[LOGO] |_| The Guardian Life Insurance Company of America (Guardian)
GUARDIAN(SM) Home Office: 7 Hanover Square
New York, NY 10004-2616
|_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office: 7 Hanover Square
New York, NY 10004-2616
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INSTRUCTIONS FOR COMPLETING THE LIFE INSURANCE APPLICATION
(Please detach before mailing)
All questions must be answered completely. Any changes to these answers must be
initialed by the Proposed Insured, Owner, if Other than Proposed Insured, and
Agent. An agent has no authority to waive, change or limit any question on the
application.
This form can be used for:
1. For all new Individual Life (Traditional, Universal, and Variable),
complete the following:
o Insurance Information Practices (all Life)
o Part I:
- Section A (all Life)
- Section B (all Life)
- Section C (Variable Life)
- Section D (all Life)
- Section E - Representations (all Life. If the Application is
taken by mail, the agent needs to check the
appropriate box when signing the Representations
section.)
o Part II (all Life)
o Avocations Supplement (as necessary)
o Aviation Supplement (as necessary)
o Conditional Receipt for Life Insurance (all Life - not applicable
for Survivorship policies)
o Request for Guard-O-Matic form (as necessary)
o Park Avenue Portfolio Request for Guard-O-Matic form (as necessary)
o Agent Certification (all Life)
o Sales Illustration Certification (as required)
2. Changes or conversions of Individual Life Insurance policies:
Complete: the Life Insurance Change Request form and all Requested
Information.
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Life Application L-AP-2000
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The notification below must be completed and given to the Proposed Insured
before the application is completed
[LOGO] |_| The Guardian Life Insurance Company of America (Guardian)
GUARDIAN(SM) Home Office: 7 Hanover Square
New York, NY 10004-2616
|_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office: 7 Hanover Square
New York, NY 10004-2616
INSURANCE INFORMATION PRACTICES
Notice to ______________________________________________________________________
Proposed Insured
Thank you for choosing insurance from Guardian. This notice is given to you at
the time you apply for life or disability insurance to tell you about the kinds
of information we may obtain in connection with your application. Only qualified
members of Guardian's or GIAC's staff will have access to your medical file to
evaluate your eligibility for insurance or to service your claim for benefits
under a policy. Your authorization will govern our request for information and
any later disclosure of that information. We will treat all personal information
about you as confidential. You have a right of access and correction with
respect to this information. If you wish a more detailed explanation of our
Information Practices, please send your written request to the Corporate
Secretary of Guardian or GIAC at 7 Hanover Square, New York, NY 10004-2616.
Fair Credit Reporting Act Pre-Notice
When we begin to process your application, we may ask for a consumer report from
a consumer reporting agency. All or part of that report may be an investigative
consumer report. Such a report will include information about your character,
general reputation, personal characteristics or mode of living, except as may be
related directly or indirectly to your sexual orientation. It will be obtained
through personal interviews with people who know you. You may ask to be
interviewed in connection with this report. We may request later consumer
reports, other than an investigative consumer report, at a future update,
renewal or extension of the insurance for which you have applied. At your
request, we will tell you if we have asked for a consumer report or an
investigative consumer report in the initial processing of your application. If
we have, we will tell you the name and address of the consumer reporting agency
to which we have made our request for a report. You can obtain a copy of this
report by contacting this consumer reporting agency. At your written request, we
will give you more detailed information about the nature and scope of this kind
of investigation.
Medical Information Bureau Pre-Notice
The Medical Information Bureau is a nonprofit membership organization of life
insurance companies. The Bureau provides an information exchange for its
members. On the request of any of its member companies to which you apply for
life or disability insurance, or to which you make a claim for benefits, the
Bureau will supply the inquiring company with the information in its files.
Guardian, GIAC or their reinsurers may make a brief report of objective findings
about you to the Bureau. We will not report what action we have taken on your
application.
If you so request of the Bureau, it will arrange to disclose the information it
may have in your file; however, medical information will be disclosed only to
your doctor. If you question the accuracy of the information in the Bureau's
file, you may contact the Bureau and seek to correct the information according
to procedures set forth in the Federal Fair Credit Reporting Act. The Bureau's
address is Post Office Box 105, Essex Station, Boston, MA 02112, telephone
617-426-3660.
Medical Records
We may request information from health care providers or others who have records
of your medical history, mental or physical condition, or treatment. Only
qualified members of Guardian's or GIAC's staff will have access to your medical
file to evaluate your eligibility for insurance or to service your claim for
benefits under a policy. Your authorization will govern our request for
information and any later disclosure of that information.
Personal Information Telephone Interview
We may phone you to verify or supplement information you have given us on your
application. The call will be made from our underwriting office or from a
consumer reporting agency acting for us.
L-FCRA-2000 L-AP-2000
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[LOGO] |_| The Guardian Life Insurance Company of America (Guardian)
GUARDIAN(SM) Home Office: 7 Hanover Square
New York, NY 10004-2616
|_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office: 7 Hanover Square
New York, NY 10004-2616
In this application, "the Company" is the insurer checked above.
This application is to be attached to and made part of the policy.
APPLICATION FOR INSURANCE
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PART I: Section A, 1st of 4 pages
<TABLE>
<CAPTION>
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Proposed Insured (please print):
<S> <C>
1. a) First Name ______________________________________MI____ g) Address _____________________________________________________
Last Name ____________________________________________ City ___________________________ State ________ Zip _________
b) Social Security # __ __ __ - __ __ - __ __ __ __ h) How long at this address? _____________
c) Sex |_| Male |_|Female i) Home Phone (___)_____________________________________________
d) Date of Birth (mm/dd/yyyy)_____________________________ j) Business Phone (___)_________________________________________
e) Place of Birth ________________________________________ k) E-Mail Address_______________________________________________
f) Are you a US citizen? |_| Yes |_| No l) (If less than 2 years at current address, please furnish
If no, give visa type and duration previous address:)
Visa Type _____________________________________________ Address ________________________________________________________
Visa Duration _________________________________________ City ________________________________ State ______ Zip _________
m) Telephone Interview- If more information is needed, a Guardian representative may call you. Show the most convenient
time and place for such a call weekdays between the hours of 9:00 AM and 9:00 PM.
|_| Home |_| Business |_| Other Phone (___)__________ Ext. ______ Time _________ |_| AM |_| PM
<CAPTION>
Business Information:
<S> <C>
2. a) Name of employer ______________________________________ d) Occupation __________________________________________________
b) Address _______________________________________________ e) Job Title ___________________________________________________
City ______________________ State ______ Zip __________ f) Nature of Business __________________________________________
Business Web Site: ____________________________________
c) If address is P.O. Box, include street address as well:
Address _______________________________________________
City ______________________ State ______ Zip __________
g) How many years employed?_______________________________ (If less than 2 years please furnish previous employer below:)
h) Former employer _______________________________________ i) Occupation __________________________________________________
Address _______________________________________________ j) Job Title ___________________________________________________
City ______________________ State ______ Zip __________ k) Nature of Business _________________________________________
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</TABLE>
(Continued on other side.)
L-AP-2000 L-AP-2000
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PART I: Section A, 2nd of 4 pages
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(Continued from previous page.)
<TABLE>
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<S> <C>
3. Complete this box only if the owner is not the proposed insured
a. Owner name (First, MI, Last) or name of trust, company e. Billing Address: ____________________________________________
or other owner: _____________________________________________________________
_______________________________________________________ _____________________________________________________________
_______________________________________________________ f. Please complete the following if owner is a trust:
_______________________________________________________ Date of Trust: ______________________________________________
b. Soc. Sec. #/Tax ID #___________________________________ Complete Names of Trustees:
c. Tax Qualified Plan |_| Yes |_| No _____________________ _____________________________________________________________
d. Relationship to proposed insured: _____________________________________________________________
_______________________________________________________ _____________________________________________________________
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4. BENEFICIARY: Print full name and relationship to Proposed Insured. (Unless otherwise indicated, all Primary Beneficiaries who
survive the Insured shall share equally. If no Primary Beneficiary survives the Insured, benefits will be paid in equal shares
to the Contingent Beneficiaries, etc, if surviving the Insured, unless otherwise specified).
a. Primary Beneficiary _______________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
b. Contingent Beneficiary ____________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
c. Tertiary Beneficiary _____________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
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5. COVERAGE REQUESTED:
a. Complete for TRADITIONAL LIFE Policies (Non-Variable/Non-Universal):
Plan of Insurance: ____________________________________ Face Amount $___________________________________________________
Riders:
Note: * "Amount" is the face amount purchased in the first policy year.
** For PUI, "Payment" is the Equivalent Annual Deposit (EAD), excluding waiver. The EAD is the annual rider premium,
not amount of each modalized payment. For PUA, "Payment" is the first year purchase payment.
<CAPTION>
General Riders: *Amount **Payment
--------------- ------ -------
<S> <C> <C>
|_| Paid-Up Additions Rider (PUA)** $__________ $__________
|_| Paid-Up Ins. Rider (PUI)** $__________ $__________
For Single Life Policies only (additional rider choices):
<CAPTION>
*Amount *Amount Payment
------ ------ -------
<S> <C> <C> <C> <C>
|_| 10 Yr. Annually Renewable Term (RTR-10) $__________ |_| Select Security Rider
|_| Accelerated Benefit Rider (complete required disclosure form) |_| Waiver of Premium (W)
|_| Accidental Death Benefit (ADB) $__________ |_| Other_______________________ $____________ $___________
|_| Exchange to Term Insurance |_| Other_______________________ $____________ $___________
|_| Guaranteed Purchase Option (GIO) $__________ |_| Other_______________________ $____________ $___________
|_| DuoGuard (List names & amounts for Designated Lives. Complete a separate application for each Designated Life.)
<CAPTION>
Name of Designated Life *Amount Name of Designated Life *Amount
----------------------- ------ ----------------------- ------
<S> <C> <C> <C>
_______________________________ $____________ _____________________________________ $____________
_______________________________ $____________ _____________________________________ $____________
_______________________________ $____________
(continued on the next page)
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</TABLE>
L-AP-2000 L-AP-2000
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<TABLE>
<CAPTION>
PART I: Section A, 3rd of 4 pages
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(Continuation of item 5 from previous page)
For Traditional Survivorship Life Policies only (additional rider choices):
*Amount
------
<S> <C> <C>
|_| DuoGuard |_| 10 Year Decreasing Term (Death Waiver)
|_| (1st Insured) ___________________ $____________ |_| (1st Insured) ________________________________
|_| (2nd Insured) ___________________ $____________ |_| (2nd Insured) ________________________________
|_| Renewable Term to 85 (RTR-85) |_| 15 Year Decreasing Term (Death Waiver)
|_| (1st Insured) ___________________ $____________ |_| (1st Insured) ________________________________
|_| (2nd Insured) ___________________ $____________ |_| (2nd Insured) ________________________________
|_| Other ___________________________ $____________ |_| Split Dollar Protector
|_| Other ___________________________ $____________ |_| (1st Insured) ________________________________
|_| Other ___________________________ $____________ |_| (2nd Insured) ________________________________
|_| Other ___________________________ $____________
|_| Second-to-Die DuoGuard
(List names and amounts for Designated Lives. Complete a separate application for each Designated Life.)
<CAPTION>
Name of Designated Life Amount Name of Designated Life Amount
----------------------- ------ ----------------------- ------
<S> <C> <C> <C>
_______________________________ $____________ _____________________________________ $____________
_______________________________ $____________ _____________________________________ $____________
<CAPTION>
b. Complete for UNIVERSAL, VARIABLE UNIVERSAL LIFE, and VARIABLE WHOLE LIFE Policies:
<S> <C> <C> <C> <C>
Plan of Insurance: _______________________________ Base Face Amount $_______________________________________________
|_| Additional Sum Insured (ASI) Face Amount (as applicable) $_________________________________
Death Benefit Option (Not all options may be available.)
|_| Option 1 |_| Option 2 |_| Option 3 |_| Other _____________________
Optional Riders or Coverage:
<CAPTION>
General Riders (as applicable): *Amount *Amount
------------------------------- ------ ------
<S> <C> <C> <C>
|_| Accidental Death Benefit (ADB) $___________ |_| Waiver of Monthly Deductions (for VUL)
|_| Adjustable Annually Renewable |_| Waiver of Premium (for PAL)
Term (AART) $___________ |_| Waiver of Specified Amount /
|_| Adjustable Renewable Term (for PAL) $___________ Disability Benefit Waiver (for VUL) $___________
|_| Level Target Death Benefit Term $___________ |_| Other _____________________________ $___________
|_| Guaranteed Insurability Option (GIO) |_| Other _____________________________ $___________
|_| Guaranteed Coverage Rider (GCR) to Age _______ |_| Other _____________________________ $___________
<CAPTION>
For Survivorship Policies only
(additional rider choices): *Amount *Amount
--------------------------- ------ ------
<S> <C> <C> <C>
|_| Single Life Term Rider |_| Other _____________________________ $___________
|_| (1st Insured) ______________ $___________ |_| Other _____________________________ $___________
|_| (2nd Insured) ______________ $___________ |_| Other _____________________________ $___________
<CAPTION>
6. Dividends (for participating policies only)
<S> <C> <C>
|_| A- Paid in cash |_| Q- One Year Term Insurance not to exceed Target Face
|_| B- Reduce premiums Amount of $______________
|_| C- Left at interest (Complete W-9 form if elected) |_| R- One Year Increasing Term Initial Target of
|_| D- Paid-Up Additional Insurance $____________
|_| Term Insurance face amount not in excess of cash value |_| S- Premium Offset - available only if a PUA rider is
|_| F- Balance to purchase paid-up additional insurance requested. Premiums to be offset at the end of the first
|_| G- Balance to reduce premium policy year by use of PUA rider additions and future
|_| K- Deferred Additional Insurance dividends
|_| Term Insurance face amount not in excess of twice face |_| with Target Face Amount
amount of basic policy: not to exceed $_________________
|_| L- Balance to purchase paid-up additional insurance
|_| P- Balance to reduce premium |_| Other ________________________________________________________
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</TABLE>
L-AP-2000 L-AP-2000
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<TABLE>
<CAPTION>
PART I: Section A, 4th of 4 pages
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(Continued from previous page.)
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7. Premium
<S> <C>
Complete for Universal Life and Variable Universal Life Policies
Planned |_| Annual Premium |_| Modal Premium (check one and enter applicable amount) $__________________
Initial Premium $___________________________
Complete for Variable Whole Life Policies
Planned Modal Unscheduled Payment (Excluding Initial Pour-in) $_______________
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<CAPTION>
8. Premium Mode
<S> <C> <C> <C>
|_| Annual |_| Semi-annual |_| Quarterly |_| Other _______________________
|_| Guard-O-Matic (be sure to complete the Request for Guard-O-Matic Arrangement form).
|_| Monthly (list bill only) this may not be available for all products.
<CAPTION>
9. Send Premium Notices to:
<S> <C> <C> <C>
|_| Residence |_| Business |_| List Bill Account |_| Other _____________________________________________________
|_| Owner's Address #_______________ ___________________________________________________________
___________________________________________________________
<CAPTION>
10. Automatic Premium Loan
<S> <C>
The automatic premium loan provision (if available) will be made effective |_| Yes |_| No
(if left blank, Automatic Premium Loan will be default option).
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<CAPTION>
11. If applying for an ALTERNATE LIFE policy, please indicate:
<S> <C>
Plan of Insurance: ________________________________________ Face Amount: _______________________________________
Details (Riders, Benefits, Dividend Option, etc.):
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12. REMARKS (or additional instructions):
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13. AMENDMENTS OR CORRECTIONS (For Home Office Or Executive Office Use Only):
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</TABLE>
L-AP-2000 L-AP-2000
<PAGE>
PART I: Section B, 1st of 2 pages
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This application is to be attached to and made part of the policy.
<TABLE>
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The following questions apply to the Proposed Insured:
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If yes, to questions 1-7, and 9, provide details in Remarks section (item 15) on the next page.
<S> <C> <C>
1. a) Do you intend to change your occupation? |_| Yes |_| No
b) Do you intend to reside or travel outside of the U.S.? |_| Yes |_| No
2. a) Do you drive a motor vehicle? |_| Yes |_| No
If yes, give Driver's License State ________ DL Number _________________________________________
b) Within the past 5 years, have you been charged with and/or convicted of any motor vehicle moving
violations or had your driver's license suspended or revoked?
(If yes details must include date of violation, description of violation and penalty.) |_| Yes |_| No
3. Within the last 3 years have you participated in any of the following: Piloting any type of aircraft;
Mountain climbing or rock climbing; Scuba diving; Hangliding, Parachuting, or skydiving; or Motor vehicle
racing? (If yes to any, complete Avocations and/or Aviation Supplement(s)). |_| Yes |_| No
4. Have you ever filed for personal or business bankruptcy?
(If yes, give full details and date of discharge in remarks section 8 below.) |_| Yes |_| No
5. Within the past 5 years, have you had disability, accident, medical or life insurance declined, postponed,
modified, rated, cancelled or withdrawn a pending application? |_| Yes |_| No
6. a) Have you smoked cigarettes in the past 24 months? If you have quit, date last used:________________ |_| Yes |_| No
b) Have you used tobacco in any form in the last 24 months? |_| Yes |_| No
If you have quit, date last used:_____________________
c) Do you currently use a nicotine patch or nicotine gum? |_| Yes |_| No
7. Do you plan to apply for or are your currently applying for any other life, disability or accident
insurance? (In details, include amount and company applied with, and whether this other insurance
will be in addition to or in lieu of insurance with Guardian/GIAC ?) |_| Yes |_| No
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<CAPTION>
8. Please list below total amount of life insurance in force on your life. If none check here. |_|
Personal or Accidental Waiver of GIO
Name of Company Year Issued Amount Business Death Amt Premium Amt
--------------- ----------- ------ -------- --------- ------- ---
(if any)
<S> <C> <C> <C> <C> <C> <C> <C>
________________________ ___________ ___________ |_| Per. |_| Bus ______________ ______________ ___________
________________________ ___________ ___________ |_| Per. |_| Bus ______________ ______________ ___________
________________________ ___________ ___________ |_| Per. |_| Bus ______________ ______________ ___________
________________________ ___________ ___________ |_| Per. |_| Bus ______________ ______________ ___________
________________________ ___________ ___________ |_| Per. |_| Bus ______________ ______________ ___________
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<CAPTION>
9. Replacement:
<S> <C> <C>
Are you considering the surrender, forfeit, assignment to an insurer, or termination of any existing life
insurance policy or annuity contract? Are you considering using funds from your existing life insurance
policies or annuity contracts to pay the premium or premiums on the new life insurance policy? (Please
complete appropriate state replacement forms. In addition, please provide details to yes answer in Remarks
section (item # 15) on next page). |_| Yes |_| No
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10. What is the purpose of this insurance?
(e.g., Mortgage, Family Income, Education, Spouse/Child Insurance, Retirement, Estate Planning, Wealth Accumulation, Buy-Sell,
Keyperson, Deferred Compensation, Selective Incentive Plans, Executive Bonus, Stock Redemption, Other - describe):
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
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</TABLE>
L-AP-2000 L-AP-2000
<PAGE>
PART I: Section B, 2nd of 2 pages
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<TABLE>
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11. Personal Finances (of owner):
<S> <C> <C> <C>
a) Total Assets $_______________ b) Total Liabilities $______________ c) Net Worth $_______________
d) Earned Income $_______________ e) Unearned Income if in excess of $10,000 $_______________
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<CAPTION>
12. Business Finances (Complete ONLY if this is Business Insurance):
<S> <C> <C>
a) Is this business: (Check One)
|_| Limited Liability Co. |_| Sole Proprietor |_| Partnership |_| S Corp |_| C Corp |_| Other_____________
b) Total Assets $_______________ c) Total Liabilities $___________________ d) Net Worth $________________
e) Net Profit After Taxes for past Two Years: Last Year $___________________ Previous Year $________________
f) How long has the business been established? ______________________________________________________________
g) What is the nature of the business? ______________________________________________________________________
h) What percentage of the business is owned by the proposed insured? ________________________________________
<CAPTION>
13. Is there business insurance applied for or in force on other key members of this firm? |_| Yes |_| No
<S>
If "Yes", provide details:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
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<CAPTION>
<S> <C> <C>
14. Life Insurance Tests Under Section 7702 of the Federal Income Tax Code
(choice only applies to Variable and Universal Life policies)
Section 7702 specifies the rules under which life insurance death proceeds are excludible from gross income. Please check one
of the tests shown below. Once elected, such test cannot be changed. If there is a choice in test and no test is elected, the
automatic Life Insurance Test will be the Guideline Premium Test. (Both tests may not be available with all products.)
|_| Cash Value Accumulation Test |_| Guideline Premium Test
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<CAPTION>
<S>
15. REMARKS (or additional instructions):
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</TABLE>
L-AP-2000 L-AP-2000
<PAGE>
The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office: 7 Hanover Square, New York, NY 10004-2616
PART I: Section C, 1st of 2 pages VARIABLE LIFE SUPPLEMENT
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This application is to be attached to and made part of the policy.
Complete if applying for Variable Life Insurance.
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<TABLE>
1. Initial Premium Allocation
(Not all funds are available with all products. All percentage allocations must be in whole numbers. There is a limit to the
number of fund allocation options that you can designate. Please check your prospectus.)
<S> <C>
_______% The Guardian Bond Fund _______% Fidelity VIP High Income Portfolio
_______% The Guardian Cash Fund _______% Fidelity VIP II Contrafund(R) Portfolio
_______% The Guardian Small Cap Stock Fund _______% Fidelity VIP II Index 500 Portfolio
_______% The Guardian Stock Fund _______% Fidelity VIP III Growth Opportunities Portfolio
_______% The Guardian VC 500 Index Fund _______% Fidelity VIP III Mid Cap Portfolio
_______% The Guardian VC Asset Allocation Fund _______% Gabelli Capital Asset Fund
_______% The Guardian VC High Yield Bond Fund _______% Janus Aggressive Growth Portfolio
_______% The Fixed Rate Option _______% Janus Capital Appreciation Portfolio
_______% American Century VP Value Fund _______% Janus Growth Portfolio
_______% American Century VP International Fund _______% Janus Worldwide Growth Portfolio
_______% AIM V.I. Capital Appreciation Fund _______% MFS Bond Series
_______% AIM V.I. Global Utilities Fund _______% MFS Emerging Growth Series
_______% AIM V.I. Value Fund _______% MFS Growth with Income Series
_______% Baillie Gifford Emerging Markets Fund _______% MFS New Discovery Series
_______% Baillie Gifford International Fund _______% MFS Research Series
_______% Davis Financial Portfolio _______% MFS Total Return Series
_______% Davis Real Estate Portfolio _______% Value Line Centurion Fund
_______% Davis Value Portfolio _______% Value Line Strategic Asset Management Trust
_______% Fidelity VIP Equity Income Portfolio _______% Other __________________________________________________________
_______% Other _____________________________________ _______% Other __________________________________________________________
_______% Other _____________________________________ 100 % Total
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<CAPTION>
2. Dollar Cost Averaging Transfer Option (Not all funds are available with all products. The portion of the Policy Account Value
attributable to The Guardian Cash Fund on the date this option is elected must be at least the minimum required in the
prospectus for the product being applied for. Please check your prospectus.)
Each month, GIAC will dollar cost average from the Guardian Cash Fund the following amounts into:
<S> <C>
$________ The Guardian Bond Fund $________ Fidelity VIP High Income Portfolio
$________ The Guardian Small Cap Stock Fund $________ Fidelity VIP II Contrafund(R) Portfolio
$________ The Guardian Stock Fund $________ Fidelity VIP II Index 500 Portfolio
$________ The Guardian VC 500 Index Fund $________ Fidelity VIP III Growth Opportunities Portfolio
$________ The Guardian VC Asset Allocation Fund $________ Fidelity VIP III Mid Cap Portfolio
$________ The Guardian VC High Yield Bond Fund $________ Gabelli Capital Asset Fund
$________ The Fixed Rate Option $________ Janus Aggressive Growth Portfolio
$________ American Century VP Value Fund $________ Janus Capital Appreciation Portfolio
$________ American Century VP International Fund $________ Janus Growth Portfolio
$________ AIM V.I. Capital Appreciation Fund $________ Janus Worldwide Growth Portfolio
$________ AIM V.I. Global Utilities Fund $________ MFS Bond Series
$________ AIM V.I. Value Fund $________ MFS Emerging Growth Series
$________ Baillie Gifford Emerging Markets Fund $________ MFS Growth with Income Series
$________ Baillie Gifford International Fund $________ MFS New Discovery Series
$________ Davis Financial Portfolio $________ MFS Research Series
$________ Davis Real Estate Portfolio $________ MFS Total Return Series
$________ Davis Value Portfolio $________ Value Line Centurion Fund
$________ Davis Value Portfolio $________ Value Line Strategic Asset Management Trust
$________ Other _______________________________ $________ Other ___________________________________
$________ Other _______________________________ $________ Other ___________________________________
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</TABLE>
L-AP-VL-2000 L-AP-2000
<PAGE>
PART I: Section C, 2nd of 2 pages VARIABLE LIFE SUPPLEMENT
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<TABLE>
3. Suitability
<S><C> <C> <C> <C> <C>
1) Have you, the Owner, received the current Prospectus? |_| Yes|_| No
2) a. Do you understand that you are applying for a Life Insurance Policy that has investment options? |_| Yes|_| No
b. What are your investment objectives? |_| Income |_| Growth |_| Aggressive Growth
|_| Tax-Advantaged |_| Preservation of Capital |_| Other_____________________
c. What is your risk tolerance? (check only one) |_| Conservative |_| Moderate |_| Aggressive
3) Do you understand that:
a. The death benefit may increase or decrease based on the policy's investment return, but will not be less than the
guaranteed amount (if applicable)? |_| Yes|_| No
b. The cash value may increase or decrease, even to the extent of being reduced to zero, based on the investment return and
is not guaranteed? |_| Yes|_| No
4) Do you believe that the policy applied for will meet your insurance needs and financial objectives? |_| Yes|_| No
5) I understand that:
a. all values under this policy which are based on the investment experience of the Separate Account are variable, may
increase or decrease and are not guaranteed;
b. the Death Proceeds, Policy Account Value and Cash Surrender Value under this policy may increase or decrease daily,
depending upon payments made, the investment experience of the Separate Account, the amount of interest credited to the
Fixed-Rate Option, the amount of charges deducted and whether partial withdrawals or policy loans are taken;
c. the Death Proceeds will never be less than the Guaranteed Insurance Amount (if applicable) provided all policy premiums are
paid when due, no partial withdrawals are made and no policy loans are taken;
d. there is no minimum guaranteed Cash Surrender Value. The loan value of this policy is less than 100% of the Cash Surrender
Value;
e. my policy will lapse any time (1) outstanding loans and accrued interest exceed policy value less surrender charges or (2)
if the policy value less outstanding loans and accrued interest and surrender charges is insufficient to pay certain
monthly deductions, or (3) a grace period expires without a sufficient payment;
f. this policy is non-participating; there are no dividends payable;
g. I understand that surrender charges may apply and are determined by factors that are unique to this individual policy as
described in the prospectus.
</TABLE>
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Telephone Transfer Authorization
|_| I have read the telephone transfer authorization rules in the prospectus
and elect telephone transfers.
Personal Security Code (Select any 5-digit number) ___ - ___ - ___ - ___ - ___
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L-AP-VL-2000 L-AP-2000
<PAGE>
[LOGO] |_| The Guardian Life Insurance Company of America (Guardian)
GUARDIAN(SM) Home Office: 7 Hanover Square
New York, NY 10004-2616
|_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office: 7 Hanover Square
New York, NY 10004-2616
This application is to be attached to and made part of the policy.
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Part I, Section D
AUTHORIZATION TO OBTAIN AND RELEASE INFORMATION FOR INDIVIDUAL LIFE INSURANCE
================================================================================
Investigative consumer report. I authorize The Guardian Life Insurance Company
of America (Guardian) or The Guardian Insurance & Annuity Company, Inc. (GIAC)
to obtain or have prepared an investigative consumer report as described in the
notice given to me.
Medical Records and other information. I authorize any physician, medical or
mental health professional practitioner, hospital, clinic, other health
facility, consumer reporting agency, the Social Security Administration, the
Medical Information Bureau, insurance or re-insurance company, or employer or
other organization, institution or person that has any records or knowledge of
me or my health to release any and all medical and non-medical information in
its possession about me or my minor children to Guardian or GIAC, or its legal
representatives. Medical information means all information in the possession of
or derived from providers of health care regarding the medical history, mental
or physical condition, or treatment of me or my minor children. Medical
information shall include but is not limited to health information that pertains
specifically to a history or diagnosis or treatment of any of the following:
mental health, alcohol and substance abuse, Human Immunodeficiency Virus and/or
Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), sexually
transmitted disease, abortion or fertility. I agree that this authorization
shall be valid for two and one half years from the date shown below and that a
copy of the authorization shall be as valid as the original.
I know that I may request and receive a copy of this authorization and that I
may revoke it in writing except to the extent that Guardian has then relied on
my consent.
I understand Guardian or GIAC will use the information obtained by this
authorization to determine eligibility for insurance or eligibility for benefits
under an existing policy. Guardian or GIAC will not release any information
obtained to any person or organization except to re-insurance companies, the
Medical Information Bureau, or other persons or organizations performing
business or legal services in connection with an application, claim, or as may
be lawfully permitted or required, or as I may further authorize.
I acknowledge receipt of Guardian's or GIAC's notice regarding its Insurance
Information Practices, the Fair Credit Reporting Act, the Medical Information
Bureau and Medical Records.
Dated at: _____________________ this __________ day of ___________, ___________.
City and State (month) (year)
________________________________
Signature of Proposed Insured
================================================================================
L-AP-AUTH-2000 L-AP-2000
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L-AP-2000 L-AP-2000
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PART I: Section E REPRESENTATIONS OF THE PROPOSED INSURED AND OWNER
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This application is to be attached to and made part of the policy.
In this Representations section, "the Company" is the insurer checked on Part I,
page 1.
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|_| No money has been paid as a deposit for life insurance with this
application.
|_| A deposit of $____________________ has been paid for:
proposed life insurance in the amount of $_____________________ in exchange
for the Conditional Receipt providing conditional coverage for this amount
of insurance only.
If a single policy is subsequently issued for an amount greater than
$1,000,000, including the above Conditional Receipt coverage, the date
appearing on the Conditional Receipt will not be the Policy Date. The
Policy Date appears on the face of the policy and governs cash values,
premium due dates, and dividends.
I (We) have read the above questions and answers and agree that they are
complete and true. I (We) agree a) that this Application:
Universal and/or Traditional Life: Part I-Sections A, B, D, E; and Part II;
Variable Life: Part I - Sections A, B, C, D, E; and Part II;
and any supplements to the application, if required, will become part of and
attached to any Policy issued; and b) that no information acquired by any
Representative of the Company shall bind the Company unless it shall have been
set out in writing in this Application; and c) that only the President, a Vice
President, or a Secretary of the Company has the authority to bind the Company
by any promise or statement or to waive or modify any of the Company's
requirements. Any misrepresentation or omission, if found to be material, may
adversely affect acceptance of the risk, claims payment or may lead to
rescission of any policy that is issued based on this application. I (We)
further agree that no insurance shall take effect (except as provided in the
Conditional Receipt if an advance payment has been made and acknowledged above
and such Receipt issued) unless and until the Policy has been delivered to and
accepted by me (us) and the first premium paid during the lifetime and prior to
any change in the health of the Proposed Insured as described in this
Application.
Changes or corrections made by the Company and noted in the "Amendments or
Corrections" section are ratified by the Owner upon acceptance of a Policy
containing this Application with the noted changes or corrections. In those
states where written consent is required by statute or State Insurance
Department regulation for amendments as to plan, amount, classification, age at
issue, or benefits, such changes will be made only with the Owner's written
consent.
---------------------------------------------------
THIS SPACE IS FOR FRAUD LANGUAGE TO BE ADDED BY IMC
---------------------------------------------------
================================================================================
Dated at: __________________________________ on _______________
City and State mm/dd/yyyy
________________________________________________ ______________________________
Signature of Proposed Insured Signature of Applicant/Owner
(Parent or Legal Guardian if Insured is a Minor) if Other than Proposed Insured
______________________________
Signature of Additional Owner
================================================================================
|_| Check here if this application is taken by mail. If application is taken
by mail, the signature of the agent does not attest to the signature of
the Proposed Insured or Owner if Other than the Proposed Insured.
|_| Check here if application is taken in person. I certify that I have taken
this application in the presence of the Proposed Insured and Owner if
Other than the Proposed Insured, and that I have truly and accurately
recorded on this application the information supplied by the Proposed
Insured and Owner if Other than the Proposed Insured.
________________________________________________ ______________________________
Signature of Licensed Agent License Number(s)
________________________________________________ ______________________________
Agent's Name State(s) where licensed
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L-AP-2000 L-AP-2000
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L-AP-2000 L-AP-2000
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[LOGO] |_| The Guardian Life Insurance Company of America (Guardian)
GUARDIAN(SM) Home Office: 7 Hanover Square
New York, NY 10004-2616
|_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office: 7 Hanover Square
New York, NY 10004-2616
This application is to be attached to and made part of the policy.
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PART II: 1st of 2 pages Health and Personal History of the Proposed Insured
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<TABLE>
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<S> <C>
1a) Name and address of your personal physician (If none, so state) Height _________ ft. _________in.
__________________________________________________________________ Weight _________ lbs.
__________________________________________________________________
__________________________________________________________________ Weight change past year:
b) Date and reason last consulted? __________________________________ |_| Gain |_| Loss _______lbs.
__________________________________________________________________ Reason for change: ______________________________________
c) What treatment or medication was given or recommended? _________________________________________________________
__________________________________________________________________ _________________________________________________________
====================================================================================================================================
<CAPTION>
If you answer yes to questions 2-14, provide details in item # 15 on the next page.
<S> <C> <C>
2) Have you ever had or been treated for cancer or tumor? |_| Yes |_| No
3) In the last ten years, have you had, been treated for or received counseling for:
a. high blood pressure, chest pain or disorder of the heart or circulatory system? |_| Yes |_| No
b. diabetes or disorder of the glands, bone, blood or skin? |_| Yes |_| No
c. complications of pregnancy, infertility, or any disorder of the breasts, reproductive or genital organs,
prostate, kidneys, or urinary systems? |_| Yes |_| No
d. hernia, hepatitis or disorder of the liver, gall bladder, stomach, pancreas, spleen, intestines or rectum? |_| Yes |_| No
e. arthritis, rheumatism, or disorder of the joints, limbs or muscles? |_| Yes |_| No
f. disorder or condition of the back, neck or spine? |_| Yes |_| No
g. allergy, asthma, sinusitis, emphysema, disorder of the lungs or respiratory system, or sleep apnea? |_| Yes |_| No
h. epilepsy, stroke, dizziness, headache, or disorder of the brain, or spinal cord? |_| Yes |_| No
i. disorder of the eyes, ears, nose or throat? |_| Yes |_| No
j. anxiety, depression, nervousness, stress, mental or nervous disorder, or other emotional disorder? |_| Yes |_| No
k. Chronic Fatigue Syndrome, Fibromyalgia, Epstein Barr virus or Lyme Disease? |_| Yes |_| No
4) Do you have any loss of hearing or sight, an amputation of any kind, or any physical deformity, impairment
or handicap? |_| Yes |_| No
5) Within the past 10 years, have you been diagnosed by or received treatment from a member of the medical
profession for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or any
deficiency of the immune system such as Human Immunodeficiency Virus? |_| Yes |_| No
6) a. Are you currently taking prescribed medication? |_| Yes |_| No
b. Are you currently taking non-prescription medication? |_| Yes |_| No
7) a. Have you ever used stimulants, hallucinogens, narcotics or any other controlled substance other than as
prescribed by a physician? |_| Yes |_| No
b. Have you ever had or been advised to have counseling or treatment for alcohol or drug use? |_| Yes |_| No
8) Are you now pregnant? If yes, expected delivery date:_____________________ |_| Yes |_| No
9) Within the past five years, have you had a sickness or injury for which you have made a benefits claim or
for which you will make a benefits claim? |_| Yes |_| No
10) Within the past five years, have you had a physical exam or check-up of any kind? |_| Yes |_| No
11) Within the past five years, have you been advised to have surgery or any diagnostic tests that were not
performed, except for HIV tests? |_| Yes |_| No
12) Within the past 12 months, have you had symptoms of any condition listed in Part II, except those
conditions listed in question 5, for which you have not sought medical attention or advice? |_| Yes |_| No
(Continued on other side)
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</TABLE>
L-AP-NONMED-2000 L-AP-2000
<PAGE>
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PART II: 2nd of 2 pages Health and Personal History of the Proposed Insured
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(Continued from other side)
13) Other than as previously stated on this application in the last five years,
have you received medical advice from physicians, medical or mental health
professionals, counselors or other practitioners, and have you been a
patient in a hospital clinic, sanatorium, or other medical facility?
|_| Yes |_| No
14) Do you have a family history of: diabetes, cancer, high blood pressure,
heart disease, mental illness or suicide? |_| Yes |_| No
-------------------------------------------------------------------
Age if Cause of Death Age at
Living Death
-------------------------------------------------------------------
FATHER
-------------------------------------------------------------------
MOTHER
-------------------------------------------------------------------
BROTHERS and SISTERS
----------------------------------------
No. Living __________
----------------------------------------
No. Dead __________
--------------------------------------------------------------------
================================================================================
15. DETAILS OF "YES" ANSWERS. IDENTIFY QUESTION & NUMBER. CIRCLE APPLICABLE
ITEMS:
Give diagnosis or symptoms, tests performed, dates, types and amounts of
medication, length of disability, degree of recovery, and names and
addresses of all physicians, medical or mental health professionals,
counselors, practitioners or hospitals. Additional paper may be attached if
necessary to explain details.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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================================================================================
I represent that all the statements and answers above are complete and true to
the best of my knowledge and belief.
Dated at: _____________________ on __________________
City and State mm/dd/yyyy
_______________________________ ______________________________________________
Signature of Proposed Insured Signature of Soliciting Agent/Dealer (Witness)
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L-AP-NONMED-2000 L-AP-2000
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[LOGO] |_| The Guardian Life Insurance Company of America (Guardian)
GUARDIAN(SM) Home Office: 7 Hanover Square
New York, NY 10004-2616
|_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office: 7 Hanover Square
New York, NY 10004-2616
<TABLE>
<CAPTION>
In this Avocations Supplement, "the Company" is the insurer checked above.
This application is to be attached to and made part of the policy.
____________________________________________________________________________________________________________________________________
AVOCATIONS SUPPLEMENT
____________________________________________________________________________________________________________________________________
Racing: Auto, Motorcycle, Motorboat, Snowmobile
<S> <C>
1. Indicate type of racing you engage in: |_| Midget |_| Stock |_| Boat
|_| Sportscar |_| Go-kart |_| Hot-rod |_| Cycle |_| Drag |_| Snowmobile |_| Other _____________________
2. Do you race for cash prizes? |_| Yes |_| No
3. Vehicle data: Make & Model ________________________ Displacement__________________________ Horsepower ________________________
4. Where do you race (indicate exact locations, i.e., track, drag strip, etc.)? _________________________________________________
_______________________________________________________________________________________________________________________________
5. How far do you travel to race? ________________________
6. Maximum speed attained: ______________ mph Average speed attained: _______________ mph
7. Type of timing: |_| Vehicle vs. Vehicle |_| Vehicle vs. Clock
8. Indicate clubs and organizations you belong to: ______________________________________________________________________________
_______________________________________________________ _____________________________________________________________
9. Have you ever had an accident? |_| Yes |_| No If yes, give details __________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
10. FREQUENCY
TYPE OF ACTIVITY ____________________________________________________
Last 12 Months 1-2 Years Ago Est. Next 12 Mos.
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
====================================================================================================================================
Underwater Diving:
1. Type of diving you engage in: |_| Skin |_| Scuba |_| Other _________________________________________________________________
2. Certification(s): ____________________________________________________________________________________________________________
3. Purpose of diving: |_| Recreation |_| Rescue |_| Salvage |_| Other ________________________________________________________
4. Locations where you dive: |_| Ocean |_| Lake |_| River |_| Pool |_| Cave |_|Quarry |_| Other ___________________________
5. Have you ever had formal diving training? |_| Yes |_| No If yes, give details:_______________________________________________
6. Do you use the buddy system? |_| Yes |_| No
_______________________________________________________________________________________________________________________________
7. FREQUENCY
DEPTH AVG DIVE TIME (MIN) ____________________________________________________
Last 12 Months 1-2 Years Ago Est. Next 12 Mos.
_______________________________________________________________________________________________________________________________
0-75 ft
_______________________________________________________________________________________________________________________________
75-100 ft
_______________________________________________________________________________________________________________________________
100-150 ft
_______________________________________________________________________________________________________________________________
Over 150 ft
_______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Remarks - (include details of mountain climbing or rock climbing, parachuting or skydiving, martial arts, and other
avocations):
____________________________________________________________________________________________________________________________________
I declare that my statements and answers are correctly recorded, complete and true to the best of my knowledge and belief. I am
aware that these statements and answers will become part of my application to Guardian or to GIAC, whichever applies.
______________________ _________________________________________________ _________________________________________
Date Signature of Soliciting Agent/Dealer- Witness Signature of Proposed Insured
____________________________________________________________________________________________________________________________________
</TABLE>
L-AP-AVOC-2000 L-AP-2000
<PAGE>
|_| The Guardian Life Insurance Company of America (Guardian)
[LOGO] Home Office: 7 Hanover Square
GUARDIAN(SM) New York, NY 10004-2616
|_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office: 7 Hanover Square
New York, NY 10004-2616
<TABLE>
<CAPTION>
In this Aviation Supplement, "the Company" is the insurer checked above.
This application is to be attached to and made part of the policy.
====================================================================================================================================
AVIATION SUPPLEMENT
====================================================================================================================================
Name: ______________________________________________________________ Date of Birth: ______________________________________________
====================================================================================================================================
FLIGHT HOURS
__________________________________________________________________________________
TYPE OF FLIGHT Date Of Last
Flight Total Hrs Each Class Past 12 Months 1-2 Years Ago Est. Next 12 Mos.
<S> <C> <C> <C> <C>
====================================================================================================================================
_______________________________
PILOT
_______________________________
____________________________________________________________________________________________________________________________________
Private-enter solo flight hours
____________________________________________________________________________________________________________________________________
Student
____________________________________________________________________________________________________________________________________
Employer-Owned
____________________________________________________________________________________________________________________________________
Non-Scheduled Commercial*
____________________________________________________________________________________________________________________________________
Scheduled Passenger Airlines
____________________________________________________________________________________________________________________________________
Military
____________________________________________________________________________________________________________________________________
Hang Gliding
____________________________________________________________________________________________________________________________________
Ballooning
____________________________________________________________________________________________________________________________________
Other*
____________________________________________________________________________________________________________________________________
_______________________________
NON-PILOT
_______________________________
____________________________________________________________________________________________________________________________________
Crew Member*
____________________________________________________________________________________________________________________________________
Non-Fare Paying Passenger
====================================================================================================================================
Note: ** If reply is "Yes" to these questions, please provide details in Remarks.
1. Enter the date and class of your latest pilot's license or certificate: Date ____/____ /______ Class__________________________
2.** Was your license granted subject to physical waiver? |_| Yes |_| No
3. Is your Medical Certificate now in effect? |_| Yes |_| No If yes, enter date of last renewal: ____/____ /______
If no, do you intend to renew? |_| Yes |_| No
4.** Do you have an Instrument Rating (IFR)? |_| Yes |_| No
5.** Have you ever had an accident or have you ever been grounded, fined or reprimanded for violation of air regulations, or have
you ever been prohibited from flying on any occasion for any reason? |_| Yes |_| No
6.** If you do not currently engage in any type of pilot activity, do you intend, in the future, to take pilot instruction, apply
for a student permit, pilot's license or medical certificate? |_| Yes |_| No
7.** Are you a member of, or do you plan to join, any military or naval air force, service or reserve? |_| Yes |_| No
8. If you indicated any pilot or non-pilot activity in any category above identified with an asterisk (*), please explain in what
capacity such flights were or will be made: __________________________________________________________________________________
9. If you indicated Hang Gliding activity above: Please enter:
a) Usual height flown ________________________________________ Greatest height flown: _________________________________
Greatest distance flown ___________________________________ Greatest duration flown ________________________________
b) List hang gliding club(s) you belong to ________________________________________________________________________________
c) **Have you made or do you plan to make any experimental flights or record attempts? |_| Yes |_| No
10. If you indicated Ballooning activity above:
a) Please check type of ballooning you engage in: |_| Gas |_| Hot Air |_| Free Flight |_| Tethered flight only
b)** If you engage in free flight ballooning, do you fly over oceans, large lakes or mountains? |_| Yes |_| No
c)** Have you ever made or do you plan to make any experimental flights or record attempts? |_| Yes |_| No
11. Coverage desired (Check One) : |_| Aviation Restriction Rider |_| Aviation Coverage Note: If selected, Aviation
Coverage may require an extra premium. Aviation Coverage is not available on Accidental Death Benefit.
____________________________________________________________________________________________________________________________________
Remarks:
____________________________________________________________________________________________________________________________________
I declare that my statements and answers are correctly recorded, complete and true to the best of my knowledge and belief. I am
aware that these statements and answers will become part of my application to Guardian or to GIAC, whichever applies.
______________________ _________________________________________________ _________________________________________
Date Signature of Soliciting Agent/Dealer- Witness Signature of Proposed Insured
____________________________________________________________________________________________________________________________________
</TABLE>
L-AP-AVIA-2000 L-AP-2000
<PAGE>
CONDITIONAL RECEIPT FOR INDIVIDUAL LIFE INSURANCE
|_| The Guardian Life Insurance Company of America (Guardian)
[LOGO] Home Office: 7 Hanover Square, New York, NY 10004-2616
GUARDIAN(SM) |_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office:7 Hanover Square, New York, NY 10004-2616
In this receipt, "the Company" is the insurer checked above.
This Conditional Receipt is to be used with the application for life
insurance on the life of ________________________________
(print)
(Proposed Insured) for the application dated ____________________________.
Proposed Insured's Date of Birth: ____________________________.
CONDITIONAL RECEIPT TO BE GIVEN FOR ADVANCE PAYMENT ON FIRST PREMIUM. ALL
PREMIUM CHECKS MUST BE MADE PAYABLE EITHER TO THE GUARDIAN LIFE INSURANCE
COMPANY OF AMERICA OR TO THE GUARDIAN INSURANCE & ANNUITY COMPANY, INC.,
WHICHEVER IS CHECKED ABOVE. DO NOT MAKE CHECK PAYABLE TO THE AGENT/DEALER OR
LEAVE PAYEE BLANK.
1) Has the Proposed Insured, within the last 12 months, been treated for or
had any known heart attack, stroke or cancer? |_|Yes |_|No
2) Has the Proposed Insured, within the last 12 months, had an
electrocardiogram because of chest pain or any other physical problem?
|_|Yes |_|No
3) Has the Proposed Insured, within the last 12 months, taken medication for
elevated blood pressure? |_|Yes |_|No
4) Within the past 10 years, has the Proposed Insured been diagnosed by or
received treatment from a member of the medical profession for Acquired
Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or any
deficiency of the immune system, such as Human Immunodeficiency Virus
(HIV)? |_|Yes |_|No
DO NOT DETACH AND DELIVER TO APPLICANT UNLESS PAYMENT IS MADE CONCURRENTLY WITH
SIGNING OF APPLICATION AND THE ANSWERS TO QUESTIONS 1, 2, 3 AND 4 LISTED ABOVE
IN THIS CONDITIONAL RECEIPT ARE NO. IF ANY SUCH QUESTIONS (1, 2, 3 AND 4) IS
ANSWERED YES, THIS CONDITIONAL RECEIPT SHALL BE VOID.
Received from _____________________________ $_______________for life insurance
in the amount of $_______________. (NOTE THIS CONDITIONAL RECEIPT APPLIES ONLY
TO THIS AMOUNT OF LIFE INSURANCE WHICH IN NO EVENT CAN EXCEED $1,000,000). This
payment must be at least: (a) one sixth of the annual premium for the life
insurance amount stated above; or (b) one Guard-O-Matic premium for such amount.
(Note: depending on the contractual provisions, this payment may not be
sufficient to put the policy in force).
Conditions for Insurance:
(1) Insurance shall be effective on the date of Part I or the last dated Part
II, whichever is later. Such insurance shall be in force only for such
proportional part of a year as the above payment bears to the full annual
premium.
(2) The Proposed Insured must be insurable as a standard risk for the amount
(see "(3)" below), plan and benefits applied for, without modification.
Evidence of insurability required by the Company must be received at its
Home Office within 60 days of the date of this receipt.
If these conditions are not met, the Company shall have no liability under
this receipt except to return the payment made.
If the Proposed Insured should die within 60 days of the date of this
receipt and:
- after the required Parts I and II have been received at the Home
Office; and
- after the last of any required medical examinations have been
completed; then the Company shall not deny liability because of
failure to submit any additional evidence of insurability it may
have required. Instead, it shall determine insurability as of the
effective date of insurance as indicated in Conditions of Insurance
item (1) above.
(3) The total amount of life insurance available under this receipt shall be
the amount shown in Part I-Section A, item 5 (a) for Traditional Life
insurance (b) for Non-Traditional Life insurance of the application; any
coverage requested under a Paid-Up Additions Rider shall be excluded from
this amount unless the paid-up additions purchase payment is paid in full
on the date the application is signed. This amount, together with any
insurance applied for or pending issue with the Company, including
accidental death benefits, shall not exceed $1,000,000.
(4) No person, except the President, a Vice President or a Secretary of the
Company has authority to alter or modify the printed provisions of this
receipt
(5) If any check or draft given in exchange for this receipt is dishonored
when first presented for payment, this receipt shall be null and void.
Dated at ________________ on _____________, ______ ___________________________
City and State month day year Signature of Agent/ Dealer
________________________________________________________________________________
I have read the terms of this receipt and have had them explained to me by the
agent/dealer. I understand that the insurance applied for shall not be effective
unless and until the conditions of this receipt have been complied with exactly.
___________________________________ _________________________________________
Signature of Proposed Insured Signature of Owner, if other than
Proposed Insured
L-AP-CR-2000 L-AP-2000
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L-AP-2000 L-AP-2000
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|_| The Guardian Life Insurance Company of America (Guardian)
[LOGO] Home Office: 7 Hanover Square, New York, NY 10004-2616
GUARDIAN(SM) |_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office: 7 Hanover Square, New York, NY 10004-2616
<TABLE>
<CAPTION>
LIFE INSURANCE CHANGE REQUEST - 1st of 3 pages
____________________________________________________________________________________________________________________________________
This application is to be attached to and made part of the policy.
NOTE: Complete item # 5 of this Life Insurance Change Request Form for all cases. Read instructions in
each box for any additionally requested information from the Life Application.
____________________________________________________________________________________________________________________________________
<S> <C>
Insured: __________________________________ Agency Name/Code: ___________________________
Agent's Name and Code: ______________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
1. Conversions & Exchanges:
Instructions: Complete Life Application Part I, Section A (#s 1-10). In addition, if the plan change involves
Variable Life Insurance, also complete Life Application Part I, Section C. [If the Conversion or Exchange
involves the addition of a benefit or rider and/or an increase in coverage or risk, complete Life Application
Part I Section A, Section B, Section C and Part II.] Include details in REMARKS below.
Is the Insured currently totally disabled as defined in the Waiver of Premium Rider? |_| Yes |_| No (If yes, give details below)
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Policy(ies) Numbered: For Partial Conversions, indicate amount remaining in force:
_____________________ |_| Full |_| Partial _______________________________________
_____________________ |_| Full |_| Partial _______________________________________
_____________________ |_| Full |_| Partial _______________________________________
|_| Effective date of Conversion or Exchange:____________________________
|_| Conversion of Spouse's Insurance from Policy Number:____________________________
|_| Conversion of Children's Insurance from Policy Number:___________________________
REMARKS: (Include any additional changes to the amount remaining in force and explain)
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
2. Guaranteed Purchase Option:
Instructions: Complete Life Application Part I, Section A (#'s 1-10), Section B (# 9). In addition, if the plan change
involves Variable Life Insurance, also complete Life Application Part I, Section C. Include details in
REMARKS below.
|_| This is an election under Guaranteed Insurability Option (GIO):
Policy(ies) Numbered: Type of Option Date: Amount Exercised
___________________________ |_| Regular |_| Alternate $ _______________________
___________________________ |_| Regular |_| Alternate $ _______________________
___________________________ |_| Regular |_| Alternate $ _______________________
|_| For Alternate Option Date, Reason: |_| marriage |_| birth of child(ren) |_| adoption of child(ren)
Date of applicable event: __________________
REMARKS:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
(continued on next page)
</TABLE>
L-AP-CHG-2000 L-AP-2000
<PAGE>
LIFE INSURANCE CHANGE REQUEST FORM - 2nd of 3 pages
<TABLE>
<CAPTION>
(continued from previous page)
____________________________________________________________________________________________________________________________________
<S> <C>
3. Universal/Variable Universal Policy Face Increase Change Policy Number(s):_____________________________
(Note: Only applicable on policy anniversary for a minimum face increase amount of $10,000.00. Also, Term Rider may
not be increased.)
Instructions: Complete Life Application Part I, Section A, Section B (#s 1-9), Section D; and Part II. Include
details in REMARKS below.
Is the Insured currently totally disabled as defined in the Waiver of Monthly Deduction Rider or the Disability Benefit
Waiver Rider? ( If yes, give details below) |_| Yes |_| No
____________________________________________________________________________________________________________________________________
Increase Request (New Insurance Segment)
Amount of Increase for Base Coverage Requested: _______________________________
Amount of Increase for Disability Waiver Requested: _______________________________
This Face Amount Increase request should result in the following:
Total Life Coverage (do not include term rider coverage): _______________________________
Total Disability Waiver Rider amount: ________________ Total GCR/Other Rider amount _______________________
New Total Planned Premium: ___________________________ Mode and Modal Planned Premium _____________________
REMARKS:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
4. OTHER POLICY CHANGES: Policy Number(s): _________________________
a. Policy changes which require additional evidence of insurability:
Instructions: Complete Life Application Part I, Section A, Section B (#s 1-9), Section D; and Part II. Indicate
proposed change below and include details in REMARKS. In addition, if the plan change involves
Variable Life Insurance, also complete Life Application Part I, Section C.
|_| Plan changes (those requiring evidence) to: __________________________________
|_| Redate (those requiring evidence) to:_________________________________
|_| Add rider / benefit __________________________________
|_| Rating improvement request__________________________________
|_| Exercise Simplified Insurability Option __________________________________
|_| Increase Coverage to:_________________________________
|_| Death Benefit Option Change from Death Benefit Option ___ to Death Benefit Option ___ (those requiring evidence)
|_| Other (explain in Remarks)
REMARKS:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
(continued on next page)
____________________________________________________________________________________________________________________________________
</TABLE>
L-AP-CHG-2000 L-AP-2000
<PAGE>
LIFE INSURANCE CHANGE REQUEST FORM - 3rd of 3 pages
<TABLE>
<CAPTION>
____________________________________________________________________________________________________________________________________
(continued from previous page - item #4, Other Policy Changes)
<S> <C>
b. Policy changes which generally do not require evidence of insurability:
Policy Number(s): _________________________________
Instructions: Indicate requested change below and include details in REMARKS.
|_| Plan changes (those not requiring evidence) to:_______________________________
|_| Redate (those not requiring evidence) to:_____________________________
|_| Cancel rider / benefit __________________________________
|_| Reduce Coverage to:_______________________________
|_| Death Benefit Option Change - from Death Benefit Option: ___ to Death Benefit Option: ___ (those not requiring
Evidence)
|_| Other (explain in Remarks)
REMARKS: (Note: for reductions in face amount, include instruction on how release of cash value is to be handled.
If not specific, release of cash value will be used to Purchase Paid Up Additions.)
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
5. REPRESENTATIONS (Complete in all cases).
I (We) understand and agree that approval by the Company of the changes requested shall be based upon this Life Insurance
Change Request form and on the statements and representations made in the below referenced sections:
1. the Life Application submitted with this form, Part I Sections A, B, C and D, and
2. Part II, "Health And Personal History of the Proposed Insured," relating to evidence of insurability, if any,
submitted in connection with this change, a copy of which shall be attached to the policy. Any misrepresentation or omission,
if found to be material, may adversely affect acceptance of the risk, claims payment or may lead to rescission of any policy
change that is issued based on this application.
I (We) further agree that: a) only the President, a Vice President, or a Secretary of the Company has the authority to bind the
Company by any promise or statement or to waive or modify any of the Company's requirements; and b) no information
acquired by any Representative of the Company shall bind the Company unless it shall have been set out in writing in this
Application.
Changes or corrections made by the Company and noted in the "Amendments or Corrections" section in Part I are ratified by
the undersigned upon acceptance of this policy change. In those states where written consent is required by statute or State
Insurance Department regulation for amendments as to plan, amount, classification, age at issue, or benefits, such changes will
be made only with the Owner's written consent.
ANY STATEMENT OR REPRESENTATION CONTAINED IN PART II, HEALTH AND PERSONAL HISTORY OF THE PROPOSED INSURED, RELATING TO EVIDENCE OF
INSURABILITY IS FULL,COMPLETE AND TRUE.
Dated at: ___________________________________ on ___________________ __________________________________________________________
City and State mm/dd/yyyy Signature of OWNER (Insured if no other owner)
______________________________________________________________ __________________________________________________________
(Signature of OFFICER: if Corporation or Assignee) (Signature of OFFICER: if Corporation or Assignee)
____________________________________________________________________________________________________________________________________
Signature of Insured required on this line if Owner other than Insured and if Life Application Section B, Section D, and
Part II, "Health And Personal History of the Proposed Insured" completed.
____________________________________________________________________________________________________________________________________
</TABLE>
L-AP-CHG-2000 L-AP-2000
<PAGE>
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<PAGE>
ANY PAGES THAT FOLLOW ARE NOT PART OF THE APPLICATION
BUT MAY BE REQUIRED FOR SUBMISSION OF AN APPLICATION
L-AP-2000 L-AP-2000
<PAGE>
THIS PAGE INTENTIONALLY LEFT BLANK
L-AP-2000 L-AP-2000
<PAGE>
|_| The Guardian Life Insurance Company of America (Guardian)
|_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
<TABLE>
<S> <C>
------------------------------
[LOGO] AGENCY USE ONLY
GUARDIAN(TM) ---------------
New Application |_|
REQUEST FOR GUARD-O-MATIC ARRANGEMENT (page 1 of 2) Bank Change |_|
In this Request for G-O-M Arrangement form, the Agency Code: __________
"Company" is the insurer checked above
See next page for VUL instructions. ------------------------------
</TABLE>
IMPORTANT: A voided blank check or photocopy is required for checking accounts
or a deposit slip for a savings account. See next page for general
Guard-O-Matic information.
Guardian and/or GIAC is requested and authorized to debit your financial
institution or to initiate electronic funds transfer on or about the 15th of
each month to pay premiums due and/or on the 1st business day of each month to
pay the policy loan on the policy(ies) identified below.
I understand that:
1. Completion of this form shall not constitute a premium payment and/or loan
payment. Authorization for premium payments is not effective until the
initial premium(s) has been received and paid at the home office.
2. The Guard-O-Matic Premium Arrangement or Loan Payment Arrangement may be
terminated by the Policyowner or by the Company upon written notice. If the
Bank Depositor is other than the policyowner, the Company will terminate
the arrangement upon written request of such Bank Depositor.
3. If the Loan Payment Arrangement is cancelled, any outstanding loans will
remain unpaid.
4. Any withdrawal returned due to insufficient funds may be deposited for
collection a second time.
<TABLE>
<S> <C> <C>
=============================================================================================================
______________________________ and (1) ______________________________ (2) ______________________________
Signature of Policyowner Signature of Bank Depositor
(if other than policyowner)
Type of account: Checking |_| Savings |_| Begin deductions effective ___________ (Month) _______(Year)
Financial Institution: ________________________________ Street Address: _______________________________
City: _____________________ State: ______ Zip: __________ Transit/ABA Number: ___________________________
Account Number: ____________________________ Name of Bank Depositor: _____________________________________
Guard-O-Matic Premium Arrangement Guard-O-Matic Loan Payment Arrangement
(Deductions to occur on or about the 15th of each (Deductions to occur on the 1st business day of each
month). month.)
List Policy Number(s) (available for Individual Life Products only)
List Policy Number(s) Amount to be Deducted
---------------------- ---------------------- ---------------------- -----------------------
---------------------- ---------------------- ---------------------- -----------------------
---------------------- ---------------------- ---------------------- -----------------------
==============================================================================================================
-------------------------------------------------------------
For Home Office Use Only, Control No.:
-------------------------------------------------------------
</TABLE>
Authorization to Honor Checks or Account Debits Drawn by:
-----------------------------------------------------------------------------
The Guardian Life Insurance Company of America (Guardian) and/or
The Guardian Insurance & Annuity Company, Inc.(GIAC)
<TABLE>
<S> <C>
Name of Bank Depositor _______________________________ Account Number _________________________________
Financial Institution _______________________________ Bank Address _______________________________________
As a convenience to me, I authorize you to pay and charge to my account checks, electronic funds transfer debits or other account
debits made upon my account by and payable to the order of Guardian/GIAC indicated above. I agree that your treatment of each
check or debit, and your rights with respect to it, will be the same as if it were signed or initialed personally by me. I further
agree that if any check or debit is dishonored for any reason you will not be under any liability even though dishonor results in
the forfeiture of insurance.
I further agree that this authorization is to remain in effect until you receive written notice from me of its revocation unless
you end it earlier.
------------- ---------------------------------------- ------------------------------------------
Date Signature of Depositor Additional Signature (if Joint Account)
</TABLE>
<PAGE>
(page 2 of 2)
--------------------------------------------------------------------------------
Complete if applying for Variable Universal Life Insurance:
In order to maintain your policy's No Lapse Guarantee (NLG) feature and
protect your policy from lapse, GIAC requires that the Guard-O-Matic drafts be
equal to at least 1/12 of the minimum annual premium during the first three
years. However, if your initial premium is large enough, you may be able to
request lower drafts during this period. To request an amount which is less
than 1/12 of the minimum annual premium, your initial payment plus the
Guard-O-Matic drafts until the end of the policy year must be equal to at
least the minimum annual premium.
On each of your first two policy anniversaries, GIAC will determine if the
draft amount will continue to meet the NLG minimum premium requirement for the
next policy year. If you have elected the Guaranteed Coverage Rider (GCR),
GIAC will also determine if the annual GCR minimum premium requirement will be
met. If either the NLG or GCR requirement will not be met, GIAC will
automatically increase the draft amount to the greater of 1/12 of the target
premium and 1/12 of the GCR minimum premium.
GIAC will send you a notice at the time of the last reduced draft informing
you of the increased premium amount. This increased amount will be deducted
from your checking account beginning in the first month following your policy
anniversary.
Please check the box below if you wish to request this option:
--------------------------------------------------------------
|_| Please deduct $_______________ monthly from my account. I understand that
this amount may be increased to the greater of 1/12 of the minimum annual
premium and 1/12 of the GCR minimum premium.
If you have any questions about your policy or about the amounts to be drafted
to pay premiums, please contact your Guardian agent.
================================================================================
GUARD-O-MATIC General Information
You have elected to pay your insurance premiums and/or your policy loan by
monthly deductions payable through your financial institution. To enjoy the
benefits of this convenient method of payment, we suggest you review the
following:
o Each month, deduct the amount(s) from your account balance. You may wish
to attach a reminder to your account until this practice becomes
automatic. The monthly deduction to your account for any policy premiums
will be made on or about the 15th day of each month. The monthly deduction
to your account for any policy loan payments will be made on the 1st
business day of each month.
o A canceled check or other notification of a charge to the account will be
provided by your financial institution with its periodic statement.
Compare your records when the statement is received.
o If your financial institution deducts the monthly amounts from your
account via the Electronic Fund Transfer System, you will notice that your
monthly statement lists the debit to your account and identifies it as
"Guardian Insur Prem" in lieu of sending you a canceled check for policy
premiums. For loan payments, your monthly statement lists the debit to
your account and identifies it as "Guardian Loan Payt".
o Please provide us with advance notification of any change in your banking
arrangements. If advance notification cannot be provided, sufficient funds
should be left in the old account to honor charges until our records are
changed.
o Please inform us of any change in name or address.
================================================================================
INDEMNIFICATION AGREEMENT
TO: The Bank named on the previous page.
In consideration of your compliance with the request and authorization of the
depositor named above,
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA AND THE GUARDIAN INSURANCE &
ANNUITY COMPANY, INC. (COLLECTIVELY, "GUARDIAN") AGREE THAT:
1. They will indemnify and hold you harmless from any liability, including
costs, legal expenses and attorney fees, to any person having an account
with you or to any beneficiary or other claimant under a policy covered by
the Guard-O-Matic Arrangement arising out of the payment by you of any
check or debit drawn by Guardian, its own order on the account of such
depositor, or arising out of the dishonor by you, whether with or without
cause, of any such check or debit drawn by Guardian, provided there are
sufficient funds in such account to pay the same upon presentation,
whether or not such claim or liability asserted against you be based upon
the forfeiture, or alleged forfeiture, of a policy the premium on which is
sought to be collected by Guardian by any such check or debit.
2. They will refund to you any amount erroneously paid by you to Guardian on
any such check or debit if claim for the amount of such erroneous payment
is made by you within fifteen months from the date of the check or debit
on which such erroneous payment was made.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA THE
GUARDIAN INSURANCE & ANNUITY COMPANY, INC.
Authorized in a resolution approved by the Board of Directors of The Guardian
Life Insurance Company of America on April 27, 1960, and by the Board of
Directors of The Guardian Insurance & Annuity Company, Inc. on November 17,
1988.
--------------------------------------------------------------------------------
R223 (REV #######)
<PAGE>
[LOGO] The Park Avenue Portfolio Request For
GUARDIAN(TM) Guard-O-Matic Premium Payments/Loan Payments
(page 1 of 2)
Agency Code___________________
o Use this form to authorize the automatic redemption of Park Avenue
Portfolio shares to pay the premium/loan payments on Guardian and/or GIAC
insurance policies.
o The Park Avenue Portfolio fund account from which you elect to redeem
shares must have a beginning balance of at least $1,000. Additionally, The
Park Avenue Portfolio fund account from which you elect to redeem shares
may not be an Individual Retirement Account (IRA) with State Bank and
Trust Company as Custodian.
o The minimum amount that may be redeemed is $100 per month.
o Fund shares will be redeemed on or about the 15th day of each month to pay
premiums due and/or on the 1st business day of each month to pay the
policy loan.
o National Financial Data Services will mail account owners written
confirmation within three (3) business days of the execution of the
transaction.
o If you have questions about completing this form, please call your
Guardian Agent for assistance. See next page for VUL instructions.
Please Print Clearly in Ink.
<TABLE>
<S> <C>
_________________________________________________________________ __________________________________________________________
I. Park Avenue Portfolio Fund Account II. Guardian/GIAC Insurance Policies
_________________________________________________________________ __________________________________________________________
_________________________________________________________________ __________________________________________________________
Account Owner or Trustee [Name as it appears on account registration] Policyowner [Name as it appears on policy(ies)]
_________________________________________________________________ __________________________________________________________
Street Address Street Address
_________________________________________________________________ __________________________________________________________
City State Zip City State Zip
________________________ _________________________ _______________________ _______________________
Home Phone Business Phone Home Phone Business Phone
________________________________________________________ Policy No._____________________ |_| New |_| Existing
Account Number
Policy No._____________________ |_| New |_| Existing
________________________________________________________ Policy No._____________________ |_| New |_| Existing
Joint Registration, Minor or Trustee
Policy No._____________________ |_| New |_| Existing
_________________________________________________________________ __________________________________________________________
III. Guard-O-Matic Instructions HO Use Only/Control No.:
_________________________________________________________________ __________________________________________________________
</TABLE>
I elect Guard-O-Matic for: |_| Premium Payments (Deductions to occur on or about
the 15th of each month)
|_| Loan Payments (Deductions to occur on the 1st
business day of each month)
(available for Individual Life Products Only)
I authorize Guardian / GIAC to redeem shares each month equal to
$_________________ from the following Park Avenue Portfolio fund:
(Check one) |_| The Guardian Cash Management Fund Class A Shares [192]
|_| The Guardian Park Avenue Fund Class A Shares [185]
Begin redemptions effective _________________________(Month) ____________(Year).
I understand that:
1) the proceeds of these redemptions will be transmitted to The Guardian Life
Insurance Company of America (Guardian) or to The Guardian Insurance &
Annuity Company, Inc. (GIAC) to pay the premium/loan payment(s) on the
insurance policy(ies) listed above;
2) each such redemption will produce a gain or loss which is likely to be
taxable to me;
3) redemptions will reduce and may ultimately exhaust the value of the
designated fund account;
4) completion of this form shall not constitute a premium and/or loan
payment;
5) this authorization not effective until Guardian / GIAC receives payment of
the initial premium(s);
6) this arrangement may be terminated by the Policyowner/Shareowner or by
Guardian / GIAC upon written notice;
7) if this arrangement is terminated, premiums falling due thereafter shall
be payable directly to Guardian / GIAC quarterly at the quarterly premium
rate applicable to the policy (individual monthly payment mode is not
available) unless the Policyowner makes other arrangements;
8) if the Loan Payment Arrangement is cancelled, any outstanding loans will
remain unpaid;
9) and, if shares are insufficient to pay my premium and/or loan payment(s),
the redemption request may be submitted a second time.
_____________________________________ ______________________________________
Signature of Park Avenue Portfolio Print Name of Park Avenue Portfolio
Account Owner Account Owner
Please sign exactly as name appears on your Park Avenue Portfolio account
registration
Date (mo/day/year): ___________________ (continued on next page)
2 Copies Required: Home Office (original) o Client
PUB-2826 (####)
<PAGE>
The Park Avenue Portfolio - Request For Guard-O-Matic
Premium Payments/Loan Payments
(continued from previous page) (page 2 of 2)
o To use Guard-O-Matic for premium payments and/or loan payments, you must
own shares of Park Avenue Portfolio fund.
o To open a Park Avenue Portfolio fund account, complete and mail a Park
Avenue Portfolio Application [EB-010163 APP] as directed on that form.
o You must also complete and mail a New Account Agreement as directed on
that form, if one is not already on file.
o Only The Guardian Park Avenue Fund (Class A) and The Guardian Cash
Management Fund (Class A) may be used in conjunction with Guard-O-Matic.
================================================================================
For Variable Universal Life Insurance:
In order to maintain your policy's No Lapse Guarantee (NLG) feature and
protect your policy from lapse, GIAC requires that the Guard-O-Matic drafts
be equal to at least 1/12 of the minimum annual premium during the first
three years. However, if your initial premium is large enough, you may be
able to request lower drafts during this period. To request an amount which
is less than 1/12 of the minimum annual premium, your initial payment plus
the Guard-O-Matic drafts until the end of the policy year must be equal to
at least the minimum annual premium.
On each of your first two policy anniversaries, GIAC will determine if the
draft amount will continue to meet the NLG minimum premium requirement for
the next policy year. If you have elected the Guaranteed Coverage Rider
(GCR), GIAC will also determine if the annual GCR minimum premium
requirement will be met. If either the NLG or GCR requirement will not be
met, GIAC will automatically increase the draft amount to the greater of
1/12 of the target premium and 1/12 of the GCR minimum premium.
GIAC will send you a notice at the time of the last reduced draft informing
you of the increased premium amount. This increased amount will be deducted
from your checking account beginning in the first month following your
policy anniversary.
Please check the box below if you wish to request this option:
--------------------------------------------------------------
|_| Please deduct $_______________ monthly from my account. I understand
that this amount may be increased to the greater of 1/12 of the minimum
annual premium and 1/12 of the GCR minimum premium.
If you have any questions about your policy or about the amounts to be
drafted to pay premiums, please contact your Guardian agent.
--------------------------------------------------------------------------------
Instructions for Completing This Form:
o Client is to receive a Photocopy of the completed form.
o Mail the original copy of this form to:
Guardian
Attn.: Individual Markets Service & Administration,
P.O. Box 26100
Lehigh Valley, PA 18002-6100
o If using certified, registered or overnight mail, send to:
Guardian
Attn.: Individual Markets Service & Administration, 3-E
3900 Burgess Place
Bethlehem, PA 18017
o Phone: 1-800-441-6455
--------------------------------------------------------------------------------
For further information, please call your Guardian Agent.
2 Copies Required: Home Office (original) o Client
PUB-2826 (####)
<PAGE>
AGENT'S CERTIFICATION
--------------------------------------------------------------------------------
This Agent's Certification is to be used with the application for life
insurance on the life
<TABLE>
<S> <C>
of ________________________________(Proposed Insured) for the application dated ____________________________.
(print) Proposed Insured's Date of Birth: ____________________________.
1. How long have you known the Proposed Insured? ________ Years; Proposed Owner? ________ Years
2. a. If Proposed Insured is a minor, indicate total insurance on premium payor's life and relationship to Proposed Insured.
(Explain in Remarks if less than for Proposed Insured) __________________________________________________________________
b. If Proposed Insured is a minor, are all children in family insured for an amount at least equal to the amount applied for
on Proposed Insured? (If No, explain in Remarks.) |_| Yes |_| No
c. If Proposed Insured is not gainfully employed, indicate amount of insurance on premium payor's life and relationship to
Proposed Insured. _______________________________________________________________________________________________________
3. If beneficiary is estate, explain in Remarks why, and who will ultimately receive the proceeds of the policy?
4. Do you have knowledge or reason to believe that replacement of an existing life insurance policy or annuity may be
involved? |_| Yes |_| No
5. Complete if Medical Examination necessary. Medical Requirements being submitted:
|_| Chest X-ray |_| EKG |_| Stress EKG |_| Finger Stick |_| Full Blood |_| Saliva |_| Urine
|_| Paramedical Exam |_| Medical Exam |_| Other _______________________________________________________________
6. Custom Dating (optional)
If no other date request is indicated, our regular dating practices will apply.
|_| Back date to save age (Individual Life Insurance Only)
|_| Issue date of (mm/dd/yyyy) _____ / _____ / _________
7. Remarks (and additional instructions):
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
8. Commissions
Servicing Agent
Producer's Name Producer'sCode Check (Only 1) Percentage Manager / GACode
-------- ------------ ---- ----------- ---------- --------------
- % -
-------------------------------- -------- ------------ ---- ----------- ---------- --------------
-------- ------------ ---- ----------- ---------- --------------
- % -
-------------------------------- -------- ------------ ---- ----------- ---------- --------------
-------- ------------ ---- ----------- ---------- --------------
- % -
-------------------------------- -------- ------------ ---- ----------- ---------- --------------
-------- ------------ ---- ----------- ---------- --------------
- % -
-------------------------------- -------- ------------ ---- ----------- ---------- --------------
-------- ------------ ---- ----------- ---------- --------------
- % -
-------------------------------- -------- ------------ ---- ----------- ---------- --------------
-------- ------------ ---- ----------- ---------- --------------
- % -
-------------------------------- -------- ------------ ---- ----------- ---------- --------------
I certify that I have taken this application in the presence of the Proposed Insured (and Owner, if Other than the Proposed
Insured, for Variable Life) and that I have truly and accurately recorded on this application the information supplied by the
Proposed Insured. The answers to all questions on this application are full, complete and true to the best of my knowledge and
belief. I know nothing unfavorable about this risk which is not fully set forth in these papers. The writing agent or broker is
duly appointed and licensed in the state in which this application was signed.
Dated at: ______________________________________ this _________________ day of ______________________, ____________.
City and State (month) (year)
____________________________________________________ ____________________________________________________
Type or print Agent's/Dealer's name Signature of Soliciting Agent
____________________________________________________ ____________________________________________________
Signature of Approved Registered Principal Signature of General Agent
(For Variable Life Only)
</TABLE>
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<PAGE>
Market Survey Data - Complete in all individual life insurance cases. All
questions must be answered. Please circle one response for each question.
<TABLE>
------------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C>
1. Purpose of Insurance 6. Sales Presentation
A) Final Expenses I) Buy-Sell A) Financial Security F) Term Conversion
B) Mortgage J) Keyperson Analysis G) Other
C) Family Income K) Other B) Personal Insurance (Specify)______________
D) Education Analysis (Specify)____________ C) Wealth Accumulation H) LEAP
E) Spouse/Child Insurance L) Deferred Compensation D) BOSS I) Financial Need Analysis
F) Retirement M) Selective Incentive Plans E) Annual Benefit (FNA)
G) Estate Planning N) Executive Bonus Review J) Estate Planning
H) Wealth Accumulation K) Retirement/Distribution
Planning Analysis
---------------------------------------------------------------------- -------------------------------------------------------------
2. How will insurance be paid for? 7. Applicant Education Level
A) Personal Funds A) HS or less C) College Degree
B) Some College D) Advanced Degree
Business Funds (please specify)
B) Non-Qualified E) Corporate Owned -------------------------------------------------------------
Deferred Comp Life Insurance 8. Occupation
C) Split Dollar F) Group Term Carve
D) Executive Bonus (162) Out A) Professional/Executive H) Juvenile
B) Manager/Administrator I) Student
---------------------------------------------------------------------- C) Business Owner J) Homemaker
3. Owner D) Sales Representative K) Unemployed
A) Corporation J) Child(ren) E) Clerical L) Retired
B) Partnership K) Revocable Trust F) Crafts or Operative M) Other
C) Sole Proprietorship L) Irrevocable Trust G) Service Worker, (Specify)___________
D) Partner or Coshareholder M) Welfare Benefit Trust Laborer, or Military
E) Insured N) Limited Liability -------------------------------------------------------------
F) Trust Company or Partnership 9. Income of Insured
G) Spouse O) Co-Owner (Shareholder, A) Under $30,000 E) $75,000 - $99,999
H) Parent or Relative Partner, Member) B) $30,000 - $39,999 F) $100,000 -$249,999
I) Other P) Charity C) $40,000 - $49,999 G) $250,000 - $500,000
(Specify)___________ D) $50,000 - $74,999 H) Over $500,000
---------------------------------------------------------------------- -------------------------------------------------------------
4. Primary Beneficiary 10. Income of Household
A) Corporation F) Trust A) Under $30,000 E) $75,000 - $99,999
B) Partnership G) Spouse B) $30,000 - $39,999 F) $100,000 - $249,999
C) Sole Proprietorship H) Parent or Relative C) $40,000 - $49,999 G) $250,000 - $500,000
D) Partner or Coshareholder I) Other D) $50,000 - $74,999 H) $Over $500,000
E) Child (Specify) ______________
-------------------------------------------------------------
---------------------------------------------------------------------- 11. Estimated Net Worth
5. Source of Sale A) Under $100,000 D) $500,001 - $1,000,000
A) Repeat Sale - E) Orphan Policyowner B) $100,000 - $250,000 E) Over $1,000,000
Guardian Client F) Advertising Lead C) $250,001 - $500,000
B) Repeat Sale - G) Direct Mail
Other Client H) Qualified Plan Lead -------------------------------------------------------------
C) Referred Lead I) Cold Canvassing 12. Will new policy replace any existing life insurance
D) Seminar J) Personal Observation |_| Yes |_| No
---------------------------------------------------------------------- -------------------------------------------------------------
</TABLE>
L-AP-2000
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<PAGE>
|_| The Guardian Life Insurance Company of America (Guardian)
Home Office: 7 Hanover Square
New York, NY 10004-2616
|_| The Guardian Insurance & Annuity Company, Inc. (GIAC)
Executive Office: 7 Hanover Square
New York, NY 10004-2616
In this Sales Illustration Certification, "the Company" is the insurer checked
above.
--------------------------------------------------------------------------------
SALES ILLUSTRATION CERTIFICATION
--------------------------------------------------------------------------------
<TABLE>
<S> <C>
Application Date: __________________________ Application for amount of: ___________________________________________
Proposed Insured(s) _______________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Applicant/Owner ___________________________________________________________________________________________________________
Section I - For use when no illustration is provided or the policy applied for is other than illustrated.
INSURANCE PRODUCER'S STATEMENT: In connection with the sale of the life insurance policy applied for on the above-referenced
Application Number, I certify that:
|_| I did not provide an illustration to the Applicant
|_| I did provide an illustration to the Applicant. However, the policy applied for is other than as shown on the illustration
I provided. I will provide the applicant with an illustration, conforming to the policy as issued, no later than the time of
policy delivery.
___________________________________ X___________________________________ ___________________________________
Print Insurance Producer's Name Insurance Producer's Signature Date
APPLICANT'S STATEMENT: I acknowledge that I have not received a sales illustration that conforms to the life insurance policy
I have applied for on the above-referenced Application Number. I understand that a sales illustration conforming to the policy
as illustrated will be provided by the Company no later than at the time of policy delivery.
X__________________________________ X___________________________________ ___________________________________
Applicant's Signature Applicant's Signature Date
===========================================================================================================================
Section II - For use with a computer screen illustration ONLY
INSURANCE PRODUCER'S STATEMENT: I certify that I displayed a computer screen illustration for the above referenced Applicant that
complied with state requirements and for which no hard copy was furnished. The illustration was based on the following personal and
policy information:
Gender |_| Male |_| Female |_| Sex Neutral Age _____________
Policy Name __________________________________________________ Rider(s) __________________________________________________
Underwriting Class ___________________________________________ Initial Premium Amount $ ________________________________
Initial Death Benefit ________________________________________ Dividend Option ___________________________________________
Type of Policy _______________________________________________ Guaranteed Interest Rate ________________ 4%_______________
Number Years Illustrated _____________________________________ Number of Premiums Contractually Payable __________
on-Guaranteed Interest Rate _________________________________
If Premium Offset Illustrated, Assumed Number Premiums Paid in Cash _______________________________________________
X__________________________________ ___________________________________ ___________________________________
Print Insurance Producer's Name Insurance Producer's Signature Date
APPLICANT'S STATEMENT: I acknowledge that I viewed a computer screen illustration based on the information as stated above. No hard
copy of the illustration was furnished. I understand that an illustration conforming to the policy as issued will be prepared and
personally delivered by the agent on or before delivery of the policy.
X__________________________________ X__________________________________ ___________________________________
Applicant's Signature Applicant's Signature Date
</TABLE>
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