsy,
headache, speech defect, paralysis or stroke,
mental, brain or nervous disorder? ____Yes ____No
(3) Asthma, emphysema, pleurisy, allergies, shortness
of breath or any disorder of the lungs or respiratory
system? ____Yes ____No
(4) Chest pain, irregular or rapid pulse, high blood pressure,
rheumatic fever, heart murmur, heart attack,
anemia or other disorder of the heart, blood or
circulatory system? ____Yes ____No
(5) Intestinal bleeding, ulcer, ulcerative colitis,
spastic colitis, diverticulitis, jaundice or any
disorder of the liver, gallbladder, or digestive system? ____Yes ____No
(6) Sugar, albumin or blood in urine, nephritis, stone or
other disorder of the kidneys, bladder, prostate,
reproductive organs or breasts? ____Yes ____No
(7) Diabetes or disorder of the thyroid or other
endocrine glands? ____Yes ____No
(8) Rheumatism, arthritis, gout, deformity or amputation
or disorder of the muscles or bones? ____Yes ____No
(9) Cancer, tumor or cyst or any disorder of the skin
or lymph glands? ____Yes ____No
b. During the past 10 years has the Proposed Insured:
(1) Been diagnosed with or treated for AIDS or ARC
caused by an HIV infection? ____Yes ____No
c. Except as stated in answer to previous questions, has the
Proposed Insured within the past 5 years:
(1) Had any mental or physical disorder not previously listed? ____Yes ____No
(2) Been seen by a physician for a checkup, illness,
injury or surgery? ____Yes ____No
(3) Been a patient in a hospital, clinic or other
medical facility? ____Yes ____No
(4) Had an ECG, X-ray, CAT scan or other diagnostic
test (other than HIV tests)? ____Yes ____No
(5) Been advised to have any diagnostic test, hospitalization
or surgery which was not completed? ____Yes ____No
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d. Is Proposed Insured now taking any medication or treatment? ____Yes ____No
e. Has Proposed Insured ever used narcotics, barbiturates,
amphetamines, cocaine, LSD, marijuana, or hallucinogenic drugs?____Yes ____No
f. Has Proposed Insured ever received counseling or treatment
for the use of alcohol or drugs? ____Yes ____No
g. Has Proposed Insured ever been a member of a support group
for the use of alcohol or drugs? ____Yes ____No
h. Does the Proposed Insured have any family history of
diabetes, cancer, heart or kidney disease? ____Yes ____No
i. Tobacco Use
(1) Has the Proposed Insured smoked one or more cigarettes
in the past twelve months? ____Yes ____No
(2) Has the Proposed Insured used any form of tobacco or
nicotine in the past twelve months? ____Yes ____No
(If yes, please provide date of last use) ____________________
(3) Has the Proposed Insured used any form of tobacco or nicotine
in the past thirty-six months? ____Yes ____No
(If yes, please provide date of last use) _____________________
j. Family History Living
Age: Father____ Mother____ Brothers____ Sisters ____
Present Health: Father____________________ Mother____________________
Brothers____________________ Sisters ____________________
Deceased
Age: Father____ Mother____ Brothers____ Sisters ____
Cause of Death: Father____________________ Mother____________________
Brothers____________________ Sisters ____________________
k. Exact height ______ ft. _______ in. Exact Weight ____ lbs.___Gained ___Lost
____________________ pounds within past year.
Reason__________________________________________________________________________
DETAILS of "Yes" answers. Identify question number. Circle applicable items.
Include nature of ailment (and pathological diagnosis, if applicable), dates,
duration and names and addresses of all attending physicians and medical
facilities. Attach an additional sheet of paper, if needed.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
16. DISCLOSURES
I hereby acknowledge receipt of the current prospectus, and any supplements, for
this policy including any required disclosure if the policy applied for will be
in a qualified plan.
____I agree to receive future prospectuses and reports electronically, if
available, by delivery to my eMail address until such time as I give notice that
I wish to receive these documents in paper form by U.S. Mail.
17. AGREEMENTS
I agree as follows:
a. Any policy including any endorsements issued as a result of this
application will, with this application and any supplemental applications,
be the entire insurance contract.
b. No agent, broker or medical examiner can: 1) waive the answers to any
questions in this application; 2) make or change any insurance contract; or
3) waive any rights or rules of First Ameritas.
c. Except as specified otherwise in a receipt provided upon a payment of
premium at the time of application, insurance will not be effective until
ALL of the following are met: a) the policy issued by First Ameritas is
delivered to and accepted by the applicant; and b) the first full premium
is paid.
d. First Ameritas may change this application by an appropriate notation in
the space marked "Endorsements/Corrections": 1) to correct apparent errors
or omissions; and 2) to conform it with any policy rider that may be
issued. No change will be made in the following without the applicant's
written consent: 1) amount of insurance; 2) plan of insurance; 3)
classification of risks; or 4) benefits. Acceptance of any policy issued
under this application ratifies any amendments.
e. I understand that: 1) the amount and duration of the death benefit may vary
with investment experience, loans and other specified conditions; 2) policy
values not in the Fixed Account will increase or decrease in accordance
with the experience of the selected investment options of the Separate
Account; 3) the amount of the benefit payable on surrender is not
guaranteed, but is dependent on the then surrender value; 4) illustrations
of benefits, including the death benefit, are available upon request; and
5) this policy meets my investment objectives and anticipated financial
needs.
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18. AUTHORIZATION
This authorization or a photocopy of it, shall remain valid for use by First
Ameritas for two (2) years from the date below. I authorize any licensed
physician, medical practitioner, hospital, clinic or other medically related
facility, insurance company, agency conducting Investigative Consumer Reports or
any information service or financial institution, family member, or associate to
release to First Ameritas or any person or entity acting on its behalf, any
personal information which is on file and relates to my health or mental
condition, general character, driving records, use of alcohol and drugs, and
hobbies of a hazardous nature. I understand that any information obtained will
be used to determine my eligibility for insurance.
In addition, I authorize the Medical Information Bureau (MIB) to release to
First Ameritas or its reinsurers, any personal information which is on file and
relates to me.
I also agree that I have received and read the Notice of First Ameritas'
Insurance Information Practices, MIB and Investigative Consumer Reports. I also
understand that my authorized representative and I can receive a copy of this
authorization if we so desire.
19. SUBSTITUTE W-9 CERTIFICATION
I certify under penalty of perjury that: 1) the number shown on this form is my
correct taxpayer identification number (or I am waiting for a number to be
issued to me); and 2) I am not subject to backup withholding because: a) I am
exempt from backup withholding; or b) I have not been notified by the Internal
Revenue Service that I am subject to backup withholding as a result of a failure
to report all interest or dividends; or c) the IRS has notified me that I am no
longer subject to backup withholding.
You must cross out item 2 if you have been notified by the IRS that you are
currently subject to backup withholding because of underreporting interest or
dividends on your tax return.
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF
THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP
WITHHOLDING.
20. SIGNATURES
I represent to the best of my knowledge and belief that all statements and
answers to this application are complete and true.
Dated at: (City)___________________________________________________________
(State)_____________ On this Date____________________________________________
Signature of Proposed Insured ________________________________________________
Signature of Other Proposed Insured __________________________________________
Signature of Child (Age 18 or older), if applicable ________________________
Signature of Owner if not a Proposed Insured (if a corporation or Trust,
show full name) ________________________________ _________________________
Signature(s) and Title of Officer or Trustee(s) ____________________________
21. AGENT'S/REGISTERED REPRESENTATIVE'S STATEMENT
Do you have any knowledge or reason to believe that replacement of existing life
insurance or annuity coverage may be involved? ____Yes ____No I certify that: 1)
the information provided by the Owner has been accurately recorded; 2) a current
prospectus and all supplements were delivered; and 3) I have reasonable grounds
to recommend the purchase of the policy as suitable for the Owner.
Signature of Agent/Registered Representative __________________________________
Print Name Here _______________________________________________________________
First Ameritas Agent Code _____________________________________________________
Agency or Broker/Dealer _______________________________________________________
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22. ENDORSEMENTS/CORRECTIONS HOME OFFICE USE ONLY.
No change in the amount, age at issue, classification, plan of insurance or
benefits shall be effective unless agreed to in writing by me.
23. SUITABILITY INFORMATION
a. Financial Information Proposed Insured Owner (if other than Proposed
Insured or Trust)
i. Annual income from occupation $ $
ii. Annual income from other sources $ $
iii. Projected income for next 12 months $ $
iv. Estimated Net Worth $ $
v. Tax Bracket % %
B. INVESTMENT OBJECTIVES & RISK TOLERANCE
This section applies to the Owner. In order to determine if this policy meets
your investment objectives and continuing financial needs, please complete the
following:
Investment Objectives: Please check at least one. Multiple objectives can be
selected. However, if more than one please rank based on importance to you.
Primary = 1, Secondary = 2, etc.
_____ Long Term Gain _____ Short Term Gain _____ Income _____ Tax Advantaged
_____ Safety of Principal
Risk Tolerance: Rank based on the level of risk. Tolerable = 1,
Least Tolerable = 4.
_____ Low Risk _____ Moderate Risk _____ Speculative Risk _____ High Risk
C. CITIZENSHIP INFORMATION
Is the Proposed Insured a citizen of the United States? ____Yes ____No
If not, permanent resident? ____Yes ____No
How long in the United States? _____________________________
If you do NOT answer all of question 23.a., you must sign here.
The SEC/NASD and state rules require that we have reasonable grounds to believe
that the policy is suitable for you. Such a decision is based on facts, if any,
disclosed by you. You have chosen not to disclose your financial information to
us. Without this information, we are unable to make this determination. If you
have NOT answered all of question 23.a. above, you are required to sign the
following statement. I (we) have chosen not to disclose this information. I (we)
understand the policy benefits and risks and believe that they are consistent
with our needs and objectives.
HOME OFFICE USE ONLY For AIC Registered Representatives Only Signature of Owners
Signature of Joint Owners (if applicable) _____________________________
Signature of Joint Owners (if applicable) _____________________________
NOTICE
All Registered Representatives must provide their Broker Dealer with client
information applicable to suitability. (See your Broker Dealer for details.)
24. MEDICALS
Should be arranged by Agent/Registered Representative.
Indicate requirements being arranged per First Ameritas published rules:
Proposed Insured: ____Examination ____Urine ____Blood ____Resting EKG
____Stress EKG
Give name of examiner_____________________________________
Did you see Proposed Insured on the application date? ____Yes ____No
25. QUALIFIED PLAN
Additional forms are required, contact First Ameritas for details.
Is this application part of a Qualified Retirement Plan? (Defined Benefit,
Money Purchase, Profit Sharing,
401K) ____Yes ____No (If "Yes", explain)
_______________________________________________________________________________
_______________________________________________________________________________
26. Policy Delivery Send to: ____Owner ____Agent/Registered Representative
Agent/Registered Representative remarks and special instructions:
_______________________________________________________________________________
_______________________________________________________________________________
27. PROVISION SM Data: Please provide the following information.
Indicate if this was a PROVISION sale by marking the box for the
module/concept used.
____Asset Conservation (PROAC) ____Charitable Gifting (PROCG)
____Estate Planning (PROEP) ____Business Continuation (PROBC)
28. QUESTIONS? If First Ameritas has questions concerning this application, whom
should we call at your office?
Name (Please Print)
Representative's Phone______________________________
Fax #______________________________
If you have questions completing this application or any other supporting
documentation, please call: 1-800-215-1096.
29. MAIL APPLICATION TO:
First Ameritas Life Insurance Corp. of New York
400 Rella Boulevard, Suite 304
Suffern, NY 10901-4253 FAX#: 914-357-3612
OVERNIGHT DELIVERIES:
First Ameritas Life Insurance Corp. of New York
400 Rella Boulevard, Suite 304
Suffern, NY 10901-4253
<PAGE>
* * * * IMPORTANT * * * *
Please detach top portion and leave with client if money accompanies the
application. Detach bottom portion and leave with client in ALL cases.
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The following information should be reviewed in conjunction with completion of a
First Ameritas Life Insurance Corp. of New York (First Ameritas) application for
insurance.
CONDITIONAL RECEIPT
NO AGENT OR ANY OTHER PERSONS IS AUTHORIZED BY THE COMPANY TO WAIVE OR MODIFY
ANY OF THE PROVISIONS OF THIS CONDITIONAL RECEIPT. ALL PREMIUM CHECKS MUST BE
MADE PAYABLE TO THE INSURANCE COMPANY. DO NOT MAKE CHECKS PAYABLE TO THE AGENT
OR LEAVE THE PAYEE BLANK.
1. NO COVERAGE WILL BECOME EFFECTIVE PURSUANT TO THIS CONDITIONAL RECEIPT UNLESS
AND UNTIL ALL OF THE FOLLOWING CONDITIONS HAVE BEEN SATISFIED COMPLETELY AND
EXACTLY:
(a) The amount of payment received with this application must be equal to the
full initial modal premium for the amount and plan of life insurance
applied for and effective at the time of delivery of the policy.
(b) All medical examinations, tests and related data required by the Company
must be completed and received at its Service Center in Lincoln, Nebraska
within sixty (60) days from the completion of this application.
(c) As of the effective date below, each person proposed for insurance in this
application must be insurable in accordance with Company rules, limits, and
standards for the plan and the amount applied for without any modifications
either as to plan, amount, riders and/or the rate of premium paid.
(d) As of the effective date, the state of health and all factors affecting the
insurability of each person proposed for insurance must be stated in this
application.
2. If the conditions of paragraph 1 are satisfied on the effective date,
insurance coverage will be provided pursuant to this Conditional Receipt on the
same terms and conditions as the policy applied for and in use on the effective
date. However, the amount of such insurance will be in an amount not to exceed
that specified in paragraph 3. "Effective date" as used herein, is the latest
of: (a) The date of the application, Part 1; or (b) The date of the completion
by Insureds of all medical examinations or tests required by the Company; or (c)
The date, if any, specifically requested in the application.
3. The maximum total amount of insurance which will be payable pursuant to any
Conditional Receipt received by the Applicant as a result of pending
applications with the Company and affiliated companies is limited to the smaller
of:
(a) The total amount of insurance applied for with the Company and affiliated
Companies; or
(b) $100,000 minus the total amount of insurance inforce with the Company and
affiliated Companies, but not less than zero.
(c) As used above, total amount of insurance includes any amounts payable under
any Accidental Death Benefit provision.
4. If one or more of the conditions in paragraph 1 on any insured have not been
satisfied completely and exactly, there shall be no liability on the part of the
Company pursuant to this Conditional Receipt except to return the applicable
premium paid for coverage on that insured.
5. Any insurance in effect pursuant to this Conditional Receipt will end at the
earliest of:
(a) The date notice is mailed that the application is not accepted; or
(b) At the end of sixty (60) days from the date of this Conditional Receipt;
or
(c) The date on which coverage under the policy applied for becomes effective.
NOTE: Condition 5(b) does not apply to Connecticut residents.
Received the sum of $________________________ from
_________________________________________ in connection with the application
for life insurance bearing the same date as this Conditional Receipt. Dated
at____________________________________ this__________________ date
of_______________________________ , 20_________.
____________________________________________________________________
Signature of Agent/Registered Representative
I acknowledge possession of this receipt. I certify that I have read it and the
terms in the Application. I also certify that the Agent/Registered
Representative has explained the provisions in paragraph No. 3, other terms of
this Conditional Receipt and the terms in the Application to me and that I
understand and accept them.
Signature of Applicant_____________________________________________
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NOTICE OF FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK'S
(First Ameritas) INSURANCE INFORMATION PRACTICES
To issue an insurance policy, we need to obtain information about you and
any other persons proposed for insurance. Some of that information will come
from you and some will come from other sources. That information and any
subsequent information collected by us may in certain circumstances be disclosed
to third parties without your specific authorization.
All insured persons have a right of access and correction with respect to
the information collected about himself or herself except information which
relates to a claim, or civil or criminal proceeding.
If you wish to have a more detailed explanation of our information
practices, please contact: First Ameritas Life Insurance Corp. of New York,
Underwriting Department, 400 Rella Boulevard, Suite 304, Suffern, NY 10901-4253.
In an effort to provide better service and products to you, First Ameritas
may use information given by you to develop marketing data. Your name will not
be associated with this data in any way. If you do not want us to use
information obtained from you for these purposes, please contact us within ten
(10) days. We need to know within 10 days because once the information is
separated from your application, we will be unable to personally identify the
information with you or your application. The address at which to contact us is:
First Ameritas Life Insurance Corp. of New York, 400 Rella Boulevard, Suite 304,
Suffern, NY 10901-4253.
Two of our sources of information about you are MIB, Inc. (Medical
Information Bureau) and Investigative Consumer Reports. The following paragraphs
describe these sources.
MIB, INC. (MEDICAL INFORMATION BUREAU)
Information regarding the Proposed Insured's insurability will be treated
as confidential. We or our reinsurers may, however, make a brief report thereon
to MIB, Inc., a non-profit membership organization of life insurance companies
which operates an information exchange on behalf of its members. If any of the
Proposed Insured(s) apply to another Bureau member company for life or health
insurance coverage, or a claim for benefits is submitted to such a company, the
Bureau, upon request, will supply such company with the information it may have
in its file.
Upon receipt of a request from any Proposed Insured (or the Parent or
Guardian, if juvenile), the Bureau will arrange disclosure of any information it
may have in the Proposed Insured's file. If there is a question as to the
accuracy of information in the Bureau's file, the Bureau may be contacted to
seek a correction in accordance with the procedures set forth in the federal
Fair Credit Reporting Act. The address of the Bureau's information office is
P.O. Box 105, Essex Station, Boston, MA 02112, telephone number (617) 426-3660.
We or our reinsurers may also release information in our file to other life
insurance companies to whom the Proposed Insured may apply for life or health
insurance or to whom a claim for benefits may be submitted.
MEDICAL AUTHORIZATION
The medical authorization on the application, or a photocopy of it, shall
remain valid for use by First Ameritas for the duration of any claim for
benefits.
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* * * * IMPORTANT * * * *
If money accompanies this application, please complete
the receipt portion on the top of this notice.
* * * * IMPORTANT * * * *
This notice must be detached and left with your client in ALL cases.
INVESTIGATIVE CONSUMER REPORTS
Depending on the size of policy applied for, we may request that an
investigative consumer reports about the Proposed Insured be given to us. It
will be conducted by a national organization skilled in obtaining information
about people.
The kind of information we may be seeking includes such facts as residence
verification, marital status, occupation, general reputation, personal
characteristics and mode of living. It will be obtained through personal
interviews with the Proposed Insured's friends, neighbors, associates and other
acquaintances. Inquiries will not be directed toward determining the Proposed
Insured's sexual orientation. Also, no adverse underwriting decision will be
made because a report shows that an Proposed Insured has demonstrated
AIDS-related concerns or has sought AIDS-related counseling. AIDS test results
received at anonymous counseling and testing sites are confidential and need not
be disclosed. Any AIDS testing is limited to FDA licensed blood tests and the
diagnosis of AIDS must be made by a member of the medical profession.
An Proposed Insured may ask to be interviewed in connection with the preparation
of the report by contacting us within 5 working days of applying for the
insurance requested. He or she may call us collect at the following number and
ask for the Underwriting Department: 800-745-6665.
ADVERSE UNDERWRITING DECISION
After review of the application submitted on the Proposed Insureds, if the
policy cannot be issued as applied for, we will provide the specific reasons for
this decision upon written request from the applicant. Send your written request
to the Underwriting Department at the address above.
