EXHIBIT 1.(10)(b)
[USAA LOGO] USAA LIFE INSURANCE COMPANY
AGREEMENT FOR EXCHANGE OF INSURANCE AND ANNUITY CONTRACTS
UNDER SECTION 1035 OF INTERNAL REVENUE CODE
USAA/Policy Number ______________________
Social Security Number______________________
ATTACH THIS FORM AND YOUR CURRENT POLICY TO YOUR APPLICATION.
I _______________________________________, the undersigned, own the following:
[ ] LIFE INSURANCE POLICY [ ] ENDOWMENT POLICY [ ] ANNUITY CONTRACT
POLICY (CONTRACT) NUMBER: ISSUED BY: ADDRESS: ON THE LIFE OF:
_________________________ __________ ____________________ _______________
_________________________ __________ ____________________ _______________
_________________________ __________ ____________________ _______________
collectively called "Old Policy(s)" which I hereby agree to exchange pursuant
to Section 1035 of the Internal Revenue Code for:
[ ] A LIFE INSURANCE POLICY [ ] AN ANNUITY CONTRACT
called "New Policy" on the life of the same insured named in the Old Policy(s)
if USAA LIFE INSURANCE COMPANY ("USAA Life") approves my application, dated
________ for the New Policy and I accept it.
In consideration of USAA Life's furnishing this form and assisting me with the
exchange of contracts under Section 1035 of the Internal Revenue Code, I
hereby further represent and agree as follows:
AT THE TIME OF THE EXCHANGE, IS THE OLD POLICY A MODIFIED ENDOWMENT CONTRACT
(MEC) UNDER INTERNAL REVENUE CODE SECTION 7702A?
[ ] YES [ ] NO
1. OWNERSHIP OF OLD POLICY
I am the sole owner of the Old Policy(s). No other person (including
fiduciaries whether or not court-appointed), firm, corporation or
governmental unit has any legal or equitable claim or interest in or
against the Old Policy(s), except as follows (describe):
NOTE: COLLATERAL ASSIGNEES, IRREVOCABLE BENEFICIARIES, ETC. MUST SIGN ON
BACK OF FORM AS INDICATED.
2. ABSOLUTE ASSIGNMENT OF OLD POLICY(S)
I hereby assign, irrevocably transfer and deliver the Old Policy(s)
described above to USAA LIFE INSURANCE COMPANY, San Antonio, Texas,
Federal ID #00-0000000, together with all right, title and interest
therein and thereto. My copy of this form is my receipt for the Old
Policy(s).
3. USAA LIFE WILL NOT PAY PREMIUMS ON OLD POLICY(S)
I understand and agree that USAA Life is not obligated to and will not
make any premium payments on the Old Policy(s). Therefore, I further
agree for myself, my heirs and assigns that USAA Life is not liable if
the Old Policy(s) lapses for non-payment of premiums. I understand that
if the Old Policy(s) is reassigned to me under the terms of Paragraph 5,
and it has lapsed because premiums have not been paid, I can reinstate
it only if the terms of the Old Policy(s) permit it to be reinstated.
4. SURRENDER OF OLD POLICY(S)
I understand and agree that:
FOR A LIFE INSURANCE POLICY
If USAA Life approves and issues the New Policy, and I accept it, USAA
Life will apply for the surrender of the Old Policy(s) for its cash
value after the New Policy is delivered to me.
As of the Surrender Date, if the Old Policy(s) is a life insurance or
endowment policy, it will no longer provide life insurance protection in
the event of the insured's death.
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If the insured under the Old Policy(s) dies BEFORE the Surrender Date,
and USAA Life's Home Office is given written notice of the death before
the Surrender Date, USAA Life will reassign the Old Policy(s) to the
owner or the owner's legal representative. The beneficiary named in the
Old Policy(s) may then apply to the issuer of the Old Policy(s) for any
death benefit available under the Old Policy(s). Upon such reassignment,
USAA Life shall be discharged from all liability with respect to the Old
Policy(s). FURTHER, IN THIS SITUATION, USAA LIFE SHALL NOT BE OBLIGATED
OR HAVE ANY LIABILITY TO PAY DEATH PROCEEDS TO ANY BENEFICIARY UNDER THE
NEW POLICY EXCEPT TO THE EXTENT SAID PROCEEDS EXCEED THE DEATH PROCEEDS
OF THE OLD POLICY.
If the insured dies ON or AFTER the Surrender Date, I understand that no
death benefits will be available under the Old Policy(s). I understand
that the cash values of the Old Policy(s) will be applied by USAA Life
as a non-repeating premium under the New Policy.
FOR AN ANNUITY CONTRACT
If USAA Life approves my application, it will apply for the surrender of
the Old Policy(s) for its cash value. Upon receipt of the cash proceeds,
USAA Life will issue a New Policy for delivery to me.
FOR ALL POLICIES
USAA Life will apply the entire cash surrender value it receives from
the Old Policy(s) as a non-repeating premium for the New Policy issued
by USAA Life.
5. REASSIGNMENT OF OLD POLICY(S)
In the event:
o USAA Life declines my application for the New Policy; or
o I refuse to accept the New Policy; or
o I return the New Policy to USAA Life under the Free Look
Provision of the New Policy; or
o The insured under the Old Policy(s) dies BEFORE the
Surrender Date, and written notice of the death is given to
USAA Life's Home Office BEFORE the Surrender Date;
then this Agreement shall be null and void and USAA Life shall reassign
the Old Policy(s) to me or my legal representative, whereupon USAA Life
shall have no further obligation with respect to the Old Policy(s). I
UNDERSTAND THAT AFTER THE SURRENDER DATE, THE OLD POLICY(S) CANNOT BE
RETURNED TO ME AND THAT NO DEATH BENEFIT WILL BE PAID UNDER IT IF THE
INSURED DIES.
6. ACKNOWLEDGEMENT OF RESPONSIBILITY FOR TAX OBLIGATIONS
I understand and agree that USAA Life is furnishing this form and
participating in this transaction at my specific request. Accordingly, I
am not relying on USAA Life, its agents or employees for any tax advice
whatsoever with respect to this transaction. I understand that any tax
obligations resulting from this transaction are mine. Further, I assume
any and all risk with respect to the accomplishment of a valid Section
1035 exchange under the Internal Revenue Code.
I also request that the surrendering company send to USAA Life a report
on any taxable gain or loss on Old Policy(s).
7. COVERAGE OF NEW POLICY (LIFE INSURANCE ONLY)
I understand that this Agreement creates no insurance.
8. SIGNATURES
Signed at X_________________________________ On X_____________________________
(City and State) (Date)
X_________________________________ X_____________________________
(Owner) (Witness)
X_________________________________ X_____________________________
(Irrevocable Beneficiary, if any) (Collateral Assignee, if any)
FOR USAA LIFE HOME OFFICE USE ONLY
Received and recorded at the Home Office of USAA LIFE INSURANCE COMPANY:
Date: ________________________ By:___________________________________________
Xxxxxx Xxx Xxxxxxx, Vice President or
Xxxxxx XxXxxxxxxx, Assistant Vice President
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