INSURANCE HISTORY.Β 1. Do you have any existing life insurance or annuities? o Yes o No
2. Will this insurance replace* any existing insurance or annuity? o Yes o No
3. List the following details for all existing coverage. (List all in force life insurance; only annuities to be replaced): Insurance Company Face Amount Type Product To Be Replaced?* 1035 Exchange?
a. $ If Replacement, policy number : b. $ If Replacement, policy number :
INSURANCE HISTORY.Β 1. Do you have any existing life insurance or annuities? π Yes π No Note: Existing coverage includes any life insurance policies that have been assigned, sold or transferred.
2. Will this insurance replace* any existing insurance or annuity? π Yes π No
3. List the following details for all existing coverage. (List all in force life insurance; only annuities to be replaced): Insurance Company Face Amount Type Product To Be Replaced?* 1035 Exchange?
a. $ π Group π Annuity π Yes π Yes If Replacement, policy number : π Individual π Life π No π No
b. If Replacement, policy number : $ π Group π Individual π Annuity π Life π Yes π No π Yes π No
c. If Replacement, policy number : $ π Group π Individual π Annuity π Life π Yes π No π Yes π No
d. $
e. $ π Group π Individual π π Group Individual π Annuity π Life π π Annuity Life π π π Yes π No π Yes π No οΏ½οΏ½ Yes π No *Replace or replaced means that the insurance being applied for may replace or cause a change in any existing insurance or annuity with any company, including the lapse or surrender of the existing policy, or the use of funds or values from the existing policy to pay for the new policy. π
4. Will this rider replace any existing long-term care coverage presently in force? π Yes No π
5. Will this rider replace any existing Acceleration of Death Benefit coverage presently in force? π Yes No
6. Is the proposed policyowner considering the transfer or sale to an investor or other third party of: policy ownership; or, any interest in the π policy benefits, either directly or indirectly as a beneficiary or owner of a trust or other entity? π Yes No π
7. Has the proposed owner been offered any money or other considerations by any person or entity in connection with this application? π Yes No If Yes, provide details: All other states:
8. Is the proposed insured or proposed owner considering the transfer or sale to a life settlement company or other investor of: policy ownership; or, any interest in the policy benefits, either directly as a named beneficiary or indirectly as a beneficiary or π owner of a trust or other entity? In LA: If YES, always complete Section I (Policyowner Statement). π Yes No
