<PAGE>
AMERICAN FAMILY LIFE INSURANCE COMPANY
6000 AMERICAN PKWY
MADISON, WI 53783-0001
APPLICATION FOR LIFE INSURANCE - PART 1 AGT/DIST CODE
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SECTION 1. GENERAL INFORMATION
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Are all of the Proposed Insureds and the Proposed Owner able to read and
understand all of the questions on this Application? ___ Yes ___ No
If No, indicate how this Application is being translated:
___ Translator Name (Translation cannot be done by the Proposed Owner or the
Beneficiary) ____ AT&T Language Line
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(first) (mi) (last) (suffix) (Operator #)
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SECTION 2. PROPOSED PRIMARY INSURED
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Proposed Primary Insured's Name
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(first) (mi) (last) (suffix)
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Any previous name(s) Gender Birth Date:
__ M __ F Age (nearest birthday):
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Address City/Town State Zip
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Social Security # Driver's License # Issuing State Telephone #
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Birthplace(Country/State)
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Occupation Information Hire Date Year
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Employer Title
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Duties
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SECTION 3. PLAN INFORMATION AMOUNT OF INSURANCE $
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TYPE OF PLAN - CHECK BOX
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<TABLE>
<S> <C> <C>
__ Whole Life __ AmeriTerm 2000 __ UL/VUL Increase
__ Ten Year Pay Whole Life __ Ten Year Level Term Policy # __________
__ Five Year Level Term __ Twenty Year Level Term Issue UL/VUL Increase
__ 25 Year Decreasing Term __ Universal Life 2000 (UL) with Waiver of Monthly
__ 30 Year Decreasing Term __ Variable Universal Life (VUL) Deductions?
__ Other ________________ __ Yes __ No
</TABLE>
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DEATH BENEFIT OPTION (UL AND VUL ONLY)
__ Option 1 __ Option 2
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DIVIDEND OPTION (CHECK CASH FOR UL AND VUL)
__ Reduce Premium __ Paid-up Additions __ Cash __ Accumulate at Interest
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TERM RIDER (NOT AVAILABLE FOR UL OR VUL) AMOUNT OF TERM RIDER $
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__ 15 Year Decreasing Term __ 25 Year Decreasing Term __ Annual Renewable Term
__ 20 Year Decreasing Term __ 30 Year Decreasing Term __ 5 Year Level Term
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ADDITIONAL INSURED/CHILDREN'S INSURANCE RIDERS (CHECK BOXES)
__ Additional Insured Rider (if Proposed Primary Insured) Amount $ ________
__ Additional Insured Rider (if other than Proposed Primary Insured)
Number of Proposed Additional Insureds: _____________
__ Children's Insurance Rider (Complete Section 13)
Number of Children to be covered immediately: ___ Amount $ 10,000 per Child
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BENEFIT RIDERS (CHECK BOXES)
__ ADB (subject to Company maximum) Amount $ _________
__ GIB/GPO (subject to Company maximum) Amount $ _________
__ Waiver of Premium (not for UL or VUL)
__ Waiver of Monthly Deductions (UL and VUL only)
__ Waiver of Specified Premium (VUL only) Amount of Premium to be Waived: $___
__ Guaranteed Minimum Death Benefit at Age 65 (Variable Universal Life only)
__ Juvenile Payor Benefit (not for UL or Variable Universal Life)
(Complete section 14)
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Page 1 of 12
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SECTION 4. PREMIUM AND BILLING AMOUNT PAID WITH APPLICATION $ ________
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BILLING MODE - CHECK BOX
Annual, Semi-Annual and Quarterly AFT billing modes are available for VUL only
__ Annually __ Semiannually __ Quarterly __ DM Monthly __ AGT Monthly
__ Emp Monthly
__ Annual AFT __ Semiannual AFT __ Quarterly AFT __ Monthly AFT
__ Amplan (Not available for UL or VUL)
Deductions other than the policy effective date, Enter date: ____________
Existing Amplan/AFT Account No.
Planned Premium and Billing for UL & VUL $
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SECTION 5. INSURANCE IN FORCE OR PENDING
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Does the Proposed Primary Insured have life and/or health insurance or an
annuity contract that lapsed in the past 6 months, that is pending or that is
in force with this or any other company? ___ Yes _____No
If Yes, complete the following:
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Company Amount ADB Amt. Yr. Issued
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SECTION 6. REPLACEMENT
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Is the insurance applied for intended to replace or change existing life
insurance or an annuity contract with this or any other insurance company?
__ Yes __ No
Agent - If Yes, complete and send Replacement Forms and if a 1035 exchange is
intended, complete and send an Absolute Assignment Form.
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SECTION 7. BENEFICIARY
(DO NOT COMPLETE FOR ADDITIONAL INSURED OR CHILDREN'S INSURANCE RIDER)
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Primary Beneficiary/Relationship to Contingent Beneficiary/ Relationship to
Proposed Primary Insured Proposed Primary Insured
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SECTION 8. OWNER
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Proposed Primary Owner
(first) (mi) (last) (suffix)
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(Business/Organization Name)
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Address City/Town State Zip
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Birth Date Social Security # or Tax ID # Relationship to
Proposed Primary Insured
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Representative (first) (mi) (last) (suffix)
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(Title)
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Proposed Contingent Owner
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(first) (mi) (last) (suffix)
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(Business/Organization Name)
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Address City/Town State Zip
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Birth Date Social Security # or Tax ID # Relationship to
Proposed Primary Insured
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Representative (first) (mi) (last) (suffix)
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(Title)
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Page 2 of 12
<PAGE>
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SECTION 9. SPECIAL REQUESTS (USE THIS AREA TO ENTER INFORMATION PERTAINING ONLY
TO THIS APPLICATION. ANY INFORMATION ENTERED HERE WILL REQUIRE EXTRA REVIEW AND
MAY REQUIRE ADDITIONAL PROCESSING TIME.)
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SECTION 10. HOME OFFICE ENDORSEMENTS ONLY
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SECTION 11. UNDERWRITING QUESTIONS (TO BE ASKED OF THE PROPOSED PRIMARY
INSURED)
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1. Does the Proposed Primary Insured have a primary health care
provider? __ Yes __ No
If Yes, complete the following:
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Primary health care provider's name
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Address City/Town State Zip
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Telephone No. Date of and reason for last contact _______ Year___
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2. What is Proposed Primary Insured's: current height: _______ ft. ______ in.
and current weight ________ lb.
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3. Has the Proposed Primary Insured been given by a member of the medical
profession, a diagnosis of or treatment for AIDS (Acquired Immune Deficiency
Syndrome) or ARC (AIDS Related Complex) or tested positive for the presence of
antibodies to HIV (Human Immunodeficiency Virus)? ___ Yes ___ No
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SECTION 11A. UNDERWRITING QUESTIONS (QUESTIONS 4. THROUGH 6. TO BE ASKED OF
THE PROPOSED PRIMARY INSURED INSURANCE AGE 18 AND OVER).
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4. Has the Proposed Primary Insured ever had, been told he/she has, or been
treated for: (Indicate applicable conditions)
a. chest pain, stroke, heart murmur, heart attack, irregular heart beat,
high blood pressure, anemia or any disorder of the heart, blood vessels,
or blood?
____ Yes ____ No
b. cancer, tumor, persistent skin lesions, disorder of the lymph glands?
____ Yes ____ No
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5. Has the Proposed Primary Insured:
a. used alcohol or drugs habitually or to excess or been treated for the
habitual or excessive use of alcohol or drugs?
____ Yes ____ No
b. been told to discontinue the use of alcohol or drugs, been counseled or
joined an organization because of such use?
____ Yes ____ No
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6. Has the Proposed Primary Insured:
a. used any nicotine products during the past 36 months? If Yes, give
product (cigarettes, cigars, etc.) and date last used.
____ Yes ____ No
b. ever had life or health insurance rejected, rated up, modified,
canceled or not renewed? Yes No
____ Yes ____ No
c. ever participated in or does he/she expect to participate in flying (as
a pilot or crew member) or any hazardous sports, avocations or hobbies
such as racing, scuba or sky diving, or mountain climbing?
____ Yes ____ No
d. any intention of traveling or residing outside the United States or
Canada?
____ Yes ____ No
e. within the past five years had his/her driver's license suspended, had
a moving traffic violation or chargeable accident?
____ Yes ____ No
f. been convicted for anything other than traffic violations?
____ Yes ____ No
g. received or is he/she currently receiving disability benefits or is
he/she currently disabled?
____ Yes ____ No
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QUESTIONS 7. THROUGH 9. TO BE ASKED OF THE PROPOSED PRIMARY INSURED INSURANCE
AGE 18 AND OLDER - (OPTIONAL IF MEDICAL EXAM IS REQUIRED)
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7. Has the Proposed Primary Insured ever had, been told he/she has, or been
treated for: (Indicate applicable conditions)
a. blurred vision, loss of vision, difficulty hearing, loss of hearing,
hoarseness or any disorder of the eyes, ears, nose, or throat?
____ Yes ____ No
b. dizziness, fainting, seizures, headaches, paralysis; mental, emotional
or neurological disorder or any other disorder of the brain or nervous
system?
____ Yes ____ No
c. shortness of breath, difficulty breathing, persistent cough, coughing
up blood, asthma or any disorder of the respiratory system?
____ Yes ____ No
d. intestinal bleeding, chronic diarrhea, recurrent indigestion, jaundice,
chronic abdominal pain or any stomach, gallbladder, intestinal or liver
disorder?
____ Yes ____ No
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Page 3 of 12
<PAGE>
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SECTION 11A. UNDERWRITING QUESTIONS (CONTINUED) QUESTIONS 7. THROUGH 9. TO
BE ASKED OF THE PROPOSED PRIMARY INSURED INSURANCE AGE 18 AND OLDER -
(OPTIONAL IF MEDICAL EXAM IS REQUIRED)
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e. frequent urination, difficulty urinating; sugar, protein, or blood in
urine; complications of pregnancy; or any disorder of the kidneys,
bladder, prostate, breast or reproductive organs; sexually transmitted
disease?
____ Yes ____ No
f. diabetes, thyroid, or hormone disorder? Yes No
____ Yes ____ No
g. deformity, lameness, amputation, chronic joint pain, swelling,
stiffness, imbalance or any disorder of the muscles, bones or joints?
____ Yes ____ No
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8. In the past five years has the Proposed Primary Insured:
a. consulted any health care provider, been hospitalized, been advised to
receive treatment or take medication or is he/she now receiving treatment,
taking medication or has he/she been advised to have or contemplated
surgery for any reason not previously explained?
____ Yes ____ No
b. had an electrocardiogram, x-ray, blood study, urinalysis or other
diagnostic study?
____ Yes ____ No
c. had an unexplained or unintentional weight loss or gain of more than
ten pounds?
____ Yes ____ No
___ Loss of pounds in months ___ Gain of pounds in months
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9. Is there a history in parent(s) or sibling(s) of diabetes; mental,
emotional or neurological disorder, heart, kidney, or circulatory disorder;
cancer; or death before age 60?
____ Yes ____ No
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GIVE DETAILS FOR QUESTIONS 3. THROUGH 9. ANSWERED YES. IF ADDITIONAL SPACE
IS NEEDED, USE AND ATTACH A PLAIN WHITE SHEET OF PAPER. INCLUDE
APPLICATION/POLICY # AND PROPOSED PRIMARY INSURED'S NAME ON ALL ADDITIONAL
SHEETS.
-------------------------------------------------------------------------------
Question # Details or Reason (Give date of diagnosis or onset; medications;
surgeries; hospitalizations; health care provider's name,
address, telephone and reason for last contact)
-------------------------------------------------------------------------------
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AGENT: If yes to Question 3. do not collect money or give a Conditional Receipt.
Consult Life Reference Manual for specific instructions.
Page 4 of 12
<PAGE>
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SECTION 11B. UNDERWRITING QUESTIONS (CONTINUED) (TO BE ASKED OF THE PROPOSED
OWNER FOR THE PROPOSED PRIMARY INSURED UNDER INSURANCE AGE 18)
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3. If the Proposed Primary Insured is insurance age five or under, was he/she
born prematurely?
____ Yes ____ No
If Yes, complete the following:
Duration of pregnancy weeks Birth weight: lbs. oz
Any ongoing observation, monitoring or treatment? If Yes, provide details:
____ Yes ____ No
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4. Has the Proposed Primary Insured ever had, been told he/she has, or been
treated for: (Indicate applicable conditions)
a. any disease, deformity, congenital defect or abnormal mental development?
____ Yes ____ No
b. any heart, respiratory, intestinal, urinary, mental, emotional or
neurological disorder?
____ Yes ____ No
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5. Has the Proposed Primary Insured been confined in a hospital for
observation, treatment or diagnosis?
____ Yes ____ No
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6. In the past five years, has the Proposed Primary Insured consulted any health
care provider or has any health care provider been consulted on behalf of the
Proposed Primary Insured for any reason not previously explained?
____ Yes ____ No
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7. Has the Proposed Primary Insured:
a. ever had life or health insurance rejected, rated up, modified,
canceled or not renewed?
____ Yes ____ No
b. ever participated in or does he/she expect to participate in flying (as
a pilot or crew member) or any hazardous sports, avocations or hobbies
such as racing, scuba or sky diving, or mountain climbing?
____ Yes ____ No
c. any intention of traveling or residing outside the United States or
Canada?
____ Yes ____ No
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8. Is there any life insurance carried on the Proposed Primary Insured's
parent(s) and sibling(s)?
____ Yes ____ No
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GIVE DETAILS FOR QUESTIONS 3. THROUGH 8.
ANSWERED YES. IF ADDITIONAL SPACE IS NEEDED, USE AND ATTACH A PLAIN WHITE
SHEET OF PAPER. INCLUDE APPLICATION/POLICY # AND PROPOSED PRIMARY INSURED'S
NAME ON ALL ADDITIONAL SHEETS.
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Question # Details or Reason (Give date of diagnosis or onset; medications;
surgeries; hospitalizations; health care provider's name,
address, telephone and reason for last contact)
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Page 5 of 12
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SECTION 12. PROPOSED ADDITIONAL INSURED
(MUST BE COMPLETED FOR ADDITIONAL INSURED RIDER) AMOUNT OF INSURANCE $
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Proposed Additional Insured's Name
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(first) (mi) (last) (suffix)
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Any previous name(s) Gender Birth Date:
__ M __ F Age (nearest birthday):
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Address City/Town State Zip
-------------------------------------------------------------------------------
Social Security # Driver's License # Issuing State Telephone #
-------------------------------------------------------------------------------
Birthplace (Country/State)
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OCCUPATION INFORMATION Hire Date Year
-------------------------------------------------------------------------------
Employer Title
-------------------------------------------------------------------------------
Duties
-------------------------------------------------------------------------------
INSURANCE IN FORCE OR PENDING
-------------------------------------------------------------------------------
Does the Proposed Additional Insured have life and/or health insurance or an
annuity contract that lapsed in the past 6 months, that is pending or that is
in force with this or any other company? __ Yes __ No
If Yes, complete the following:
-------------------------------------------------------------------------------
Company Amount ADB Amt Yr. Issued
-------------------------------------------------------------------------------
REPLACEMENT
-------------------------------------------------------------------------------
Is the insurance applied for intended to replace or change existing life
insurance or an annuity contract? __ Yes __ No
Agent - If Yes, complete and send Replacement Forms and if a 1035 exchange is
intended, complete and send an Absolute Assignment Form.
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BENEFICIARY (FOR ADDITIONAL INSURED RIDER)
-------------------------------------------------------------------------------
Primary Beneficiary/Relationship to Contingent Beneficiary/ Relationship to
Proposed Additional Insured Proposed Additional Insured
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UNDERWRITING QUESTIONS (TO BE ASKED OF THE PROPOSED ADDITIONAL INSURED
INSURANCE AGE 18 AND OVER)
-------------------------------------------------------------------------------
1. Does the Proposed Additional Insured have a primary health care provider?
If Yes, complete the following:
__ Yes __ No
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Primary health care provider's name
-------------------------------------------------------------------------------
Address City/Town State Zip
-------------------------------------------------------------------------------
Telephone No. Date of and reason for last contact ________ Year _____
-------------------------------------------------------------------------------
2. What is the Proposed Additional Insured's: current height: ft. in.
and current weight lbs.
-------------------------------------------------------------------------------
3. Has the Proposed Additional Insured been given by a member of the medical
profession, a diagnosis of or treatment for AIDS (Acquired Immune Deficiency
Syndrome) or ARC (AIDS Related Complex) or tested positive for the presence
of antibodies to HIV (Human Immunodeficiency Virus)?
__ Yes __ No
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Page 6 of 12
<PAGE>
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UNDERWRITING QUESTIONS (CONTINUED) QUESTIONS 4. THROUGH 6. TO BE ASKED OF THE
PROPOSED ADDITIONAL INSURED INSURANCE AGE 18 AND OVER.
-------------------------------------------------------------------------------
4. Has the Proposed Additional Insured ever had, been told he/she has, or
been treated for: (Indicate applicable conditions)
a. chest pain, stroke, heart murmur, heart attack, irregular heart beat,
high blood pressure, anemia or any disorder of the heart, blood vessels,
or blood?
__ Yes __ No
b. cancer, tumor, persistent skin lesions, disorder of the lymph glands?
__ Yes __ No
-------------------------------------------------------------------------------
5. Has the Proposed Primary Insured;
a. ever had, been told he/she has, or been treated for habitual or
excessive use of alcohol or drugs?
__ Yes __ No
b. been told to discontinue the use of alcohol or drugs, been counseled or
joined an organization because of such use?
__ Yes __ No
-------------------------------------------------------------------------------
6. Has the Proposed Additional Insured:
a. used any nicotine products during the past 36 months? If Yes, give
product (cigarettes, cigars, etc.) and date last used.
__ Yes __ No
b. ever had life or health insurance rejected, rated up, modified,
canceled or not renewed?
__ Yes __ No
c. ever participated in or does he/she expect to participate in flying
(as a pilot or crew member) or any hazardous sports, avocations or hobbies
such as racing, scuba or sky diving, or mountain climbing?
__ Yes __ No
d. any intention of traveling or residing outside the United States or
Canada?
__ Yes __ No
e. within the past five years had his/her driver's license suspended, had
a moving traffic violation or chargeable accident?
__ Yes __ No
f. been convicted of anything other than traffic violations?
__ Yes __ No
g. received or is he/she currently receiving disability benefits or is
he/she currently disabled?
__ Yes __ No
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QUESTIONS 7. THROUGH 9. TO BE ANSWERED BY PROPOSED ADDITIONAL INSURED
INSURANCE AGE 18 AND OLDER - (OPTIONAL IF MEDICAL EXAM IS REQUIRED)
-------------------------------------------------------------------------------
7. Has the Proposed Additional Insured ever had, been told he/she has, or
been treated for: (Indicate applicable conditions)
a. blurred vision, loss of vision, difficulty hearing, loss of hearing,
hoarseness or any disorder of the eyes, ears, nose, or throat?
__ Yes __ No
b. dizziness, fainting, seizures, headaches, paralysis; mental, emotional
or neurological disorder or any other disorder of the brain or nervous
system?
__ Yes __ No
c. shortness of breath, difficulty breathing, persistent cough, coughing
up blood, asthma or any disorder of the respiratory system?
__ Yes __ No
d. intestinal bleeding, chronic diarrhea, recurrent indigestion, jaundice,
chronic abdominal pain or any stomach, gallbladder, intestinal or liver
disorder?
__ Yes __ No
e. frequent urination, difficulty urinating; sugar, protein, or blood in
urine; complications of pregnancy; or any disorder of the kidneys,
bladder, prostate, breast or reproductive organs; sexually transmitted
disease?
__ Yes __ No
f. diabetes, thyroid, or hormone disorder?
__ Yes __ No
g. deformity, lameness, amputation, chronic joint pain, swelling,
stiffness, imbalance or any disorder of the muscles, bones or joints?
__ Yes __ No
-------------------------------------------------------------------------------
8. In the past five years has the Proposed Additional Insured:
a. consulted any health care provider, been hospitalized, been advised to
receive treatment or take medication or is he/she now receiving treatment,
taking medication or has he/she been advised to have or contemplated
surgery for any reason not previously explained?
__ Yes __ No
b. had an electrocardiogram, x-ray, blood study, urinalysis or other
diagnostic study?
__ Yes __ No
c. had an unexplained or unintentional weight loss or gain of more than
ten pounds?
__ Yes __ No
Loss of pounds in months
Gain of pounds in months
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9. Is there a history in parent(s) or sibling(s) of diabetes; mental,
emotional or neurological disorder, heart, kidney, or circulatory disorder;
cancer; or death before age 60?
__ Yes __ No
-------------------------------------------------------------------------------
Page 7 of 12
<PAGE>
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GIVE DETAILS FOR QUESTIONS 3. THROUGH 9. ANSWERED YES. IF ADDITIONAL SPACE IS
NEEDED, USE AND ATTACH A PLAIN WHITE SHEET OF PAPER. INCLUDE
APPLICATION/POLICY # AND PROPOSED ADDITIONAL INSURED'S NAME ON ALL ADDITIONAL
SHEETS.
-------------------------------------------------------------------------------
Question # Details or Reason (Give date of diagnosis or onset; medications;
surgeries; hospitalizations; health care provider's name,
address, telephone and reason for last contact)
-------------------------------------------------------------------------------
AGENT: If Yes to Question 3. Do not collect money or give a Conditional
Receipt. Consult Life Reference Manual for specific instructions.
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AGREEMENT (FOR THE PROPOSED ADDITIONAL INSURED) (READ COMPLETELY BEFORE
SIGNING)
-------------------------------------------------------------------------------
By signing this Application, I understand and agree as follows:
1. I have personally read (or have had read to me) and verified all statements
and answers provided to American Family Life Insurance Company (the
Company) as part of this Application. They are true and complete to the
best of my knowledge and belief. The Company will rely on such statements
and answers when making its decision to issue a policy. Any false or
incomplete statements or answers may invalidate coverage.
2. No agent of the Company or medical examiner can make or alter any contract
or waive any of the Company's rights or requirements. No change in Amount
of Insurance/Specified Amount, classification, plan of insurance or
benefits will be effective unless agreed to in writing by the Owner.
3. This Application will become part of the Policy.
4. Except as provided in the Conditional Receipt, no insurance becomes
effective unless and until: a) the Policy is accepted in writing by the
Owner; b) the first full Premium is paid during the lifetime of the
person(s) to be covered; and c) the health and insurability of the
person(s) to be covered remains as described in this Application.
5. I have full right and authority to sign this Application.
6. This Application becomes effective on the date the last required signature is
obtained.
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AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION (FOR THE PROPOSED
ADDITIONAL INSURED)
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By signing this Application, I authorize the following to give information to
American Family Life Insurance Company (the Company) or any person or group
acting on behalf of the Company, any health care provider, consumer reporting
agency, employer, insurance or reinsurance company, insurance agent,
governmental or other organization; the Medical Information Bureau, Inc. (MIB),
a family member or other person. "Information" means facts regarding my physical
or mental health and includes diagnosis or medical history, psychiatric history
or treatment, results of genetic tests, treatment or prognosis of any physical
or mental condition, and drug or alcohol abuse history or treatment or any
non-medical information. I understand that this information will be used by the
Company to determine eligibility for insurance or insurance benefits and may be
disclosed by the Company to insurance or reinsurance companies, the MIB, or to
other organizations or persons performing services in connection with this
Application or any claim. I agree that a copy of this Authorization may be used
in place of the original and that this Authorization is valid for 26 months from
the date I signed this Application. I understand that I have the right to
receive a copy of this Authorization upon request. I have received the Notice to
Proposed Primary/Additional Insured (or Parent/Legal Guardian of a Minor). The
Company can obtain and release information pursuant to that Notice. I authorize
the Company to obtain an investigative consumer report on me or my minor
child(ren) and understand that I may request to be personally interviewed in the
preparation of such report. If such report is required, I ask to be personally
interviewed. __ Yes __ No
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ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING
A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM
CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
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Proposed Additional Insured's Signature Date
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Page 8 of 12
<PAGE>
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SECTION 13. PROPOSED CHILD INSURED (COMPLETE THIS SECTION FOR EACH CHILD IF
APPLYING FOR CHILDREN'S INSURANCE RIDER) (TO BE ASKED OF THE PROPOSED OWNER
FOR THE CHILD INSURED UNDER INSURANCE AGE 18)
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Proposed Child Insured's Name
-------------------------------------------------------------------------------
(first) (mi) (last) (suffix)
-------------------------------------------------------------------------------
Relationship to Proposed Primary Insured Social Security # Birth Date
-------------------------------------------------------------------------------
INSURANCE IN FORCE OR PENDING
-------------------------------------------------------------------------------
Does the Proposed Child Insured have life and/or accident insurance or an
annuity policy that lapsed in the past 6 months, that is pending or that is in
force with this or any other company? ____ Yes _____ No
If Yes, complete the following:
-------------------------------------------------------------------------------
Company Amount ADB Amt. Yr. Issued
-------------------------------------------------------------------------------
REPLACEMENT
-------------------------------------------------------------------------------
Is insurance applied for intended to replace or change existing life insurance
or an annuity contract?
__ Yes __ No
Agent - If Yes, complete and send Replacement Forms and if a 1035 exchange is
intended, complete and send an Absolute Assignment Form.
-------------------------------------------------------------------------------
UNDERWRITING QUESTIONS (TO BE ASKED OF THE PROPOSED OWNER FOR THE CHILD
INSURED UNDER INSURANCE AGE 18)
-------------------------------------------------------------------------------
1. Does the Proposed Child Insured have a primary health care provider? If
Yes, complete the following:
__ Yes __ No
-------------------------------------------------------------------------------
Primary health care provider's name
-------------------------------------------------------------------------------
Address City/Town State Zip
-------------------------------------------------------------------------------
Telephone No. Date of and reason for last contact _________ Year ____
-------------------------------------------------------------------------------
2. What is the Proposed Child Insured's: current height: ft. in.
and current weight lbs.
-------------------------------------------------------------------------------
3. Has the Proposed Child Insured been given by a member of the medical
profession, a diagnosis of or treatment for AIDS (Acquired Immune Deficiency
Syndrome) or ARC (AIDS Related Complex) or tested positive for the presence
of antibodies to HIV (Human Immunodeficiency Virus)?
__ Yes __ No
-------------------------------------------------------------------------------
4. If the Proposed Child Insured is insurance age five or under, was he/she
born prematurely?
__ Yes __ No
If Yes, complete the following: Duration of pregnancy weeks
Birth weight: lbs. oz
Any ongoing observation, monitoring or treatment? If Yes, provide details:
__ Yes __ No
-------------------------------------------------------------------------------
5. Has the Proposed Child Insured ever had, been told he/she has, or been
treated for: (Indicate applicable conditions)
a. any disease, deformity,congenital defect or abnormal mental development?
__ Yes __ No
b. any heart, respiratory, intestinal, urinary, mental, emotional or
neurological disorder?
__ Yes __ No
-------------------------------------------------------------------------------
6. Has the Proposed Child Insured been confined in a hospital for
observation, treatment or diagnosis?
__ Yes __ No
-------------------------------------------------------------------------------
7. In the past five years, has the Proposed Child Insured consulted any health
care provider or has any health care provider been consulted on behalf of the
Proposed Child Insured for any reason not previously explained?
__ Yes __ No
-------------------------------------------------------------------------------
8. Has the Proposed Child Insured ever had life or health insurance rejected,
rated up, modified, canceled or not renewed?
__ Yes __ No
-------------------------------------------------------------------------------
GIVE DETAILS FOR QUESTIONS 3. THROUGH 8. ANSWERED YES. IF ADDITIONAL SPACE IS
NEEDED, USE AND ATTACH A PLAIN WHITE SHEET OF PAPER. INCLUDE
APPLICATION/POLICY # AND PROPOSED CHILD INSURED'S NAME ON ALL ADDITIONAL
SHEETS.
-------------------------------------------------------------------------------
Question # Details or Reason (Give date of diagnosis or onset; medications;
surgeries; hospitalizations; health care provider's name, address,
telephone and reason for last contact)
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
AGENT: If yes to Question 3., do not collect money or give a Conditional
Receipt. Consult Life Reference Manual for specific instructions.
Page 9 of 12
<PAGE>
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SECTION 14. PROPOSED PAYOR FOR JUVENILE PAYOR BENEFIT (COMPLETE IF APPLYING
FOR JUVENILE PAYOR BENEFIT)
-------------------------------------------------------------------------------
Proposed Payor's Name
-------------------------------------------------------------------------------
(first) (mi) (last) (suffix)
-------------------------------------------------------------------------------
Any previous name(s) Gender Birth Date:
__ M __ F Age (nearest birthday):
-------------------------------------------------------------------------------
Relationship to Proposed Primary Insured:
-------------------------------------------------------------------------------
Address City/Town State Zip
-------------------------------------------------------------------------------
Social Security # Driver's License # Issuing State Telephone #
-------------------------------------------------------------------------------
Birthplace (Country/State)
-------------------------------------------------------------------------------
OCCUPATION INFORMATION Hire Date Year
-------------------------------------------------------------------------------
Employer Title
-------------------------------------------------------------------------------
Duties
-------------------------------------------------------------------------------
UNDERWRITING QUESTIONS (TO BE ASKED OF THE PROPOSED PAYOR FOR THE JUVENILE
PAYOR BENEFIT)
-------------------------------------------------------------------------------
1. What is the Proposed Payor's: current height: ft in.
and current weight: lbs.
-------------------------------------------------------------------------------
2. Has the Proposed Payor been given by a member of the medical profession, a
diagnosis of or treatment for AIDS (Acquired Immune Deficiency Syndrome) or
ARC (AIDS Related Complex) or tested positive for the presence of antibodies
to HIV (Human Immunodeficiency Virus)?
__ Yes __ No
3. Has the Proposed Payor ever had, been told he/she has, or been treated for:
(Indicate applicable conditions)
a. dizziness, fainting, seizures, headaches, paralysis; mental, emotional
or neurological disorder or any other disorder of the brain or nervous
system?
__ Yes __ No
b. any heart, respiratory, intestinal, urinary, endocrine or metabolic
disorders?
__ Yes __ No
-------------------------------------------------------------------------------
4. Has the Proposed Payor been confined in a hospital for observation,
treatment or diagnosis?
__ Yes __ No
-------------------------------------------------------------------------------
5. In the past five years, has the Proposed Payor consulted any health care
provider or been hospitalized for any reason not previously explained?
__ Yes __ No
-------------------------------------------------------------------------------
6. Has the Proposed Payor:
a. ever had life or health insurance rejected, rated up, modified,
canceled or not renewed?
__ Yes __ No
b. ever participated in or does he/she expect to participate in flying (as
a pilot or crew member) or any hazardous sports, avocations or hobbies
such as racing, scuba or sky diving, or mountain climbing?
__ Yes __ No
c. any intention of traveling or residing outside the United States or
Canada?
__ Yes __ No
d. within the past five years had his/her driver's license suspended, had
a moving traffic violation or chargeable accident?
__ Yes __ No
e. been convicted for anything other than traffic violations?
__ Yes __ No
f. received or is he/she currently receiving disability benefits or is he/she
currently disabled?
__ Yes __ No
-------------------------------------------------------------------------------
GIVE DETAILS FOR QUESTIONS 3. THROUGH 6. ANSWERED YES. IF ADDITIONAL SPACE IS
NEEDED, USE AND ATTACH A PLAIN WHITE SHEET OF PAPER. INCLUDE
APPLICATION/POLICY # AND PROPOSED PAYOR'S NAME ON ALL ADDITIONAL SHEETS.
-------------------------------------------------------------------------------
Question # Details or Reason (Give date of diagnosis or onset; medications;
surgeries; hospitalizations; health care provider's name, address,
telephone and reason for last contact)
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
AGENT: If yes to Question 2., do not collect money or give a Conditional
Receipt. Consult Life Reference Manual for specific Instructions.
Page 10 of 12
<PAGE>
-------------------------------------------------------------------------------
SECTION 15. VARIABLE UNIVERSAL LIFE (COMPLETE IF APPLYING FOR VARIABLE
UNIVERSAL LIFE)
-------------------------------------------------------------------------------
ALLOCATIONS OF NET PREMIUMS
-------------------------------------------------------------------------------
10% is the minimum allowed for any account. Use whole numbers only - no
fractions or decimals. Sum of percentage allocations must total 100%. The
allocation indicated below will apply to future contributions unless later
changed.
<TABLE>
<CAPTION>
-------------------------------------------------------------------------------
% FUND OPTIONS
-------------------------------------------------------------------------------
<S> <C>
----% Fixed Account
----% Federated International Equity Fund II
----% Federated Quality Bond Fund II
----% Fidelity VIP Equity Income Portfolio Service Class 2
----% Fidelity VIP Growth Portfolio Service Class 2
----% Fidelity VIP II Contrafund Portfolio Service Class 2
----% Fidelity VIP III Growth and Income Portfolio Service Class 2
----% SEI VP Prime Obligation Fund
----% The Strong Mid Cap Growth Fund II
----% The Strong Opportunity Fund II
----% Other __________________________
<CAPTION>
-------------------------------------------------------------------------------
NAME OF FUND MANAGER
-------------------------------------------------------------------------------
<C>
American Family Life Insurance Company
Federated Securities Corporation
Federated Securities Corporation
Fidelity Investments
Fidelity Investments
Fidelity Investments
Fidelity Investments
SEI Investments
Strong Capital Management, Inc.
Strong Capital Management, Inc.
Other ________________________
TOTAL _____________% MUST EQUAL 100%
</TABLE>
-------------------------------------------------------------------------------
DOLLAR COST AVERAGING (OPTIONAL) NOT AVAILABLE IF ASSET ALLOCATION IS
ELECTED. THERE IS NO MAXIMUM TIME REQUIREMENT.
-------------------------------------------------------------------------------
___ I elect Dollar Cost Averaging (DCA) on the day that coincides with the
policy's effective date and the frequency chosen.
A MINIMUM OF $1,000 MUST BE PRESENT IN THE MONEY MARKET ACCOUNT TO BE ELIGIBLE.
Frequency option: __ Monthly __ Quarterly __ Semiannual __ Annual
Amount to be transferred each time: $ _________________
(Minimum of $250 per frequency option chosen).
Total Amount to be transferred: $ _______________________
From the Money Market Account to the following: (Minimum of 10% per fund and
must be stated as whole numbers).
-----% Federated International Equity Fund II
-----% Federated Quality Bond Fund II
-----% Fidelity VIP Equity-Income Portfolio Service Class 2
-----% Fidelity VIP Growth Portfolio Service Class 2
-----% Fidelity VIP II Contrafund Portfolio Service Class 2
-----% Fidelity VIP III Growth & Income Portfolio Service Class 2
-----% SEI VP Prime Obligation Fund
-----% The Strong Mid Cap Growth Fund II
-----% The Strong Opportunity Fund II
-----% Other __________________________
TOTAL _______________MUST EQUAL 100%
-------------------------------------------------------------------------------
Fixed Account and Money Market Account are not eligible to receive funds
under DCA.
-------------------------------------------------------------------------------
ASSET REALLOCATION (OPTIONAL) NOT AVAILABLE IF DOLLAR COST AVERAGING (DCA)
IS IN EFFECT.
-------------------------------------------------------------------------------
__ I ELECT ASSET REALLOCATION on the day that coincides with the policy's
effective date and frequency chosen. Amounts in the fund options are
reallocated to reflect the percentages indicated on this Application. The
policy's Accumulation Value minus the loaned amount must exceed $1,000 to be
eligible for this feature. Any changes to future allocations will not
automatically change the asset reallocation percentages. Any changes to the
asset reallocation option must be submitted by an Application for Policy
Change form or by telephone, if the Telephone Transfer Authorization option
below was selected. Amounts in the fund options not indicated on this
Application are not included in reallocation unless a reallocation election
form has been submitted. The asset reallocation option will continue until
American Family Life Insurance Company receives instructions to stop.
Frequency: __ Monthly __ Quarterly __ Semiannually __ Annually
-------------------------------------------------------------------------------
TELEPHONE TRANSFER AUTHORIZATION (OPTIONAL)
-------------------------------------------------------------------------------
__ I HEREBY AUTHORIZE and direct American Family Life Insurance Company to
accept telephone asset transfer instructions from any person who can furnish
proper identification. This Authorization is subject to the conditions and
provisions in the policy and prospectus. I agree that American Family Life
Insurance Company will not be responsible for any loss, liability, cost, or
expense for acting on the telephone instructions.
-------------------------------------------------------------------------------
Page 11 of 12
<PAGE>
-------------------------------------------------------------------------------
SECTION 16. CONDITIONAL RECEIPT
-------------------------------------------------------------------------------
Was a Conditional Receipt given to the Proposed Owner? __ Yes __ No
Conditional Receipt No.________________
-------------------------------------------------------------------------------
SECTION 17. AGREEMENT (READ COMPLETELY BEFORE SIGNING)
-------------------------------------------------------------------------------
By signing this Application, I understand and agree as follows:
1. I have personally read (or have had read to me) and verified all statements
and answers provided to American Family Life Insurance Company (the Company) as
part of this Application. They are true and complete to the best of my
knowledge and belief. The Company will rely on such statements and answers when
making its decision to issue a policy. Any false or incomplete statements or
answers may invalidate coverage. 2. No agent of the Company or medical examiner
can make or alter any contract or waive any of the Company's rights or
requirements. No change in Amount of Insurance/Specified Amount,
classification, plan of insurance or benefits will be effective unless agreed
to in writing by the Owner. 3. This Application will become part of the Policy.
4. Except as provided in the Conditional Receipt, no insurance becomes
effective unless and until: a)the Policy is accepted in writing by the Owner;
b) the first full Premium is paid during the lifetime of the person(s) to be
covered; and c) the health and insurability of the person(s) to be covered
remains as described in this Application. 5. I have full right and authority to
sign this Application. 6. This Application becomes effective on the date the
last required signature is obtained.
-------------------------------------------------------------------------------
SECTION 18. AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
-------------------------------------------------------------------------------
By signing this Application, I authorize the following to give information to
American Family Life Insurance Company (the Company) or any person or group
acting on behalf of the Company: any health care provider, consumer reporting
agency, employer, insurance or reinsurance company, insurance agent,
governmental or other organization; the Medical Information Bureau, Inc.
(MIB), a family member or other person. "Information" means facts regarding my
physical or mental health or that of my minor child(ren) and includes
diagnosis or medical history, psychiatric history or treatment, results of
genetic tests, treatment or prognosis of any physical or mental condition and
drug or alcohol abuse history or treatment or any non-medical information. I
understand that this information will be used by the Company to determine
eligibility for insurance or insurance benefits and may be disclosed by the
Company to insurance or reinsurance companies, the MIB, or to other
organizations or persons performing services in connection with this
Application or any claim. I agree that a copy of this Authorization may be
used in place of the original and that this Authorization is valid for 26
months from the date I signed this Application. I understand that I have the
right to receive a copy of this Authorization upon request. I have received
the Notice to Proposed Primary/Additional Insured (or Parent/Legal Guardian
of a Minor). The Company can obtain and release information pursuant to that
Notice. I authorize the Company to obtain an investigative consumer report on
me or my minor child(ren) and understand that I may request to be personally
interviewed in the preparation of such report. If such report is required, I
ask to be personally interviewed. __ Yes __ No
-------------------------------------------------------------------------------
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING
A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM
CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
-------------------------------------------------------------------------------
State where signed:
-------------------------------------------------------------------------------
Proposed Primary Insured's Signature (age 18 and over) Date
-------------------------------------------------------------------------------
Proposed Owner's Signature (if not Proposed Primary Insured) Title Date
-------------------------------------------------------------------------------
Proposed Payor's Signature for Juvenile Payor Benefit
(if other than Proposed Owner) Date
-------------------------------------------------------------------------------
Parent/Legal Guardian's signature required if Owner is not the Proposed
Primary Insured's parent and the Proposed Primary Insured is under age 18.
Natural parent's signature required if the Proposed Owner is other than a
parent or legal guardian.
-------------------------------------------------------------------------------
Parental Consent: I hereby give my consent for this Application on the life
of my child. I have reviewed the answers given on this Application and verify
that such statements are true and complete to the best of my knowledge and
belief.
-------------------------------------------------------------------------------
Parent/Legal Guardian's Signature Date
-------------------------------------------------------------------------------
Translator's Signature Date
-------------------------------------------------------------------------------
AGENT: TO THE BEST OF YOUR KNOWLEDGE AND BELIEF IS THE INSURANCE APPLIED FOR
INTENDED TO REPLACE OR CHANGE EXISTING LIFE INSURANCE OR AN ANNUITY?
__ Yes __ No
-------------------------------------------------------------------------------
Agent's/Registered Representative's/ Agt/Dist Code Date
Licensed CSR's Signature as witness
(Signature also certifies the replacement
question)
-------------------------------------------------------------------------------
Page 12 of 12
