Exhibit 1(10)
(m) Form of Application Supplement
Application Supplement
Conditional Interim Coverage Agreement
Paragon Life Insurance Company ("Company")
St. Louis, MO 63105
Proposed Contractholder ("Employer")___________________________________________
_______________________________________________________________________________
Subject to the following terms and conditions, the Company agrees to provide
insurance coverage on a certain group of the Employer's full-time employees
(hereafter called "Executive"). This coverage is pursuant to the Application for
Group Life Insurance submitted by the Employer. Attached to this agreement, and
made part of it, is a Minimum Premium Summary listing each proposed insured's
name, date of birth, social security number, insurance amount, and minimum
monthly premium. For coverage to be effective for the following month during
this agreement, the premium must be received by the Company at its Home Office
prior to the first of the month for which coverage is to be provided. Coverage
is subject to the Company's underwriting evaluation and there is no guarantee
that excess coverage will be issued.
Amount of Interim Binder Coverage
---------------------------------
If a covered person dies while this binder coverage is in force, the Company
will pay the amount of guaranteed issue coverage plus any guaranteed to issue
coverage shown in the attached Minimum Premium Summary. The guaranteed issue
coverage shall not exceed the applicable guaranteed issue limited shown in the
attachment. The guaranteed to issue coverage shall not exceed [$750,000] less
any guaranteed issue coverage and any prepaid pending or inforce coverage in the
Company.
When Interim Coverage Begins
----------------------------
Interim coverage will begin on ________ at 12:01 a.m. Central [Daylight] time
(which will hereafter be referred to as "Coverage Date") subject to the receipt
of a premium which is no less than shown on the Minimum Premium Summary and the
signed application(s) referenced above. Interim Coverage may also apply to new
additions to the Minimum Premium Summary for newly eligible Executives until
termination of this Agreement. New additions will have Coverage Date be their
respective date of eligibility.
When Interim Coverage Ends
--------------------------
Interim coverage will end ("Termination Date") on the earliest of:
A. [90] days from the inception of Coverage Date; and
B. Concurrently with the delivery of a policy certificate to either the
Employer or an Executive; and
C. Termination of this Agreement.
Termination of Agreement
------------------------
This agreement may be terminated by Company or Employer upon 30 days written
notice to either party.
Conditions of Interim Coverage
------------------------------
1. It is understood that for a period from Coverage Date until Termination Date
and in consideration of an advance premium which will not be less than shown
in the attached Minimum Premium
1
Summary that the insurance will be in force for the amounts shown on the life
of each Executive which has been named in said summary.
2. Coverage for amounts in excess of the amounts otherwise available within
standard underwriting limits not to exceed [$2 million] per life are not
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covered under this agreement and will be effective only on the policy
effective date of issue after underwriting approval by Paragon Life and the
receipt of the premium by the Company.
3. It is agreed that should the Employer decide not to proceed with a Group
Contract or to accept issued certificates that the advance premium will be
returned without interest and reduced by the cost of insurance for the term
period that coverage was provided by this Agreement.
4. The Employer represents that each Executive named in the Minimum Premium
Summary is a full-time employee of the Employer or affiliate whose normal
work week is at least 30 hours a week. The Employer also represents that
none of the Executives is receiving, or is entitled to receive, disability
income from any of the Employer's disability income or retirement programs.
5. The immediate beneficiary and owner for each Executive named in the Minimum
Premium Summary shall be the same as that shown on the Employer records for
group insurance coverages if being replaced by the Employer. If none exists,
the beneficiary shall be the Estate of the named Executive and ownership
shall be the named Executive. These beneficiary and ownership provisions
will stand until confirmed or changed on the individual application. If an
individual application is not received prior to the Termination Date, interim
coverage will cease, and no further coverage will be provided on the
Executive. Any premium for such coverage will cease accordingly.
6. The Company agrees to issue a policy certificate to each Executive named in
the Minimum Premium Summary for the amount of insurance shown for each
Executive in that Summary no later than [60] days after Termination Date
provided that monthly premium of at least the amounts shown in the Minimum
Premium Summary and a valid signed application on such Executive have been
received. The program is subject to the prescribed participation requirement
for issue of certificates. Nothing contained herein shall be construed as
altering the underwriting parameters established by us. The date of issue of
such policy certificate will be as determined in the Group Contract. Nothing
in this agreement shall be construed as providing for coverage under both
this agreement and the applied for certificate. Further, the Company is not
obligated to provide temporary insurance coverage under this agreement or to
issue a certificate if a material misrepresentation was made regarding the
fact that none of the Executives listed on the Minimum Premium Summary are
receiving, or are entitled to receive, any disability income from any of the
Employer's disability income or retirement plans. Should a policy
certificate be issued for a named Executive, the appropriate minimum premium
will be applied to such policy certificate as of the later of the date of
issue or the receipt of such premium.
7. This agreement is valid only if accompanied by the completed Minimum Premium
Summary and receipt by us of a premium which is no less than that shown said
Summary. Only an officer of the Company can approve this Minimum Premium
Summary or waive or change any part of this agreement, and any such changes
must be made a written part of this agreement.
8. By executing this agreement the Employer certifies certify that all
information and conditions which are contained within it are understood,
agreed to, and viewed as accurate.
For Employer:_________________ Paragon Life Insurance Company
By:___________________________ By:___________________________
Title:________________________ Title:________________________
Date:_________________________ Date:_________________________
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