(10) Form of Application
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TRANSAMERICA LIFE COMPANIES
Transamerica Occidental
Life Insurance Company
Home Office: Los Angeles, CA
Life Insurance Application For One Life Part 1
Proposed Insured:
First Middle Last Mr./Mrs./Ms./Dr.
Birthdate: Mo. ______ Day ______ Yr.______ Birth Place: _____________
Age _______ [] Male [] Female Soc. Sec. No. ______
Occupation:
Residence:
No. & Street
Duties
Last
City
Annual Income $
State
Zip
Relationship
Soc. Sec. or Tax No.
Home Phone
Work Phone
Owner's Name:
If other than Proposed Insured
No. & Street
City
Mo. Day Yr.
State
Zip
Beneficiary's Name and Relationship:
Address:
No. & Street
City
State
1. Plan Applied For:______________________ Kind Code: ____________________
Preferred [] Standard []
2. Non-Nicotine Qualification [] Nicotine Qualification []
3. Amount Applied For $ ____________________
4. Additional Benefits by Rider: [] Waiver Provision [] Accident Indemnity
5. Rating Class of Risk Applied For: [] Standard [] Extra Rating of
6. Premium Payment Mode: [] Annual [] Semi-Annual [] Quarterly [] Monthly/PAC
7. Complete for Flexible Premium Plans:
Required Premium Per Year (RAP) $
Planned Periodic Premium
+ Initial Lump Sum ________________
Total Initial Premium $
8. If the Automatic Premium Loan provision is available, it is to be:
Effective [] Not Effective []
9. Total insurance in force with all companies:
Life Insurance $ _________________________ Accidental Death $
10. Mail Additional Premium Notices To:
Address
No. & Street
City
Zip
Date of Trust. if Applicable
Yes No
[] [] 11. May insurance, including annuities, in any company be
discontinued or changed if the insurance applied for is issued?
If Yes", give company names.
[] [] 12. Is any application for life insurance pending with any other
company? If Yes", give company name, amount applied for and total
amount to be placed.
[] [] 13. Do you intend to travel outside the U.S. or Canada within the next
two years, except purely for vacation travel?
If "Yes' give destination, purpose of travel and length of stay in Remarks.
[] [] 14. In the past two years, have you participated in aeronautics,
powered racing or competitive vehicles, skin or scuba diving,
mountain climbing, rodeos or competitive skiing?
[] [] 15. Have you used nicotine at any time? Date Last Used
[] [] Cigarettes
[] [] Cigar/Pipe/Chewing Tobacco
[] [] Other
[] [] 16. Driver's license #:______________________ State: _______
In the past ten years, have you been convicted of or pleaded guilty to:
[] [] a. Moving violations? If Yes', give dates and type.
[] [] b. Driving under the influence of alcohol and/or other drugs?
If `Yes", give dates.
[] [] c. Reckless driving? If Yes", give dates.
[] [] 17. Do you intend to fly other than as a passenger or have flown other
than as a passenger during the past two years?
If Yes', complete Aviation Questionnaire.
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Remarks: Give details for any questions answered YES"
It is represented that the statements and answers given in this Application are
true, complete and correctly recorded to the best of my knowledge AND BELIEF. IT
IS AGREED: (1)THIS Application shall consist of Part 1 and Part 2 and shall be
the basis for any policy issued on this Application; (2) Except as otherwise
provided in the conditional receipt, if issued, with the same Proposed Insured
as on this Application, any policy issued on this Application shall not take
effect until after all of the following conditions have been met: (a) The full
first premium is paid, (b)The Owner has personally received the policy during
the lifetime of and while the Proposed Insured is in good health, and (c)All of
the statements and answers given in this Application to the best of my belief
must be true and complete as of the date of Owner's personal receipt of the
policy and that the policy will not take effect if the facts have changed; (3)
No waiver or modification shall be binding upon Transamerica Occidental Life
Insurance Company unless in writing and signed by the President or a Vice
President and the Secretary or an Assistant Secretary.
I understand that omissions or misstatements in this Application could cause an
otherwise valid claim to be denied under any policy issued from this
Application.
AUTHORIZATION TO OBTAIN INFORMATION
Transamerica Occidental Life. Insurance Company ("the Company")
I AUTHORIZE ANY physician, medical practitioner, hospital, clinic, other medical
or medically related facility, insuring or reinsuring company, the Medical
Information Bureau, Inc., consumer reporting agency, or employer having
information available as to testing, diagnosis, treatment and prognosis with
respect to any physical or mental condition (for example: coronary disease;
cancer; HIV related test results or disorders; metabolic, pulmonary, or
neurological disorders) and/or treatment of me and any other non-medical
information of me to give the Company or its legal representative, any and all
such information.
I understand the information obtained by use of the Authorization will be used
by the Company to determine eligibility for insurance and eligibility for
benefits under an existing policy. Any information obtained will not be released
by the Company to any person or organization except to reinsuring companies, the
Medical Information Bureau, Inc., or other persons or organizations performing
business or legal services in connection with my application, claim or as may be
otherwise lawfully required or as I may authorize.
I KNOW that I may request to receive a copy of this Authorization. I agree that
a photographic copy of this Authorization shall be as valid as the original. I
AGREE this Authorization shall be valid for two and one half years from the date
shown below. (For Rhode Island applications, this shall be valid for 24 months
from the policy issue date.)
I acknowledge receipt of the Notice of Disclosure of Information. I understand
that if an investigative consumer report is ordered in connection with this
application, I may elect to be interviewed in connection with the preparation of
the report and, upon request, I will be provided with a copy of the report. I
elect to be interviewed if an investigative consumer report is prepared. [] Yes
[] No
PLEASE MAKE CHECKS PAYABLE TO THE COMPANY. DO NOT MAKE CHECKS PAYABLE TO THE
AGENT OR LEAVE PAYEE SPACE BLANK.
Amount paid with this Application $________________ Check or MO. # ___________
Signed at (city-state)_________________________________ on (date) ____________
x_________________________________________________________
Signature of Proposed Insured
x_______________________ x ________________________
Owner (if other than Proposed Insured) If Owner is a corporation, an authorized
officer, other than Proposed Insured must
sign as owner, give Corporate title and
full name of corporation.
x _______________
Witness to all signatures x ___________________________________
Countersigned (Licensed Resident Agent, if your
state requires)
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(NOT PART OF APPLICATION) REPORT BY AGENCY OFFICE DATE: _________
AGENCY NAME: __________________ AGENCY CODE. _________ AGENCY CLERK: __________
AGENT 1: ______________________________________ GA/SA CODE: _____ SHARE %:
LAST FIRST (4 DIGITS) (6 DIGITS)
Complete the Solicitor information below if Agent is a Firm Name.
SOLICITOR'S NAME AND I.D. NUMBER
----------------------------------
AGENT 2: ______________________________________ GA/SA CODE: SHARE %:
LAST FIRST (4 DIGITS) (6 DIGITS)
Indicate City/County Code as required in Alabama and Kentucky
What is the purpose for insurance? How long have you known the Proposed Insured?
Proposed Insured is: [] Single []Married [] Divorced [] Widowed
[] Yes []No Is this insurance in the category for which commission payment may
be restricted under the laws of your state?
[] Yes [] No If "Yes", are you qualified to receive commissions?
[] Yes [] No To the best of your knowledge could replacement be involved?
__________________________ Signature of Agent
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CONDITIONAL RECEIPT
Transamerica Occidental Life Insurance Company has received a payment of $ from
______________ for the life insurance applied for in the application for
__________________________________ as Proposed Insured.
This receipt is not valid unless it is signed by an agent of the Company. This
receipt is not valid unless the amount paid with the application, if paid by
check or draft, is honored on first presentation for payment. IMPORTANT: The
payment is received subject to the conditions on the other side of this receipt.
This receipt does not provide any insurance until after all of its conditions
are met.
Dated at __________________________ on _______________________________________
Agent Signature Type of Policy
All premium checks must be made payable to the COMPANY. DO NOT MAKE PAYABLE TO
THE AGENT OR LEAVE PAYEE BLANK.
If you do not hear from the Company regarding the proposed insurance within 30
days, notify the Company at its Administrative Office at Post Office Box 419521,
Kansas City, MO 64141 giving your full name, date of birth, the name of the
agent, date and amount of this receipt.
APA 40R-197
IMPORTANT: This Conditional Receipt does not provide any insurance until after
its conditions are met.
The payment for premiums is received subject to the following conditions:
(A) 1. If all the underwriting requirements by the Company are completed; and
2. If the Company at its Home Office is satisfied that, at the time of
completing Part 1 and Part 2 of the application, each person to be
covered was insurable under the Company' s rules for insurance on the
plan, in the amount, and at the class of risk applied for in Part 1 of
the application;
Then, but only after these conditions are met, the policy applied for shall be
effective from the date of Part 1, the date of Part 2, or the date requested in
the application, whichever is the latest, regardless of any change of
insurability of each person to be covered occurring after completion of both
parts of the application. If less than the full first premium has been paid for
such policy, it shall remain in effect only for the fraction of one year that
the payment made for such policy bears to the annual premium for such policy.
The Company slid not be required to make insurance effective for an amount
which, together with any amount effective in the Company on each person to be
covered would exceed the following limits: (a) $250,000 of life Insurance if
such person is age 16 through 65 and is insurable as a standard class of risk,
or $100,000 at all other ages and classes of risk; and (b) $50,000 of benefits
for death by accident.
Any Insurance applied for as an alternate or additional to the plan and amount
of insurance applied for in the application shall not become effective under
this conditional receipt.
(B) If the conditions of (A) are met for the insurance applied for in the
application, except that if any person to be covered is not insurable under the
Company' s rules for benefits for disability or accidental death AS applied for,
the life insurance, and any portion of such benefits for which the Proposed
Insured is insurable under the Company's rules, shall be effective as provided
in (A).
Except. provided In this conditional receipt, any policy issued by the Company
shall not take effect unit after all of the following conditions are met: (a)
The full first premium is paid, (b) The Owner has personally received the policy
during the lifetime and while the Proposed Insured(s) is (are) in good health,
arid (C) All of the statements and answers given in this application to the best
of my (our) belief must also be true and complete as of the date of the Owner's
personal receipt of the policy and that the policy will not take effect if the
facts have changed. Neither the agent nor the medical examiner is authorized to
accept risks or pass upon insurability, to make or modify contract, or to waive
any of the Company's rights or requirements.
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AUTHORIZATION FOR PARTICIPATION IN THE PRE-AUTHORIZED WITHDRAWAL PLAN
I (we) hereby authorize and request Transamerica Occidental Life Insurance
Company to initiate electronic debit entries or effect a charge by any other
commercially accepted practice to my (our) account indicated on the attached
check for premiums and other such payments indicated. I (we) request that this
Authorization, unless previously revoked, continue to apply to any conversion,
renewal, or change later made in the policies. I (we) agree that this
Authorization in no way affects the terms of the policy, other than the mode of
payment and I (we) understand that if premiums are not paid within the grace
period allowed by the policy, as in the event of withdrawals being dishonored,
or for any other reason, then the policy shall terminate subject to any
nonforfeiture provision of the policy.
PROPOSED INSURED AMOUNT
Preferred Withdrawal Date: _________________________ Bank Name:
Policyowner Signature Date Signature of Bank Account Owner Date If check is not
submitted with the application, please attach voided check.
PLEASE DETACH IF PAC IS NOT REQUESTED
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NOTICE OF DISCLOSURE OF INFORMATION
Information regarding your insurability will be treated as confidential except
that Transamerica Occidental Life Insurance Company may make a brief report to
the Medical Information Bureau (MIB), a non-profit membership organization of
life insurance companies which operates an information exchange on behalf of its
members. Upon request by another member insurance company to which you have
applied for life or health insurance, or to which a claim is submitted, MIB will
supply such company with the information it may have in its files. The Company
may also release information in its file to reinsurers and to other life
insurance companies to which you may apply for life or health insurance, or to
which a claim is submitted.
Upon receipt of a request from you, MIB will arrange disclosure of any
information it may have in your file. If you question the accuracy of
information in the file, you may seek correction in accordance with the
procedures set forth in the Federal Fair Credit Reporting Act. The address of
MIBs information office is Post Office Box 105, Essex Station, Boston, MA 02112,
telephone (617) 426-3660.
APA 40N-197
Notice to Persons Applying for Insurance: Federal law requires us to advise you
that in connection with this application, an investigative consumer report may
be prepared whereby information is obtained through personal interviews with
your neighbors, friends or others with whom you are acquainted. Such reports are
usually part of the process of evaluating risks for life and health insurance.
Inquiry may be made into your character, general reputation, personal
characteristics and mode of living. It is possible that a representative of a
firm employed to make such reports may call upon you in person. You have the
right to request disclosure of the nature and scope of the investigation by your
written request made within a reasonable time after receipt of this notice.
Notice of Insurance Information Practice: The information collected about you by
us may in certain circumstances be disclosed to third parties without your
specific authorizations as permitted by law. You have the right of access and
correction with respect to the information collected 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 your agent or
write the Company at its Administrative Office, P.O. Box 419521, Kansas City, MO
64141.
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Transamerica Occidental
Life Insurance Company
Home Office: Los Angeles, Application Supplement
CA APE 62-199
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1. CHILD(REN) PROPOSED FOR COVERAGE UNDER THE CHILDREN'S INSURANCE RIDER
------------------------------------------------------------------------ -------- -------------------- -------- ------------ ------
NAME: FIRST, MIDDLE INITIAL, LAST AGE DATE OF BIRTH SEX HEIGHT WEIGHT
------------------------------------------------------------------------ -------- -------------------- -------- ------------ ------
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2. Yes No Is coverage under the Children's Insurance Rider being requested for all minor children
of the Proposed Insured?
If no, give details in Remarks.
3. Yes No Are any children proposed for coverage not living with the Proposed Insured?
If yes, give details in Remarks.
4. Give details to all yes answers in Remarks, including all dates and diagnoses.
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Yes No HAS ANY CHILD PROPOSED FOR COVERAGE:
--------- ------- -----------------------------------------------------------------------------------------------------------------
--------- ------- -----------------------------------------------------------------------------------------------------------------
Congenital Heart Abnormalities, Heart Disorder; Epilepsy,
Cancer, Malignancy, Leukemia, Diabetes, Cystic Fibrosis,
Kidney Disease, Brain or Neurological Disorder?
--------- ------- -----------------------------------------------------------------------------------------------------------------
--------- ------- -----------------------------------------------------------------------------------------------------------------
Asthma or other lung disease or injury or illness requiring hospitalization
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It is represented that the statements and answers given in this Supplement are
true, complete and correctly recorded to the best of my knowledge and belief. It
is agreed that this Supplement shall be a part of the Application for life
insurance for as Proposed Insured.
Signed at Date:
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(city-state)
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Signature of Proposed Insured Witness of Proposed Insured signature
Signed at on
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(city-state) (date)
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Owner (if other than Proposed Insured) Witness of Owner signature
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REMARKS
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Transamerica Occidental APPLICATION SUPPLEMENT
Life Insurance Company Variable Universal Life Insurance
1150 South Olive Street
Los Angeles, CA 90015
Proposed Insured:
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Additional Proposed Insured:
------------------------------------------
Application Date:
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PREMIUM ALLOCATION: You may allocate your net premiums among the investment
options indicated below. All allocation percentages must be in whole numbers and
must total 100%. The Company may limit the number of sub-accounts of the
separate account to which you may allocate your net premiums.
INVESTMENT OPTIONS: PREMIUM ALLOCATION PERCENTAGE:
[Alger American Income & Growth _________%
Alliance VP Growth and Income _________%
Alliance VP Premier Growth _________%
Dreyfus VIF Appreciation _________%
Dreyfus VIF Small Cap _________%
Janus Aspen Series Balanced _________%
Janus Aspen Series Worldwide Growth _________%
MFS(R)Emerging Growth Series _________%
MFS(R)Growth With Income Series _________%
MFS(R)Research Series _________%
MS UIF Emerging Markets Equity _________%
MS UIF Fixed Income _________%
MS UIF High Yield _________%
MS UIF International Magnum _________%
OCC Accumulation Trust Managed _________%
OOC Accumulation Trust Small Cap _________%
PIMCO VIT StocksPLUS Growth and Income _________%
Transamerica VIF Growth _________%
Transamerica VIF Money Market _________%
----------------------------------------- ---------%
----------------------------------------- ---------%
----------------------------------------- ---------%
Fixed Account _________%
TOTAL: 100%
TELEPHONE ACCESS PRIVILEGE: This option allows you or your registered
representative to authorize certain transactions (within limits) under the
policy by telephone. These transactions include transfers, allocation changes
and policy loan requests (within limits). Additional information is included in
the Acknowledgements and Signatures section. YOU WILL AUTOMATICALLY HAVE THIS
PRIVILEGE UNLESS YOU CHECK THE FOLLOWING BOX:
|_| I (WE) DO NOT want the telephone access privilege.
APE 1-101 Page 1
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ACKNOWLEDGMENTS AND SIGNATURES: I (we) acknowledge receipt of the current
prospectuses that describe the variable universal life insurance policy applied
for and the sub-accounts of the separate account that are available under this
policy. I (we) have reviewed the prospectuses and believe that the variable
universal life insurance policy is consistent with my (our) insurance needs,
investment objectives and investment risk tolerance.
I (WE) UNDERSTAND THAT ANY DEATH BENEFIT IN EXCESS OF THE FACE AMOUNT AND ANY
POLICY VALUE OF THE POLICY APPLIED FOR MAY INCREASE OR DECREASE DEPENDING ON THE
INVESTMENT RESULTS OF THE SUB-ACCOUNTS OF THE SEPARATE ACCOUNT AND INTEREST
EARNINGS OF THE FIXED ACCOUNT. THE PORTION OF THE POLICY VALUE IN THE FIXED
ACCOUNT WILL EARN INTEREST AT A RATE SET BY THE COMPANY (THE GUARANTEED MINIMUM
INTEREST RATE IS [4]%). THERE IS NO GUARANTEED MINIMUM POLICY VALUE OR NET CASH
VALUES. THE POLICY VALUE AND NET CASH VALUES MAY DECREASE TO THE POINT WHERE THE
POLICY WILL LAPSE WITHOUT FURTHER VALUE, UNLESS ADDITIONAL PREMIUM PAYMENTS ARE
MADE.
I (WE) AGREE that no registered representative or broker is authorized to amend,
alter or modify the terms of this application supplement. I (WE) AGREE that,
unless I (we) did not accept the telephone access privilege, I (we) understand
that the Company is authorized to honor telephone requests by me (us) or by my
(our) registered representative to make certain transactions under the policy. I
(we) also understand that partial surrenders or a full surrender of the policy
cannot be made by telephone.
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This Application Supplement is a part of the application for the policy. All
conditions under the application apply to this Application Supplement.
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Signed at (city, state): On (date):
-------------------------------- -----------------------------------------------
X X
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Signature of Proposed Insured Signature of Additional Proposed Insured
X X
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Signature of Owner (if other than Proposed Insured) If owner is a corporation, an authorized officer,
other than the proposed insured, must sign as owner, give
corporate title and full name of corporation.
( ) ( )
Daytime Phone Number Daytime Phone Number
E-mail address E-mail Address
X X
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Witness to all Signatures Countersigned (Licensed Resident agent, if required)
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APE 1-101 Page 2
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(NOT PART OF APPLICATION OR APPLICATION SUPPLEMENT)
REGISTERED REPRESENTATIVE INFORMATION
Indicate City/County as required in Alabama and Kentucky:
What is the purpose for this insurance?
<S> <C> <C>
How long have you known the Proposed Insured(s)? |
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(Proposed Insured) (Additional Proposed Insured)
Proposed Insured is: |_| Single |_| Married |_| Divorced |_| Widowed
Additional Proposed Insured is: |_| Single |_| Married |_| Divorced |_| Widowed
|_| Yes |_| No Is this insurance in the category for which commission payment
may be restricted under the laws of your State?
|_| Yes |_| No If yes, are you qualified to receive commissions? |_| Yes |_| No
To the best of your knowledge, could replacement be involved?
Based on information furnished by the proposed insured(s) or owner(s), I certify
that I have reasonable grounds to believe that the purchase of the policy
applied for is suitable. I further certify that the prospectuses were delivered
and that no written sales materials other than those furnished or approved by
the Company were used.
X
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Signature of Registered Representative Date
Print Name of Registered Representative Registered Representative Number Share %
X
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Signature of Second Registered Representative (if applicable) Date
Print Name of Second Registered Representative (if applicable) Registered Representative Number Share %
( ) ( )
Daytime Phone Number Fax Number
Business E-mail address
Broker/Dealer Affiliation General Agency Affiliation (if any) GA Code
Address Address
UNDERWRITING REQUIREMENTS (CHECK ONE)
|_| The initial underwriting requirements have been ordered, including
scheduling the paramedical examination. |_| I request that the Underwriting
Department manage the gathering of the initial underwriting requirements. |_|
Other (please provide detailed information)
X Date Approved as to Suitability:
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Signature of Registered Principal
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