EXHIBIT 99.A9
Exhibit 5
Application for Flexible Payment Variable Accumulation Deferred Annuity Contract
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[PHOTO]
Freedom Variable Annuities
Variable Annuity Application
[LOGO OF WRL]
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Application Instructions
1 Annuitant
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Please provide all of the information requested for the Annuitant. The Annuitant
is the person/individual who will receive the Annuity Payments and whose life
expectancy payments are based.
Please provide the Annuitants Taxpayer Identification Number, this is also known
as the Social Security Number.
2 Contract Owner
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Complete ONLY if Contract Owner is not the same as the Annuitant. Please provide
all of the information requested for the Contract Owner. Should the Owner be a
Trust, a complete trust date must be supplied. A copy of the Trust Certification
should also be included. If this is to be an Individual Retirement Annuity, the
Contract Owner must be the same as the Annuitant.
Please provide the Contract Owners Taxpayer Identification Number. For
individuals, this is the Social Security Number, for Corporations, this is the
Federal Employer Tax Identification Number.
3 Joint Contract Owner
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NOTE: IF THIS CONTRACT IS INTENDED TO BE AN INDIVIDUAL RETIREMENT ANNUITY (IRA),
A JOINT CONTRACT OWNER IS NOT PERMITTED.
Joint Owners may be named in the Wealth Creator only, provided the Joint Owners
are husband and wife.
4 Beneficiary Designation
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If the Annuitant is also the Owner or if the Owner is not a natural person, and
the Annuitant dies before the maturity date, a death benefit is payable. The
Primary Beneficiary, if living, is entitled to receive the death benefit
proceeds. If the Primary Beneficiary is already deceased, the Contingent
Beneficiary, if designated, will receive the death benefit proceeds; otherwise,
the proceeds will be paid to the Owners estate. The relationship of the
Beneficiary to the Annuitant must be provided. In the event of death of one
Joint Owner, the contract will continue with the surviving Joint Owner as sole
Owner. If Owner and Annuitant are natural people but not the same person, a
death benefit is not payable upon death of either. (Please consult the
prospectus)
5 Replacement
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The Contract Owner must answer the replacement question. If replacing a life
insurance policy or an annuity contract from another company, please check the
box marked Yes, and complete the required form(s). If not replacing a policy or
a contract, check the box marked No.
6 Type of Plan
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Indicate the type of plan being applied for.
(IRA sources: TransferTrustee to Trustee; Rollover/Direct RolloverQualified
Retirement Plan to IRA, (Trustee to Trustee or Trustee to
Individual/Participant); from a Direct Rollover with the intent to roll back
into another Qualified Retirement Plan)
7 Purchase Payments
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Refer to the prospectus for the minimum initial purchase payment, payable by
check, wire transfer*, 1035 Tax Free Exchange, Custodian to Custodian Transfer,
Direct Rollover or a combination thereof. Indicate the initial purchase amount
if enclosed with the application.
* Call the home office.
8 Allocation or Purchase Payments
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Payments may be allocated to any combination of the available Sub-Accounts, or
the Fixed Account. Please indicate each allocation selected as a whole
percentage of the Purchase Payment; note that the total allocations must equal
100%. Future Purchase Payments will be allocated as shown in this section,
unless Western Reserve Life is notified differently by the Contract Owner.
9 Statement of Owner
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The Owner must sign, as indicated, exactly as the name appears in either Item 1,
if Annuitant and Owner are the same, or in Item 2, if Annuitant and Owner are
different. In the event of Joint Owners, both Joint Owners must sign, as
indicated, exactly as the name appears in Item 2 and Item 3. The State in which
the application was written and the date signed are also required.
NOTE: SOME STATES REQUIRE THAT THE CONTRACT OWNER(S) ACKNOWLEDGE A FRAUD WARNING
STATEMENT. PLEASE REFER TO THE FRAUD WARNING STATEMENT ON THE REVERSE SIDE OF
THE APPLICATION.
10 Broker/Dealer Information
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The Registered Representative must complete all of the information. Please be
sure the replacement question is answered.
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Optional Feature Instructions
11 Automatic Monthly Investing
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Complete this section if Automatic Monthly Investing by electronic funds is
desired. A voided, unsigned check from the bank account to be debited must be
attached to the application. The amount debited will be allocated according to
the instructions in Section 8 of the Application, or as subsequently changed by
the Owner. Credit Unions and Savings accounts may not be eligible. Automatic
Partial Surrenders are not available in conjunction with this feature.
12 Telephone Transfer
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Your variable annuity contract will automatically receive telephone transfer
privileges described in the applicable prospectus unless instructions to the
contrary are indicated.
Western Reserve Life will not be liable for complying with the telephone
instructions it reasonably believes to be authentic, nor for any loss, damage,
costs or expense in acting on such telephone instructions, and Owners will bear
the risk of any such loss. Western Reserve Life will employ such procedures to
confirm that the telephone instructions are genuine. Such procedures may
include, among others, requiring forms of personal identification prior to
acting upon such telephone instructions, providing written confirmation of such
transactions to Owners and/or tape recording of telephone transfer request
instructions received. If Western Reserve Life does not employ such procedures,
it may be liable for losses due to unauthorized or fraudulent instructions.
13a Dollar Cost Averaging
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Complete this section if Dollar Cost Averaging (DCA) is desired. If selected,
Western Reserve Life will automatically transfer the stated amount(s) from the
designated Sub-Account(s) or the Fixed Account* to the other Sub-Account(s) or
Fixed Account indicated on the chosen date of each month. The Dollar Cost
Averaging feature is a long-term investment method which provides for regular,
level investments over time. Western Reserve Life makes no guarantee that the
Dollar Cost Averaging feature, if implemented, will result in a profit or
protect from loss. To complete this section, indicate the Sub-Account(s) or
Fixed Account* from which the Dollar Cost Averaging is to be made, one
Sub-Account or Fixed Account* per From line. A minimum of $10,000 ($5,000 for
Wealth Creator) must be allocated in each Sub-Account chosen (or Fixed Account*)
at the time this option is initiated. At least $1,000 ($100 Wealth Creator) in
the aggregate must be transferred each month. DCA is only available from the WRL
AEGON Bond Account, WRL J.P. Morgan Money Market Account or the WRL Fixed
Account.
* No more than 1/10 of the amount in the Fixed Account at the beginning of the
Dollar Cost Averaging can be transferred each month. (Note: This option is not
available if the Asset Rebalancing option is selected.)
13b Asset Rebalancing
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Complete this section if Asset Rebalancing is desired. If selected, Western
Reserve Life will automatically transfer amounts among the chosen Sub-Accounts
quarterly, semi-annually or annually to maintain a desired allocation of the
annuity purchase value among the various Sub-Accounts offered. Western Reserve
Life makes no guarantee that the Asset Rebalancing feature, if implemented, will
result in a profit or protect against loss. The minimum amount for this feature
is $5,000 Wealth Creator, $10,000 Attainer, $25,000 Bellwether. (Note: This
option is not available if the Dollar Cost Averaging option is selected.)
13c Automatic Partial Surrenders
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The Owner(s) may select to withdraw up to 10% of the Contract value annually,
payable in equal monthly, quarterly, semi-annual, or annual installments of at
least $200 per month. To be eligible, a minimum initial payment of $25,000 must
accompany this application. A penalty tax equal to 10% of the amount of the
withdrawals treated as taxable income will generally be imposed on the
withdrawals prior to the Owners age 5912. Withdrawals will be processed on the
date specified herein. If the date an Automatic Withdrawal transaction would
otherwise be processed falls on a non- business day, the Automatic Withdrawal
will be processed on the next business day. For Tax-Qualified contracts, or if
the Owner(s) is/are a resident of a community property state, spousal signature
is required. If an alternate payee is designated, and the payee is a bank
account, the Automatic Withdrawal will be directly deposited by electronic funds
transfer. If the payee is not a bank, please allow 7 to 10 days for receipt of
funds by mail. Indicate whether or not to withhold Federal income tax from the
withdrawal payments.
Note: This option is not available if THE Automatic Monthly Investing option is
selected.
14 Approval of Optional Features
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If any of the Optional Features available in Section(s) 11, 12 and 13 have been
selected, please complete this section by printing and signing your name as
indicated.
For assistance in completing this application, please call your dedicated 800
line and dial extension 6525 for our Sales Support Team.
Please Mail Application and Check Payable to:
Western Reserve Life Assurance Co. of Ohio
Attention: Annuity Department
P.O. Box 9051
Clearwater, FL 33758-9051
If Overnight Delivery:
Western Reserve Life Assurance Co. of Ohio
Attention: Annuity Department
8550 Ulmerton Road, Suite 101
Largo, FL 33771
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Variable Annuity Application
Western Reserve Life Assurance Co. of Ohio
P.O.Box 9051, Clearwater, Florida 33758
ANNUITY Selection (Check one)
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[ ] WRL Freedom Attainer [ ] WRL Freedom Bellwether
[ ] WRL Freedom Wealth Creator [ ] Other _______________
1 Annuitant
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[ ] Male [ ] Female
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Last First MI
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Address
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City State Zip
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Social Security Number
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Date of Birth (mm/dd/yyyy)
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Daytime Telephone
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E-Mail Address (optional)
2 Contract Owner (If other than annuitant)
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[ ] Male [ ] Female
Last First MI
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Address
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City State Zip
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Social Security Number
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Date of Birth (mm/dd/yyyy)
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Daytime Telephone
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E-Mail Address (optional)
3 Joint CONTRACT OWNER (Optional) Wealth Creator only
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[ ] Male [ ] Female
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Last First MI
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Address
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City State Zip
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Social Security Number
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Date of Birth (mm/dd/yyyy)
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Daytime Telephone
4 Beneficiary Designation
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Primary Beneficiary
Name Relationship to Annuitant
First Last
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Contingent Beneficiary
Name Relationship to Annuitant
First Last
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(If more than one Primary or Contingent Beneficiary is
designated, proceeds will be divided equally among the survivors within the
classification unless otherwise indicated.)
5 Replacement
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Required: Will this Annuity replace or change any existing Annuity or Life
Insurance?
[ ] Yes [ ] No If Yes, give name of company and policy number below:
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Company Name
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Policy Number
6 Type of Plan
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[ ] Non-Qualified [ ] SEP/IRA [ ] SIMPLE IRA
[ ] Roth IRA [ ] Traditional IRA
[ ] Other ___________________________________________
(Indicate the source of the IRA below)
[ ] Transfer [ ] Conduit
[ ] Rollover/Direct Rollover
[ ] Contributory: tax year ______________________________
7 Purchase payments
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Make Check Payable to Western Reserve Life
Initial Purchase Payment $______________________________
[ ] Automatic Monthly Investing
(Complete preauthorization section)
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1
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8 Allocation of Purchase Payments*
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WRL Janus Growth ........................................................... %
WRL Janus Global ........................................................... %
WRL Alger Aggressive Growth ................................................ %
WRL VKAM Emerging Growth ................................................... %
WRL AEGON Bond ............................................................. %
WRL AEGON Balanced ......................................................... %
WRL LKCM Strategic Total Return %
WRL Federated Growth & Income .............................................. %
WRL J.P. Morgan Money Market ............................................... %
WRL J.P. Morgan Real Estate Securities ..................................... %
WRL Dean Asset Allocation .................................................. %
WRL GE U.S. Equity ......................................................... %
WRL GE International Equity ................................................ %
WRL Third Avenue Value ..................................................... %
WRL NWQ Value Equity ....................................................... %
WRL C.A.S.E. Growth ........................................................ %
WRL Goldman Sachs Growth ................................................... %
WRL Goldman Sachs Small Cap ................................................ %
WRL T. Rowe Price Dividend Growth .......................................... %
WRL T. Rowe Price Small Cap ................................................ %
WRL Salomon All Cap ........................................................ %
WRL Pilgrim Baxter Mid Cap Growth .......................................... %
WRL Dreyfus Mid Cap ........................................................ %
WRL Great Companies - America(SM)........................................... %
WRL Great Companies - Technology(SM)........................................ %
WRL Value Line Aggressive Growth ........................................... %
Fidelity VIP III Growth Opportunities ...................................... %
Fidelity VIP II Contrafund ................................................. %
Fidelity VIP Equity-Income ................................................. %
Fixed Account .............................................................. %
Other ...................................................................... %
Other ...................................................................... %
Total 100%
* In some states the initial premium payment will be allocated to the WRL
J.P.Morgan Money Market sub-account during the right to examine period.
9 Statement of Owner
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(If applicable, complete the state specific fraud warning)
I hereby represent my answers to the above questions are true to the best of my
knowledge and belief. I agree that this application shall be a part of the
annuity contract. I have received a current Prospectus for the contract. I
understand that I should consult my own tax advisor and/or legal counsel as to
the consequences of using this product in conjunction with my own particular tax
or financial plan. I understand that under the contract applied for values may
increase or decrease depending upon investment experience. I also state that the
contract is in accordance with my financial objectives. The standard maturity
date is the anniversary nearest Annuitants age 90.
The standard annuity option is variable account life annuity with 120
monthly payments guaranteed. Option to change election is permitted by the
contract.
Under penalty of perjury, I (the owner) certify that my Taxpayer I.D. # is
correct as it appears on the application and that I am not subject to backup
withholding.
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Signed in (State)
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Date Signed
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Signature of Contract Owner
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Signature of Joint Owner (if any, Wealth Creator only)
10 BRoker/Dealer INformation (Registered Representative use only)
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I certify that (1) the Applicant signed this completed Application in my
presence; (2) I am authorized and qualified to discuss the contract herein
applied for.
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Registered Representative Signature Date
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Print RR Name, Agent Number, Production %, State License (If Applicable)
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Name of Broker/Dealer Dealer Number Dealer Branch
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Phone Number Fax #
[ ] [ ] [ ] [ ] [ ] High Mid Level (Wealth Creator only
RR Number --------------------
(circle one)
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Split case information (if applicable)
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Print RR Name, Agent Number, Production %, State License (If Applicable)
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Phone Number Fax #
[ ] [ ] [ ] [ ] [ ]
RR Number
Required: Will this contract replace or change any existing life insurance or
annuity in this or any other company? l Yes l No If Yes, explain
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Optional Features
11 Automatic Monthly Investing (Attach voided check)
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[ ] I authorize the making of Purchase Payments by electronic funds transfer on
a monthly basis, in the amount of $__________________, beginning on the
__________ day of each month (except the 29th, 30th, or 31st). I have attached
to this form a voided, unsigned check from the bank account to be debited. I may
notify Western Reserve Life at the Administrative Office to cancel this
authorization at any time. (Note: Credit unions and savings accounts may not be
eligible please consult your banking institution.)
12 Telephone transfer (See prospectus for telephone transfer procedures)
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Your Variable Annuity Contract will automatically receive telephone transfer
priviledges described in the prospectus unless instructions to the contrary are
indicated below. These priviledges allow you to give the registered
representative of record for your contract authority to make telephone transfers
and to change the allocation of future payments among the Sub-Accounts and the
Fixed Account (restrictions may apply) on your behalf according to your
instructions.
[ ] I do not want telephone transfer privileges as described above.
13a Dollar Cost Averaging (DCA) (Minimum $10,000 needed in attainer,
$25,000 Bellwether, $5,000 Wealth creator)
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I hereby request and authorize Western Reserve Life to transfer funds from the
selected Sub-Account(s) or Fixed Account* to invest in the portfolio(s), in the
amount indicated below. The transfers are to be made on the ___________ day of
the month (except the 29th, 30th, or 31st). The minimum total to be transferred
each month is $1,000 for Attainer and Bellwether, $100 for Wealth Creator. (* No
more than 110 of the amount in the Fixed Account at the beginning of the Dollar
Cost Averaging can be transferred each month.)
<TABLE>
<CAPTION>
<S> <C> <C> <C>
Transfer From: $_____________________ $_____________________ $_____________________
WRL AEGON Bond WRL Fixed Account* WRL J.P. Morgan
Money Market
Transfer To: Transfer To:
___________________ $_____________________ ______________________ $______________________
___________________ $_____________________ ______________________ $_____________________
</TABLE>
Note: The first transfer will take place the month following the issuance of the
contract. I understand that DCA transfers do not guarantee a profit and do not
protect against a loss. I further understand and agree: (1) Western Reserve Life
shall not be subjected to any claim, loss, liability, cost or expense if it acts
in reliance upon the instructions contained in the authorization; and (2) this
authorization shall not affect the allocation of future net purchase payments;
and (3) once elected, transfers will be processed monthly until the earlier of:
(a) the date the entire value of each Sub-Account or the Fixed Account from
which transfers are made is completely depleted; (b) the date Western Reserve
Life receives written instructions from me at the Administrative Office to
cancel the monthly DCA transfers; or the date Western Reserve Life discontinues
this DCA transfer privilege.
13b Asset Rebalancing (Minimum initial purchase payment of $5,000 Wealth
Creator, $10,000 Attainer, $25,000 Bellwether)
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I hereby request and authorize Western Reserve Life to automatically transfer
amounts among the chosen Sub-Accounts (as indicated below) on the frequency
selected to maintain a desired allocation of the Annuity Purchase Value among
the various Sub-Accounts offered.
Frequency: [ ] Quarterly [ ] Semi-Annual [ ] Annual
Note: Western Reserve Life will effect the initial rebalancing of the Cash Value
on the next such anniversary, in accordance with the Contracts current Net
Purchase Payment Allocation schedule. Asset Rebalancing will be processed in the
frequency requested until the earlier of: (a) the date Western Reserve Life
receives written instructions from me at the Administrative Office to cancel the
Asset Rebalancing or (b) the date any transfer is made to, or from any
Sub-Account, other than a scheduled rebalancing: or (c) the date Western Reserve
Life discontinues this Asset Rebalancing privilege. Asset rebalancing is not
available for any amounts in the Fixed Account.
Sub-Account Asset Rebalancing Allocation
$________ WRL VKAM Emerging Growth
$________ WRL T. Rowe Price Small Cap
$________ WRL Goldman Sachs Small Cap
$________ WRL Pilgrim Baxter Mid Cap Growth
$________ WRL Alger Aggressive Growth
$________ WRL Third Avenue Value
$________ WRL GE International Equity
$________ WRL Janus Global
$________ WRL Salomon All Cap
$________ WRL Janus Growth
$________ WRL Goldman Sachs Growth
$________ WRL C.A.S.E. Growth
$________ WRL GE U.S. Equity
$________ WRL Dreyfus Mid Cap
$________ WRL NWQ Value Equity
$________ WRL T. Rowe Price Dividend Growth
$________ WRL Dean Asset Allocation
$________ WRL LKCM Strategic Total Return
$________ WRL J.P. Morgan Real Estate Securities
$________ WRL Federated Growth & Income
$________ WRL AEGON Balanced
$________ WRL AEGON Bond
$________ WRL J.P. Morgan Money Market
$________ WRL Great Companies - America(SM)
$________ WRL Great Companies - Technology(SM)
$________ WRL Value Line Aggressive Growth
$________ Fidelity VIP III Growth Opportunities
$________ Fidelity VIP II Contrafund
$________ Fidelity VIP Equity-Income
$________ Other
$________ Other
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Optional Features
13c Automatic Partial Surrenders (Minimum initial premium of $25,000)
(Fixed account not available) Aggregate Partial Surrender cannot exceed
10% of cash value annually
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subject to the provisions of the prospectus and this authorization, I hereby
request and authorize Western Reserve Life to systematically make partial
surrenders of $__________________________(minimum $200) per month, $600 per
quarter, $1,200 semi-annually, $2,400 annually, beginning
(month/year)_____________/_____________ on the _______________ day (except the
29th, 30th, or 31st) of each frequency selected from the Sub-Accounts shown
below and to make payment to me unless a different payee is named below.
[ ] Standard Systematic Partial Surrender
[ ] RMD (Required Minimum Distribution)
[ ] 72T/72Q (Substantially Equal Payments)
(Additional requirements may be necessary to effect 72T/72Q.)
Sub-Account Partial Surrender Allocation
$________ WRL VKAM Emerging Growth
$________ WRL T. Rowe Price Small Cap
$________ WRL Goldman Sachs Small Cap
$________ WRL Pilgrim Baxter Mid Cap Growth
$________ WRL Alger Aggressive Growth
$________ WRL Third Avenue Value
$________ WRL GE International Equity
$________ WRL Janus Global
$________ WRL Salomon All Cap
$________ WRL Janus Growth
$________ WRL Goldman Sachs Growth
$________ WRL C.A.S.E. Growth
$________ WRL GE U.S. Equity
$________ WRL Dreyfus Mid Cap
$________ WRL NWQ Value Equity
$________ WRL T. Rowe Price Dividend Growth
$________ WRL Dean Asset Allocation
$________ WRL LKCM Strategic Total Return
$________ WRL J.P. Morgan Real Estate Securities
$________ WRL Federated Growth & Income
$________ WRL AEGON Balanced
$________ WRL AEGON Bond
$________ WRL J.P. Morgan Money Market
$________ WRL Great Companies - America(SM)
$________ WRL Great Companies - Technology(SM)
$________ WRL Value Line Aggressive Growth
$________ Fidelity VIP III Growth Opportunities
$________ Fidelity VIP II Contrafund
$________ Fidelity VIP Equity-Income
$________ Fixed Account
$________ Other
$________ Other
Election for recipients of periodic payments instructions
(Failure to complete this section may result in a delay of requested
withdrawals)
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Amounts received as partial surrenders from non-tax qualified annuity contracts
prior to the maturity date are first treated as taxable income to the extent of
any gain. Additionally, a penalty tax equal to 10% of the amount treated as
taxable gain will generally be imposed on partial surrenders made prior to the
Owners age 59 1/2. This authorization applies only to this Western Reserve Life
application/contract being applied for. A separate authorization must be
completed for any additional Variable Annuity Contracts owned. I understand and
agree to the terms and conditions as set forth in the Prospectus.
o Check box A if you do not want any Federal income tax withheld from your
annuity partial surrender payments.
o Check box B if you do want Federal income tax withheld from your annuity
partial surrender payments.
Even if you elect not to have Federal income tax withheld, you are liable for
payment of Federal income tax on the taxable portion of your annuity payments.
You may also be subject to tax penalties under the estimated tax payment rules
if your payment of estimated tax and withholding, if any, is inadequate.
(Check one only)
A [ ] I do not want to have Federal income tax withheld from my annuity partial
surrender payments.
B [ ] I wish to have Federal income tax withheld from my annuity partial
surrender payments: ________________%
(If percentage not indicated, 10% will be withheld.)
Alternate Payee Designation: If the alternate payee is a Bank Account, Please
attach a voided check for direct deposit by electronic funds transfer. Note:
Provide the following information only if the name of the payee differs from the
Owner. Western Reserve Life is directed to make monthly Automatic Partial
Surrender Payments to:
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Payee Name or Bank Bank Account
(Attach a voided check for bank payee) Routing Number
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Address City State Zip
14 Approval OF Optional Features
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By signing below, I hereby attest that I have selected the options available in
any or all Sections 11, 12 and 13 above, according to the information which I
have entered in each section.
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Owners Name Please Print Owners Signature Date
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Joint Owners Name (Creator Only) or Signature of Spouse * Date
Name of Spouse Please Print
* Signature of Spouse required if the contract is a Tax-Qualified plan or if the
Owner is a resident of a community property state.
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4
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WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO
P.O. BOX 5068
CLEARWATER, FLORIDA 33758
FRAUD WARNING
The following states require that contract owners acknowledge a fraud warning
statement. Please refer to the fraud warning statement for your state as
indicated below.
For applicants in ARKANSAS/LOUISIANA
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.
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Applicants Signature Date
For applicants in COLORADO
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,
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 policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder 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.
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Applicants Signature Date
For applicants in DISTRICT OF COLUMBIA
It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of insurance benefits.
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Applicants Signature Date
For applicants in FLORIDA
Any person who knowingly and with intent to injure, defraud, or deceive
any insurer files a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony in the third degree.
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Applicants Signature Date
For applicants in KENTUCKY, OHIO and pennsylvania
Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or a 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.
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Applicants Signature Date
For applicants in NEW JERSEY
Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
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Applicants Signature Date
For applicants in NEW MEXICO
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
criminal penalties.
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Applicants Signature Date
For applicants in VIRGINIA and MAINE
It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of insurance benefits.
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Applicants Signature Date
5
