CONSECO VARIABLE INSURANCE COMPANY
ADMINISTRATIVE OFFICE: 11815 N. PENNSYLVANIA STREET
P.O. BOX 1911, CARMEL, INDIANA 46082-1911
MAIL APPLICATION TO:
CONSECO VARIABLE INSURANCE CO. SERVICE CENTER
9735 LANDMARK PARKWAY DRIVE
ST. LOUIS, MISSOURI 63127-1646
<TABLE>
<CAPTION>
MULTIPLE INSURED LIVES
------------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C>
Has any individual to be insured used tobacco in any form in the past 12 months? [_] Yes [_] No
If "Yes" indicate type and date last used. Name Type Month Year
------------------------------------------------------------------------------------------------------------------------------------
SECTION I
SPOUSE (COMPLETE IF APPLYING FOR SPOUSE RIDER)
------------------------ ---- ---------------------------------------- ---------- ------------------- ---------- ------------- -----
First Name MI Last Name (indicate if hyphenated name) [_] Male Social Security Date of Birth Place Ht.
No. Birth
[_] Female Wt.
------------------------ ---- ---------------------------------------- ---------- ------------------- ---------- ------------- -----
JOINT INSURED (COMPLETE IF APPLYING FOR JOINT LIFE INSURANCE OR JOINT LIFE TERM RIDER)
------------------------ ---- -------------------- ------------------- ---------- ------------------- ---------- ------------- -----
First Name MI Last Name Relationship [_] Male Social Security Date of Birth Place Ht.
No. Birth
[_] Female Wt.
------------------------ ---- -------------------- ------------------- ---------- ------------------- ---------- ------------- -----
CHILD/DEPENDENTS (ATTACH A SEPARATE SHEET FOR ADDITIONAL PERSONS NOT LISTED)
------------------------ ---- -------------------- ------------------- ---------- ------------------- ---------- ------------- -----
First Name MI Last Name Relationship [_] Male Social Security Date of Birth Place Ht.
No. Birth
[_] Female Wt.
------------------------ ---- -------------------- ------------------- ---------- ------------------- ---------- ------------- -----
First Name MI Last Name Relationship [_] Male Social Security Date of Birth Place Ht.
No. Birth
[_] Female Wt.
------------------------ ---- -------------------- ------------------- ---------- ------------------- ---------- ------------- -----
First Name MI Last Name Relationship [_] Male Social Security Date of Birth Place Ht.
No. Birth
[_] Female Wt.
------------------------ ---- -------------------- ------------------- ---------- ------------------- ---------- ------------- -----
First Name MI Last Name Relationship [_] Male Social Security Date of Birth Place Ht.
No. Birth
[_] Female Wt.
------------------------ ---- -------------------- ------------------- ---------- ------------------- ---------- ------------- -----
OTHER INSURED (ATTACH A SEPARATE SHEET FOR ADDITIONAL PERSONS NOT LISTED)
------------------------ ---- -------------------- ------------------- ---------- ------------------- ---------- ------------- -----
First Name MI Last Name Relationship [_] Male Social Security Date of Birth Place Ht.
No. Birth
[_] Female Wt.
------------------------------------------------------------------------------------------------------------------------------------
SECTION 2 - BENEFICIARY DESIGNATION
------------------------------------------------------------------------------------------------------------------------------------
Joint Insured
a. Joint Insured Primary Beneficiary:_______________________________________________Age__________Relationship_____________________
Address________________________________________________________________________________________________________________________
Telephone No:______________________________________________ Social Security No:_____________________________________________
(If Beneficiary is a Trust, provide name and date of Trust)
Name of Trust_______________________________________________________ Date of Trust____________________________________________
b. Joint Insured Contingent Benficiary_________________________________ Relationship_____________________________________________
------------------------------------------------------------------------------------------------------------------------------------
SECTION 3
LIFE INSURANCE IN FORCE AND PENDING ON ALL INDIVIDUALS TO BE INSURED, INCLUDING BUSINESS INSURANCE:
(IF NONE, INSERT "NONE")
------------ ---------- ------------- ----------- ----------------- ----------- ------------ -------------- ----------- ------------
Spouse Joint Child/ Other Name of Company Type of Face Amount Accidental Year To Be
Insured Dependent Insured Coverage Death Insured Replaced
------------ ---------- ------------- ----------- ----------------- ----------- ------------ -------------- ----------- ------------
------------ ---------- ------------- ----------- ----------------- ----------- ------------ -------------- ----------- ------------
------------ ---------- ------------- ----------- ----------------- ----------- ------------ -------------- ----------- ------------
------------ ---------- ------------- ----------- ----------------- ----------- ------------ -------------- ----------- ------------
Joint Dependent/ Other
REGARDING ALL INDIVIDUALS TO BE INSURED: Spouse Insured Child Insured
Yes No Yes No Yes No Yes No
REPLACEMENT: (a) Has any life or health insurance been denied, postponed,
rated, or modified? |_| |_| |_| |_| |_| |_| |_| |_|
(b) Is the coverage applied for intended to replace any
existing life Insurance or annuity with this or any
other company? |_| |_| |_| |_| |_| |_| |_| |_|
(If "Yes," complete replacement form, if required).
(c) Do you now have any application for life, accident or health
insurance or reinstatement pending with any company? |_| |_| |_| |_| |_| |_| |_| |_|
</TABLE>
1
CVIC-5002
<PAGE>
IF "YES" was answered to any of the above questions, please give details:
CVIC-5002 2
<PAGE>
<TABLE>
<CAPTION>
SECTION 4
ANSWER QUESTIONS BELOW ON ALL INDIVIDUALS TO BE INSURED OR OTHER THAN PRIMARY INSURED
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
COMPLETE APPROPRIATE QUESTIONNAIRE IF ANSWERING "YES" TO BOLD PRINT IMPAIRMENT. Spouse Joint Dependent/ Other
Insured Child Insured
Yes No Yes No Yes No Yes No
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
<S> <C> <C> <C> <C> <C> <C> <C> <C>
1a. Do you have any intentions to travel or reside outside the U.S. or Canada? |_| |_| |_| |_| |_| |_| |_| |_|
(indicate country and dates)
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
1b. In the past 5 years have you, OR do you intend to engage in PILOTING AN |_| |_| |_| |_| |_| |_| |_| |_|
AIRCRAFT, motor vehicle racing, SCUBA DIVING, sky diving, hang gliding,
parachuting, mountain climbing, horse racing or any other hazardous sports?
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
1c. Have you ever been convicted of a felony, or reckless driving, or driving |_| |_| |_| |_| |_| |_| |_| |_|
under the influence of drugs or alcohol, or had your license suspended, or in
the past three years had more than two moving traffic violations?
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
1d. Have you ever used heroin, cocaine, crack, LSD, any derivative of these |_| |_| |_| |_| |_| |_| |_| |_|
drugs, or any other illegal or controlled substance except as prescribed by
a physician?
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
2a. In the past 10 years have you had or been treated for: chest pain, high |_| |_| |_| |_| |_| |_| |_| |_|
blood pressure, heart attack, stroke, diabetes, ULCER, glucose intolerance,
ASTHMA, emphysema, cancer, malignant tumor, or leukemia; a disease or disorder
of the heart, lungs, kidneys, pancreas, liver, gastrointestinal, genito-urinary,
or cardiovascular systems; or anemia, ARTHRITIS, BACK/SPINE pain or injury or
disease of the blood, bones, muscles, joints, skin, connective tissue or glands,
the ears, eyes, nose, throat or any internal organs; or any sexually transmitted
disease, albumin, sugar, pus, or blood in the urine; or an endocrine or
metabolic disorder, including, but not limited to thyroid, hyperlipidemia,
pituitary, or adrenal gland disorder?
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
2b. In the past 10 years have you had or been treated for a mental, nervous, or |_| |_| |_| |_| |_| |_| |_| |_|
neurological disorder, EPILEPSY, SEIZURES, paralysis, sleep apnea, memory loss,
depression, dementia, Alzheimer's or Parkinson's disease?
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
2c. In the past 10 years have you received or been advised to seek counseling |_| |_| |_| |_| |_| |_| |_| |_|
for ALCOHOL or DRUG ABUSE?
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
3. In the past 10 years have you been treated or diagnosed as having Acquired |_| |_| |_| |_| |_| |_| |_| |_|
Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or tested
positive for antibodies to Human Immunodeficiency Virus (HIV)?
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
4a. In the past 5 years have you been hospitalized or consulted a physician or |_| |_| |_| |_| |_| |_| |_| |_|
any member of the medical profession (list all occurrences)?; or have you had
any blood tests (other than HIV or AIDS test), electrocardiograms, or other
medical tests or studies (indicate tests and results)?; or have you taken or
been advised to take any medication (list reason and medication)?
-------------------------------------------------------------------------------------------- ----------- -------------- -----------
4b. Have you ever had any mental or physical disorder not listed above? |_| |_| |_| |_| |_| |_| |_| |_|
-----------------------------------------------------------------------------------------------------------------------------------
Provide details to questions 1- 4 in the space provided below. Include QUESTION NUMBER, INSURED NAME, IMPAIRMENT, DIAGNOSIS,
TREATMENT, MEDICATION, DATE OF OCCURRENCE, CURRENT STATUS AND NAME AND ADDRESS OF ALL DOCTORS, HOSPITALS, AND MEDICAL FACILITIES.
Add additional sheets if necessary.
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
5. Name of Spouse's physician (If none, state "None")
-----------------------------------------------------------------------------
Address:
----------------------------------------------------------------------------------------------------------------------------
6. Name of Joint Insured's physician (If none, state "None")
-----------------------------------------------------------------------
Address:
----------------------------------------------------------------------------------------------------------------------------
7. Name of Children's physician (If none, state "None")
---------------------------------------------------------------------------
Address:
----------------------------------------------------------------------------------------------------------------------------
8. Name of Other Insured's physician (If none, state "None")
-----------------------------------------------------------------------
Address:
----------------------------------------------------------------------------------------------------------------------------
</TABLE>
CVIC-5002 3
<PAGE>
--------------------------------------------------------------------------------
SECTION 5 - DECLARATIONS
--------------------------------------------------------------------------------
I /(We) represent that all statements and answers made in all parts of this
application are full, complete and true. It is understood and agreed that:
(1) All such statements and answers shall be the basis for and become a part of
any policy issued as a result of this application.
(2) No agent, producer, broker, nor examiner has the authority to accept risks,
to make or change contracts, or to waive any of the Company's rights or
requirements.
(3) AS A CONDITION PRECENDENT TO THE POLICY TAKING EFFECT, THE PROPOSED
INSURED(S) MUST BE ALIVE AND IN THE SAME CONDITION OF HEALTH AS DESCRIBED
IN THIS APPLICATION WHEN THE POLICY IS DELIVERED TO THE OWNER AND THE FULL
FIRST PREMIUM MUST BE PAID. ALTHOUGH THE POLICY WOULD NOT BE IN EFFECT, IF
A CONDITIONAL RECEIPT OR TEMPORARY INSURANCE AGREEMENT (TIA) HAS BEEN
SIGNED BY THE PROPOSED INSURED AND THE FULL FIRST PREMIUM HAS BEEN PAID,
COVERAGE MAY BE PROVIDED, SUBJECT TO ALL THE TERMS AND CONDITIONS OF THE
CONDITIONAL RECEIPT OF OR TIA.
(4) Acceptance of a policy by the Owner shall constitute ratification of any
changes made by the Company.
--------------------------------------------------------------------------------
SECTION 6 - FRAUD WARNING
--------------------------------------------------------------------------------
Any person who knowingly and with intent to defraud any insurance company that
submits an application for insurance or statement of claim containing any
materially false information, or conceals information concerning any fact
material thereto for the purpose of misleading, may be committing a crime which
is subject to criminal and civil penalties.
AR, OH AND PA RESIDENTS: Any person who knowlingly, and with intent to defraud
any insurance company or other person, files an application for insurance or
statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
DC RESIDENTS: Warning: It is a crime to provide false or misleading information
to an insurer for the purpose of defrauding the insurer or any other person.
Penalities include imprisonment and/or fines. In addition, an insurer may deny
insurance benefits if false information materially related to a claim was
provided by the applicant.
CO RESIDENTS: It is unlawful to knowlingly provide false, incomplete, or
misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, and denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowlingly provides false,
incomplete, or misleading facts or information to a contractholder or claimant
for the purpose of defrauding or atempting to defraud the contractholder or
claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado Division of Insurance within the department of
regulatory agencies.
LA RESIDENTS: Any person who knowingly presents a false or faudulent claim for
payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
VA RESIDENTS: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company.
Penalties may include imprisonment, fines or a denial for insurance benefits.
--------------------------------------------------------------------------------
SECTION 7 - AUTHORIZATION
--------------------------------------------------------------------------------
I /(We) understand that Conseco Services, LLC, Conseco Variable Insurance
Company (hereinafter collectively "Company"), affiliates of the Company, its
reinsurers, any insurance support organizations, and those persons authorized to
represent them, may need to collect information on me/(us) in regard to proposed
coverage. I/(we) authorize any: (1) person licensed to provide health care
service; (2) hospital; clinic or other medical facility; (3) insurer; (4)
reinsurer; (5) insurance support organizations, including MIB (Medical
Information Bureau); (6) veterans organization; (7) financial source; and (8)
employer, to give the types of information listed below when this Authorization
is presented.
The types of information may include my: (1) mental and physical health; (2)
other insurance coverage; (3) hazardous activities; (4) character; (5) general
reputation; (6) mode of living; (7) finances; (8) vocation; (9) Acquired Immune
Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or Human
Immunodeficiency Virus (HIV); (10) drug and alcohol treatment, (11) other
personal information; and (12) government records, such as motor vehicle record.
The Company and its reinsurers will use the information in order to determine
whether I am insurable pursuant to the Company's underwriting standards. The
insurance agent, producer, or broker may also use the information to help update
and improve my insurance program.
Those parties named in the first paragraph of this Authorization, excluding
insurance support organizations, may disclose the information that they have
collected. They may disclose this information to: (1) other insurers to which I
have applied or may apply for insurance; (2) reinsurers; (3) the Medical
Information Bureau; or (4) other persons who perform business, professional, or
insurance tasks for them. They may also disclose information according to any
contract with a member company or organization. Information may also be
disclosed as allowed by law.
This Authorization will be valid for 30 months after the date of signing, and
cannot be revoked. A copy of this Authorization shall be as valid as the
original. I understand I have a right to receive a copy of this Authorization. I
acknowledge receipt of a copy of the "Notice of Information Practices," which
includes pre-notification information relating to investigative consumer reports
and the Medical Information Bureau, Inc.
If a minor child is proposed for coverage, statements made in this application
are made by the person authorized to act on behalf of the minor child.
CVIC-5002 4
<PAGE>
I understand and agree that this policy may include an internal appeals process
that must be exhausted prior to any other action being taken at law or in
equity. This internal appeals process provides for optional mediation and/or
arbitration.
SOLICITING AGENT STATEMENT:
WILL THERE BE ANY REPLACEMENT, AS DEFINED BY ANY REGULATION OF THE STATE IN
WHICH THIS APPLICATION IS TAKEN?
(IF "YES", FULFILL ALL STATE REQUIREMENTS) |_| Yes |_| No
<TABLE>
<S> <C>
Signed at: On:
----------------------------------------------------------------------------- -----------------------------------------
City and State Month/Day/Year
---------------------------------------------------------------------- -------------------------------------------------------
Signature of Spouse if proposed for coverage Signature of Joint Insured if proposed for coverage
(sign full legal name) (sign full legal name)
---------------------------------------------------------------------- -------------------------------------------------------
Signature of Other Insured if proposed for coverage Signature of Other Insured if proposed for coverage
(sign full legal name) (sign full legal name)
---------------------------------------------------------------------- -------------------------------------------------------
Signature of Parent or Guardian if individual to be insured is a minor Print Name of Parent or Guardian if individual to be
(sign full legal name) insured is a minor
---------------------------------------------------------------------- -------------------------------------------------------
Signature of Witness Print Name of Witness
(Licensed Agent must witness where required by law.)
</TABLE>
CVIC-5002 5
<PAGE>
CONDITIONAL RECEIPT
CONSECO VARIABLE INSURANCE COMPANY
Name(s) of Proposed Insured: __________________________________________________
RECEIPT FOR ADVANCE PAYMENT. Check must be made payable to the insurance
company: do not leave the payee blank. The amount of the advance payment must be
equal to a minimum of the first initial premium due.
Received from _____________________________________ the sum of
$_________________ as an advance payment to be submitted with the foregoing
application for insurance with the Company. This advance payment is made by the
Proposed Insured and accepted by the Company subject to all the terms and
conditions of this Conditional Receipt.
This Conditional Receipt shall not be valid and no coverage will be provided if
any check or draft is not honored upon presentment.
AGE REQUIREMENTS: No person is authorized to accept an advance payment under the
terms of this Conditional Receipt for a Proposed Insured under 15 days of age or
over age 70 (nearest birthday).
COMPANY'S MAXIMUM LIABILITY UNDER CONDITIONAL RECEIPT(S): Company's maximum
liability under the terms of this Conditional Receipt or any other Conditional
Receipt shall not exceed either: (1) Up to Age 65 - $500,000 or (2) Over Age 65
- $200,000. The maximum liability applies to all life insurance pending with any
Conseco company, including any advance payment.
EFFECTIVE DATE: This Conditional Receipt shall be effective on the date of the
application provided the Conditional Receipt bears the same date.
INSURABILITY: In order for the Company to have any liability under the terms of
this Conditional Receipt: (i) the Proposed Insured must be insurable as a risk
acceptable to the Company for the coverage as applied for on the application,
and (ii) all underwriting requirements must have been completed.
SIXTY (60) DAY MAXIMUM: This Conditional Receipt shall terminate automatically
the earliest of:
1. Sixty (60) days from the date of this Conditional Receipt;
2. The date the insurance takes effect under the policy applied for (the
Policy Date);
3. The date that a policy, other than applied for, is offered to the Proposed
Insured; or
4. The date the Company mails notice of termination of this Conditional
Receipt to the Proposed Insured at the address provided in the application.
Any sums deposited will be returned to the party named as the Owner on the
application.
SUICIDE: If the Proposed Insured commits suicide, whether sane or insane, while
this Conditional Receipt is in effect, the Company's sole liability shall be to
return the amount of the advance payment.
If the advance payment is being submitted with this application, I acknowledge
receipt of this Conditional Receipt. I have read the Conditional Receipt and I
understand and agree to the terms and conditions of this Conditional Receipt.
DATE:____/____/____ Signature of Proposed Insured ____________________________
DATE:____/____/____ Signature of Agent _______________________________________
CVIC-5001CR (09/00)
<PAGE>
CVIC-5001CR (09/00)
<PAGE>
CONSECO VARIABLE INSURANCE COMPANY
ADMINISTRATIVE OFFICE: 11815 N. PENNSYLVANIA STREET
P.O. BOX 1911, CARMEL, INDIANA 46082-1911
Mail Application To:
Conseco Variable Insurance Co. Service Center
9735 Landmark Pkwy. Dr.
St. Louis, MO 63127-1646
<TABLE>
SINGLE INSURED LIFE
------------------------------------------------------------------------------------------------------------------------------------
SECTION 1 - APPLICATION FOR INSURANCE - PRIMARY INSURED
------------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C>
First Name MI Last Name (indicate if hyphenated name) |_| Male Date of Birth Ht.
|_| Female Wt.
-------------------------------------------------------------------- ---------------------------------------------------------------
Address City, State, Zip code
--------------------------------- ------------------------------------------------- ------------------------ -----------------------
Social Security No. Drivers License No. & State Phone No. E-Mail Address
-------------------------------------------- ---------------------------------------------------------------------------------------
Occupation Occupation Duties and Employer
-------------------------------------------- ----------------------------------------------------- ---------------------------------
Gross Income Assets $________________ Birthplace (state or country)
Current Year $________________________ Liabilities $________________
Net Worth $________________
------------------------------------------------------------------------------------------------------------------------------------
Have you used tobacco in any form in the past 36 months |_| Yes |_| No; 24 months |_| Yes |_| No; 12 months |_| Yes |_| No
If Yes, indicate type:
------------------------------------------------------------------------------------------------------------------------------------
List any other name(s) and/or Social Security Number(s) the Primary Insured has ever used.
------------------------------------------------------------------------------------------------------------------------------------
SECTION 2 - OWNER FOR POLICY IF OTHER THAN PRIMARY INSURED:
---------------------------------- ------- -------------------------------------------------- ------------- --------------- --------
First Name MI Last Name (indicate if hyphenated name) |_| Male Date of Birth Ht.
|_| Female Wt.
------------------------------------------------------------------------ -----------------------------------------------------------
Address City, State, Zip code
------------------------------------------------------------------------ -----------------------------------------------------------
Relationship to Insured Trust ID No. - Name and Date of Trust (if owner is a Trust)
------------------------------------------------------------------------------------------------------------------------------------
SECTION 3 - JOINT OWNER FOR POLICY IF OTHER THAN PRIMARY INSURED:
------------------------------------------------------------------------------------------------------------------------------------
--------------------------------- ------ ------------------------------------------ ------------- ----------------------------------
First Name MI Last Name (indicate if hyphenated name) |_| Male Social Security No. or Tax ID No.
|_| Female
------------------------------------------------------------------------ -----------------------------------------------------------
Address City, State, Zip code
------------------------------------------------------------------------ -----------------------------------------------------------
Relationship to Insured Trust ID No. - Name and Date of Trust (if joint owner is a
Trust)
------------------------------------------------------------------------------------------------------------------------------------
SECTION 4 - PLAN OF INSURANCE, RIDERS AND BENEFITS
------------------------------------------------------------------------------------------------------------------------------------
Plan of DEATH BENEFIT OPTION
Insurance_______________________________________________________ |_| Option A (Level)
Product Name |_| Option B (Includes Accumulation Value)
Specified Amount $____________________ |_| Option C (Includes Premiums less Partial Withdrawals) -
(if amount of coverage exceeds $500,000, complete This election is irrevocable for the life of the policy.
Financial Questionnaire) DEATH BENEFIT QUALIFICATION TEST - This election is
irrevocable for the life of the policy.
|_| Guideline Premium Test
|_| Cash Value Accumulation Test
------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
1
CVIC-5001
<PAGE>
<TABLE>
--------------------------------------------------------------------- --------------------------------------------------------------
<S> <C> <C> <C> <C> <C>
RIDERS |_| Guaranteed Insurability Option $__________________
|_| Accelerated Death Benefit |_| Joint Life Term Rider $__________________
|_| Accidental Death Benefit $_____________________ |_| Life Insurance Protection Rider $__________________
|_| Child Rider $_____________________ |_| Policy Split Option
|_| Death Benefit Guarantee |_| Spouse Rider $__________________
|_| Disability Income Benefit $_____________________ |_| Unemployment Waiver of Cost
|_| Estate Preservation |_| Waiver of Planned Periodic Premium
|_| Exchange of Insured |_| Other____________________________________________________
______________________________________________________________
(Riders and Benefits vary by Plan and
may not be available in all states)
--------------------------------------------------------------------- --------------------------------------------------------------
SECTION 5 - PREMIUM PAYMENTS - METHOD AND FREQUENCY
--------------------------------------------------------------------- --------------------------------------------------------------
$ ___________________Cash with Application For flexible premium plans, indicate
(Check one box only) $____________ Planned Periodic Premium
METHOD ANNUAL SEMI-ANNUAL QUARTERLY MONTHLY (Write "None" if no future billing is desired.)
Direct |_| |_| |_| N/A
Electronic $____________ Additional First Year Premium
Funds
Transfer N/A N/A N/A |_| IRC Section 1035 Exchange? |_|No
Single Pay |_| N/A N/A N/A |_|Yes
List Bill |_| |_| |_| |_| $____________ Single Premium
List Bill Billing Control No._____________________________
-------------------------------------------- ---------------------------------------------------------------------------------------
Who will pay premiums? Payor Address, if different from Insured or Owner City State Zip code
------------------------------------------------------------------------------------------------------------------------------------
To whom shall mail be sent? |_| Primary Insured |_| Owner |_| Other (please give name and address)
------------------------------------------------------------------------------------------------------------------------------------
SECTION 6 - REQUESTS
------------------------------------------------------------------------------------------------------------------------------------
SPECIAL REQUESTS
------------------------------------------------------------------------------------------------------------------------------------
SECTION 7 - HOME OFFICE ENDORSEMENTS
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
SECTION 8 - BENEFICIARY DESIGNATION
------------------------------------------------------------------------------------------------------------------------------------
a. Primary ____________________________________ Age_______ Relationship ___________________________________________________
Address_________________________________________________________________________________________________________________________
Telephone No:____________________________________________________ Social Security No.______________________________________
(If Beneficiary is a Trust, provide name and date of Trust)
Name of Trust _____________________________________________ Date of Trust____________________________________________
b. Contingent ____________________________________________ Relationship_____________________________________________
------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
CVIC-5001 2
<PAGE>
<TABLE>
-----------------------------------------------------------------------------------------------------------------------------------
SECTION 9 - REPLACEMENT
------------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C>
a. Has any life or health insurance been denied, postponed, rated or modified? |_| Yes |_| No
b. Is the coverage applied for intended to replace any existing life insurance or annuity with this or any other company?
|_| Yes |_| No
c. Is the replacement to be handled as an IRC Section 1035 Exchange? |_| Yes |_| No
d. Do you now have any application for life, accident or health insurance or reinstatement of such insurance pending in any
company? |_| Yes |_| No
PLEASE PROVIDE DETAIL TO "YES" ANSWERS ________________________________________________________________________________________
e. LIFE INSURANCE IN FORCE AND PENDING INCLUDING BUSINESS INSURANCE: (IF NONE, INSERT "NONE")
------------------------------------------------------------------------------------------------------------------------------------
NAME OF TYPE OF FACE ACCIDENTAL YEAR TO BE
COMPANY COVERAGE AMOUNT DEATH ISSUED REPLACED?
-------------------------------- ------------------------ -------------------- -------------------- ------------------- ------------
-------------------------------- ------------------------ -------------------- -------------------- ------------------- ------------
-------------------------------- ------------------------ -------------------- -------------------- ------------------- ------------
-------------------------------- ------------------------ -------------------- -------------------- ------------------- ------------
------------------------------------------------------------------------------------------------------------------------------------
SECTION 10 - SUITABILITY
---------------------------------------------------------------------------------------------------------- ------------ ------------
Yes No
1. Do you understand the amount and duration of the death benefit may vary, depending on the
investment performance of the Investment Portfolios in the Separate Account? |_| |_|
2. Do you understand that the policy values may increase or decrease, depending on the investment
experience of the Investment Portfolios in the Separate Account? |_| |_|
3. Did you receive the Separate Account prospectus and the fund prospectus for the policy applied
for? |_| |_|
If yes, give date shown on prospectus:______________Separate Account Fund Date:______________
4. Do you understand that any personalized illustrations received are based on hypothetical
interest assumptions which may not be indicative of actual future investments, experience
of our Separate Account or actual interest credited in our Fixed Account. |_| |_|
---------------------------------------------------------------------------------------------------------- ------------ ------------
5. Do you believe that this policy will meet your insurance needs and financial objectives? |_| |_|
---------------------------------------------------------------------------------------------------------- ------------ ------------
PLEASE PROVIDED DETAIL TO "NO" ANSWERS:
------------------------------------------------------------------------------------------------------------------------------------
POLICY VALUES MAY INCREASE OR DECREASE, AND MAY EVEN BE REDUCED TO ZERO, IN ACCORDANCE WITH THE EXPERIENCE OF THE INVESTMENT
PORTFOLIOS IN THE SEPARATE ACCOUNT (SUBJECT TO ANY SPECIFIED MINIMUM GUARANTEES). THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER
SPECIFIED CONDITIONS. CURRENT ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH BENEFITS AND CASH SURRENDER VALUES, ARE AVAILABLE UPON
REQUEST.
------------------------------------------------------------------------------------------------------------------------------------
SECTION 11- TELEPHONE TRANSFER (READ CAREFULLY)
------------------------------------------------------------------------------------------------------------------------------------
I/We hereby authorize and direct Conseco Variable Insurance Company to accept telephone and internet asset transfer instructions,
premium allocation changes, and loan request from any person who can furnish proper identification. This authorization is subject to
the terms and provisions in the policy and prospectus. I agree that Conseco Variable Insurance Company will not be responsible for
any loss, liability, cost, or expense for acting on the telephone or internet instructions. Conseco Variable Insurance Company will
employ reasonable procedures to confirm that telephone or internet instructions are genuine. If Conseco Variable Insurance Company
does not do so, it may be liable for losses due to unauthorized or fraudulent transfers.
CHECK HERE TO DECLINE. |_|
------------------------------------------------------------------------------------------------------------------------------------
</TABLE>
CVIC-5001 3
<PAGE>
<TABLE>
------------------------------------------------------------------------------------------------------------------------------------
SECTION 12 - INVESTMENT SELECTIONS
------------------------------------------------------------------------------------------------------------------------------------
Use whole percentages to indicate the investment allocation desired. The minimum for each elected portfolio is 5%. The percentages
allocated for all portfolios must equal 100%.
---------------------------------------------- -------------------------------------------- ----------------------------------------
<S> <C> <C> <C> <C> <C>
CONSECO SERIES TRUST DREYFUS FUNDS NEUBERGER & BERMAN ADVISORS
________% Balanced Portfolio _______% Disciplined Stock Portfolio MANAGEMENT TRUST
________% Equity Portfolio _______% International Value Portfolio ________% Limited Maturity Bond Portfoli
________% Fixed Income Portfolio _______% Dreyfus Stock Index Fund ________% Partners Portfolio
________% Government Securities Portfolio _______% Dreyfus Socially Responsible STRONG OPPORTUNITY FUND II,
________% Money Market Portfolio Growth Fund, Inc. INC.
________% Focus 20 Portfolio FEDERATED INSURANCE SERIES ________% Opportunity Fund II
________% High Yield Portfolio _______% Federated High Income Bond STRONG VARIABLE INSURANCE
THE ALGER AMERICAN FUND Fund II FUNDS INC.
________% Alger American Growth _______% Federated International Equity ________% Strong MidCap Growth Fund II
Portfolio
Fund II VAN ECK WORLDWIDE
________% Alger American Leveraged _______% Federated Utility Fund II INSURANCE TRUST
AllCap Portfolio SELIGMAN PORTFOLIOS, INC. ________% Worldwide Bond Fund
________% Alger American MidCap Growth _______% Seligman Communications ________% Worldwide Emerging Markets
Portfolio and Information Portfolio Fund
________% Alger American Small _______% Seligman Global Technology ________% Worldwide Hard Assets Fund
Capitalization Portfolio Portfolio ________% Worldwide Real Estate Fund
AMERICAN CENTURY VARIABLE JANUS ASPEN SERIES RYDEX VARIABLE TRUST
PORTFOLIOS, INC. _______% Aggressive Growth Portfolio ________% OTC Fund
________% VP Income & Growth Fund _______% Growth Portfolio ________% NOVA Fund
________% VP International Fund _______% Worldwide Growth Portfolio
________% VP Value Fund LAZARD RETIREMENT SERIES,
BERGER INSTITUTIONAL INC. GENERAL ACCOUNT
PRODUCTS TRUST _______% Lazard Retirement Equity ________% Fixed Interest Account
________% Berger IPT-Growth Fund Portfolio
________% Berger IPT-Growth and Income Fund _______% Lazard Retirement Small Cap
Portfolio
________% Berger IPT-Small Company Growth Fund LORD ABBETT SERIES FUND, INC.
________% Berger/BIAM IPT-International Fund _______% Growth & Income Portfolio
________% Berger IPT-New Generation MITCHELL HUTCHINS SERIES TRUST
Fund
_______% Growth & Income Portfolio
---------------------------------------------- -------------------------------------------- ----------------------------------------
</TABLE>
CVIC-5001 4
<PAGE>
<TABLE>
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SECTION 13 - DOLLAR COST AVERAGING
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<S> <C> <C> <C> <C> <C>
|_| Dollar Cost Averaging from Money Market Account - You need a total of $2,000 in the money market account to participate. The
transfers will occur into the Portfolios designated below on the date of the month you elect below (or next business day if the date
of month you selected falls on a weekend or holiday). THIS PROGRAM CANNOT BE ACTIVE AT THE SAME TIME AS THE ASSET REBALANCING
PROGRAM.
A. Select the date of month _____________________. (1st through 28th only).
B. Select total monthly amount to be transferred $___________________.
C. Select the Portfolios and indicate how total is to be allocated in whole percents. The minimum for each elected portfolio is
5%.
---------------------------------------------- -------------------------------------------- ----------------------------------------
CONSECO SERIES TRUST DREYFUS FUNDS NEUBERGER & BERMAN ADVISORS
________% Balanced Portfolio _______% Disciplined Stock Portfolio MANAGEMENT TRUST
________% Equity Portfolio _______% International Value Portfolio ________% Limited Maturity Bond Portfoli
________% Fixed Income Portfolio _______% Dreyfus Stock Index Fund ________% Partners Portfolio
________% Government Securities Portfolio _______% Dreyfus Socially Responsible STRONG OPPORTUNITY FUND II,
________% Money Market Portfolio Growth Fund, Inc. INC.
________% Focus 20 Portfolio FEDERATED INSURANCE SERIES ________% Opportunity Fund II
________% High Yield Portfolio _______% Federated High Income Bond STRONG VARIABLE INSURANCE
THE ALGER AMERICAN FUND Fund II FUNDS INC.
________% Alger American Growth _______% Federated International Equity ________% Strong MidCap Growth Fund II
Portfolio Fund II VAN ECK WORLDWIDE
________% Alger American Leveraged _______% Federated Utility Fund II INSURANCE TRUST
AllCap Portfolio SELIGMAN PORTFOLIOS, INC. ________% Worldwide Bond Fund
________% Alger American MidCap Growth _______% Seligman Communications ________% Worldwide Emerging Markets
Portfolio and Information Portfolio Fund
________% Alger American Small _______% Seligman Global Technology ________% Worldwide Hard Assets Fund
Capitalization Portfolio Portfolio ________% Worldwide Real Estate Fund
AMERICAN CENTURY VARIABLE JANUS ASPEN SERIES RYDEX VARIABLE TRUST
PORTFOLIOS, INC. _______% Aggressive Growth Portfolio ________% OTC Fund
________% VP Income & Growth Fund _______% Growth Portfolio ________% NOVA Fund
________% VP International Fund _______% Worldwide Growth Portfolio
________% VP Value Fund LAZARD RETIREMENT SERIES,
BERGER INSTITUTIONAL INC. GENERAL ACCOUNT
PRODUCTS TRUST _______% Lazard Retirement Equity ________% Fixed Interest Account
________% Berger IPT-Growth Fund Portfolio
________% Berger IPT-Growth and Income _______% Lazard Retirement Small Cap
Fund Portfolio
________% Berger IPT-Small Company LORD ABBETT SERIES FUND,
Growth Fund INC.
________% Berger/BIAM IPT-International _______% Growth & Income Portfolio
Fund MITCHELL HUTCHINS SERIES
________% Berger IPT-New Generation TRUST
Fund _______% Growth & Income Portfolio
---------------------------------------------- -------------------------------------------- ----------------------------------------
11-29-00 Draft 3
</TABLE>
CVIC-5001 5
<PAGE>
<TABLE>
<CAPTION>
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SECTION 14 - ASSET REBALANCING
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Yes, I choose to participate in the Asset Rebalancing program. This program allows you to automatically rebalance your policy to
return to your current percentage allocations on a quarterly, semi-annual or annual basis. You can discontinue rebalancing at any
time. The transfer date will be the date you indicate below on the date of the month you elect below (or next business day if the
date of month you selected falls on a weekend or holiday.) THE FIXED ACCOUNT IS NOT PART OF ASSET REBALANCING.
I elect to rebalance: |_| Quarterly; |_| Semi-annually; |_| Annually.
Select the date of month . (1st through 28th only)
THIS PROGRAM CAN NOT BE ACTIVE AT THE SAME TIME AS THE DOLLAR COST AVERAGING PROGRAM.
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SECTION 15 - GENERAL INFORMATION
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COMPLETE APPROPRIATE QUESTIONNAIRE IF ANSWERING "YES" TO BOLD PRINT IMPAIRMENT. YES NO
<S> <C> <C> <C>
1 a. Do you have any intentions to travel or reside outside the U.S. or Canada? (indicate country & dates below) |_| |_|
------------------------------------------------------------------------------------------------------------------------------------
b. In the past 5 years have you, OR do you intend to engage in PILOTING AN AIRCRAFT, motor vehicle racing,
SCUBA DIVING, sky diving, hang gliding, parachuting, mountain climbing, horse racing or any other
hazardous sports? |_| |_|
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c. Have you ever been convicted of a felony, reckless driving, or driving under the influence of drugs or
alcohol, had your license suspended, or in the past three years had more than two moving traffic
violations? |_| |_|
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d. Have you ever used heroin, cocaine, crack, LSD, any derivative of these drugs, or any other illegal or
controlled substance except as prescribed by a physician? |_| |_|
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2 a. In the past 10 years have you had or been treated for: chest pain, high blood pressure, heart attack,
stroke, diabetes, ULCER, glucose intolerance, ASTHMA, emphysema, cancer, malignant tumor, or leukemia; a
disease or disorder of the heart, lungs, kidneys, pancreas, liver, gastrointestinal, genito-urinary, or
cardiovascular systems; anemia, ARTHRITIS, BACK/SPINE pain or injury or disease of the blood, bones,
muscles, joints, skin, connective tissue or glands, the ears, eyes, nose, throat or any internal organs;
any sexually transmitted disease, or albumin, sugar, pus, or blood in the urine; or an endocrine or
metabolic disorder, including, but not limited to thyroid, hyperlipidemia, pituitary, or adrenal gland
disorder? |_| |_|
-----------------------------------------------------------------------------------------------------------------------------------
b. In the past 10 years have you had or been treated for: a mental, nervous, or neurological disorder,
EPILEPSY, SEIZURES, paralysis, sleep apnea, memory loss, depression, dementia, Alzheimer's or Parkinson's
disease? |_| |_|
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c. In the past 10 years have you received or been advised to seek counseling for ALCOHOL or DRUG ABUSE? |_| |_|
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3. In the past 10 years have you been treated or diagnosed as having
Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or tested positive for
antibodies to Human Immunodeficiency Virus (HIV)? |_| |_|
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4 a. In the past 5 years have you been hospitalized or consulted a physician or any member of the medical
profession (list all occurrences); or have you had any blood tests (other than HIV or AIDS test),
electrocardiograms, or other medical tests or studies (indicate tests and results); or have you taken or
been advised to take any medication (list reason and medication-below)?
|_| |_|
------------------------------------------------------------------------------------------------------------------------------------
b. Have you ever had any mental or physical disorder not listed above? |_| |_|
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5. Has any immediate family member died of cardiovascular disease, cancer, or diabetes prior to age 60? |_| |_|
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6. Name of Physician: (if no physician, write "None")
-----------------------------------------------------------------------
Name:
-------------------------------------------------------------------------------------------------------------------------------
Address: Telephone No.
-------------------------------------------------------------------- ------------------------------------
====================================================================================================================================
REMARKS
Provide details to Section 14 questions 1 - 5 in the space provided below. Include QUESTION NUMBER, IMPAIRMENT, DIAGNOSIS,
TREATMENT, MEDICATION, DATE OF OCCURRENCE, CURRENT STATUS, AND NAME AND ADDRESS OF ALL DOCTORS, HOSPITALS, AND MEDICAL FACILITIES.
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11-29-00 Draft 3
</TABLE>
CVIC-5001 6
<PAGE>
<TABLE>
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<S> <C>
REMARKS (continued)
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(Attach extra sheet of paper if necessary.)
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SECTION 16 - DECLARATIONS
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I represent that all statements and answers made in all parts of this application are full, complete and true. It is understood and
agreed that:
(1) All such statements and answers shall be the basis for and become a part of any policy issued as a result of this application.
(2) No agent, producer, broker nor examiner has the authority to accept risks, to make or change contracts or to waive any the
Company's rights or requirements.
(3) AS A CONDITION PRECEDENT TO THE POLICY TAKING EFFECT, THE PROPOSED INSURED MUST BE ALIVE AND IN THE SAME CONDITION OF HEALTH AS
DESCRIBED IN THIS APPLICATION WHEN THE POLICY IS DELIVERED TO THE OWNER AND THE FULL FIRST PREMIUM MUST BE PAID. ALTHOUGH THE
POLICY WOULD NOT BE IN EFFECT, IF A CONDITIONAL RECEIPT OR TEMPORARY INSURANCE AGREEMENT (TIA) HAS BEEN SIGNED BY THE PROPOSED
INSURED AND THE FULL FIRST PREMIUM HAS BEEN PAID, COVERAGE MAY BE PROVIDED, SUBJECT TO ALL THE TERMS AND CONDITIONS OF THE
CONDITIONAL RECEIPT OR TIA.
(4) Acceptance of a policy by the Owner shall constitute ratification of any changes made by the Company.
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SECTION 17 - FRAUD WARNING
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Any person who knowingly and with intent to defraud any insurance company that submits an application for insurance or statement of
claim containing any materially false information, or conceals information concerning any fact material thereto for the purpose of
misleading, may be committing a crime which is subject to criminal and civil penalties.
AR, OH AND PA RESIDENTS: Any person who knowingly, and with intent to defraud any insurance company or other person, files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
DC RESIDENTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the
insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.
CO RESIDENTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, and denial of insurance
and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading
facts or information to a contractholder or claimant for the purpose of defrauding or attempting to defraud the contractholder or
claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of
Insurance within the department of regulatory agencies.
LA RESIDENTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
VA RESIDENTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties may include imprisonment, fines or a denial for insurance benefits.
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11-29-00 Draft 3
</TABLE>
CVIC-5001 7
<PAGE>
<TABLE>
<CAPTION>
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SECTION 18 - AUTHORIZATION
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I/(Proposed Insured) understand that Conseco Services, LLC, Conseco Variable Insurance Company (hereinafter, collectively
"Company"), affiliates of the Company, its reinsurers, any insurance support organizations, and those persons authorized to
represent them may need to collect information on me in regard to proposed coverage.
Therefore, I authorize any: (1) person licensed to provide health care service; (2) hospital; clinic or other medical facility; (3)
insurer; (4) reinsurer; (5) insurance support organizations, including MIB (Medical Information Bureau); (6) veterans organization;
(7) financial source; and (8) employer, to give the types of information listed below when this Authorization is presented.
The types of information may include my: (1) mental and physical health; (2) other insurance coverage; (3) hazardous activities; (4)
character; (5) general reputation; (6) mode of living; (7) finances; (8) vocation; (9) Acquired Immune Deficiency Syndrome (AIDS) or
AIDS Related Complex (ARC) or Human Immunodeficiency Virus (HIV); (10) drug and alcohol treatments; (11) other personal information;
and (12) government records, such as motor vehicle record.
The Company and its reinsurers will use the information in order to determine whether I am insurable pursuant to the Company's
underwriting standards. The insurance agent, producer, or broker may also use the information to help update and improve my
insurance program.
Those parties named in the first paragraph of this Authorization, excluding insurance support organizations, may disclose the
information that they have collected. They may disclose this information to: (1) other insurers to which I have applied or may apply
for insurance; (2) reinsurers; (3) the Medical Information Bureau; or (4) other persons who perform business, professional, or
insurance tasks for them. They may also disclose information according to any contract with a member company or organization.
Information may also be disclosed as allowed by law.
This Authorization will be valid for 30 months after the date of signing and cannot be revoked. A copy of this Authorization shall
be as valid as the original. I understand I have a right to receive a copy of this Authorization. I acknowledge receipt of a copy of
the "Notice of Information Practices," which includes pre-notification information relating to investigative consumer reports and
the Medical Information Bureau, Inc. and the current prospectus, if applying for Variable Universal Life.
If a minor child is proposed for coverage, these statements are made by the person authorized to act on behalf of the minor child
named in the application.
I understand and agree that this policy may include an internal appeals process that must be exhausted prior to any other action
being taken at law or in equity. This internal appeals process provides for optional mediation and/or arbitration.
<S> <C>
Signed at____________________________________________________________________on________________________________________________
City and State Month, Day, Year
-----------------------------------------------------------------------------------------------------------------------------------
Sign Full Legal Name
X_____________________________________________________________ X____________________________________________________________
Signature of Primary Insured Signature of Applicant/Owner
If other than the Primary Insured
X_____________________________________________________________ X____________________________________________________________
Signature of Parent or Guardian Signature of Co-Owner
If other than Primary Insured If other than Primary Insured
X_____________________________________________________________ X____________________________________________________________
Signature of Witness Print Name of Witness
(Licensed Agent must witness where required by law.)
X_____________________________________________________________ X____________________________________________________________
Signature (e.g. Trustee Signature, Trustee) Print Name of Trustee
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|_| I consent to the delivery of the following documents to me in electronic format, if available electronically: Profiles,
prospectuses, prospectus supplements, annual reports, semi-annual reports and proxy statements/materials. I understand that
Conseco Variable Insurance Company will send me the above documents in electronic format, when available, until I revoke this
consent.
|_| I prefer to receive printed copies of profiles prospectuses, prospectus supplements, annual reports and semi-annual reports.
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11-29-00 Draft 3
</TABLE>
CVIC-5001 8
<PAGE>
<TABLE>
<CAPTION>
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SECTION 19 - REGISTERED REPRESENTATIVE CERTIFICATION
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<S> <C> <C> <C>
Will the proposed contract replace any existing annuity or life insurance policy? |_| Yes |_| No
IF YES, REPLACEMENT REQUIREMENTS MUST BE FOLLOWED.
I certify that I have asked all the questions in the application and correctly recorded the answers of the proposed Insured. I have
presented to the Company all the pertinent facts, and I know nothing unfavorable about the Proposed Insured that is not stated in
this application.
Signed at_____________________________________this___________day of ___________________in the year of_____________________________
(CITY AND STATE)
X___________________________________________________________ X____________________________________________________________
Signature of Registered Representative Signature of Registered Representative
------------------------------------------------------------ -------------------------------------------------------------
Print Name Print Name
CONSECO VARIABLE REPRESENTATIVE'S #:_____________________ CONSECO VARIABLE REPRESENTATIVE'S #:_________________________
PHONE #:_________________________________________________ PHONE #:_____________________________________________________
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11-29-00 Draft 3
</TABLE>
CVIC-5001 9
<PAGE>
<TABLE>
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IF ELECTRONIC FUND TRANSFER ATTACH VOIDED CHECK HERE AND SIGN AUTHORIZATION
------------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C>
As a convenience to me, I hereby request and authorize you to initiate debit entries, whether by electronic or paper means, with
these debits made to my account and drawn by Conseco Services LLC, Carmel, Indiana provided there are sufficient collected funds in
that account to pay the same upon presentation. I agree that your rights in respect to such debit shall be the same as if they were
a check drawn on you and signed personally by me. I hereby agree that if any debit is not paid by me for any reason with or without
cause or whether such nonpayment is intentional, inadvertent or otherwise, you shall be under no liability whatsoever, even though
such nonpayment results in the forfeiture of insurance. This authorization is to remain in full force and effect until revoked by me
upon 30 days advance written notice, and until you actually receive such notice, I agree that you shall be fully protected in
honoring any such debit to my account.
------------------------------------------------------------------------------------------------------------------------------------
|_| Checking - Attach Void Check
TRANSIT / ROUTING # ACCOUNT # (Deposit slip not acceptable)
------------------------------------------------------------------------------------------------------------------------------------
|_| Savings - Deposit slip acceptable
------------------------------------------------------------------------------------------------------------------------------------
|_| Credit Union Account
DATE:________________________________________SIGNATURE X____________________________________________________________________________
(As it appears on bank records)
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AGENT'S REPORT
------------------------------------------------------------------------------------------------------------------------------------
A. 1. How long have you known the Proposed Insured?_______________________________________________________________________
2. What is your relationship to the Proposed Insured?__________________________________________________________________
B. Did you personally see the Proposed Insured(s) sign the application? |_| Yes |_| No
C. Have you placed coverage on this applicant with any other Company? |_| Yes |_|No
D. 1. Which of the following requirements have been ordered? |_| Agent Administered HOS Collection Kit
|_| None Ordered |_| HOS |_| Blood Profile |_| EKG |_| APS
|_| Exam |_| Other__________________________________
a. Name of facility________________________________________Phone Number:_______________________________________________
b. Date scheduled______________________________________________________________________________________________________
E. Production credits will be granted only as indicated below:
% of Credit Name Agent's Number
------------------ -------------------------------------------------------- -----------------------
------------------ -------------------------------------------------------- -----------------------
------------------ -------------------------------------------------------- -----------------------
F. Personal History Interview Information for Proposed Insured
------------------------------------------------------------------------------------------------------------------------------------
Phone Number Time Zone (Circle) Business Phone Number Time Zone (Circle)
( ) E C M P ( ) E C M P
------------------------------------------------------------------------------------------------------------------------------------
Interview Time: |_| Morning |_| Afternoon |_| Evening
DELAYS OCCUR WHEN WE CANNOT REACH YOUR CLIENT. Most Convenient Place: |_| Home |_| Business
G. Explanation and general remarks:
------------------------------------------------------- -------------------------------------------
------------------------------------------------------- -------------------------------------------
------------------------------------------------------- -------------------------------------------
Agent's Telephone Number ( )
--------------------- -------------------------------------------
Agent's Signature
Agent's Fax Number:
------------------------------------ -------------------------------------------
Print Name
Name of Up Line:
--------------------------------------- -------------------------------------------
Date
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11-29-00 Draft 3
</TABLE>
CVIC-5001 10
