[LOGO] ALLMERICA
FINANCIAL(R)
Allmerica Financial Life
Insurance and Annuity Company
000 Xxxxxxx Xxxxxx
Xxxxxxxxx, XX 00000
Conditional Receipt for Advance
Payment of Premium
================================================================================
Conditional Insurance Agreement
There is no insurance under this agreement until all the conditions have been
met.
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RECEIPT
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A payment of $____________________ has been received on _________________ with
the application for insurance on the life of
_______________________________________________________________________________.
the proposed insured (for survivorship contracts, please list both proposed
insureds).
ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO THE COMPANY.
DO NOT MAKE CHECKS PAYABLE TO THE AGENT OF LEAVE THE PAYEE BLANK.
Received for the Company by _________________________
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DEFINITIONS
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"Proposed Insured" means the person (or both persons in the case of an
application for a survivorship contract) whose life will be insured if the
application is approved.
"We", "our", and "us" refer to the Company.
"Underwriting Date" means the date of the application, medical questionnaire, or
the Conditional Receipt, whichever date is later. If an Other Insured Rider is
applied for, the "Underwriting Date" for coverage on the Other Insured is the
later of the date of Conditional Receipt, the Supplemental Application for the
Other Insured, or the Medical Exam if required.
"Standard Underwriting Class" means the acceptable under the Company's
underwriting rules for the plan and amount of insurance applied for without any
additional premium change or restrictive rider.
"Non-standard Underwriting Class" means acceptable for the type of insurance
applied for under the Company's underwriting rules but subject to higher charges
or a restrictive rider.
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CONDITIONS TO BE MET
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The following conditions must be met before we have any liability under this
agreement, other than the return of the premium received.
1. The application must be completed and signed by the proposed insured(s)
and the owner, if not the insured.
2. The proposed insured(s) must be in a standard or non-standard
underwriting class on the underwriting date.
3. The proposed insured(s) must be under the age of 71.
4. The proposed insured(s) must have undergone a medical exam if required
by us.
5. If the date of the Conditional Receipt is later than the date of the
medical questionnaire and the Supplemental Application for Other Insured
(if applicable), the proposed insured must not have consulted or been
treated by any physician or practitioner of any healing art nor had any
tests listed in the application since their completion.
If all of the above conditions have been met, some insurance will be provided
under this agreement. However, the insurance will be subject to all of the
further provisions of this agreement.
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LIFE INSURANCE NOT IN EFFECT
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If a person proposed for life insurance is not insurable on either a standard
or a non-standard basis, no life insurance will be in effect.
1CR-97 PAGE 1
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BENEFITS
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Amount of Insurance
If a proposed insured is in a standard underwriting class, the death benefit
provided under this agreement will be the lesser of the amount applied for or
the limit indicated in the Maximum Death Benefit Table below.
If a proposed insured is in a non-standard underwriting class that requires
higher insurance charges to apply, the amount of the death benefit will be
reduced. The reduced benefit is determined by using the same factor or
percentage that applies to the non-standard insurance charges. In no event will
the death benefit exceed the maximum limits indicated in the Maximum Death
Benefit Table below. If a proposed insured is in a non-standard underwriting
class which requires a restrictive rider, the death benefit provided under this
agreement will be the lesser of the following:
(a) the amount applied for;
(b) the maximum limit applicable to the proposed insured; and
(c) the premium paid if the proposed insured's death comes within the terms
of the restrictive rider which would have been attached to the policy
when issued.
Maximum Limit
The maximum limit under this agreement for life insurance is an amount which,
when added to any death benefit provided under any life insurance policy or
conditional insurance agreement having a date of issue or underwriting date,
respectively, within 90 days prior to the underwriting date of this agreement,
does not exceed the amounts listed in the Maximum Death Benefit Table below. The
maximum limit will not be increased because payment has been made to the Company
which is larger than the premium required for such reduced insurance. Upon
receipt of due proof of the death of the proposed insured, that portion of the
premium paid for any excess insurance shall be paid to the beneficiary named in
the application.
Maximum Death Benefit Table
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Standard Underwriting Class Non-Standard Underwriting Class
Age* Range Maximum Death Benefit Maximum Death Benefit
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0-15 years old $50,000 $25,000
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16-60 years old $500,000 $250,000
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61-65 years old $250,000 $125,000
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66-70 years old $100,000 $50,000
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71 years of age and older no benefit no benefit
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*'Age' means how old the Proposed Insured is on his/her nearest birthday. If a
survivorship contract is being applied for, the age of the younger Proposed
Insured is used.
Suicide Exclusion
If a proposed insured commits suicide while this agreement is in effect, the
Company's liability will be limited to the return of the premium paid.
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TERMINATION
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This agreement may be terminated at any time prior to incurrence of a claim.
The Company's sole liability shall be limited to the refund of the premium
paid. Such termination will occur on the earliest of the following:
1. The delivery of the insurance issued on this application.
2. The date the Company mails a termination notice with a refund of your
payment to you.
3. Ninety days after the underwriting date.
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GENERAL
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Any check or draft is accepted subject to collection. No agent or broker is
authorized to amend, alter, or modify the terms of this agreement. All
statements in the application are representations, not warranties. If you do
not hear from us within 60 days of the date of this agreement, please write to
us without delay, stating the facts concerning this application. Our address
is 000 Xxxxxxx Xxxxxx, Xxxxxxxxx, XX 00000.
1CR-97 PAGE 2
[LOGO] ALLMERICA
FINANCIAL(R)
Allmerica Financial Life
Insurance and Annuity Company
000 Xxxxxxx Xxxxxx
Xxxxxxxxx, XX 00000
Supplementary Application for
the Other Insured & Child
Insurance Rider
================================================================================
Name of Basic Insured: _____________________________________________
This application is for: |_| Other Insured Rider
|_| Child Insurance Rider
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1. INSURED(S) The person(s) upon whose life this insurance coverage is proposed.
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Insured A
_________________________________________
Insured Name
________-______-______ |_| M |_| F
Social Security Number Sex
M/____D/____Y/____ ______________
Date of Birth State of Birth
$_____________________________
Existing Life Insurance
$_____________________________
Amount of Insurance Requested
Insured B
_________________________________________
Insured Name
________-______-______ |_| M |_| F
Social Security Number Sex
M/____D/____Y/____ ______________
Date of Birth State of Birth
$_____________________________
Existing Life Insurance
$_____________________________
Amount of Insurance Requested
Insured C
_________________________________________
Insured Name
________-______-______ |_| M |_| F
Social Security Number Sex
M/____D/____Y/____ ______________
Date of Birth State of Birth
$_____________________________
Existing Life Insurance
$_____________________________
Amount of Insurance Requested
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2. INFORMATION ABOUT THE INSURED(S) Please complete the following information.
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Current height and weight
Height _____________ Weight _______________
Weight change during the past 12 months if any: __________________
Name, address, and telephone number of Personal Physician:
__________________________________________________________
__________________________________________________________
__________________________________________________________
(__________)______________________________________________
Date and Reason last consulted:
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Will the proposed rider replace any existing annuity or life insurance
contract(s)?
|_| Yes |_| No
If yes, please complete appropriate Transfer of Assets and/or 1035 Exchange Form
included with this application package. If required, the appropriate state
replacement form must accompany the Transfer of Assets or 1035 Exchange Form.
Current height and weight
Height _____________ Weight _______________
Weight change during the past 12 months if any: __________________
Name, address, and telephone number of Personal Physician:
__________________________________________________________
__________________________________________________________
__________________________________________________________
(__________)______________________________________________
Date and Reason last consulted:
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Will the proposed rider replace any existing annuity or life insurance
contract(s)?
|_| Yes |_| No
If yes, please complete appropriate Transfer of Assets and/or 1035 Exchange Form
included with this application package. If required, the appropriate state
replacement form must accompany the Transfer of Assets or 1035 Exchange Form.
Current height and weight
Height _____________ Weight _______________
Weight change during the past 12 months if any: __________________
Name, address, and telephone number of Personal Physician:
__________________________________________________________
__________________________________________________________
__________________________________________________________
(__________)______________________________________________
Date and Reason last consulted:
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Will the proposed rider replace any existing annuity or life insurance
contract(s)?
|_| Yes |_| No
If yes, please complete appropriate Transfer of Assets and/or 1035 Exchange Form
included with this application package. If required, the appropriate state
replacement form must accompany the Transfer of Assets or 1035 Exchange Form.
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3. BENEFICIARY The person or entity to whom policy proceeds are payable.
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The beneficiary shall be the owner, if living, otherwise the owner's estate,
unless this right is expressly released. The owner may name another as
beneficiary (attach 'Nomination of Beneficiary and Request' form, if
applicable).
1SCR-97 PAGE 1
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4. MEDICAL HISTORY The medical history of the person(s) upon whose life this
insurance coverage is proposed.
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Has any person listed in Section 1 of this application: Insured A Insured B Insured C
4a. Had an illness or injury during the past 6
months that has prevented him/her from
working five consecutive days? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4b. During the past 3 years had their motor
vehicle license suspended or revoked, been
convicted of driving while intoxicated, or
been convicted of more than one moving
violation? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4c. During the past 3 years participated in or
intend to participated in scuba diving,
parachuting, motor racing, hang gliding or
similar flying activity? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4d. During the past 3 years flown, or intend to
fly, as a trainee, pilot or crew member? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4e. During the past 12 months, smoked one or
more cigarettes? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4f. Currently been using cigars, pipes, chewing
tobacco or other tobacco products? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4g. Made plans to travel outside the United
States or Canada? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4h. Ever had a life or health insurance
application declined, postponed, modified,
or rated? |_| Y |_| N |_| Y |_| N |_| Y |_| N
During the past 10 years, has any person listed in
Section 1 of this application had, been told
he/she had, or been treated for:
4i. Disorder of the eyes, ears, nose or throat? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4j. High blood pressure, chest pain, heart
attack, heart murmur, stroke, or other
cardiac disorder? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4k. Disorder of the kidneys, prostate,
genito-urinary tract, or reproductive
system, or any sexually transmitted disease
(other than AIDS, ARC)? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4l. Any immune system disorder, including
Acquired Immune Deficiency Syndrome (AIDS),
or AIDS-related complex (ARC)? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4m. Diabetes, thyroid disorder, or other
endocrine gland disorder? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4n. Ulcers, hepatitis, colon polyp, colitis,
disorder of the pancreas, liver, or
intestines? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4o. Asthma, shortness of breath, disorder of
the blood, lymph glands, or respiratory
system? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4p. Cancer, tumors, arthritis, disorder of the
skin, muscles, bones, joints, or connective
tissue disease? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4q. Mental, nervous, or brain disorder,
depression, suicide attempt, seizures,
headaches, dizziness, or fainting? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4r. Alcoholism, or have you been advised to
reduce or discontinue the use of alcohol
for health reasons? |_| Y |_| N |_| Y |_| N |_| Y |_| N
During the past 5 years, has any person listed in
Section 1 of this application:
4s. Used or received treatment or counseling
for marijuana, cocaine, barbiturates,
narcotics, excitants, or hallucinogens,
except as prescribed medication? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4t. Been a patient in a hospital, clinic,
sanitarium, or other medical facility or
been advised to have a test or surgery that
was not done? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4u. Consulted for any reason other than any
listed above, a physician or other physical
or mental health advisor? |_| Y |_| N |_| Y |_| N |_| Y |_| N
4v. Is any person listed in Section 1 currently
taking any medication? |_| Y |_| N |_| Y |_| N |_| Y |_| N
1SCR-97 PAGE 2
Please explain any 'yes' answers to 4a-4v here. Please indicate the insured
being described. You may continue on a separate sheet of paper if necessary.
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Insured Question Condition/Diagnosis Medication/Treatment Date Still Being Physician/Address
A,B,C # Treated?
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5. ACKNOWLEDGEMENTS AND SIGNATURES
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IT IS UNDERSTOOD AND AGREED: (1) That the representations above recorded are
true and complete to the best of my knowledge and belief; (2) That no
liability exists until this rider is delivered and the first premium paid
during the lifetime of the proposed Insured(s) and then only if the proposed
Insured(s) has (have) not consulted or been treated by any physician or
practitioner of any healing art nor had any special tests since the date of
this application; but, if the premium is paid prior to the delivery of the
rider and a conditional receipt is delivered by a registered representative,
insurance shall be effective subject to the terms of the conditional receipt;
(3) No registered representative or broker is authorized to amend, alter, or
modify the terms of this agreement.
This application is made at the request of the undersigned who hereby agrees
to be bound by each statement, representation, and agreement herein, and
further agrees that any policy of insurance issued in connection with this
application shall be issued on the condition that each statement,
representation, and agreement shall be binding upon the owner(s) to the same
extent and degree as if made by the owner(s).
X_____________________________________________________ _______________________
Full signature of Insured under the rider or Date
applicant for Child Rider
X_____________________________________________________ _______________________
Full signature(s) of Owner(s) of the policy Date
under the rider or applicant for Child Rider
______________________________________________________
Official Title/Capacity (cannot be Insured)
______________________________________________________ _______________________
Signed at City State
1SCR-97 PAGE 3
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6. INFORMATION ABOUT THE INSURED(S) TO BE COMPLETED BY THE AGENT
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Please complete the Questions 6a - 6d if this application is for the Other
Insured Rider (OIR):
6a. The need for the proposed insurance is: ____________________________________
6b. The supporting spouse or parent is insured for the benefit of the family.
The amount of insurance is: $ ______________________________________________
6c. The supporting spouse or parent is not insured because: ____________________
____________________________________________________________________________
6d. Supporting spouse's/parent's Name, Date of Birth, and Income: ______________
____________________________________________________________________________
Please complete Questions 6e - 6f if this application is for the Child
Insurance Rider (CIR):
6e. Are all children who have not reached their 18th birthday included in this
application? |_| Yes |_| No
If no, please explain: ________________________________________________
_______________________________________________________________________
6f. How long have you known the parent/person with whom the children
are living? ________________________________________________________________
If children are living with a person other than the proposed Insured,
please explain: ________________________________________________________
________________________________________________________________________
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7. AGENT'S SIGNATURE
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Agent/Registered Representative Statement
As Registered Representative, I certify witnessing the signature of the
applicant and that all information, statements, and answers in this
application are correct, complete, and true and have been accurately recorded,
to the best of my knowledge and belief. Based on the information furnished by
the Owner or Insured in this application, I certify that I have reasonable
grounds for believing the purchase of the policy applied for is suitable for
the Owner. I further certify that the Prospectuses were delivered and that no
written sales materials other than those furnished or approved by the Company
were used.
It is hereby stated that I/we personally solicited this application and except
as specified below, no other agent or broker has any commission interest in
this sale. (If more than one agent indicate split, otherwise the Company
assumes that any division of commission is in equal shares.)
Signature of Licensed Agent: ___________________________________________________
Underwriting Approval: ___________________________________________________
1SCR-97 PAGE 4
[LOGO] ALLMERICA
FINANCIAL(R)
Allmerica Financial Life
Insurance and Annuity Company
000 Xxxxxxx Xxxxxx
Xxxxxxxxx, XX 00000
Variable Life Application
(Part II)
================================================================================
Insured: _________________________________________ D.O.B.:___/___/___
Social Security Number:___________________
2nd Insured:______________________________________ D.O.B.:___/___/___
Social Security Number:___________________
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1. MEDICAL HISTORY Medical history of the person(s) upon whose life insurance
coverage is proposed.
--------------------------------------------------------------------------------
Insured 2nd Insured
1a. Have you ever had a life or health insurance
application declined, postponed, modified, or
rated? |_| Y |_| N |_| Y |_| N
During the past 10 years, have you had, been told you
had, or been treated for:
1b. Disorder of the eyes, ears, nose or throat? |_| Y |_| N |_| Y |_| N
1c. High blood pressure, chest pain, heart attack,
heart murmur, stroke, or other cardiac disorder? |_| Y |_| N |_| Y |_| N
1d. Disorder of the kidneys, prostate, genito-urinary
tract, or reproductive system, or any sexually
transmitted disease (other than AIDS, ARC)? |_| Y |_| N |_| Y |_| N
1e. Any immune system disorder including Acquired
Immune Deficiency Syndrome (AIDS), or AIDS-related
complex (ARC)? |_| Y |_| N |_| Y |_| N
1f. Diabetes, thyroid disorder, or other endocrine
gland disorder? |_| Y |_| N |_| Y |_| N
1g. Ulcers, hepatitis, colon polyp, colitis, disorder
of the pancreas, liver, or intestines? |_| Y |_| N |_| Y |_| N
1h. Asthma, shortness of breath, disorder of the
blood, lymph glands, or respiratory system? |_| Y |_| N |_| Y |_| N
1i. Cancer, tumors, arthritis, disorder of the skin,
muscles, bones, joints, or connective tissue
disease? |_| Y |_| N |_| Y |_| N
1j. Mental, nervous, or brain disorder, depression,
suicide attempt, seizures, headaches, dizziness,
or fainting? |_| Y |_| N |_| Y |_| N
1k. Alcoholism, or have you been advised to reduce or
discontinue the use of alcohol for health reasons? |_| Y |_| N |_| Y |_| N
During the past 5 years, have you:
1l. Used or received treatment or counseling for
marijuana, cocaine, barbiturates, narcotics,
excitants, or hallucinogens, except as prescribed
medication? |_| Y |_| N |_| Y |_| N
1m. Been a patient in a hospital, clinic, sanitarium,
or other medical facility or been advised to have
a test or surgery that was not done? |_| Y |_| N |_| Y |_| N
1n. Are you currently taking any medication? |_| Y |_| N |_| Y |_| N
1o. Have you consulted for any reason other than any
listed above, a physician or other physical or
mental health advisor? |_| Y |_| N |_| Y |_| N
Please provide additional information for any 'yes' answers in Section 4.
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2. FAMILY HISTORY Please complete the following Family Record.
--------------------------------------------------------------------------------
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Family Record Age if Living Present State of Health or Cause of Death Age at Death
1st Insured 2nd Insured 1st Insured 2nd Insured 1st Insured 2nd Insured
-----------------------------------------------------------------------------------------------------------
Father
-----------------------------------------------------------------------------------------------------------
Mother
-----------------------------------------------------------------------------------------------------------
Siblings
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1AM-97 PAGE 1
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3. PHYSICAL CONDITION Physical condition of the person(s) upon whose life
insurance coverage is proposed.
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Insured
3a. Name, address and telephone number of personal physician
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Date and Reason Last Consulted: _____________________________
_____________________________________________________________
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3b. Do you engage in a scheduled exercise program?
|_| Yes |_| No If yes, please give details (duration, type, frequency):
_____________________________________________________________
_____________________________________________________________
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3c. Are you currently pregnant? |_| Yes |_| No
If yes, please give expected delivery date: _____________
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3d. Please provide your current height and weight.
Height:_______________ Weight: __________________
Weight change during the past 12 months, if any:_________
2nd Insured
Name, address and telephone number of personal physician
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Date and Reason Last Consulted: _____________________________
_____________________________________________________________
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Do you engage in a scheduled exercise program?
|_| Yes |_| No If yes, please give details (duration, type, frequency):
_____________________________________________________________
_____________________________________________________________
--------------------------------------------------------------------------------
Are you currently pregnant? |_| Yes |_| No
If yes, please give expected delivery date: _____________
--------------------------------------------------------------------------------
Please provide your current height and weight.
Height:_______________ Weight: __________________
Weight change during the past 12 months, if any:_________
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4. ADDITIONAL MEDICAL INFORMATION Complete for appropriate items in Section
1a-1o. Please specify 1st or 2nd Insured. Continue on a separate sheet of
paper if necessary.
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1st/2nd Question Condition/Diagnosis Medication/Treatment Date Still Being Physician/Address
Insured # Treated?
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ACKNOWLEDGEMENTS & SIGNATURES
--------------------------------------------------------------------------------
I understand and agree that the foregoing statements and answers are correct,
complete and true and have been accurately recorded to the best of my knowledge
and belief, and that they shall be part of the policy if issued.
X______________________________________ X__________________________________
Signature of Proposed Insured Signature of Proposed 2nd Insured
(if applicable)
X______________________________________ ___________________________________
Signature of Examiner/Agent Date
1AM-97 PAGE 2
[LOGO] ALLMERICA
FINANCIAL(R)
Allmerica Financial Life
Insurance and Annuity Company
000 Xxxxxxx Xxxxxx
Xxxxxxxxx, XX 00000
Variable Life Application
(Part I)
================================================================================
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1. INSURED The person upon whose life this insurance coverage is proposed.
--------------------------------------------------------------------------------
_________________________________________________________
First Name Middle Last
_________________________________________________________
Street Address Years at this Address
_________________________________________________________
City State Zip
M/____D/____ Y/____ ______________ |_| M |_| F
Date of Birth State of Birth Sex
______________________________
Social Security Number
______________________________ ___________
Driver's License Number State
_________________________________________________________
Employer/Occupation
$___________________ $__________________
Annual Income Net Worth
(______)____________ (______)___________
Home Phone Business Phone
Allmerica or its representatives may contact you to discuss this application.
The best time for us to call is ____________________ at your
|_| Home |_| Business
--------------------------------------------------------------------------------
2. SECOND INSURED If completed, survivorship insurance coverage will be issued.
--------------------------------------------------------------------------------
_________________________________________________________
First Name Middle Last
_________________________________________________________
Street Address Years at this Address
_________________________________________________________
City State Zip
M/____D/____ Y/____ ______________ |_| M |_| F
Date of Birth State of Birth Sex
______________________________
Social Security Number
______________________________ ___________
Driver's License Number State
_________________________________________________________
Employer/Occupation
$___________________ $__________________
Annual Income Net Worth
(______)____________ (______)___________
Home Phone Business Phone
Allmerica or its representatives may contact you to discuss this application.
The best time for us to call is ____________________ at your
|_| Home |_| Business
--------------------------------------------------------------------------------
3. INSURANCE How much life insurance coverage I would like.
--------------------------------------------------------------------------------
3a. Life Insurance amount applied for $ _________________
3b. Life Insurance plan applied for _____________________
3c. I would like insurance coverage to be: (Choose one)
|_| Level (Option 1) |_| Adjustable (Option 2)
3d. I want the following additional insurance benefits:
|_| Accidental Death Benefit $_______________________
|_| Waiver Premium upon disability |_| Living Benefits Rider
|_| Waiver Charges upon disability |_| Exchange Option Rider
|_| Guaranteed Insurability Rider $__________________
|_| Child Insurance Rider (Complete Supplementary Application)
|_| Other Insured Rider (Complete Supplementary Application)
|_| 4 Year Term (Survivorship Coverage Only)
|_| Split Option (Survivorship Coverage Only)
|_| _________________________________________________
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4. BENEFICIARY The person or entity to whom policy proceeds are payable.
--------------------------------------------------------------------------------
_________________________________________________________
Name of Primary Beneficiary Relationship to Insured
_________________________________________________________
Social Security/Tax I.D. Number
_________________________________________________________
Name of Contingent Beneficiary Relationship to Insured
_________________________________________________________
Social Security/Tax I.D. Number
|_| 10-day Common Disaster Clause*
|_| _____-day Common Disaster Clause*
* A Common Disaster Clause requires that the Beneficiary survive the Insured for
a specified length of time before becoming entitled to the policy proceeds. The
Contingent Beneficiary will receive the policy proceeds rather than the estate
of the Primary Beneficiary.
--------------------------------------------------------------------------------
5. POLICYOWNER The person or entity exercising the rights under this contract.
--------------------------------------------------------------------------------
The policyowner will be the insured unless specified here.
_________________________________________________________
Name
_________________________________________________________
Social Security/Tax I.D. Number
_________________________________________________________
Street Address
_________________________________________________________
City State Zip
______/_____/_________
Date of Trust (if applicable)
1A-97 PAGE 1
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6. PAYMENT The monetary contribution to the policy.
--------------------------------------------------------------------------------
Initial Payment (Check one):
|_| I have enclosed a check for my initial payment of $ _______ and have
received a Conditional Receipt.
(Please make check payable to Allmerica Financial)
|_| My initial payment will be transferred from another company.
Approximate amount $ _____________
Future payments:
Amount $_________________
|_| Monthly |_| Quarterly |_| Semi-Annually |_| Annually
(If monthly, include a voided check & 'Bank Drafting Application' form) Premium
Notices will be mailed to the Owner's home address unless otherwise specified in
the "Remarks" section of this application.
--------------------------------------------------------------------------------
7. ALLOCATION How I want my payments invested.
--------------------------------------------------------------------------------
7a. Allocate payment as follows: Use whole percentages. You may allocate your
payments to no more than 20 of the variable accounts listed below.
_______ % Allmerica Select Aggressive Growth Fund
_______ % Allmerica Select Capital Appreciation Fund
_______ % Allmerica Select Value Opportunity Fund
_______ % Allmerica Select Emerging Markets Fund
_______ % X. Xxxx Price International Stock Portfolio
_______ % Fidelity VIP Overseas Portfolio
_______ % Allmerica Select International Equity Fund
_______ % Delaware International Equity Series
_______ % Fidelity VIP Growth Portfolio
_______ % Allmerica Select Growth Fund
_______ % Allmerica Select Strategic Growth Fund
_______ % Allmerica Growth Fund
_______ % Allmerica Equity Index Fund
_______ % Fidelity VIP Equity-Income Portfolio
_______ % Allmerica Select Growth and Income Fund
_______ % Fidelity VIP II Asset Manager Portfolio
_______ % Fidelity VIP High Income Portfolio
_______ % Allmerica Investment Grade Income Fund
_______ % Allmerica Government Bond Fund
_______ % Allmerica Money Market Fund
_______ % General Account
_______ %
_______ %
_______ %
_______ % Total
7b. Deductions of all charges will be made pro rata according to the value of
each account and the General Account, unless specified below:
|_| Deduct all charges from ________________________
(Enter any single account except the General Account)
--------------------------------------------------------------------------------
8. AUTOMATIC ACCOUNT REBALANCING
--------------------------------------------------------------------------------
|_| I elect Automatic Account Rebalancing among the variable accounts to the
allocation specified in Section 7:
|_| Monthly |_| Quarterly |_| Semi-Annually |_| Annually
NOTE: Automatic Account Rebalancing and Dollar Cost Averaging cannot be in
effect simultaneously.
--------------------------------------------------------------------------------
9. DOLLAR COST AVERAGING
--------------------------------------------------------------------------------
Transfer $ _______________ ($100 minimum)
Select one account from which to transfer money.
From:
|_| Government Bond |_| Allmerica Money Market Fund
Every:
|_| Monthly |_| Quarterly |_| 6 Months |_| 12 Months
To
$ _______ Allmerica Select Aggressive Growth Fund
$ _______ Allmerica Select Capital Appreciation Fund
$ _______ Allmerica Select Value Opportunity Fund
$ _______ Allmerica Select Emerging Markets Fund
$ _______ X. Xxxx Price International Stock Portfolio
$ _______ Fidelity VIP Overseas Portfolio
$ _______ Allmerica Select International Equity Fund
$ _______ Delaware International Equity Series
$ _______ Fidelity VIP Growth Portfolio
$ _______ Allmerica Select Growth Fund
$ _______ Allmerica Select Strategic Growth Fund
$ _______ Allmerica Growth Fund
$ _______ Allmerica Equity Index Fund
$ _______ Fidelity VIP Equity-Income Portfolio
$ _______ Allmerica Select Growth and Income Fund
$ _______ Fidelity VIP II Asset Manager Portfolio
$ _______ Fidelity VIP High Income Portfolio
$ _______ Allmerica Investment Grade Income Fund
$ _______ Allmerica Government Bond Fund
$ _______ Allmerica Money Market Fund
$ _______ General Account
$ _______
$ _______
--------------------------------------------------------------------------------
10. TELEPHONE TRANSFER
--------------------------------------------------------------------------------
Unless I check the box below I will automatically be able to transfer account
values and change the allocation of future investments by telephone or fax.
I understand that the Company is authorized to honor telephone requests by me or
by individuals authorized by me, to transfer account values among sub-accounts
and to change the allocation of my future payments.
|_| I do not accept this telephone transfer privilege.
--------------------------------------------------------------------------------
11. REPLACING OTHER CONTRACTS
--------------------------------------------------------------------------------
Will the proposed policy replace any existing annuity or life insurance
contract(s):
Insured: |_| Yes |_| No
2nd Insured: |_| Yes |_| No
If yes, please complete the appropriate Transfer of Assets or 1035 Exchange Form
included with this application package.
1A-97 PAGE 2
--------------------------------------------------------------------------------
12. INFORMATION ABOUT INSURED(S)
--------------------------------------------------------------------------------
12a. Have you had an illness or injury during the past 6 months that has
prevented you from working five consecutive days?
Insured: |_| Yes |_| No
2nd Insured: |_| Yes |_| No
12b. During the past 3 years have you had your motor vehicle license suspended
or revoked, been convicted or driving while intoxicated, or been convicted
of more than one moving violation?
Insured: |_| Yes |_| No
2nd Insured: |_| Yes |_| No
12c. During the past 3 years, have you participated in or do you intend to
participate in scuba diving, parachuting, motor racing, hang gliding or
similar flying activity?
Insured: |_| Yes |_| No
2nd Insured: |_| Yes |_| No
12d. During the past 3 years have you flown, or do you intend to fly as a
trainee, pilot or crew member?
Insured: |_| Yes |_| No
2nd Insured: |_| Yes |_| No
12e. During the past 12 months, have you smoked one or more cigarettes?
Insured: |_| Yes |_| No
2nd Insured: |_| Yes |_| No
12f. Do you currently use cigars, pipes, chewing tobacco or other tobacco
products?
Insured: |_| Yes |_| No
2nd Insured: |_| Yes |_| No
12g. Will you be travelling outside the U.S. or Canada?
Insured: |_| Yes |_| No
2nd Insured: |_| Yes |_| No
Name, address and telephone number of personal
physician, and the date/reason last consulted:
Insured:_________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
2nd Insured:_____________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Please explain any "yes" answers to 12a-12g. Specify 1st or 2nd Insured.
Continue on separate sheet if necessary.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
--------------------------------------------------------------------------------
13. SUITABILITY Insureds, Owners, and Agents MUST review and complete this
section.
--------------------------------------------------------------------------------
13a. Reason for Insurance:
|_| Estate Taxes |_| Family Income |_| Death Benefit
|_| Retirement Income |_| Cash Accumulation
|_| Business Insurance |_| Fund Business Agreement
|_| Gift |_| Other
13b. Owner's estimated financial data:
Securities: $_________ Savings: $_________
Liquid Net Worth: $___________ Tax Bracket: _______%
Gross Annual Income: $_____________________________
13c. Risk profile:
|_| Conservative |_| Moderate |_| Aggressive
Source of Funds: ___________________________________
13d. Investment objective:
|_| Emphasize Growth |_| Emphasize Stability
|_| Balances Growth and Stability
13e. Are any |_| life insurance, |_| annuities, |_| mutual funds, |_|
securities, or |_| unmatured CD's being liquidated to purchase this
variable life insurance policy?
If yes, a switching letter signed by the policyowner is attached:
|_| Yes |_| No
If yes, has the agent explained the potential advantages and disadvantages
of this transaction?
|_| Yes |_| No
13f. Are you an associated person of another broker or dealer?
|_| Yes |_| No
13g. Have you received a current prospectus describing the variable life
insurance policy, including the underlying funds, and do you believe that a
flexible-premium variable life insurance policy is consistent with your
investment objectives and financial needs?
|_| Yes |_| No
Authorization:
____________________________________________________ ___________________
(Completed by a Home Office Registered Principal) Date
1A-97 PAGE 3
--------------------------------------------------------------------------------
14. ACKNOWLEDGEMENTS & AUTHORIZATIONS
--------------------------------------------------------------------------------
Authorization to Obtain Information
To all physicians, medical professionals, hospitals, clinics, other health care
providers, employers, Medical Information Bureau, Inc. (MIB), consumer reporting
agencies, other insurance support organizations, the united States Internal
Revenue Service, the Puerto Rice Bureau of Income Tax, and other persons who
have the types of information described about the proposed insured:
I authorize you to give the Company, its reinsurers, or its agent (a) all
information you have as to illness, injury, medical history, diagnosis,
treatment, and prognosis (including any drug or alcohol abuse condition or
treatment) with respect to any physical or mental condition of the proposed
Insured; and (b) any non-medical information including, but not limited to, an
investigative consumer reports and copies of my tax returns filed with the
United States Internal Revenue Service and/or the Puerto Rico Bureau of Income
Tax, that the Company believes it needs to perform the business functions
described below. I also authorize the Company to give the MIB health or
non-medical information it has about me and that of any minor member of my
family applying for insurance.
The information obtained will be used to determine if the proposed insured is
eligible for: (a) the insurance requested; or (b) benefits under a policy which
is in force. It will also be used for any other business purpose which relates
to the insurance requested or the policy which is in force.
This authorization will be valid for 30 months. I know that under federal
Regulations I may revoke this authorization as it applies to drug and alcohol
abuse treatment information at any time, but my revocation will not affect any
information that has been released prior thereto. I know that I may request a
copy of this form. I agree that a photocopy is as valid as the original. I have
received the Insurance Information Practices notice.
--------------------------------------------------------------------------------
I understand that any death benefit in excess of the face amount, the policy
value allocated to the variable account, and/or the duration of coverage for the
flexible premium variable life insurance policy applied for, may increase or
decrease to reflect the investment experience of the sub-accounts and are not
guaranteed as to dollar amount. The policy value allocated to the General
Account will accumulate interest at a rate set by the Company which shall not be
less than the minimum guaranteed rate of 4% annually. There is no guaranteed
minimum policy value. The policy value may decrease to the point where the
policy will lapse and provide no further death benefit without additional
premium payments.
IT IS UNDERSTOOD AND AGREED THAT: (1) The application consists of this
application form and the medical questionnaire; (2) The representations are true
and complete to the best of my knowledge and belief; (3) No liability exists and
the insurance applied for will not take effect until the policy is delivered and
the payment is made during the lifetime of the proposed Insured(s) and then only
if the proposed Insured(s) has (have) not consulted or been treated by any
physician or practitioner of any healing art or had any tests listed in the
application since its completion; but if the payment is paid prior to delivery
of the policy and a conditional receipt is delivered by the registered
representative, insurance will be effective subject to the terms of the
conditional receipt; and (4) No registered representative or broker is
authorized to amend, alter, or modify the terms of this agreement.
X_____________________________________ X______________________________________
Signature of Insured Date Signature of Spouse Date
(if application is for Other
Insured Rider)
______________________________________ _______________________________________
Print Name of Insured Print Name of Spouse
X_____________________________________ _______________________________________
Signature of 2nd Insured Date Signed at City State
______________________________________
Print Name of 2nd Insured
X_____________________________________
Signature of Owner Date
(if other than Insured)
______________________________________
Print Name of Owner
1A-97 PAGE 4
Agent's Report
--------------------------------------------------------------------------------
15. REPLACEMENT Agents are required to complete this section.
--------------------------------------------------------------------------------
Is the insurance being applied for considered a replacement according to its
definition in the replacement regulations (if any) of the state in which the
business was written? (send Replacement and/or 1035 Exchange forms where
applicable)
|_| Yes |_| No
Indicate any replacement in the chart below.
--------------------------------------------------------------------------------
16. LIFE INSURANCE IN EFFECT Agents are required to complete this section.
--------------------------------------------------------------------------------
Please list all life insurance currently in effect; indicate if insurance being
applied for will replace any of the listed policies:
---------------------------------------------------------------------------------------------
Company/Policy # Year Amount Accidental Waiver Replacing Other
Personal Business Death Benefit Policies?*
---------------------------------------------------------------------------------------------
$ $ $ |_| Yes |_| No |_| Yes |_| No
---------------------------------------------------------------------------------------------
|_| Yes |_| No |_| Yes |_| No
---------------------------------------------------------------------------------------------
|_| Yes |_| No |_| Yes |_| No
---------------------------------------------------------------------------------------------
|_| Yes |_| No |_| Yes |_| No
---------------------------------------------------------------------------------------------
|_| Yes |_| No |_| Yes |_| No
---------------------------------------------------------------------------------------------
Total $ $ $
--------------------------------------------------------------------
*If life insurance applied for is replacing existing policy
--------------------------------------------------------------------------------
17. BUSINESS INSURANCE Please complete this section if business insurance is
applied for.
--------------------------------------------------------------------------------
17a. Social Security or Tax I.D. Number: _______________________________________
17b. Business Address: _________________________________________________________
_________________________________________________________
_________________________________________________________
17c. Type of Business: |_| Corporation |_| S-Corporation |_| Partnership
|_| Sole Proprietorship
17d. Date Incorporated/Organized: _________________ State Incorporated: ________
Number of Employees: ___________
17e. Have directors authorized this application? |_| Yes |_| No
17f. How long has the Insured been employed by or worked
with the owner? _____________________
Salary: $ ________________ $ _____________________
(Last Year) (Previous Year)
17g. Net Earnings for Business for: $ ____________________ $ ___________________
(Last Year) (Previous Year)
17h. Percentage of Business owned by Insured:________________%
1A-97 PAGE 5
17i. Purpose for Insurance: |_| Stock Purchase |_| Split Dollar
|_| Stock Redemption |_| Executive Bonus |_| Deferred Compensation
|_| Business Keyperson |_| Executive Income Plan |_| Other
17j. Aggregate Business Insurance Authorized on this in all companies: $________
17k. Please list all other partners or associates. If any are insured or
proposed for business coverage, please include titles, amounts, and
companies:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
--------------------------------------------------------------------------------
18. AGENT'S SIGNATURE
--------------------------------------------------------------------------------
As Registered Representative, I certify witnessing the signature of the
applicant and that all information, statements, and answers in this application
are correct, complete, and true and have been accurately recorded, to the best
of my knowledge and belief. Based on the information furnished by the Owner or
Insured in this application, I certify that I have reasonable grounds for
believing the purchase of the policy applied for is suitable for the Owner. I
further certify that the Prospectuses were delivered and that no written sales
materials other than those furnished or approved by the Company were used.
It is hereby stated that I/we personally solicited this application and, except
as specified below, no other agent or broker has any commission interest in this
sale. (If more than one agent indicate split, otherwise the Company assumes that
any division of commission is in equal in shares.)
X__________________________________________ _____________
Signature of Registered Representative %
___________________________________________ _____________
Print Name of Registered Representative Date
__________________________________________________________
Agency Name/Code
X__________________________________________ _____________
Signature of Registered Representative %
___________________________________________ _____________
Print Name of Registered Representative Date
__________________________________________________________
Agency Name/Code
X__________________________________________ _____________
Signature of Registered Representative %
___________________________________________ _____________
Print Name of Registered Representative Date
__________________________________________________________
Agency Name/Code
X__________________________________________ _____________
Signature of Registered Representative %
___________________________________________ _____________
Print Name of Registered Representative Date
__________________________________________________________
Agency Name/Code
--------------------------------------------------------------------------------
REMARKS
--------------------------------------------------------------------------------
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
--------------------------------------------------------------------------------
FOR HOME OFFICE USE ONLY
--------------------------------------------------------------------------------
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
1A-97 PAGE 6
================================================================================
FIRST ALLMERICA FINANCIAL LIFE INSURANCE COMPANY
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
WORCESTER, MASSACHUSETTS 01653
APPLICATION FOR
INDIVIDUAL ADULT LIFE BASIC PACKAGE
AND/OR HEALTH INSURANCE
INSURANCE INFORMATION PRACTICES
Name of Proposed Insured________________________________________________________
Personal information about you may be obtained from persons other than you. You
have a right of access and correction with respect to personal information
obtained about you. The Company may in some cases also disclose personal or
privileged information it has about you to other third parties without your
authorization. A detailed description of the Company's information practices
will be furnished on your request.
Any request for information should be directed to Individual Insurance
Underwriting at the Home Office.
Medical Information Bureau Pre-Notice
Information regarding your insurability and/or any past or future claims will be
treated as confidential. The Company, or its reinsurers, may, however, make a
brief report thereon to the Medical Information Bureau, a nonprofit membership
organization of life insurance companies which operates an information exchange
on behalf of its members. If you apply to another Bureau member company for life
or health insurance coverage, or a claim for benefits is submitted to such a
company, the Bureau, upon request, will supply such company with the information
in its file.
Upon receipt of your request, the Medical Information Bureau, will arrange for
disclosure of the information about you contained in its file. If you question
the accuracy of the information in the Bureau's file, you may contact the Bureau
to seek a correction in accordance with the procedure established in the Federal
Fair Credit Reporting Act. The address of the Bureau's Information office is
P.O. Box 105, Essex Station, Boston, Massachusetts 02112: the Bureau's telephone
number is (000) 000-0000.
The Company, or its reinsurers, may also release information in its file to
other life insurance companies to whom you may apply for life or health
insurance, or to whom a claim for benefits may be submitted.
Fair Credit Reporting Act Pre-Notice
In making this application for insurance it is understood that an investigative
consumer report may be made. Information will be obtained through personal
interviews with third parties such as family members, business associates,
financial sources, friends, neighbors or others with whom you are acquainted.
This inquiry includes information as to your character, general reputation,
personal characteristics and mode of living, whichever may be applicable. Upon
written request, you will be told if an investigative consumer report has been
ordered. If so, you may ask to be interviewed in connection with its
preparation. You have the right to make a written request within a reasonable
period of time for a complete and accurate disclosure of additional information
concerning the nature and scope of the investigative consumer report. You also
have the right to inspect and obtain a copy of the investigative consumer report
from the investigating consumer reporting agency.
Personal Information Telephone Interview
Thank you for your application for insurance. While an underwriter is evaluating
your application, we may ask one of our Home Office Interviewers to contact you
for additional information. Whenever possible, calls will be made at your
convenience and to the telephone number you have provided. Your agent will
review with you the information we need to initiate the call and will record it
on a separate form.
FORM 05207-90 (9/95) ADULT
CONDITIONAL RECEIPT FOR
ADVANCE PAYMENT OF PREMIUM Worcester, Massachusetts 01653
No. 315076
|_| FIRST ALLMERICA FINANCIAL LIFE INSURANCE COMPANY (THE "COMPANY")
|_| ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY (THE "COMPANY")
(check one)
--------------------------------------------------------------------------------
Advance payment of $ _______(Life) $ _______ (Health) on _______ (date) with the
application for insurance has been received on the life of ____________________,
the proposed insured. This receipt bears the same serial numbers as the
application.
Received for the Company by ___________________
CONDITIONAL INSURANCE AGREEMENT
THERE IS NO INSURANCE UNDER THIS AGREEMENT UNTIL ALL THE CONDITIONS
HAVE BEEN MET.
GENERAL
Definitions
"Underwriting Date" means the date of Part I, Part II, the Conditional Receipt
or the Medical Exam, whichever date is later. If an Other Insured Rider is
applied for, the "Underwriting Date" for coverage on the Other Insured is the
later of the date of the Conditional Receipt, the Part IA or the Medical Exam if
required.
"Insurable on a standard basis" means acceptable under the Company's
underwriting rules for the plan and amount of insurance applied for without any
additional premium charge or restrictive rider.
"Insurable on a non-standard basis" means acceptable for the type of insurance
applied for under the Company's underwriting rules but not on a standard basis.
General
Any check or draft is accepted subject to collection. No agent or broker is
authorized to amend, alter, or modify the terms of this agreement. All
statements in the application are representations, not warranties. If you do not
hear from us within 60 days of the date of this agreement, please write to us
without delay, stating the facts concerning the application. Our address is 000
Xxxxxxx Xxxxxx, Xxxxxxxxx, XX 00000.
CONDITIONS TO BE MET
Conditions Precedent
The following conditions precedent must be met before we have any liability
under this agreement other than the return of the premium received:
1. The application must be completed and signed by the proposed
insured(s) and the owner, if not the insured.
2. The proposed insured(s) must be insurable on either a standard or
non-standard basis on the underwriting date if life insurance only
is applied for. The proposed insured(s) must be insurable on a
standard basis on the underwriting date for any health insurance.
3. The proposed insured(s) must be under the age of 71 for life
insurance and under the age of 61 for health insurance.
4. The proposed insured(s) must have undergone a medical exam if
required by us.
5. If the date of the Conditional Receipt is later than the date of
Part II and Part IA (if applicable), the proposed insured must not
have consulted or been treated by any physician or practitioner of
any healing art nor had any tests listed in the application since
the completion of Part II and Part IA.
If all of the conditions have been met, some insurance will be provided under
this agreement. However, the insurance will be subject to all of the further
provisions of this agreement.
Insurance Not in Force. If application is made for both health and life
insurance, no health insurance will be in force on any proposed insured who is
insurable on a non-standard basis.
If a person proposed for life insurance is not insurable on either a standard or
a non-standard basis, no life or health insurance will be in force.
--------------------------------------------------------------------------------
Form 1CR-87 Rev. 9/95
--------------------------------------------------------------------------------
BENEFITS
Amount of Insurance - Life. If a proposed insured is insurable on a standard
basis, the death benefit provided under this agreement will be the lesser of the
amount applied for or the limit described below.
If a proposed insured is insurable on a non-standard basis which requires a
higher premium than the premium on the policy applied for, the amount of the
death benefit will be reduced. The reduced benefit will be in the same ratio to
the amount applied for as the premium paid with this receipt is to the total
premium that would be required on the plan the Company is willing to issue; but
in no event more than the maximum limit set forth below.
If the proposed insured is insurable on a non-standard basis which does not
require a higher premium, the death benefit provided under this agreement will
be the lesser of the following:
(a) the amount applied for;
(b) the maximum limit applicable to the proposed insured; and
(c) the premium paid if the proposed insured's death comes within the
terms of the restrictive rider which would have been attached to the
policy when used.
Maximum Limit - Life Insurance. The maximum limit under this agreement for life
insurance, including accidental death benefit, is an amount which when added to
any death benefit provided under any life insurance policy or conditional
insurance agreement having a date of issue or underwriting date respectively
within 90 days prior to the underwriting date of this agreement does not exceed
the following applicable amounts:
(a) If insurable on a standard basis, for issue ages 0 through 15,
$50,000; 16 through 60, $500,000; 61 through 65, $250,000; 66
through 70, $100,000; 71 and over, none.
(b) If insurable on a non-standard basis, for issue ages 0 through 15,
$25,000; 16 through 60, $250,000; 61 through 65, $125,000; 66
through 70, $50,000; 71 and over, none.
The maximum limit will not be increased because payment has been made to the
Company which is larger than the premium required for such reduced insurance.
Upon due proof of the death of the proposed insured that portion of the premium
paid for any excess insurance shall be paid to the beneficiary named in this
application.
Suicide Exclusion. If the proposed insured commits suicide while this agreement
is in force, the Company's liability will be limited to the return of the
premium paid.
Amount of Insurance - Health. If the proposed insured becomes totally disabled
as defined in the policy, the maximum monthly benefit will be the lesser of the
amount applied for and the maximum limit set forth below.
Maximum Limit - Health Insurance. The maximum limit under this agreement for
monthly indemnity is an amount which, when added to any monthly indemnity
provided by the Company under any health insurance policy or conditional
insurance agreement having a date of issue or underwriting date respectively
within 90 days prior to this agreement, does not exceed the lesser of:
(a) $2,000; and
(b) the published limit of the Company in effect on the underwriting
date.
Such health insurance will be subject to the elimination period elected in the
application, if any. Benefits will be payable for no more than 24 months or the
benefit period applied for, if less. Any such insurance in excess of the maximum
limit shall be void and all premiums paid for such excess shall be returned.
The maximum limit under this agreement for any health insurance other than
monthly indemnity will be the lesser of the amount applied for and the
applicable published limit of the Company in effect on the underwriting date of
this agreement.
TERMINATION
Termination - This agreement may be terminated at any time prior to incurrence
of a claim. The Company's sole liability shall be limited to the refund of the
premium paid. Such termination will occur on the earliest of the following:
1. The delivery of the insurance issued on this application.
2. The date the Company mails a termination notice with a refund of
your payment to you.
3. Ninety days after the underwriting date.
--------------------------------------------------------------------------------
Form 1CR-87 Rev. 9/95
First Allmerica Financial Life Insurance Company (The "Company")
Allmerica Financial Life Insurance and Annuity Company (The "Company")
Name of Proposed Insured _______________________________________________________
AUTHORIZATION TO OBTAIN INFORMATION
--------------------------------------------------------------------------------
To all physicians; medical professionals; hospitals; clinics; other health care
providers; employers; Medical Information Bureau, Inc. (MIB); consumer reporting
agencies; other insurance support organizations; and other persons who
have the types of information described below about the proposed insured:
I authorize you to give the Company, its reinsurers, or its agent: (a) all
information you have as to illness, injury, medical history, diagnosis,
treatment, and prognosis (including any drug or alcohol abuse condition or
treatment) with respect to any physical or mental condition of the proposed
insured; and (b) any non-medical information, including an investigative
consumer report, which the Company believes it needs to perform the business
functions described below. I also authorize the Company to give MIB health or
non-medical information it has about me and that of any minor member of my
family applying for insurance.
The information obtained will be used to determine if the proposed insured is
eligible for: (a) the insurance requested; or (b) benefits under a policy which
is in force. It will also be used for any other business purpose which relates
to the insurance requested or the policy which is in force.
This authorization will be valid for 30 months. I know that under Federal
Regulations, I may revoke this authorization as it applies to drug and alcohol
abuse treatment information at any time; but my revocation will not affect any
information that has been released prior thereto. I know that I may request a
copy of this form. I agree that a photocopy is as valid as the original. I have
received the Insurance Information Practices notice.
_________________ _______________________________________________________
Date Signature of proposed insured (if proposed insured is a
minor, signature of legal guardian)
_______________________________________________________
Signature of spouse (if proposed for insurance)
Form 4826-90 Rev. 3/95
--------------------------------------------------------------------------------
|_| First Allmerica Financial Life Insurance Company
|_| Allmerica Financial Life Insurance And Annuity Company
PERSONAL HISTORY INTERVIEW INFORMATION
--------------------------------------------------------------------------------
Proposed Insured's Name (Professional Title)
|_| Adult Application for
|_| Life - Amount $_______
|_| Juvenile |_| Disability - Amount $_______
--------------------------------------------------------------------------------
Home Telephone No. (Area Code) and No.
Business Telephone No. (Area Code) and No.
( ) ( )
--------------------------------------------------------------------------------
Driver's License Information
No. State
--------------------------------------------------------------------------------
The best time for us to call you is 1st Choice ____________ Eastern
at |_| Home |_| Business 2nd Choice ____________ Time
--------------------------------------------------------------------------------
Agency Agent Date Received in P.H.I. Unit
--------------------------------------------------------------------------------
Attempts to Call Attempts to Call
Date/Time ________________________ Date/Time ________________________
Date/Time ________________________ Date/Time ________________________
Date/Time ________________________ Date/Time ________________________
--------------------------------------------------------------------------------
Date call completed Time ____________ Remarks
|_|AM |_|PM
--------------------------------------------------------------------------------
No. 315076
APPLICATION FOR INDIVIDUAL
ADULT LIFE AND/OR HEALTH
INSURANCE - PART I |_| First Allmerica Financial Life
Insurance Company
|_| Allmerica Financial Life
Insurance and Annuity Company
|_| Life |_| Disability
Check applicable box(es)
All Answers Must Be Handwritten Worcester, Massachusetts 01653
--------------------------------------------------------------------------------
COMPLETE FOR ALL APPLICATIONS
--------------------------------------------------------------------------------
1.a) PROPOSED INSURED First - Middle Initial - Last
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
b) Sex c) BIRTH d) Owner's Soc. Sec. or I.D.
-----------------------
|_| M |_| F Mo. Day Yr. State
|____|____|____||___|___| - -
--------------------------------------------------------------------------------
2. a) RESIDENCE
No. Street Apt. Yrs.
--------------------------------------------------------------------------------
City State Zip
|___|___||___|___|___|___|___|
--------------------------------------------------------------------------------
b) BUSINESS ADDRESS
No. Street Apt. Yrs.
--------------------------------------------------------------------------------
City State Zip
|___|___||___|___|___|___|___|
--------------------------------------------------------------------------------
3. PREMIUM PAYABLE
|_| Annual |_| Semi-Annual |_| Quarterly
|_| M.A.P. |_| Other ___________________________________________________
Existing M.A.P. or List Bill No._____________________________________________
--------------------------------------------------------------------------------
4. Periodic Premium (Exceptional Life Only)
$
--------------------------------------------------------------------------------
5. a) Premium Notices To
|_| Insured |_| Owner at |_| Residence |_| Business
|_| Other (Name)_____________________________________________________________
b) No._____ Str.___________________________________ Apt._____________________
__________________________________|___|___||___|___|___|___|___|
City State Zip
--------------------------------------------------------------------------------
6. Has the initial premium been paid and the Yes No
Company's Conditional Receipt been given? |_| |_|
Life $______________ Disability $______________________
--------------------------------------------------------------------------------
7. a) Have you smoked one or more Yes No
cigarettes in the last 12 months? |_| |_|
b) Do you currently use any other form of tobacco? |_| |_|
|_| Cigars |_| Pipe |_| Chew |_| Other________________________________
--------------------------------------------------------------------------------
8. a) Employer, Occupation and Duties b) Yrs.________________________________
Yes No
c) Any change contemplated? |_| |_|
d) During the past 6 months has an illness or injury
prevented you from engaging in the usual duties
of your occupation for more than 7 days? |_| |_|
--------------------------------------------------------------------------------
9. Will the insurance applied for replace or change
any existing insurance or annuities in any company? |_| |_|
--------------------------------------------------------------------------------
10. Have you applied for any life or disability insurance
with another company in the last six months? |_| |_|
--------------------------------------------------------------------------------
11. Do you intend to travel outside the United States
and Canada? |_| |_|
--------------------------------------------------------------------------------
12. In the last 3 years have you
a) Had your motor vehicle license suspended
or revoked or have you been convicted
of driving under the influence of drugs
or alcohol or been convicted of more
than one moving violation? |_| |_|
b) Participated in or do you intend to
participate in |_| |_|
|_| Motor Racing |_| Scuba Diving
|_| Hang Gliding or |_| Parachuting
similar flying activities
c) Flown or intend to fly as a trainee,
pilot or crewmember? |_| |_|
If 12b or c "yes" - Complete Appropriate Questionnaire
================================================================================
Explain "yes" answers 8-12
--------------------------------------------------------------------------------
COMPLETE FOR LIFE INSURANCE
--------------------------------------------------------------------------------
13. LIFE INSURANCE APPLIED FOR
Amount Plan
$______________________________________|___________________________________
--------------------------------------------------------------------------------
14. Flex Term Plans |_| Decreasing Term
|_| Level term Int. Rate ____________________%
|_| Level Prem. Red. Term. No. of Yrs. __________________
--------------------------------------------------------------------------------
15. Death Benefit Option (Exceptional Life only)
|_| Option 1 |_| Option 2
--------------------------------------------------------------------------------
16. RIDERS |_| Exchange Option Rider
|_| GIR $_________________ |_| Flex Term Rider $______________
|_| OIR (Complete Part 1a) |_| Level Term
|_| CIR (Complete Part 1a) |_| Level Prem. Red. Term
|_| AIR __________________ |_| Decreasing Term
|_| Paid up Additions Rider Int. Rate ___________________%
|_| Annual Premium $___________________ No. of Yrs.__________________
|_| Single Premium $___________________ |_| LBR
--------------------------------------------------------------------------------
17. OPTIONAL BENEFITS
a) |_| Waiver of Premium c) |_| ADB $__________________________________
b) |_| Waiver of Charges d) |_| APL
================================================================================
18. DIVIDEND OPTION (First Allmerica Financial Only)
a) |_| Paid in Cash d) |_| Paid up Adds
b) |_| Reduced Prem. e) |_| Accumulate at Interest
c) |_| Other ______________________________________________________________
================================================================================
19. a) PRIMARY BENEFICIARY Relationship
|_| _________________ day Common Disaster Clause
----------------------------------------------------------------------------
b) CONTINGENT BENEFICIARY
================================================================================
20. OWNER (if other than insured)
--------------------------------------------------------------------------------
Form 1A-90 Page 1 Rev. 9/95
--------------------------------------------------------------------------------
COMPLETE FOR DISABILITY INSURANCE
--------------------------------------------------------------------------------
21. DISABILITY INSURANCE APPLIED FOR
a) |_| INCOME REPLACEMENT Elim. Ben.
Mo. Ben. $ __________ Per. __________ Per. ____________
RIDERS
|_| Regular Occupation |_| Residual Disability
|_| Lifetime Accident |_| Partial Disability
|_| Life Sick/Acc |_| Hosp. Conf. $__________________________
Elim. Ben.
|_| AIB: Mo. Ben. $ __________ Per. __________ Per. __________
Elim. Ben.
|_| SIS: Mo. Ben. $ __________ Per. __________ Per. __________
|_| AIO PLUS ______
|_| COLA
|_| Key Person $________________________________________________________
|_| Other________________________________________________________________
b) |_| DISABILITY BUY-OUT Amt. $_____________ Elim. Per.________________
|_| Additional Ins. Option $_________________________________________
c) |_| OVERHEAD EXPENSE
Elim. Ben.
Amt. $_________________ Per. __________ Per. __________
|_| Residual Rider
|_| Additional Insurance Benefit _______________________________%
|_| Additional Insurance Option Rider $__________________________
--------------------------------------------------------------------------------
22. OVERHEAD EXPENSE DATA
a) Your share of the average monthly overhead expenses
for the last six months.
Rent $____________________ Laundry $____________________
Electricity $____________________ Janitorial Svs. $____________________
Telephone $____________________ Depreciation $____________________
Heat & Water $____________________ (office furniture & equipment only)
Taxes $____________________ ____________________
Salaries $____________________ ____________________
Mortgage Int. $____________________ TOTAL $____________________
b) Are you sole owner of the business? |_| Yes |_| No
c) If not, your share ___________________________________%
How many other owners _____________________________________
--------------------------------------------------------------------------------
23. ANNUAL EARNED INCOME*
a) Last Tax Year $_________________________________________________
Prior Tax Year $_________________________________________________
Two Years Ago $_________________________________________________
b) Unearned Income (indicate source) $____________________________________
c) Net Worth Personal $________________________________________________
Business $________________________________________________
*Earned income is the total of your annual salaries, wages, bonuses,
commissions and fees less ordinary business expenses.
--------------------------------------------------------------------------------
24. Record all disability income and overhead expense coverage in force
(include fringe, individual, group, salary continuation, association, union
benefits or state disability benefits). If none, write "NONE".
---------------------------------------------------------------------------------------------------------
Company or Source Year Disability Overhead Monthly Elim. Benefit Offset By
Issued Income Expense Indemnity Period Period Social Security
---------------------------------------------------------------------------------------------------------
$ $
---------------------------------------------------------------------------------------------------------
$ $
---------------------------------------------------------------------------------------------------------
$ $
---------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------
COMPLETE FOR ALL APPLICATIONS
--------------------------------------------------------------------------------
Special Request Home Office Amendments and Corrections/Administrative Purpose
--------------------------------------------------------------------------------
It is agreed that: (1) The application consists of Parts I, II and IA, if IA
applies. (2) The representations are true and complete to the best of my
knowledge and belief, (3) No liability exists and the insurance applied for will
not take effect unless the policy is delivered and the premium is paid during
the lifetime of the proposed insured(s) and then only if the proposed insured(s)
has (have) not consulted or been treated by any physician or practitioner of any
healing art nor had any tests listed in the application since its completion;
but, if the premium is paid prior to delivery of the policy and a conditional
receipt is delivered by the agent, insurance shall be effective subject to terms
of the conditional receipt. (4) No agent or broker is authorized to amend,
alter, or modify the terms of this agreement.
--------------------------------------------------------------------------------
Signed at (City and State) Date Full signature of proposed insured
--------------------------------------------------------------------------------
This application is made at the request of the undersigned who hereby ratifies
each statement, representation and agreement herein and agrees that any contract
of insurance issued in connection with this application shall be issued on the
condition that each statement, representation and agreement shall be binding
upon the above named owner(s) to the same extent and degree as if made by the
owner(s).
--------------------------------------------------------------------------------
Signed at (City and State) Date Full signature(s) of owner(s)
(other than insured)
--------------------------------------------------------------------------------
Soliciting Agent's Signature Date If Business, name of establishment
and title/capacity
--------------------------------------------------------------------------------
Form 1A-90 Page 2 Rev. 9/95
First Allmerica Financial Life Insurance Company
Allmerica Financial Life Insurance
AGENT'S REPORT and Annuity Company
--------------------------------------------------------------------------------
SECTION A COMPLETE FOR ALL APPLICATIONS
--------------------------------------------------------------------------------
1. Name First - Middle Initial - Last
--------------------------------------------------------------------------------
2. Proposed Insured
a) Years Known ______________ b) Marital Status _______________
c) |_| Relative |_| Friend |_| Client |_| Stranger
--------------------------------------------------------------------------------
3. Home Telephone No. (Area Code) and No.
( )
--------------------------------------------------------------------------------
4. Driver's License Number and State
|
--------------------------------------------------------------------------------
5. What is the proposed insured's annual
income? (Life only)
Earned $ _____________________________ Unearned $_____________________________
Financial Worth $
--------------------------------------------------------------------------------
6. Quick Pay years (NOT GUARANTEED)
--------------------------------------------------------------------------------
7. Occupational Class (Disability only)
|_|4AS |_|4A |_|3A |_|2A |_|A
--------------------------------------------------------------------------------
8. a) Is the insurance being applied for considered a
replacement according to its definition in the
replacement regulations (if any) in the state the
business was written? |_| Yes |_| No
(Send Replacement forms or 1035 Exchange where applicable)
b) If the answer to a above is "yes", list below
all existing life, disability or annuity contracts
proposed to be replaced.
Policy Number Name of Issuing Company
------------- -----------------------
--------------------------------------------------------------------------------
9. List all life insurance in force
--------------------------------------------------------------------------------
Company Year Insurance Amount ADB Waiver
------------------------------
Personal Business
--------------------------------------------------------------------------------
$ $ $ |_| Yes |_| No
--------------------------------------------------------------------------------
|_| Yes |_| No
--------------------------------------------------------------------------------
|_| Yes |_| No
--------------------------------------------------------------------------------
|_| Yes |_| No
--------------------------------------------------------------------------------
TOTAL $ $ $
--------------------------------------------------------------------------------
SECTION B COMPLETE FOR ALL APPLICATIONS WHEN BUSINESS INSURANCE APPLIED FOR
--------------------------------------------------------------------------------
10. a) Type of Business
|_| Corporation |_| S-Corporation
|_| Partnership |_| Sole Proprietorship
b) Date Incorporated or organized __________________________________
c) Number of employees______________________________________________
d) If Corporation, State of incorporation___________________________
Have directors authorized this application? |_| Yes |_| No
--------------------------------------------------------------------------------
11. a) How long has proposed
insured been with owner?________________________________________
b) Percentage of business
owned by proposed insured?______________________________________%
--------------------------------------------------------------------------------
12. Net Earnings (after tax) of business for
Last Year $ Previous Year $
--------------------------------------------------------------------------------
13. Purpose of Insurance
|_| Stock Purchase |_| Business Keyperson
|_| Split Dollar |_| Executive Bonus
|_| Stock Redemption |_| Executive Income Plan
|_| Deferred Compensation
|_| Other_______________________________
--------------------------------------------------------------------------------
14. Salary of proposed insured for
Last year $ Previous year $
--------------------------------------------------------------------------------
15. a) What is aggregate business insurance (existing and
new) authorized on this life in all companies?
Existing $______________________ New $__________________________________
b) Are any other partners or associates insured or
proposed for business coverage? |_| Yes |_| No
Give names, titles, amounts and companies.
c) If partnership, give full name of all partners.
--------------------------------------------------------------------------------
16. Home Office Assistance
|_| B.I. Handbook |_| Financial Topics
|_| Sales Proposals |_| Technical Release
|_| Inquiry |_| Other ______________________________
|_| What's New
Was this case a result of any previous assistance either
direct or indirect? |_| Yes |_| No
--------------------------------------------------------------------------------
SECTION C COMPLETE WHEN OIR AND/OR CIR IS APPLIED FOR
--------------------------------------------------------------------------------
17. For CIR
Are all children who have not reached their
18th birthday included? |_| Yes |_| No
If "no", explain
--------------------------------------------------------------------------------
18. For CIR and OIR (child) How long have you
known the parent or person with whom the
child (children) is (are) living? (If other than the
applicant, give name and explain)
--------------------------------------------------------------------------------
19. For CIR and OIR
a) To the best of your knowledge, will the life
insurance being applied for replace life
insurance or annuities in any company? |_| Yes |_| No
(Send replacement forms where applicable.)
b) If the answer to a above is "yes", list all existing life
insurance or annuity contracts proposed to be replaced.
Policy Number Name of Issuing Company
--------------------------------------------------------------------------------
Form 1AR-90 Page 1 Rev. 3/95
--------------------------------------------------------------------------------
SECTION D COMPLETE FOR LIFE APPLICATION WHEN APPLICANT IS DEPENDENT SPOUSE OR
DEPENDENT CHILD
--------------------------------------------------------------------------------
20. a) What is the need for proposed insurance?
b) If supporting spouse or parent is insured for benefit
of family, give amount. If not insured, give reasons.
c) Regarding supporting spouse or parent
Full Name____________________________________
Birthdate____________________________________
Income_______________________________________
--------------------------------------------------------------------------------
SECTION E COMPLETE FOR LIFE APPLICATION WHEN INSURANCE IS FOR ESTATE PLANNING
PURPOSES
--------------------------------------------------------------------------------
21. a) Home Office Assistance
|_| What's New |_| Inquiry
|_| Technical Release
|_| Financial Topics |_| Other_______________________
b) Was this case a result of any previous assistance
either direct or indirect? |_| Yes |_| No
--------------------------------------------------------------------------------
22. a) Was an Estate Analysis prepared? |_| Yes |_| No
b) Was a Liquidity Analysis prepared? |_| Yes |_| No
--------------------------------------------------------------------------------
SECTION F COMPLETE FOR LIFE APPLICATION WHEN INSURANCE IS FOR FINANCIAL
PLANNING PURPOSES
--------------------------------------------------------------------------------
23. a) Home Office Assistance
|_| Financial Topics |_| Plan Prep./Review
|_| Inquiry |_| Other__________________________
b) Was this case a result of any previous assistance
either direct or indirect? |_| Yes |_| No
--------------------------------------------------------------------------------
24. a) Was a financial plan prepared? |_| Yes |_| No
b) If "yes", type of plan |_| Basic
|_| Comprehensive
|_| Focus
c) Was a fee charged? |_| Yes |_| No
--------------------------------------------------------------------------------
SECTION G COMPLETE FOR ALL APPLICATIONS FOR MARKET RESEARCH
--------------------------------------------------------------------------------
25. Need
|_| Personal |_| Business |_| Estate
--------------------------------------------------------------------------------
26. Occupation
|_| Business owner |_| Manager/Exec.
|_| Professional |_| Self-Employed
|_| Other white collar |_| Blue collar
--------------------------------------------------------------------------------
27. Industry
|_| Medical |_| Retail Trade
|_| Construction |_| Finances, Ins., Real Estate
|_| Manufacturing |_| Professional Service
|_| Trans./Public Util. |_| Public Administration
|_| Wholesale Trade |_| Education
|_| Agriculture, Forestry |_| Other
--------------------------------------------------------------------------------
28. a) Was this a competitive situation? |_| Yes |_| No
b) Competing Company_____________________________________________________
c) Home Office Assistance |_| Yes |_| No
--------------------------------------------------------------------------------
29. Reason for Insurance
|_| Death Taxes |_| Family Income
|_| Gift |_| Retirement Income
|_| Estate Protection |_| Fund Bus. Agreement
|_| Cash Accumulation |_| Other
--------------------------------------------------------------------------------
30. Source |_| Observation
|_| Personal |_| Seminar
|_| Direct Mail |_| Referred Lead
|_| Cold Call |_| Policyholder
|_| Orphan |_| Telemarketing Lead
--------------------------------------------------------------------------------
31. Other Investments |_| Money Market
|_| Stocks & Bonds |_| Commodities
|_| Investment Property |_| Savings Account
|_| Group Benefit Plan |_| Pension Plan
--------------------------------------------------------------------------------
32. Planning Tools Used |_| Ledger Proposal
|_| FSA |_| Next $
|_| Ins Mark |_| Other
--------------------------------------------------------------------------------
It is hereby stated that (we) (I) personally solicited this application and,
except as specified below, no other agent or broker has any commission interest
in this sale. It is certified that the information supplied by the proposed
insured has been truly and accurately recorded. (If more than one agent indicate
split otherwise the Company assumes that any division of commission is in equal
shares.)
--------------------------------------------------------------------------------
Signature of Agent Print Full Name Code Agency
%
--------------------------------------------------------------------------------
Signature of Agent Print Full Name Code Agency
%
--------------------------------------------------------------------------------
Signature of Agent Print Full Name Code Agency
%
--------------------------------------------------------------------------------
Signature of Agent Print Full Name Code Agency
%
--------------------------------------------------------------------------------
Form 1AR-90, Page 2 Rev. 3/95
APPLICATION FOR INDIVIDUAL
ADULT LIFE AND/OR DISABILITY
INSURANCE - PART II |_| First Allmerica Financial Life
Insurance Company
|_| Allmerica Financial Life
Insurance and Annuity Company
|_| Life |_| Disability
Check applicable box(es)
All Answers Must Be Handwritten Worcester, Massachusetts 01653
--------------------------------------------------------------------------------
1. Proposed Insured Birth Date
First M.I. Last Mo. Day Yr.
| |
--------------------------------------------------------------------------------
2. Personal Physician
a) |_| Name and Address b) |_| None
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Reason Last Consulted Date
c) |_| Routine Exam Were all findings normal? |_| Yes |_| No
d) |_| As indicated in #27 on page 2
e) |_| Other - Give Details
Date Reason Result
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
--------------------------------------------------------------------------------
3. In the past 10 years have you been told you had or been
treated for immune system disorder including acquired
immune deficiency syndrome (AIDS) or AIDS related
complex (ARC)? |_| Yes |_| No
--------------------------------------------------------------------------------
4. During the past 5 years have you used marijuana, cocaine,
barbiturates, narcotics, excitants, or hallucinogens, except
as prescribed medication? |_| Yes |_| No
--------------------------------------------------------------------------------
5. Do you engage in a scheduled exercise program?
(If "yes", give details = type, duration, frequency)
|_| Yes |_| No
--------------------------------------------------------------------------------
6. Are you now pregnant? |_| Yes |_| No
If yes, expected date of delivery
--------------------------------------------------------------------------------
Explain "yes" answers to #3-5.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
During the Past 10 years have you had, been told you had, or been treated for
7. a) |_| Chest pain or Angina c) |_| Heart Murmur e) |_| Heart Attack g) |_| Palpitations i) |_| None of These
b) |_| Rheumatic fever d) |_| High Blood Pressure f) |_| Blood Vessel h) |_| Heart
Disorder Disorder
8. a) |_| Pneumonia d) |_| Persistent Cough g) |_| Coughing of j) |_| Asthma m) |_| None of These
b) |_| Bronchitis e) |_| Persistent Hoarseness Blood k) |_| Pleurisy
c) |_| Tuberculosis f) |_| Allergies h) |_| Emphysema l) |_| Chronic
i) |_| Respiratory Shortness
Disorder of Breath
9. a) |_| Recurrent Headache c) |_| Dizziness or Fainting e) |_| Brain Disorder g) |_| Seizures i) |_| None of These
b) |_| Paralysis d) |_| Stroke f) |_| Speech Loss h) |_| Memory Loss
10. a) |_| Nervous Disorder b) |_| Mental Disorder c) |_| Depression d) |_| Suicide e) |_| None of These
Attempt
11. a) |_| Ulcer b) |_| Recurring Indigestion c) |_| Vomiting Blood d) |_| Difficulty e) |_| None of These
Swallowing
12. a) |_| Colon Polyp b) |_| Ileitis or Colitis c) |_| Persistent d) |_| Bloody Stools e) |_| None of These
Diarrhea
13. a) |_| Hepatitis c) |_| Cirrhosis e) |_| Jaundice g) |_| Gall Bladder i) |_| None of These
b) |_| Stomach Disorder d) |_| Liver Disorder f) |_| Intestinal Disorder
Disorder h) |_| Pancreas
Disorder
14. a) |_| Cancer c) |_| Skin Cancer e) |_| Tumor g) |_| Cyst h) |_| None of These
b) |_| Fibroids d) |_| Skin Disorder f) |_| Lymph Gland
Disorder
15. a) |_| Diabetes b) |_| Thyroid Disorder c) |_| Disease of d) |_| Glandular e) |_| None of These
Breast Disorder
16. a) |_| Sugar in Urine d) |_| Pus in Urine g) |_| Kidney Disorder i) |_| Urinary k) |_| None of These
b) |_| Albumin in Urine e) |_| Prostate Disorder h) |_| Reproductive Disorder
c) |_| Blood in Urine f) |_| Bladder Disorder System Disorder j) |_| Sexually
Transmitted
Disease
17. a) |_| Anemia b) |_| Leukemia c) |_| Blood Disorder d) |_| Recurrent e) |_| None of These
Infections
18. a) |_| Hernia b) |_| Hemorrhoids c) |_| Varicose Veins d) |_| Rectal e) |_| None of These
Disorder
19. a) |_| Deformity c) |_| Back Pain e) |_| Amputation g) |_| Arthritis i) |_| None of These
b) |_| Rheumatism d) |_| Gout f) |_| Bone or Muscle h) |_| Back, Spine,
Disorder Joint
Disorders
20. a) |_| Eye Disorder b) |_| Ear Disorder c) |_| Nose Disorder d) |_| Throat e) |_| None of These
Disorder
Form 1AM-90 Page 1 Rev. 9/95
All Answers Must Be Handwritten
--------------------------------------------------------------------------------
21. Height in shoes __________________ Weight in clothing ______________________
Have you had any change in weight in the past year?
|_| Yes |_| No |_| Gain |_| Loss Amount_______________________________
Reason
--------------------------------------------------------------------------------
22. Other than as indicated in 7-20, during the
past 5 years have you
a) Been or are you now under observation,
treatment, therapy, counseling, or medi- Yes No
cations or have you had any check up,
illness or surgery? |_| |_|
b) Had electrocardiogram, x-ray or blood studies? |_| |_|
c) Been advised to have a test or surgery
which was not done? |_| |_|
d) Been treated or received counseling for
alcohol or drug use? |_| |_|
e) Been a patient in a hospital, clinic,
sanitarium or other medical facility? |_| |_|
f) Consulted any other physician or chiropractor? |_| |_|
--------------------------------------------------------------------------------
23. Have you ever requested or received a pension Yes No
benefit or payments because of an injury,
sickness or disability? |_| |_|
--------------------------------------------------------------------------------
24. Have you ever changed occupation or residence
because of health? |_| |_|
--------------------------------------------------------------------------------
25. Has any member of your family ever had high
blood pressure, diabetes, cancer, mental illness
or hereditary disease? |_| |_|
--------------------------------------------------------------------------------
26. Family Age if Present State of Health Age at
Record Living or Cause of Death Death
----------------------------------------------------------------------------
Father
----------------------------------------------------------------------------
Mother
----------------------------------------------------------------------------
Brothers
& Sisters
--------------------------------------------------------------------------------
27. COMPLETE FOR EACH APPROPRIATE ITEM CHECKED IN 7-25
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------
No. Diagnosis Medication/Treatment Date Still Under Physician/Medical Facility Name
Treatment? (Include Address if not in 2 above)
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I understand and agree that the foregoing statements and answers are
complete, true and correctly recorded to the best of my knowledge and
belief, and that they shall be part of the contract if issued.
Date ______________ Witness _______________________ __________________________
Examiner or Agent Signature
of Proposed Insured
Form 1AM-90 Page 2 Rev. 9/95
