THE TRAVELERS INSURANCE COMPANY o XXX XXXXX XXXXXX x XXXXXXXX, XX o 06183
================================================================================
VARIABLE LIFE SUPPLEMENT
================================================================================
This supplement accompanies an application for a Variable Universal Life
Insurance Policy to be issued by The Travelers Insurance Company.
ALL QUESTIONS MUST BE ANSWERED COMPLETELY AND THE APPLICATION AND SUPPLEMENT
MUST BE SIGNED IN ORDER FOR THE COMPANY TO PROCESS THE APPLICATION. MAY BE
REFERENCED BY ATTACHMENT.
Proposed Insured(s)
---------------------------------------------------
First, Middle, Last
Date of Birth
----------------------------------------------------------
Social Security Number
-------------------------------------------------
================================================================================
FUND INFORMATION
Select one or more funds and indicate percentage of allocation. Total must equal
100%; allocations must be whole percentages of 5% or more.
|_| AIM Capital Appreciation Portfolio ___ % |_| MFS Research Portfolio ___ %
|_| Alliance Growth Portfolio ___ % |_| MFS Total Return Portfolio ___ %
|_| Alliance Growth & Income Portfolio -- Class B ** ___ % |_| PIMCO Total Return Portfolio--Administrative Class ___ %
|_| Alliance Premier Growth Portfolio -- Class B ___ % |_| Pioneer Mid_Cap Value VCT Portfolio -- Class II ** ___ %
|_| American Funds Global Growth Fund -- Class 2 ** ___ % |_| Putnam Diversified Income Portfolio * ___ %
|_| American Funds Growth Fund -- Class 2 ** ___ % |_| Putnam VT International Growth Fund -- Class IB ___ %
|_| American Funds Growth - Income Fund -- Class 2 ** ___ % |_| Putnam VT Small Cap Value Fund -- Class IB ___ %
|_| Capital Appreciation Fund (JANUS) ___ % |_| Xxxxxx VT Voyager II Fund -- Class IB ___ %
|_| CitiStreet Diversified Bond Fund * ___ % |_| Salomon Brothers Variable Capital Fund ___ %
|_| Credit Suisse Emerging Markets Portfolio ___ % |_| Salomon Brothers Variable Investors Fund ___ %
|_| Delaware VIP REIT Series ___ % |_| Salomon Brothers Variable Strategic Bond Fund ___ %
|_| Delaware Small Cap Value Series * ___ % |_| Salomon Brothers Variable Total Return Fund ___ %
|_| Dreyfus Stock Index Fund ** ___ % |_| Xxxxxxx VIT EAFE(R) Equity Index Fund ___ %
|_| Dreyfus VIF Appreciation Portfolio -- Initial Shares ___ % |_| Xxxxxxx VIT Small Cap Index Fund ___ %
|_| Dreyfus VIF Small Cap Portfolio -- Initial Shares ___ % |_| Xxxxx Xxxxxx Aggressive Growth Portfolio ___ %
|_| Equity Income Portfolio (FIDELITY) ___ % |_| Xxxxx Xxxxxx Fundamental Value Portfolio ___%
|_| Equity Index Portfolio -- Class 1 ___ % |_| Xxxxx Xxxxxx International All Cap Growth Portfolio ___ %
|_| Fidelity VIP Asset Manager Portfolio -- Initial Class ___ % |_| Xxxxx Xxxxxx Large Cap Growth Portfolio ___ %
|_| Fidelity VIP Contrafund(R)Portfolio -- Service Class 2 ___ % |_| Social Awareness Stock Portfolio (XXXXX XXXXXX) ___ %
|_| Fidelity VIP Mid Cap Portfolio -- Service Class 2 ___ % |_| Xxxxxxxxx Foreign Securities Fund -- Class 2 ** ___ %
|_| Franklin Small Cap Fund -- Class 2 ___ % |_| Travelers Convertible Securities Portfolio ___ %
|_| Janus Aspen Series Balanced Port. -- Service Shares ___ % |_| Travelers Disciplined Mid Cap Stock Portfolio ___ %
|_| Janus Aspen Series Global Tech. Portfolio--Service Shares ___ % |_| Travelers High Yield Bond Trust ___ %
|_| Janus Aspen Series Worldwide Growth Port. - Svc. Shares ___ % |_| Travelers Money Market Portfolio ___ %
|_| Large Cap Portfolio (FIDELITY) ___ % |_| Travelers Quality Bond Portfolio ___ %
|_| Lazard International Stock Portfolio ___ % |_| Travelers U.S. Government Securities Portfolio ___ %
|_| MFS Emerging Growth Portfolio ___ % |_| Xxx Xxxxxx Enterprise Portfolio ___ %
|_| MFS Mid Cap Growth Portfolio ___ %
TOTAL 100%
* CLOSED TO NEW CASES AS OF SEPTEMBER 24, 2001
** FUNDS XXX XXXXXXXXX XX XXXXXXXXXXX
X-00000 (8/02) The Travelers Insurance Company and its Affiliates
o Xxx Xxxxx Xxxxxx x Xxxxxxxx, XX 00000
SUITABILITY
================================================================================
a. Have you received the prospectus relating to the policy applied for?
Yes No
Date of prospectus:__________ Date of prospectus supplement(s):____________
b. Do you understand that the Contract Value and Death Benefit associated with
the policy you have applied for may increase or decrease depending upon the
investment experience of the investment options which you have selected?
Yes No
c. With this in mind, is the policy in accord with your insurance objectives
and anticipated financial needs? Yes No
APPLICANT declares to the best of his/her knowledge and belief that all of the
statements made in his/her application and supplement, if required, are complete
and true.
ALL VALUES AND BENEFITS PROVIDED BY THE BASIC POLICY APPLIED FOR ARE VARIABLE
AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. EXCEPT AS STATED IN THE
TEMPORARY INSURANCE AGREEMENT/ADVANCE PAYMENT RECEIPT CORRESPONDING TO THIS
APPLICATION, THE COMPANY WILL APPLY THE FIRST NET PREMIUM PAYMENT TO THE CREDIT
OF THE BASIC POLICY APPLIED FOR AS OF THE VALUATION DATE ON OR NEXT FOLLOWING
THE POLICY DATE.
Except as stated in the Employer-Sponsored Temporary Life Insurance Binder
Agreement, no insurance will take effect until:
(1) the policy is delivered to the Applicant; and
(2) the first modal premium is paid in full while the health and other
conditions relating to insurability remain as described in the application. No
agent is authorized: (1) to make, alter, or discharge any policy; (2) to waive
or change any condition or provision of any policy, application or receipt; and
(3) to accept any risk or to pass on insurability. The Proposed Insured will be
the Applicant of any policy issued on this application unless otherwise
indicated. The right to privacy is protected as required by law.
I have paid to _________________________________ the sum of $_______________ and
hold a receipt bearing the number ______________ Dated _____________ at (city or
town/state) ____________________________________
___________________________________________________
Owner/Designated Representative (SIGNATURE IN FULL)
___________________________________________________
Witnessed by (LICENSED RESIDENT AGENT)
___________________________________________________
Signature of Principal
___________________________________________________
Signature of Broker/Dealer
L-15325 (8/02) The Travelers Insurance Company and its Affiliates
o Xxx Xxxxx Xxxxxx x Xxxxxxxx, XX 00000
THE TRAVELERS INSURANCE COMPANY o XXX XXXXX XXXXXX x XXXXXXXX, XX o 06183
================================================================================
APPLICATION FOR CORPORATE OWNED LIFE INSURANCE
================================================================================
NAME OF POLICY OWNER:___________________________________________________________
___________________________________________________________
ADDRESS OF POLICY OWNER:________________________________________________________
CORPORATE (OWNER) TAX ID #:________________ ISSUE DATE OF POLICY:_______________
PLAN OF INSURANCE: Guideline Premium Test Cash Value Accumulation Test
PREMIUM PAYMENT PLAN: Single Annual Semi-Annual Quarterly Monthly
DEATH BENEFIT OPTION: Level Death Variable Death Annual Increase Death
Benefit Benefit Benefit
BENEFICIARY: The Corporation shall be the sole beneficiary unless otherwise
________________________________________________________________________________
specified.
________________________________________________________________________________
Is the right to change the Beneficiary and to exercise all other policy rights
without the consent of the Beneficiary reserved to the Owner? Yes No
It is agreed that:
1. This application, which includes the attached Schedule A, will be the basis
for any policies issued in response to it.
2. Application is made to Us for individual life insurance policies on the
lives of the individuals specified in Schedule A.
3. The amount of insurance for each policy applied for shall be the amount
specified for each individual in Schedule A.
4. Each policy applied for shall be of the plan specified in the Plan of
Insurance section above.
For the most recent 90 days, have all of the Proposed Insureds been actively at
work for at least 30 hours per week, at their usual place of business,
performing their regular occupations? Yes No
During the most recent 90 days, have any of the Proposed Insureds been
hospitalized or absent from work (other than for recreational days and holidays)
for more than 5 consecutive workdays? Yes No
AGENT'S STATEMENT: Will this insurance replace, change or use the cash value of
any existing insurance policy or annuity? Yes No
Is this insurance intended to be a 1035 tax-free exchange? Yes No
If you answered "Yes" to either of these replacement questions, has the required
replacement paperwork been completed? Yes No
List company name, amount and attach applicable forms required by state in which
application is signed.
________________________________________________________________________________
______________________________________ ________________________________________
SIGNATURE OF AGENT SIGNATURE OF OWNER / DESIGNATED
REPRESENTATIVE
Dated_________________________________ Dated___________________________________
L-15236
SCHEDULE A
PROPOSED DATE OF INITIAL BASE TERM INITIAL PLANNED SMOKER/
INSURED SEX BIRTH SS# POLICY INSURANCE PREMIUM PREMIUM NONSMOKER
DEATH BENEFIT RIDER ("S" OR "N")
====================================================================================================================================
I represent that I have read the questions and answers on this application, and
declare that they are complete and true to the best of my knowledge and belief.
Furthermore, I understand that this application will become a part of any policy
issued. I agree that no Agent/Representative of the Company shall: have the
authority to waive a complete answer to any question on this Application;
transfer insurability; make or alter any contract; or, waive any of the
Company's other rights or requirements. I further agree that no insurance shall
take effect unless and until the Policy has been delivered to and accepted by
me; and, the initial modal premium is paid during the lifetime and prior to any
change in health of the Proposed Insured.
Signed for the Policy Owner by the following duly authorized official:
________________________________ _________________________ ___________________
Signature Title Date
L-15236
THE TRAVELERS INSURANCE COMPANY o XXX XXXXX XXXXXX x XXXXXXXX, XX o 06183
================================================================================
APPLICATION FOR SIMPLIFIED ISSUE LIFE INSURANCE
================================================================================
NAME OF POLICY OWNER: _______________________________________________________
ADDRESS OF POLICY OWNER: _______________________________________________________
_______________________________________________________
_______________________________________________________
CORPORATE TAX ID #: _______________________________________________________
OWNER TAX ID # (IF OTHER
THAN CORPORATION) _______________________________________________________
PLAN OF INSURANCE: _______________________________________________________
BENEFICIARY: The Corporation shall be the sole beneficiary unless
_______________________________________________________
otherwise specified.
_______________________________________________________
Will this insurance replace, change or use the cash value of any existing
insurance policy or annuity?
Yes No
(If you answered "Yes" to this question, list company name, amount and attach
applicable forms required by state in which application is signed.)
______________________________________ ________________________________________
SIGNATURE OF AGENT SIGNATURE OF OWNER
Dated_________________________________ Dated___________________________________
SECTION B:
For the most recent 90 days, have you been actively at work for at least 30
hours per week, at your employer's usual place of business, performing your
customary duties of your regular occupation?
Yes No
During the most recent 90 days, have you been hospitalized or were you absent
from work (other than for recreational days and holidays) for more than 5
consecutive workdays? Yes No
Have you used any tobacco products within the past 12 months? Yes No
If "Yes" how much (i.e., units per week/month) and date last used:
Cigarettes__________ Cigars__________ Pipe__________ Smokeless tobacco__________
L-15240
SECTION C
1. PERSONAL PHYSICIAN (Give full name, address and phone # of your doctor who
you consult for routine check-ups and physicals): _________________________
___________________________________________________________________________
DATE AND REASON LAST CONSULTED:____________________________________________
2. PROPOSED INSURED: Height ________ Weight ________ Amount of weight loss
in past 12 months
3. Have you within the past 2 years:
a) Flown or plan to fly as a pilot, student pilot or
crew member or intend to do so? Yes No
b) Engaged in scuba diving, vehicle racing, parachute
jumping or any form of motorcycling, or any other
hazardous sport or hobby? Yes No
4. In the past 10 years have you:
a) Used Drugs not prescribed by a doctor? Yes No
b) Been treated for alchoholism? Yes No
c) Been advised to have medical treatment or
counseling from a commonly recognized practitioner
or organization for alcohol or drug use? Yes No
5. Have you in the past 10 years:
a) Been diagnosed or treated for Acquired Immune
Deficiency Syndrome (AIDS) by a member of the
medical profession? Yes No
b) Been diagnosed or treated for immune deficiency
(other than AIDS), anemia or other blood disorder
(other than for HIV)? Yes No
c) Had recurrent fever, fatigue or unexplained weight
loss? Yes No
6. Other than the above, have you ever been diagnosed or
treated for:
a) Chest pain, high blood pressure, stroke, or
disease of the heart, blood vessels, or lungs; Yes No
b) Diabetes, mental or emotional disorder; disease of
the brain or nervous system, convulsions; Yes No
c) Cancer; tumor; disease of the stomach, intestines,
liver or kidneys? Yes No
7. Have you in the last five years, been advised to have
any diagnostic test, hospitalization or surgery by any
licensed physician, practitioner or health facility
that has not yet been performed? Yes No
FOR ALL QUESTIONS ANSWERED "YES," FURNISH DETAILS. _____________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
I represent that the above statements are true and complete to the best of my
knowledge and belief. I understand that this application will become a part of
any policy issued. I also understand that any misrepresentations contained in
this application and relied on by the Company may be used to reduce or deny a
claim or void the contract if: (1) it is within its contestable period; and (2)
if such misrepresentation materially affects the acceptance of the risk.
_____________________________________ Dated____________ At______________________
Signature of Proposed Insured (City, State)
L-15240
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
I authorize The Travelers Insurance Company (referred to as The Travelers), its
Reinsurers, insurance support organizations, and their authorized
representatives to obtain medical and other information in order to evaluate
this application for insurance. I authorize any physician, medical practitioner,
hospital, clinic, other medical or medically related facility, insurance
company, the Medical Information Bureau, Inc., employer, consumer reporting
agency, or other insurance coverage, medical care, treatment, supplies or advice
with respect to me to furnish such information to The Travelers, its Reinsurers
or their authorized representatives.
This authorization will be valid from the date signed for a period of 26 months.
I agree that a photographic copy of this authorization is as valid as the
original. Information given in my application, including health care
information, may be made available without my prior authorization to other
insurance companies to which I make application for life or health insurance
coverage or to which a claim is submitted.
I have read this authorization and understand that I have a right to receive a
copy. I acknowledge receipt of the notice regarding: "Notification Regarding Use
and Release of Information to the Medical Information Bureau, Inc. and Other
Life Insurance Companies"
_____________________________________ Dated____________ At______________________
Signature of Proposed Insured (City, State)
L-15240-A
================================================================================
THE TRAVELERS INSURANCE COMPANY
NOTIFICATION REGARDING USE AND RELEASE OF INFORMATION TO THE MEDICAL
INFORMATION BUREAU, INC. AND OTHER LIFE INSURANCE COMPANIES
Any health care information developed is necessary to classify insurance risks,
conduct normal administrative procedures and process claims, and will be used
for those purposes only. No other use of this information will be made without
first obtaining your written consent.
This information will be treated as confidential except that The Travelers
Insurance Company or its Reinsurer(s) may make a brief report to the Medical
Information Bureau, Inc., a non-profit membership corporation of life insurance
companies which operates an information exchange on behalf of its members. Upon
request by another member insurance company to which you have applied for life
or health insurance coverage or to which a claim is submitted, the Bureau will
supply such company with the information it may have in its files.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your files. Medical information will be disclosed
only to your attending physician.
If you question the accuracy of information in the Bureau's file, you may
contact the Bureau and seek a correction in accordance with the procedures set
forth in the federal Fair Credit Reporting Act. The address of the Bureau's
information office: Xxxx Xxxxxx Xxx 000, Xxxxx Xxxxxxx, Xxxxxx, Xxxxxxxxxxxxx
00000, Telephone: (000)000-0000.
The Travelers Insurance Company or its Reinsurer(s) may release information
given in your application file, including health care information, to other life
insurance companies to which you apply for life or health insurance or to which
a claim is submitted.
L-15240-M
THE TRAVELERS INSURANCE COMPANY o XXX XXXXX XXXXXX x XXXXXXXX, XX o 06183
================================================================================
EMPLOYER-SPONSORED TEMPORARY LIFE INSURANCE BINDER AGREEMENT
================================================================================
This Temporary Life Insurance Binder Agreement (the "Agreement") is made by and
between The Travelers Insurance Company (the "Company") and ____________________
(the "Owner").
In offering this Agreement, the Company has relied upon the attached census of
employees to be insured as well as information provided by the Employer.
While this Agreement is in effect, the Employer is not and will not become a
party to any other Agreement to provide life insurance coverage on any of the
employees listed in the Census without the prior agreement of the Company.
Subject to the terms of this Agreement and in consideration of the deposit
received, temporary life insurance will be provided from the Effective Date for
the qualified Proposed Insureds listed in the census.
1. Definitions:
(a) Proposed Insured - an individual 70 years of age or less applying for
permanent insurance who is listed in this Agreement and has been
actively at work for the last 90 days for at least 30 hours per week.
(b) Effective Date - the date on which temporary life insurance begins.
The Effective Date under this Agreement is __________________________.
(c) Termination Date - the date on which temporary life insurance for each
Proposed Insured ends. It will be the earlier of:
(1) the date on which the policy on the Proposed Insured is issued;
or
(2) the date on which a full or partial refund of the Deposit is
mailed to the Employer because an application is declined or
withdrawn; or
(3) _____ days after the Effective date; or
(d) Binder Premium - the amount of premium deposit needed to effect the
temporary life insurance coverage on the Proposed Insureds
contemplated by this Agreement. The Binder Premium for the coverage
provided by this Agreement is $___________________.
2. Binder Coverage - the amount of temporary life insurance per Proposed Insured
provided by this Agreement is the amount to be applied for as stated on the
attached census subject to a per life maximum of $1,000,000 for all current
applications pending with the Company and its subsidiaries.
3. Death Benefits - For any death benefits to be paid under this Agreement.
Owner must represent and warrant that under applicable state law it has an
insurable interest in the insured employee and has obtained from the insured
employee any consent required by such law.
4. Suicide and Material Misrepresentation - If a Proposed Insured commits
suicide, or death is caused in whole or in part by any intentionally
self-inflicted injury or if there is found to be material misrepresentation on
the application, the Company's only liability as to such a Proposed Insured
shall be return the applicable portion of the premium to the Employer.
5. Beneficiary - any death benefits claimed under this Agreement shall be
payable to the employer unless an alternative beneficiary is named in the
application.
6. Amendments - this Agreement may only be modified or amended in writing by the
Company through its duly authorized officers.
TEMPORARY INSURANCE IS PROVIDED UNDER THE TERMS OF THIS AGREEMENT FOR THE
QUALIFIED ACTIVELY AT WORK PROPOSED INSUREDS WHO ARE LISTED IN THE ATTACHED
CENSUS. WE WILL REQUIRE CONSENT FORMS FOR EACH INSURED
Offered by:____________________________________________TITLE:___________________
SIGNATURE DATE THE TRAVELERS
INSURANCE COMPANY
Accepted by:_____________________________________________ ____________________
COMPANY OFFICER TITLE DATE COMPANY
Witnessed by:_____________________________ ____________________ ______________
BROKER DATE BROKER/AGENT # FIRM
L-15242
