EXHIBIT (e)(12)
This form must be completed, signed and left with the applicant.
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Limited Temporary Life Insurance Agreement (Agreement)
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THIS AGREEMENT PROVIDES A LIMITED AMOUNT OF LIFE INSURANCE COVERAGE FOR A
LIMITED PERIOD OF TIME, SUBJECT TO THE TERMS AND CONDITIONS SET FORTH BELOW.
PLEASE FOLLOW STEPS 1 - 4.
1. Check appropriate Company:
[ ] American General Life Insurance [ ] The United States Life Insurance
Company, Houston, TX Company in the City of New York,
New York, NY
In this Agreement, "Company" refers to the insurance company whose name is
checked above, which is solely responsible for the obligation and payment of
benefits under any policy that it may issue. No other company shown is
responsible for such obligations or payments. In this Agreement, "Policy"
refers to the Policy or Certificate applied for in the application.
2. Complete the following:
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Primary Proposed Insured (please print) ________________________________________
Other Proposed Insured (if applicable) _________________________________________
Owner _______________________ Modal Premium Amount Received ____________________
Date of Policy Application _____________________________________________________
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3. Answer the following questions:
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a. Has any Proposed Insured ever had a heart attack, stroke, YES NO
cancer, diabetes or disorder of the immune system, or during
the last two years been confined in a hospital or other
health care facility or been advised to have any diagnostic
test or surgery not yet performed?
b. Is any Proposed Insured age 71 or above?
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STOP If the answer to any question above is YES, or any question is answered
falsely or left blank, coverage is not available under this Agreement and
it is void. This form should not be completed and premium may not be
collected. Any collection of premium will not activate coverage under this
Agreement.
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TERMS AND CONDITIONS OF COVERAGE UNDER THIS AGREEMENT
A. Eligibility for Coverage: If any Proposed Insured answers YES to either of
the questions listed above, temporary insurance is NOT available and this
Agreement is void.
Agents do not have authority to waive these requirements or to collect
premium by any means including cash, check, bank draft authorization, credit
card authorization, salary savings, government allotment, payroll deduction
or any other monetary instrument if any Proposed Insured is ineligible for
coverage under this Agreement.
B. When Coverage Will Begin: COVERAGE WILL BEGIN WHEN ALL OF THE FOLLOWING
CONDITIONS HAVE BEEN MET:
. Part A of the application must be completed, signed and dated; and
. The first modal premium must be paid; and
. Part B of the application must be completed, signed and dated and all
medical exam requirements satisfied.
AGLC101431-2005 Page 1 of 2
Coverage under this Agreement will not exist until all of the conditions
listed above have been met.
The first modal premium will be considered paid, if one of the following
valid items is submitted with Part A of the application: (i) a check in the
amount of the first modal premium; (ii) a completed and signed Automatic Bank
Draft Agreement; (iii) a completed and signed Credit Card Authorization form;
(iv) a completed and signed salary savings authorization; (v) a completed and
signed government allotment authorization; (vi) a completed and signed
payroll deduction authorization. Temporary life insurance under this
Agreement will automatically terminate if any form of payment submitted is
not honored. All premium checks must be made payable to the Company checked
above. Do not make check payable to the agent or leave payee blank. The
prepayment for this temporary insurance will be applied to the first premium
due if the policy is issued, or refunded if the Company declines the
application or if the policy is not accepted by the Owner.
C. When Coverage Will End: COVERAGE UNDER THIS AGREEMENT WILL END at 12:01 A.M.
ON THE EARLIEST OF THE FOLLOWING DATES:
. The date the policy is delivered to the Owner or his/her agent and all
amendments and delivery requirements have been completed;
. The date the Company mails or otherwise provides notice to the Owner or
his/her agent that it was unable to approve the requested coverage at the
premium amount quoted and a counter offer is made by the Company;
. The date the Company mails or otherwise provides notice to the Owner or
his/her agent that it has declined or cancelled the application;
. The date the Company mails or otherwise provides notice to the Owner or
his/her agent that a Proposed Insured is not eligible for coverage under
this Agreement and the application will not be considered on a prepaid
basis;
. The date the Company mails or otherwise provides a premium refund to the
Owner or his/her agent; or
. 60 calendar days from the date coverage begins under this agreement.
D. Coverage Amount: Upon receiving proof of the death of the Primary Proposed
Insured, and of the Other Proposed Insured if this is a joint life or
survivorship policy, and if all eligibility requirements and conditions for
coverage under this Agreement have been met, the total amount that will be
paid by the Company pursuant to this and any other limited temporary life
insurance agreements covering the Proposed Insured(s) will be the lesser of:
. The plan amount the Proposed Insured applied for; or
. $500,000.00 plus the amount of any premium paid for coverage in excess of
$500,000.00.
The Company will pay the death benefit to the beneficiary named in the
application. If death is due to suicide, payment will be limited to the amount
of premium paid.
4. Complete and sign this section:
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Any misrepresentation contained in this Agreement and relied on by the Company
may be used to deny a claim or to void this Agreement. The Company is not bound
by any acts or statements that attempt to alter or change the terms of this
Agreement.
I, the Owner, have received, read and understand this Agreement and agree to be
bound by the terms and conditions stated herein.
Signature of Owner ________________________________________ Date _______________
Signature of Primary Proposed Insured _____________________ Date _______________
Signature of Other Proposed Insured (if applicable) _______ Date _______________
Writing Agent Name (please print) _________________________ Writing Agent # ____
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AGLC101431-2005 Page 2 of 2
