EXHIBIT 1(A)(10)
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APPLICATION NO. PAGE 1
APPLICATION (PART 1A)
To: [_] Massachusetts Mutual Life Insurance Company [_] MML Bay State Life Insurance Company
Home and Principal Administrative Office: Principal Administrative Office:
Springfield, Massachusetts 01111-0001 Springfield, Massachusetts 01111-0001
[_] C.M. Life Insurance Company
Principal Administrative Office:
Springfield, Massachusetts 01111-0001
The words "we," and "our" refer to the life insurance company specified above.
Underwriting Method: [_] Guaranteed Issue [_] Simplified Issue [_] Full Underwriting
Owner Data
1. Owner a. [_] Employer d. [_] As indicated on Part 1B
(Check one only) b. [_] Proposed Insured (Include Census) e. [_] Other (Give full name, address and Taxpayer ID No)
c. [_] Trust (Give name of Trust, Address and Trust Taxpayer ID No)
2. Owner Name(s):
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a. Name of Trustee(s) (if applicable)
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b. Date of Trust (if applicable)
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3. Owner Address:
Street & No. City State Zip
4. Taxpayer ID No.: 5. Nature of Business
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Program Sponsor Data (If different than owner)
6. Name(s):
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7. Program Sponsor Address:
Street & No. City State Zip
8. Primary Contact (include name and telephone number):
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9. Taxpayer ID No.: 10. Nature of Business
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Proposed Insured Data
11. Proposed Insured: as indicated on Part 1B.
12. Have all eligible participants been Actively at Work prior to their participation in the program for the Employer
or its affiliate(s)? "Actively at Work" means working full time at a rate of at least 30 hours per week with no
hospitalization, and no absence due to illness or accident of more than 3 days, during the preceding 3 months.
[_] Yes [_] No If "No," give detailed explanation in Remarks.
Life Insurance Data (Please check ( ) on the appropriate line if you desire the specified feature.)
13. Permanent Plan (select one):
[_] Flexible Premium Variable Adjustable Life Insurance ( ) Indicate Product
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[_] Flexible Premium Adjustable Life Insurance ( ) Indicate Product
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[_] Flexible Premium Whole Life Insurance with Table of Selected Face Amounts ( )
--------------------------------
Indicate Product
[_] Flexible Premium Variable Whole Life Insurance with Table of Selected Face Amounts ( )
-------------------------
Indicate Product
[_] Other ( ) Indicate Product
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APPLICATION NO. PAGE 1
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14. DEATH BENEFIT OPTION
[_] Option 1 - Selected Face Amount
[_] Option 2 - Selected Face amount plus Account Value
[_] Option 3 - Selected Face Amount plus Sum of Premiums Paid
(if applicable)
15. RIDER OPTIONS (if applicable):
a. [_] Term Rider: 1. [_] Yes [_] No
2. [_] As indicated on Part 1B
IF "YES" COMPLETE ONE OF THE FOLLOWING:
---
TERM RIDER SELECTED FACE AMOUNT $
------------------------
or
PERCENTAGE OF TOTAL SELECTED FACE AMOUNT
-----------------%
b. [_] Waiver of Monthly 1. [_] Yes [_] No
Charges Rider
2. [_] As indicated on Part 1B
(Full underwriting only)
16. Endorsement Election: [_] Alternate Cash Surrender Valuye Benefit
Endorsement (Home Office Approval Required)
17. Loan Interest Rate: [_] Adjustable [_] 6% Fixed
18. Definition of Life Insurance Test
[_] Cash Value Accumulation Test [_] Guideline Premium Test
(if applicable)
19. INITIAL POLICY DATE ---------- ---------- ----------
mo. day year
20. PREMIUM AMOUNTS (if applicable):
(a) Initial Premium paid with Application $ (Allocated among all indureds as
--------------------------- indicated in 20c.)
(b) Planned Annual Premium for: Policy year one $
---------------------------
Pollicy year two $
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Policy year three $
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Policy year four $
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Policy year five $
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(c) Method of premium allocation to each policy.
21. DIVIDEND OPTION (if applicable):
[_] Cash [_] Accumulations [_] Reduce Premium [_] Paid-Up Additions
Dividends will be applied as Paid-Up Additions if no option is elected.
22. The policies applied for will be uded in conjuction with an employer-
sponsored program involving both males and females. All policies will be
issued on a sex-distinct basis unless checked here for unisex basis.
[_] Unisex Basis
(Home Office Approval
Required)
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APPLICATION NO. PAGE 3
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23. Beneficiary:
a. [_] Employer
If the Employer is the beneficiary, the Employer certifies,
represents and warrants that
(i) The Employer has a lawful and substantial economic interest in
the life, health and bodily safety of each Proposed Insured; and
(ii) The Services of each such Proposed Insured are such that the
Employer expects to realize either:
. A substantial pecuniary gain through the continued life of
the Proposed Insured; or
. A substantial pecuniary loss in the event of the Proposed
Insured's death.
b. [_] As designated by Proposed Insured on Application (Part 1B)
c. [_] Owner (if other than Proposed Insured)
d. [_] See memo attached
If two or more persons are the beneficiaries in any class, payment shall be made
equally to them or equally to the surviving beneficiaries in that class unless
otherwise requested. If percentages or fractions are indicated and any
beneficiary dies before the Proposed Insured, any share due that beneficiary
will be paid proportionately to the surviving beneficiaries in that class. If
payment is made in one sum and other is no beneficiary entitled to payment when
the Proposed Insured dies and the Proposed Insured is the Owner at that time,
payment shall be made to the estate of the Proposed Insured; but if the Proposed
Insured is not the Owner, payments shall be made to the Owner:
24. Will the insurance now being applied for replace or change, or is it
intended to replace or change, any insurance or annuity, in whole or in
part, issued by this or any other company? [_] Yes [_] No
If "Yes," give company name, policy number, amount and plans in remarks.
Payment Data
25. Premium and Other Notices:
"I hereby designate (check one only) as my attorney in fact to receive all
premium and other notices on my behalf"
[_] Program Sponsor [_] Producer [_] Other
If "Other," enter name and address
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If no option is elected, all premium and other notices will be sent to the
Owner.
26. Remarks:
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APPLICATION NO. PAGE 4
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27. Complete the following if applicable: (variable life products)
Has the owner received an Offering Memorandum or a Prospectus
for the policy(ies) being applied for? [_] Yes [_] No
If "Yes," give date shown on the Offering Memorandum
or Prospectus:
---------------------------
Does the Owner understand that:
. The death benefit and the duration of insurance may be
variable or fixed under specified conditions? [_] Yes [_] No
. The variable account value of the policy may increase or
decrease in accordance with the experience of the Separate
Account (there are no minimum guarantees as to the variable
account value)? [_] Yes [_] No
. The fixed account value of the policy earns interest at a
rate no less than a minimum specified rate? [_] Yes [_] No
In view of the above, does the Owner believe that this policy
will meet his/her insurance needs and financial objectives? [_] Yes [_] No
The person(s) signing below acknowledge and agree that:
THE APPLICATION - This is part of an application for permanent life insurance.
The application includes this Part 1A and its attached Census and Table of
Temporary Insurance Rates, the Part 1B (which has been or which will be
completed by the Proposed Insured), any Part 2 that may be required, and any
amendments or supplements to either Part. To the best of the knowledge and
belief of the person(s) signing below, all statements in this application are
complete and true and were truly recorded. Each person signing below adopts all
the statements made in the application and agrees to be bound by them. This
Application (Part 1A) is valid until withdrawn by the Owner by written notice to
us at our Home Office. Withdrawal of this Application (Part 1A) shall not
necessarily affect its use with applications submitted prior to the date we
receive such notice.
AUTHORITY OF AGENTS - No agent can change the terms of this application or any
policy, contract or certificate issued by us. No agent can waive any of our
rights or requirements, or extend any time for payment.
CHANGES AND CORRECTIONS - Any change or correction of the application will be
shown on an Amendment of Application attached to the policy, contract or
certificate. Acceptance of any policy, contract or certificate of coverage
issued shall be acceptance of any change or correction of the application we
made. However, unless otherwise indicated in this application, any correction
or change of amount, classification, plan of issuance or riders must be agreed
to in writing.
TAXPAYER IDENTIFICATION (APPLIES ONLY IF THE EMPLOYER IS THE OWNER) - The Owner
certifies, under penalties of perjury, that: (i) the number referred to in No. 4
of this Application (Part 1A) is the correct Taxpayer Identification Number (or
the Employer is waiting for a number to be issued): and (ii) the Owner is not
subject to backup withholding either because the Internal Revenue Service (IRS)
has not notified the Owner that the Owner is subject to backup withholding as a
result of a failure to report all interest or dividends, or because the IRS has
notified the Owner of termination of backup withholding, If the IRS has notified
said Owner that he/she is subject to backup withholding and he/she has not
received notice from the IRS that backup withholding has terminated, he/she is
not subject to backup withholding due to notified payee underreporting.
Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for
insurance may be guilty of a crime and may be subject to fines and confinement
in prison.
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For the Owner/Program Sponsor:
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Print Name and Title of Persons Signature of Authorized Person
to Sign for the Owner/Program Sponsor
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Signed at on
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City State Date
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General Agent Submitting Application Signature of Soliciting Producer
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TEMPORARY LIFE INSURANCE AGREEMENT
TO: [_] MASSACHUSETTS MUTUAL LIFE INSURANCE CO. [_] MML BAY STATE LIFE INSURANCE CO.
HOME AND PRINCIPAL ADMINISTRATIVE OFFICE: PRINCIPAL ADMINISTRATIVE OFFICE:
SPRINGFIELD, MASSACHUSETTS 01111-0001 SPRINGFIELD, MASSACHUSETTS 01111-0001
[_] C.M. LIFE INSURANCE CO.
PRINCIPAL ADMINISTRATIVE OFFICE:
SPRINGFIELD, MASSACHUSETTS 01111-0001
The words "we," and "our" refer to the life insurance company specified above.
Underwriting Method: [_] Guaranteed Issue Only
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1. Owner/Program Sponsor Name
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Owner Address:
-
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street & no. city state zip
2. The Owner/Program Sponsor applies for temporary life insurance on the life of
each Proposed Insured listed in the attached census: [_] Yes [_] No
If "No," the following provisions of this section do not apply.
3. The Effective date of the temporary insurance is the latest of:
(i) The date we receive from the Owner/Program Sponsor an amount of
premium equal to one-forth of the sum of the minimum initial premiums
("temporary insurance premium") for the policies applied for;
(ii) The date of the Application (Part 1A) is signed by one of our
Officers; or
(iii) The date chosen by the Owner/Program Sponsor (please specify date).
----- ----- ----------
Mo Dy Yr
During the temporary insurance period, the amount of premium received in excess
of the temporary insurance premium will be held in a suspense account. Not
interest will be credited on any amounts submitted and held in the suspense
account.
4. The amount of temporary insurance on the life of each Proposed Insured is:
[_] The Selected Face Amount and any Supplemental Monthly Term Insurance
Rider (if applicable) as shown in the census; or
[_] Other - (Provide formula)
---------------------------------------------
In no event however, may the amount of temporary insurance be greater than our
Guaranteed Issue limits.
5. Any temporary insurance on the life of a Proposed Insured will terminate at
the earliest of:
(i) The date the permanent life insurance applied for in this application
takes effect on the life of that Proposed Insured:
(ii) The date that Proposed Insured fails to meet any requirements to
qualify for the permanent insurance applied for:
(iii) The date 90 days after the effective date of the temporary insurance:
or
(iv) The date the Owner/Program Sponsor's written notice of termination of
the insurance is received by us at our Principal Administrative Office.
Temporary Insurance Beneficiary Designation:
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If the temporary insurance on the life of a Proposed Insured terminates for the
reason specified above in 5(i), the amount of premium paid with this Application
that was allocated to the policy on the life of that Proposed Insured will be
applied as premiums under that permanent life insurance policy. If the temporary
insurance on the life of a Proposed Insured terminated for any other reason, we
will refund the amount of premium paid with this Application that was allocated
to the policy on the life of that Proposed Insured less a mortality charge. This
mortality charge will be for the period from the effective date of the temporary
insurance to, but not including, the termination date. The mortality charge for
that Proposed Insured will be based on the amount of temporary insurance on the
Proposed Insured's life, and the term rate from the attached Table of Temporary
Insurance Rates for the Proposed Insured's age. Any unearned mortality charges
as of the termination date will be refunded. We will also pay interest at the
rate paid under Option D as of the termination date on any temporary insurance
premium amounts remaining after termination.
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APPLICATION NO. PAGE 6
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Acknowledgement and Signature
The person(s) signing below acknowledge and agree that:
The Application - This is part of an application for permanent life insurance.
The application includes a Part 1A and its attached Census and Table of
Temporary Insurance Rates, the Part 1B (which has been or which will be
completed by the Proposed Insured), any Part 2 that may be required, and any
amendments or supplements to either Part. To the best of the knowledge and
belief of the person(s) signing below, all statements in this application are
complete and true and were truly recorded. Each person signing below adopts all
the statements made in the application and agrees to be bound by them. This
supplements is valid until withdrawn by the Owner by written notice to us at our
Home Office. Withdrawal of this Application (Part 1A) shall not necessarily
affect its use with applications submitted prior to the date we receive such
notice.
Our Liability - A minimum amount of premium may be paid to the agent in exchange
for temporary life insurance as discussed in this Temporary Insurance Agreement.
If this is done, we shall be liable only as set forth in that Agreement. If that
amount of premium is not paid, we shall have no liability unless and until:
- The application has been approved by us at our Principal Administrative
Office; and
- The first premium has been paid during the lifetime of the Proposed
Insured; and
- The Proposed Insured is actively working during the 90 days prior to their
participation in the program for the Employer or its affiliate(s); and
- The policy, contract or certificate of coverage has been delivered to the
person named as Owner in the certificate; and
- At the time of payment and delivery, all statements in the application
which ar material to the risk are complete and true as though they were
made at that time.
If any of these conditions are not met, the policy, contract or certificate of
coverage and rider(s) applied for shall not take effect.
Authority of Agents - No agent can change the terms of this application or any
policy, contract or certificate issued by us. No agent can waive any of our
rights or requirements, or extend any time for payment.
Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for
insurance may be guilty of a crime and may be subject to fines and confinement
in prison.
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For the Owner/Program Sponsor:
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Print Name and Tiele of Person Signature of Authorized Person
Authorized to Sign for the
Owner/Program Sponsor
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Signed at On
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City State Date
For the Life Insurance Cojpany specified above
(if temporary insurance applied for):
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Print Name and Title of Officer Signature of Soliciting Producer
Authorized to Sign for Life
Insurance Company
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General Agent Submitting Application Signature of Soliciting Producer
APPLICATION NO. PAGE 7
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APPLICATION (PART 1B)
To: [_] Massachusetts Mutual Life Insurance Company [_] MML Bay State Life Insurance Company
Home and Principal Administrative Office: Principal Administrative Office:
Springfield, Massachusetts 01111-0001 Springfield, Massachusetts 01111-0001
[_] C.M. Life Insurance Company
Principal Administrative Office:
Springfield, Massachusetts 01111-0001
The words "we," and "our" refer to the life insurance company specified above.
Underwriting Method: [_] Guaranteed Issue (Complete Section 1 Only)
[_] Simplified Issue (Complete Sections 1, 2&3) [_] Full Underwriting (complete Sections 1&2 Only)
Owner Data
SECTION 1
1. The Application consists of the Part 1B and Part 1A No.
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2. Owner Name (Complete only if question 1d, is checked on application Part 1A)
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2a. Name of Trustee(s) (if applicable) b. Date of Trust (if applicable)
-------------------------------- ------------------
3. Owner Address:
Street & No. City State Zip
3a. Owner's Tax ID Number/Social Security Number
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4. Program Sponsor Name (If applicable, no address needed):
Proposed Insured Data
5. Proposed Insured's Name (Last, First, MI):
Last First MI
6. Proposed Insured's Home Address:
Street & No. City State Zip
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7. Date of Birth: 8. Social Security No.
Mo Day Yr
9. Sex: [_] Male [_] Female
10. Citizenship, if not USA: Type of Visa: [_] Permanent [_] Temporary
11. Business Address:
Street & No. City State Zip
12. Policy Date
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APPLICATION NO. PAGE 2
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13. a. Has the Proposed Insured been Actively at Work prior to their
participation in the plan for the Employer or its affiliate(s)?
"Actively at Work" means working full time at a rate of at least 30
hours per week with no hospitalization, and no absence due to illness or
accident of more than 5 days, during the preceding 3 months.
[_] Yes [_] No If "No," give detailed explanation in
Remarks.
b. Is the proposed Insured receiving or applying to receive disability
benefits?
[_] Yes [_] No If "Yes," give detailed explanation in
Remarks.
c. Has the Proposed Insured smoked cigarettes in the last 12 months?
[_] Yes [_] No
d. If "No," has the Proposed Insured used tobacco or nicotine in any other
form during the past 12 months?
[_] Yes [_] No
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LIFE INSURANCE INFORMATION
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14. Selected Face Amounts (SFA)
a. Initial $
----------------------
b. Subsequent (if applicable) - A pattern of SFA's may be elected here
subject to current issue limits. The SFA for the last Policy Year shown
will apply to all later Policy Years. If no SFA is elected here, the
Initial SFA will apply to all Policy Years.
Policy Year to and including Policy Year Alternatives
-------------------------> Increase by % per year [_]
----------------- -----------------
Increase by $ per year
-----------------
-------------------------> Increase by % per year [_] Remain Level
-----------------
Increase by $ per year [_]
----------------- -----------------
c. Term Rider Option (Complete if question 15a (2) is completed on
application Part 1A)
[_] Yes [_] No If "Yes" complete one of the following:
Term Rider Selected Face Amount $ or
------------------
Percentage of Total Selected Face Amount %
---------------
15. First premium paid with application $
-------------------------
Planned annual premium for year $
-------------------------
16. Beneficiary: (Complete only if question 23b is checked on application
Part 1A).
(for all beneficiaries, print full name(s) and relationship(s) to the
Proposed Insured).
Death benefit proceeds will be paid in one sum unless otherwise requested.
(a) Primary
------------------------------------------------------------
SS#
---------------------------------
(b) Secondary (optional)
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SS#
---------------------------------
(c) Tertiary (optional)
---------------------------------------------------
SS#
---------------------------------
If two or more persons are the beneficiaries in any class. payment
shall be equally to them or equally to the surviving beneficiaries in that class
unless otherwise requested. If percentages or fractions are indicated and any
beneficiary dies before the Proposed Insured, any share due to that beneficiary
will be paid proportionately to the surviving beneficiaries in that class. If
payment is made in one sum and there is no beneficiary entitled to payment when
the Proposed Insured dies and the Proposed Insured is the Owner at that time,
payment shall be made to the estate of the Proposed Insured; but if the Proposed
Insured is not the Owner, payment shall be made to the Owner.
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APPLICATION NO. PAGE 9
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Underwriting Data
SECTION 2
17. Amount of insurance currently applied for, or now in force, on the Proposed
Insured in other companies.
If none, check here[_].
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Amount of Year
Accidental Death Waiver of of or Currently
Company Name Face Amount Benefit Premium Issue Applied for (X)
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[_] Yes [_] No
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[_] Yes [_] No
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18. What is your Occupation(s) and Exact Duties?
Occupation(s) Exact Duties
Please Submit Completed Medical Form along with a Medical Information
Bureau authorization form, if Full Underwriting is selected.
19. Waiver or Monthly charges Rider Option (Complete if question 15b(2) is
completed on application Part 1A)
[_] Yes [_] No
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SECTION 3
20. Have you ever been treated for, or been diagnosed by a member of the
medical profession as having, a deficiency of the immune system such as
acquired immune deficiency syndrome (AIDS) or AIDS related complex (ARC)?
[_] Yes [_] No
21. Have you ever consulted or been treated by a physician for cancer or
disease of the heart? [_] Yes [_] No
22. Have you applied for life insurance and been declined or postponed in the
last 5 years? [_] Yes [_] No
If "Yes," answers given in 20, 21, or 22 give details in Remarks.
23. Remarks
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APPLICATION NO. PAGE 10
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Agreement and Signature
24. Complete the following if applicable:
Has the Owner received an Offering Memorandum or a Prospectus for the
policy(ies) being applied for? [_] Yes [_] No
If "Yes," give date shown on the Offering Memorandum or Prospectus:
---------
Does the Owner understand that:
. The death benefit and the duration of insurance may be variable or fixed
under specified conditions? [_] Yes [_] No
. The variable account value of the policy may increase or decrease in
accordance with the experience of the Separate Account (there are no
minimum guarantees as to the variable account value)? [_] Yes [_] No
. The fixed account value of the policy earns interest at a rate no less
than a minimum specified rate? [_] Yes [_] No
In vies of the above, does the Owner believe that this policy will meet his/her
insurance needs and financial objectives? [_] Yes [_] No
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To the best of my knowledge and belief, all answers and statements are full,
complete and true and were correctly recorded. before I signed my name below.
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION - I have received the Notice
regarding the Medical Information Bureau, Inc. and the Fair Credit Reporting
Act. I understand that an investigative consumer report may be made regarding my
character, general reputation, personal characteristics and mode of living, and
authorize that report to be made. I hereby authorize any licensed physician,
medical practitioner, hospital, clinic, other medical or medically related
facility, insurance company, the Medical Information Bureau, Inc., or other
organization that has any records or knowledge of me and my health, to make such
information available to the life insurance company or its reinsurers. A copy of
this authorization shall be as valid as the original. (This authorization is
only valid where permitted by state law.)
TAXPAYER IDENTIFICATION (APPLIES ONLY IF PROPOSED INSURED IS OWNER) - The
Proposed Insured herein certifies, under penalties of perjury, that (1) the
number referred to in no. 4 of this Part 1B is his/her correct Taxpayer
Identification Number (or he/she is waiting for a number to be issued); and (ii)
he/she is not subject to backup withholding either because he/she has not been
notified by the Internal Revenue Service (IRS) that he/she is subject to backup
withholding as a result of a failure to report all interest or dividends, or
because the IRS has notified him/her that he/she is no longer subject to backup
withholding. If the IRS has notified the Proposed Insured that he/she is subject
to backup withholding and he/she has not received notice from the IRS that
backup withholding has terminated, he/she should strike out language above in
(ii) that he/she is not subject to backup withholding due to notified payee
underreporting.
Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for
insurance may be guilty of a crime and may be subject to fines an confinement in
prison.
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Signature of Proposed Insured Signature of Soliciting
Producer/Registered Representative
---------------------------------------
Signature of Owner (only if question 1d,
is checked on Application Part 1A)
signed at On
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City State Date
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APPLICATION NO. PAGE 11
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CONSENT FORM (PART 1B)
To: [_] Massachusetts Mutual Life Insurance Company [_] MML Bay State Life Insurance Company
Home and Principal Administrative Office: Principal Administrative Office:
Springfield, Massachusetts 01111-0001 Springfield, Massachusetts 01111-0001
[_] C.M. Life Insurance Company
Principal Administrative Office:
Springfield, Massachusetts 01111-0001
The words "we," and "our" refer to the life insurance company specified above.
Underwriting Method: [_] Guaranteed Issue Only
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1. Your Name
First Last MI
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2. Your Home Address:
Street & No. City State Zip
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3. Name of Employer
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4. Please check one:
a. [_] Yes, I consent to my employer purchasing a life insurance policy on my
life. I agree and understand that:
. The employer will pay all the premiums, have all the rights of
ownership, and be the sole beneficiary of the policy. I agree that my
administrators, estate, heirs and assigns have no rights to any policy
proceeds; and
. The employer or their successors will continue to be the owner and
beneficiary of the policy(ies) after the end of my employment with the
employer or its successors.
b. [_] No. I do not consent to my employer purchasing a life insurance policy
on my life.
5. Have you been actively at work prior to their participation in the plan for
the Employer or its affiliate(s)? "Actively at Work" means working full time
at a rate of at least 30 hours per week with no hospitalization, and no
absence due to illness or accident of more than 5 days, during the preceding
3 months. [_] Yes [_] No If "No," explain in Remarks.
6. Are you receiving or applying to receive disability benefits?
[_] Yes [_] No If "No," explain in Remarks.
7. Have you smoked cigarettes in the last 12 months? [_] Yes [_] No
If "No," have you used tobacco or nicotine in any other form during the past
12 months? [_] Yes [_] No
Please complete the following information:
8. Sex: [_] Male [_] Female
9. Date of Birth: 10. Social Security No.
---- ----- ---- ------------------
Mo Day Yr
11. Proposed Insured's Signature Required
--------------------------------- --------------------------------
Proposed Insured's Signature Date
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