Exhibit 1.A.(10)(a)
--------------------------------------------------------------------------------
ING [LOGO] RELIASTAR
RELIASTAR LIFE INSURANCE COMPANY SECURITY-CONNECTICUT LIFE INSURANCE COMPANY
00 XXXXXXXXXX XXXXXX XXXXX 00 XXXXXXXX XXXXX
XXXXXXXXXXX, XXXXXXXXX 00000 AVON, CONNECTICUT 06001-4237
APPLICATION FOR LIFE INSURANCE
FIXED AND VARIABLE PRODUCTS
--------------------------------------------------------------------------------
INSTRUCTIONS TO AGENTS AND APPLICANTS
* CONDITIONAL RECEIPT. A Receipt must be given to Applicant/Owner if a premium
payment is made. No agent has the authority to alter the provision of the
Conditional Receipt.
Premium cannot be collected with the application if the face amount applied
for exceeds $4,500,000 or if the total amount in force and/or currently
applied for exceeds (1) $10,000,000 through age 68; or (2) $5,000,000 if the
Proposed Insured is age 69 or greater.
In Alaska, California and Pennsylvania no premium is to be collected with
applications if the face amount is in excess of (1) $500,000 through age 68;
or (2) $250,000 if the Proposed Insured is age 69 or greater.
Additional state limitations may be added upon notification by ReliaStar Life
Insurance Company or Security-Connecticut Life Insurance Company (the
"Company").
Applicant/Owner should understand all provisions of the Conditional Receipt.
* Check appropriate Company box on all parts of the application.
* If special requirements need to be considered, be sure to submit a separate
cover letter with all details.
* Please print all responses on this application in black ink.
* Use the remarks section (question 25) for any special instructions, or where
additional space is needed, i.e., beneficiary or payor information.
* The word "You" refers to the Proposed Insured.
* Be sure to fully complete the signature box on page 11.
THE LAWS OF THE FOLLOWING STATES REQUIRE THAT WE PROVIDE THESE NOTICES:
COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING
FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR
ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES,
DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR ITS AGENT WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A
POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD
WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE
REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF
REGULATORY AGENCIES.
KENTUCKY: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS
FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM
CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
PENNSYLVANIA: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF
CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS, FOR PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL
AND CIVIL PENALTIES.
LOUISIANA: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND
CONFINEMENT IN PRISON.
ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO
RELIASTAR LIFE INSURANCE COMPANY OR
SECURITY-CONNECTICUT LIFE INSURANCE COMPANY.
A12301 05/2000
AUTHORIZATION AND ACKNOWLEDGMENT
For underwriting and claim purposes, I authorize any physician, medical
practitioner, hospital, clinic or medically related facility, insurance or
reinsuring company, Medical Information Bureau, Inc. ("MIB"), any consumer
reporting agency, or any other organization to release to ReliaStar Life
Insurance Company or Security-Connecticut Life Insurance Company (the "Company")
or its authorized representative (including any consumer reporting agency)
acting on its behalf ALL INFORMATION on my behalf (except as limited below).
This includes but is not limited to: (a) any medical information available as to
diagnosis, treatment and prognosis with respect to any physical or mental
condition and/or treatment of me or my minor children who are to be insured; and
(b) any non-medical information of me or my minor children who are to be
insured.
I give my permission to the Company to get consumer or investigative consumer
reports about these same persons.
I give my permission to the Company and other insurance companies affiliated
with the Company to get any and all medical record information for the purposes
described in this form. I know that my medical records, including any alcohol or
drug abuse information, may be protected by Federal Regulations - 42CFR Part 2.
I may revoke this permission as it applies to any information protected by 42CFR
Part 2 at any time, but not to the extent action has been taken in reliance on
it. I understand that release of medical records will not be requested with
respect to tests performed to determine the presence of the human
immunodeficiency virus (HIV) antibody.
In connection with any application for life insurance or other insurance
transaction that I may have with the Company or any of its affiliated companies,
I specifically consent that some or all of the information obtained by this
authorization may be: (a) communicated between the Company and its affiliates;
and (b) sent to MIB, reinsurers, employees or contractors who process
transactions regarding any insurance coverage I may have applied for or have
with the Company or its affiliated companies. I understand the information
obtained by use of the Authorization will be used by the Company to determine
eligibility for insurance, and eligibility for benefits under an existing
policy. I understand that I may request that this information not be
communicated to companies affiliated with the Company.
* I understand that I may request to be interviewed if an investigative
consumer report is prepared. You may contact me between the hours of
________ and ________. My telephone number is (____) _____________.
* I know that I have a right to get a copy of this form. A photocopy of this
form will be as valid as the original.
* This form will be valid for twenty-six months from the date shown below.
* I acknowledge receipt of the following Company notices: Notice Regarding
Consumer Reports; Notice Regarding MIB; and Notice Regarding Information
Practices.
[______________________________________________________________________________]
Print name of Proposed Insured
[_______________________________________] [______________________]
Signature of Proposed Insured/ Date
or of Parent or Guardian if a Minor
A12301 2 05/2000
CONSUMER PRIVACE NOTICE
PLEASE DETACH PAGE AND GIVE TO PROPOSED INSURED
NOTICE REGARDING CONSUMER REPORTS
Insurance companies commonly ask an outside source to verify and add to the
information given in an application. The agency that makes the report will be
one that is discreet and impartial. If you wish, we will send you the name,
address and phone number of any agency we ask to prepare a consumer report about
you. You can ask that the agency interview you if you so state on the
authorization form.
Consumer reports are used to help us decide if you are eligible for the
insurance for which you have applied. The report deals with your mode of living,
character, general reputation, and such personal items as your health, job, and
finances. It may include information on the following: your marital status; past
and present employment record; job duties; driving record; avocations; health
history; use of alcohol and drugs; and hazardous sports activities. The agency
may get information in these ways: from public records; by contacting you,
members of your family, business associates and employers, financial sources,
friends or others you know. This information will not be used to determine your
sexual orientation. If the report affects your application as requested, we will
so notify you and provide you with the name and address of the reporting firm.
We use the report only to be sure that each application is evaluated on a
fair basis. We will not reveal any of the information we obtain to your friends
or associates. We may reveal the information we obtain to other companies or
entities affiliated with ReliaStar Life Insurance Company or
Security-Connecticut Life Insurance Company (the "Company"). You may request
that this information not be communicated to other companies affiliated with the
Company.
The information may be kept by the consumer reporting agency; it may also
later be given to others who have a legitimate need for these reports. It will
be given only to the extent permitted by these laws: the Federal Fair Credit
Reporting Act as amended by the Consumer Credit Reporting Reform Act of 1996;
your state's Fair Credit Reporting Act, if any; and your state's Insurance
Information and Privacy Protection Act, if any. The agency will give you a copy
of the report if you ask for one and provide the proper identification.
NOTICE REGARDING MIB
(MEDICAL INFORMATION BUREAU, INC.)
We or our reinsurers may make brief reports to MIB. The reports will include
the factors that affect the insurability of any person for whom coverage is
being requested.
MIB is a nonprofit organization of life insurance companies. It operates an
information exchange for its members. If you apply to some other member company
for life or health coverage, or send in a claim for benefits, MIB may supply
that company with any information in its file. If you ask MIB, it will arrange
to disclose to you the information it has in your file. If you question the
accuracy of the information in MIB's file, you may contact MIB to seek
correction, as provided in the Federal Fair Credit Reporting Act. The address of
MIB's information office is: Post Xxxxxx Xxx 000, Xxxxx Xxxxxxx, Xxxxxx,
Xxxxxxxxxxxxx 00000. MIB's phone number is (000) 000-0000.
We or our reinsurers may also release information in our files. We may
release it 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.
NOTICE REGARDING INFORMATION PRACTICES
To issue an insurance policy, we need to obtain information about you and any
other persons proposed for insurance. Some of that information will come from
you. Some will come from other sources. That information and any information
collected by us later may, in certain circumstances, be disclosed to third
parties without your specific permission.
You have a right to access and correct the information collected about you.
This right does not extend to information that relates to a claim or civil or
criminal proceeding.
If you wish to have a more detailed explanation of our information practices,
please write to us at:
Vice President, Underwriting
ReliaStar Life Insurance Company
00 Xxxxxxxxxx Xxxxxx Xxxxx
Xxxxxxxxxxx, XX 00000
or
Vice President, Underwriting
Security-Connecticut Life Insurance Company
00 Xxxxxxxx Xxxxx
Xxxx, XX 00000
A12301 3 05/2000
THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK.
ING [LOGO] RELIASTAR CONDITIONAL RECEIPT
[ ] ReliaStar Life Insurance Company, 00 Xxxxxxxxxx Xxxxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxxx 00000
[ ] Security-Connecticut Life Insurance Company, 00 Xxxxxxxx Xxxxx, Xxxx, XX
00000
IF PREMIUM IS COLLECTED, DETACH THIS RECEIPT AND GIVE TO CLIENT.
IF WITHIN THE LAST YEAR, THE PROPOSED INSURED HAS RECEIVED ANY TREATMENT OR
ADVICE FROM A PHYSICIAN FOR TUMOR OR CANCER OR ANY BRAIN, HEART, LUNG OR KIDNEY
DISORDER, A CONDITIONAL RECEIPT MAY NOT BE GIVEN AND PREMIUM MAY NOT BE
COLLECTED.
Received from
[______________________________________________________________________________]
the sum of
[______________________________________________________________________________]
in payment of the first full modal premium for an insurance policy applied for
on the life of
[______________________________________________________________________________]
Proposed Insured, for which this application as dated below has been made to
ReliaStar Life Insurance Company or Security-Connecticut Life Insurance Company
(the "Company").
THIS CONDITIONAL RECEIPT DOES NOT CREATE TEMPORARY OR INTERIM INSURANCE AND IT
DOES NOT PROVIDE ANY COVERAGE EXCEPT AS PROVIDED HEREIN. THIS PAYMENT IS MADE
AND ACCEPTED SUBJECT TO THE LIMITS PROVISION AND TO THE FOLLOWING TERMS AND
CONDITIONS:
IF:
1 no Proposed Insured has within the last 60 days been advised by any
physician or other practitioner to have any diagnostic test or surgery not
yet performed; and
2 all required parts of the application and all medical examinations and tests
required by published Company rules and practices have been completed within
60 days of the date of this receipt; and
3 the Company determines that, as of the date of the last of any medical
examinations or tests initially required under the published rules and
practices of the Company because of the Proposed Insured's age or the amount
of insurance applied for, or the date of the payment whichever shall be
later, the Proposed Insured was insurable and acceptable under the published
rules and practices of the Company for the policy in the amount, on the plan
and otherwise exactly as applied for; and
4 the amount paid as stated above is the correct first full modal premium
required for the insurance on the basis applied for, including any extra
premium required for a risk other than standard; and
5 on the date of this receipt all answers and statements contained in each
part of the application are full, complete and true to the best of the
Applicant/Owner's knowledge and belief, as though given on the date of this
receipt; and
6 a change in insurability, which occurs after all the other conditions were
met, was not the result of suicide:
THEN: the insurance under the terms of the policy applied for shall take effect
as of the date of the completion of all required parts of the application,
medical examinations and tests or as of the date of issue requested, if later.
UNLESS ALL THE PRECEDING CONDITIONS ARE MET, THERE SHALL BE NO LIABILITY ON THE
PART OF THE COMPANY EXCEPT TO RETURN THIS PAYMENT.
No agent of the Company has authority to make, alter or modify the terms of this
receipt or of the application or of any policy issued thereon or to waive any of
the Company's requirements or to extend the time for payment of premiums.
LIMITS PROVISION. The Company shall not be liable under this Conditional Receipt
for any insurance on the life of the Proposed Insured which, together with any
insurance on such life under any and all other Conditional Receipts of the
Company, exceed the following limits: (1) $500,000 if Proposed Insured has not
reached his/her 69th birthday; or (2) $250,000 if the Proposed Insured has
reached, or exceeded, his/her 69th birthday. These limits include amounts under
any accidental death benefit agreement applied for. If the total amount of
insurance applied for exceeds the above limits, the Company shall have no
liability with respect to such excess amount except to return the premium.
Your check shall be considered payment for which the receipt is issued only if
such amount is actually received by the Company.
Signed at City/State
[______________________________________________________________________________]
Licensed Agent Signature Date
[_____________________________________________] [____________________________]
A12301 4 05/2000
THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK.
ING [LOGO] RELIASTAR PART I OF AN APPLICATION FOR LIFE INSURANCE
[ ] ReliaStar Life Insurance Company, 00 Xxxxxxxxxx Xxxxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxxx 00000
[ ] Security-Connecticut Life Insurance Company, 00 Xxxxxxxx Xxxxx, Xxxx, XX
00000
THIS APPLICATION CONSISTS OF PAGES 5, 6, 7, 8, 9, 11, AND PAGE 10 WHEN APPLYING
FOR A VARIABLE PRODUCT.
1 a. Proposed Insured Name (First/Middle Initial/Last)
[_________________________________________________________________________]
b. Date of Birth (MM/DD/YYYY) c. Age d. [ ] Male
[_________________________] [_____] [ ] Female
e. Place of Birth (City/State/Country)
[_________________________________________________________________________]
f. Are you a U.S. Citizen? [ ] Yes [ ] No
If "No," give details under Item #25.
g. SSN [_____________________________________________________________________]
2 a. Home Address (No. & Street/City/State/Zip Code)
[_________________________________________________________________________]
b. Home Phone # [_(____)_____________________________________________________]
c. Business Phone # [_(____)_________________________________________________]
3 a. Base Plan of Insurance (Specific Product Name)
[_________________________________________________________________________]
[ ] Fixed or [ ] Variable (If Variable complete Part III and Variable
Supplement. If Universal Life, fully complete #4.)
Amount of Insurance $[____________________________________________________]
b. Optional Riders - Check all that apply
[ ] Waiver of Monthly Deductions
[ ] Waiver of Premium
[ ] Waiver of Specified Premium.........$[________________________________]
[ ] Children's Rider....................$[________________________________]
(Complete Children's Application)
[ ] ADB.................................$[________________________________]
[ ] Primary Insurance Rider.............$[________________________________]
[ ] Other [___________________________] $[________________________________]
c. How will premiums be paid?
[ ] Annually [ ]Semi-Annually [ ]Quarterly
[ ] Month-O-Matic (complete form on page 13)
[ ] List Xxxx # (if known) [______________________________________________]
[ ] Other [_______________________________________________________________]
Premium notices will be sent to owner unless otherwise indicated
in Item #25.
d. Automatic Premium Loan, if available? [ ] Yes [ ] No
(If available, APL will be effective unless "No" is checked.)
4 UNIVERSAL LIFE PLANS ONLY - FIXED AND VARIABLE
Complete the following:
a. Total amount of Initial Premium $[________________________________________]
(To include Planned Periodic Premium)
b. What is the amount of premium you plan to pay regularly (the Planned
Periodic Premium)?
[$________________________________________________________________________]
c. Death Benefit Option
[ ] Option 1 or Option A - Level
[ ] Option 2 - Increasing or Option B - Variable
[ ] Option C - Face Amount + Premium
[ ] Other [_______________________________________________________________]
d. Do you wish to add an Other Insured(s) to your policy? [ ] Yes [ ] No
(If yes, list the additional Insureds below and complete a separate
Application for each.)
Proposed Other Insured Amount
---------------------- ------
[_________________________________________________________________________]
Questions 5a and 6a, if Trust, include name and date of Trust.
5 a. Primary Date of Relationship %
Beneficiary Birth to Insured Share
[_________________________________________________________________________]
b. Address (No. & Street/City/State/Zip Code)
[_________________________________________________________________________]
c. SSN or TIN
[_________________________________________________________________________]
All primary beneficiaries who survive the insured shall share equally
unless otherwise indicated above.
A12301 5 05/2000
6 a. Contingent Date of Relationship %
Beneficiary Birth to Insured Share
[_________________________________________________________________________]
b. Address (No. & Street/City/State/Zip Code)
[_________________________________________________________________________]
c. SSN or TIN
[_________________________________________________________________________]
7 a. Policyowner Relationship to Insured
[_________________________________________________________________________]
if no owner is designated, the insured shall be the owner
b. Address (No. & Street/City/State/Zip Code)
[_________________________________________________________________________]
(Include billing address in item #25 if it is different from above
address.)
c. Policyowner's SSN or TIN
[_________________________________________________________________________]
8 a. Name of Employer
[_________________________________________________________________________]
b. Nature of Business
[_________________________________________________________________________]
c. Business Address (No. & Street/City/State/Zip Code)
[_________________________________________________________________________]
d. Occupation (Describe Exact Duties)
[_________________________________________________________________________]
e. How long in this job? [___________________________________________________]
f. Are you presently working full time? [ ] Yes [ ] No
9 Do you now, or do you intend to fly as a pilot, student pilot or crew member?
[ ] Yes [ ] No
If "Yes," an Aviation Questionnaire is required.
10 Do you now, or do you intend to participate in automobile, motorboat or
motorcycle racing, skydiving, hang gliding, skin or scuba diving, mountain
or rock climbing or engage in any other hazardous activity? [ ] Yes [ ] No
If "Yes," an Avocation Questionnaire is required.
11 Do you intend to change your residence or travel outside the United States
or Canada? [ ] Yes [ ] No
If "Yes," a Foreign Travel or Residence Questionnaire is required.
12 Do you currently use or have you ever used tobacco or nicotine products in
any form, e.g., cigarettes, cigars, pipes, chewing tobacco, nicotine gum or
nicotine patches? (Complete a. through f.)
YES NO
--- --
a. Cigarettes 12a. [ ] [ ]
If yes, Month__________ Year__________ last used
Number of packs per day__________
b. Xxxxxx 00x. [ ] [ ]
If yes, Month__________ Year__________ last used
Number of cigars per month__________
c. Pipe 12c. [ ] [ ]
If yes, Month__________ Year__________ last used
d. Chewing Tobacco 12d. [ ] [ ]
If yes, Month__________ Year__________ last used
e. Nicotine Gum 12e. [ ] [ ]
If yes, Month__________ Year__________ last used
f. Nicotine Patches 12f. [ ] [ ]
If yes, Month__________ Year__________ last used
13 Have you ever applied for any life, accident or health insurance which has
not been granted exactly as applied for in kind, amount, or rate? Has any
insurance issued to you been cancelled or its renewal or reinstatement
refused? [ ] Yes [ ] No
If "Yes," give details under Item #25.
14 What is the total amount of life insurance inforce on your life? (Do not
include Group policies.)
[ ] I have no life insurance inforce.
When Business Ins.?
Amount ADB Issued Company (Y or N)
[___________________________________________________________________________]
15 Are you negotiating for other life, disability or health insurance?
[ ] Yes [ ] No
If "Yes," give details under Item #25.
16 Do you intend the replacement or change of any of your existing life
insurance policies or annuities in connection with this application for life
insurance? [ ] Yes [ ] No
If "Yes," give company, policy number, amount, and reason.
[___________________________________________________________________________]
A12301 6 05/2000
17 What is the purpose of this insurance?
(Check where applicable)
[ ] PERSONAL [ ] BUSINESS
_____________________________________________________________________________
[ ] Estate Liquidity [ ] Key Employee
[ ] Family Protection [ ] Buy/Sell
[ ] Loan Protection [ ] Creditor
[ ] Tax Planning [ ] Employee Benefits
[ ] Retirement Planning (Split Dollar, Deferred
[ ] Cash Accumulation Compensation, etc.)
[ ] Other: [____________________] [ ] Other: [____________________]
18 Does the Proposed Owner(s) think that this policy will meet his/her insurance
and financial objectives? [ ] Yes [ ] No
19 Personal Finances
a. Earned Income d. Savings/Liquid Net Worth
[_______________________________] [_______________________________]
b. Unearned Income e. Total Liabilities
[_______________________________] [_______________________________]
c. Total Assets f. Net Worth
[_______________________________] [_______________________________]
20 Business Finances
(Complete question #20 only if this is business insurance.)
a. Total Assets
[________________________________________________________________________]
b. Total Liabilities
[________________________________________________________________________]
c. Net Worth
[________________________________________________________________________]
d. Net Profit After Taxes for Past Two Years:
Last Year Previous Year
[_______________________________] [_______________________________]
e. What is your percentage ownership of this firm?
[________________________________________________________________________]
f. Is business insurance applied for or inforce on other key members of
this firm? [ ] Yes [ ] No
Please explain.
[________________________________________________________________________]
If face amount exceeds one million dollars, submit a copy of the business'
most recent financial statement and/or annual report.
21 Have you or your company ever filed for bankruptcy? [ ] Yes [ ] No
If "Yes," give details under item #25.
22 a. Proposed Insured Driver's License:
Number State
[________________________________________________________________________]
b. Have you had a moving violation, traffic accident or your driver's license
suspended or revokedwithin the last three years? [ ] Yes [ ] No
23 Except for traffic violations, have you been convicted in a criminal
proceeding or are you the subject of a pending criminal proceeding?
[ ] Yes [ ] No
24 I have paid $[_______________] to the agent or broker in exchange for the
Conditional Receipt, and I agree to the conditions.
25 REMARKS AND DETAILS OF PREVIOUS QUESTIONS. (Include any special dating
requirements, details to "Yes" responses, etc. Please attach a separate
signed and dated sheet of paper if additional space is needed to continue.)
Question # Comments
_____________________________________________________________________________
[___________________________________________________________________________]
Additional Comments
[___________________________________________________________________________]
A12301 7 05/2000
ING [LOGO] RELIASTAR PART II OF AN APPLICATION FOR LIFE INSURANCE
[ ] ReliaStar Life Insurance Company, 00 Xxxxxxxxxx Xxxxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxxx 00000
[ ] Security-Connecticut Life Insurance Company, 00 Xxxxxxxx Xxxxx, Xxxx, XX
00000
(NON-MEDICAL)
1 a. Proposed Insured Name (First/Middle Initial/Last)
[_________________________________________________________________________]
b. Date of Birth (MM/DD/YYYY) c. Age d. [ ] Male
[_________________________] [_____] [ ] Female
2 a. Name and address of your personal physician.
[_________________________________________________________________________]
b. Date and reason last consulted:
[_________________________________________________________________________]
c. What advice and treatment was given or medication prescribed?
[_________________________________________________________________________]
3 a. Height b. Weight
[________________________________] [________________________________]
PROVIDE DETAILS TO "YES" ANSWERS FOR QUESTIONS #4-11 IN SPACE PROVIDED AT ITEM
#13.
4 In the past 10 years, have you ever been treated for or been diagnosed as
having: YES NO
--- --
a. Disorder of eyes, ears, nose or throat? 4a. [ ] [ ]
b. Dizziness, fainting, convulsions, headache, speech defect, paralysis,
stroke, mental or nervous disorder? 4b. [ ] [ ]
c. Shortness of breath, persistent hoarseness or cough, spitting of blood,
asthma, emphysema, tuberculosis or chronic respiratory disorder?
4c. [ ] [ ]
d. Chest pain, palpitations, high blood pressure, heart murmur, heart attack
or other disorder of the heart or blood vessels? 4d. [ ] [ ]
e. Jaundice, intestinal bleeding, ulcer, hernia, hepatitis, colitis,
diverticulitis, recurrent indigestion, or other disorder of the stomach,
intestine, liver or gall bladder? 4e. [ ] [ ]
f. Sugar, albumin, blood or pus in urine, venereal disease, nephritis, stone,
or other disorder of kidney, bladder, breasts, prostate or reproductive
organs? 4f. [ ] [ ]
g. Diabetes, thyroid or other endocrine disorder? 4g. [ ] [ ]
h. Neuritis, sciatica, rheumatism, arthritis, gout or disorder of the muscles
or bones? 4h. [ ] [ ]
i. Deformity, lameness or amputation? 4i. [ ] [ ]
j. Disorder of skin, lymph glands, cyst, tumor or cancer? 4j. [ ] [ ]
k. Allergies, anemia or other disorder of the blood? 4k. [ ] [ ]
5 In the past 10 years have you ever been diagnosed by a medical doctor for
Acquired Immunodeficiency Syndrome(AIDS)? 5 [ ] [ ]
6 a. Have you used or do you now use barbiturates, amphetamines, hallucinogenic
drugs (including marijuana), narcotics or any prescription drug except in
accordance with a physician's instruction? 6a. [ ] [ ]
b. Have you ever received counseling, medical advice and/or treatment from a
commonly recognized practitioner or treatment organization for alcohol or
drug use? 6b. [ ] [ ]
7 Are you now under observation, treatment or taking medication?
7 [ ] [ ]
8 To the best of your knowledge are you now pregnant? 8 [ ] [ ]
If "Yes," give expected delivery date.
[____________________________________________________________________________]
9 Have you within the past 5 years:
a. Been diagnosed or treated by a medical professional for any mental or
physical disorder? 9a. [ ] [ ]
b. Had a checkup, consultation, illness, injury or surgery or received any
medical advice? 9b. [ ] [ ]
c. Been a patient in a hospital, clinic, sanitarium or other medical facility?
9c. [ ] [ ]
d. Had an electrocardiogram, x-ray or other diagnostic test? 9d. [ ] [ ]
e. Been advised by a medical professional to have any diagnostic test,
hospitalization or surgery which has not been completed? 9e. [ ] [ ]
10 Have you ever had military service deferment, rejection or discharge
because of a physical or mental condition? 10 [ ] [ ]
11 Have you ever requested or received a pension, benefits, or payment because
of an injury, sickness or disability? 11 [ ] [ ]
A12301 8 05/2000
12 Family History of Proposed Insured
Age if Age at
Living Death Current Health or Cause of Death
Father [________________________________________________________________]
Mother [________________________________________________________________]
Brothers [________________________________________________________________]
Sisters [________________________________________________________________]
13 REMARKS AND DETAILS OF "YES" ANSWERS: (From questions 4-11)
(Identify question. Give dates, diagnosis, details and treatment plus names
and addresses of all attending physicians and medical facilities. Please
attach a separate signed and dated sheet of paper if additional space is
needed to continue.)
Question Name and Address of
# Date Physician or Facility Treatment, Medication, Details
_____________________________________________________________________________
[___________________________________________________________________________]
Additional Comments:
[___________________________________________________________________________]
A12301 9 05/2000
ING [LOGO] RELIASTAR 00 Xxxxxxxxxx Xxxxxx Xxxxx, Xxxxxxxxxxx, Xxxxxxxxx 00000
PART III OF AN APPLICATION FOR LIFE INSURANCE
(SUITABILITY FOR VARIABLE PRODUCTS ONLY)
This section must be completed on the Proposed Owner only if applying for a
variable universal life insurance policy. A supplement also must be completed to
choose premium payment allocation.
IMPORTANT NOTICE: The Death Benefit and the Cash Surrender Value and endowment
benefits under the Variable Account may increase or decrease with the investment
performance of the allocations to the variable investment options. Regardless of
the investment performance, the Death Benefit will never be less than the Face
Amount as long as there are no unpaid monthly deductions, policy loans or
partial withdrawals. There is no guaranteed Cash Surrender Value or endowment
benefits for amounts in the Variable Account, and these amounts may be reduced
to zero. Upon request, the company will furnish you with a comparison of
benefits of the policy applied for and a fixed life insurance policy.
1 Did the Proposed Owner(s) receive a Prospectus describing the policy,
investment divisions, and important features?..................[ ] Yes [ ] No
2 If yes, which Prospectus was delivered?
a. [ ] N700.176 & 46623 c. [ ] N700.181 & 46623 e. [ ] 46203 & 46623
Date of Prospectus Date of Prospectus Date of Prospectus
[_________________] [_________________] [_________________]
b. [ ] 48024 & 48162 d. [ ] 47621 & 46623 f. [ ] Other-Form #______
Date of Prospectus Date of Prospectus Date of Prospectus
[_________________] [_________________] [_________________]
3 a. Does the Proposed Owner(s) consent to delivery of prospectuses, prospectus
supplements, statements of additional information, transactional
confirmation and periodic statements in one or more of the following forms?
(Check all that apply.) [ ] 3.5" Floppy Disk [ ] CD Rom [ ] Internet
Website
[ ] E-Mail, and my e-mail address is [____________________________________]
This consent is valid until revoked by the Proposed Owner(s) in writing.
The Proposed Owner(s) understands that ReliaStar Life may choose to
discontinue delivery of the above types at any time and may choose to
deliver a paper version.
b. Does the Proposed Owner(s) consent to eliminate duplicate mailing of
identical documents to the same household if they have more than one
ReliaStar Life policy?......................................[ ] Yes [ ] No
4 Do you understand and acknowledge:
a. That the Policy applied for is variable, employs the use of variable
investment options, which means that you need to receive and understand
the current prospectus for the Policy and the underlying
accounts?...................................................[ ] Yes [ ] No
b. That any benefits, values or payments based on performance of the variable
investment options may vary; and are not guaranteed by the Company, any
other insurance company, the U.S. or any state government?..[ ] Yes [ ] No
c. That any benefits, values or payments based on performance of the variable
investment options may vary; and are not federally insured by the FDIC,
the Federal Reserve Board or any other agency, Federal or
State?......................................................[ ] Yes [ ] No
d. That in essence, all risk is borne by the Owner, except for funds placed in
a fixed interest account?...................................[ ] Yes [ ] No
e. That the policy is designed to provide life insurance coverage and to allow
for the accumulation of values in the variable investment
accounts?...................................................[ ] Yes [ ] No
f. The amount or duration of the death benefit may increase or decrease,
depending on the investment experience of the separate
account?....................................................[ ] Yes [ ] No
g. The Policy Values may increase or decrease, depending on fund performance
and certain expense deductions?.............................[ ] Yes [ ] No
5 Do you believe the Policy you selected meets your insurance and investment
objectives and your anticipated financial needs?...............[ ] Yes [ ] No
A12301 10 05/2000
ING [LOGO] RELIASTAR
[ ] ReliaStar Life Insurance Company, 00 Xxxxxxxxxx Xxxxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxxx 00000
[ ] Security-Connecticut Life Insurance Company, 00 Xxxxxxxx Xxxxx, Xxxx, XX
00000
By signing this application, all who sign below agree to all of the following
terms and conditions. I have read the preceding questions and answers. I affirm
that my answers are complete and true to the best of my knowledge and belief. I
agree that (1) This application (Part I, Part II if required, and any special
questionnaires required) shall form a part of any policy issued. (2) No waiver
or change shall bind the Company unless it is in writing and signed by the
President, a Vice President or the Secretary. (3) No agent is authorized to (a)
waive the answer to any questions in this application, (b) make or change any
insurance contract, (c) waive any of the Company's underwriting requirements or
other rights. (4) NO INSURANCE SHALL TAKE EFFECT UNLESS DURING THE LIFETIME AND
CONTINUED INSURABILITY OF THE PROPOSED INSURED AS STATED IN THIS APPLICATION,
THE POLICY HAS BEEN DELIVERED TO AND ACCEPTED BY THE OWNER, AND THE FIRST
PREMIUM FOR THE POLICY HAS BEEN PAID: except that if the first premium has been
paid and the Company's Conditional Receipt has been issued, the provisions of
such Conditional Receipt shall apply. (5) I understand that if, within the last
year, I have received any treatment or advice from a physician for tumor or
cancer or any brain, heart, lung or kidney disorder, a Conditional Receipt may
not be given and premium may not be collected. Further, I hereby declare that my
Social Security Number stated herein is correct. I waive to such extent as may
be lawful all provisions of law that would forbid the disclosure of any
information about me by: (1) any physician or any other person who has attended
or examined me; or (2) any physician or other person who may attend or examine
me in the future. I waive this on behalf of myself. This waiver shall be valid
for twenty-six months from the date shown below.
If I am applying for a Variable Universal Life insurance policy, then:
a. I agree to arbitrate, under the rules and procedures of the National
Association of Securities Dealers, Inc., any dispute, claim, demand, or
controversy arising out of such policy including without limitation, the
sale thereof, and involving one or more of the following persons: ReliaStar
Life Insurance Company (ReliaStar Life), its affiliated broker dealers,
including Washington Square Securities, Inc. (WSSI), representatives
thereof, and any unaffiliated broker dealers and representatives thereof.
Any arbitration awarded or rendered against any party may be entered as
judgment in any court of competent jurisdiction.
b. [ ] Yes [ ] No I AUTHORIZE ReliaStar Life to act on telephone/fax
instructions from the Proposed Owner, the Registered Representative of
record for the proposed contract or the Registered Representative's
Assistant(s), provided that any instructions entered by the Registered
Representative or Registered Representative's Assistant(s) have been
expressly authorized by me. The instructions may include allocating funds
among the available Variable Investment Options and changing the allocation
for future payments. Under no circumstances shall the Registered
Representative or the Registered Representative's Assistant(s) have
discretionary authority or the ability to make investment decisions for the
Contract Owner. I AUTHORIZE ReliaStar Life to use my Social Security Number
or my Tax Identification Number as my personal identification code. I
UNDERSTAND that ReliaStar Life must be given my personal identification
code whenever telephone instructions are made. I UNDERSTAND that all
telephone/fax instructions given pursuant to this Authorization are subject
to the conditions (including fund, frequency and amount limitations) set
forth in the applicable ReliaStar Life prospectus for the product being
applied for. I UNDERSTAND that I am responsible for promptly reviewing all
confirmation notices. I UNDERSTAND that ReliaStar Life and /or its
affiliated broker dealers will not be liable for any loss liability, cost,
or expense when ReliaStar Life and/or its affiliated broker dealers act in
accordance with the telephone/fax transfer instructions which are received,
and if by telephone, are recorded on voice recording equipment. ReliaStar
Life will employ reasonable procedures to confirm that instructions
communicated by telephone/fax are genuine. If ReliaStar Life does not
employ such procedures, ReliaStar Life may be liable for any losses due to
unauthorized or fraudulent instructions. I UNDERSTAND telephone/fax
requests must be received at ReliaStar Life no later than 3:00 p.m. Central
Standard Time in order to assure same day pricing of the transaction.
Telephone/fax requests will not be accepted after that time. I UNDERSTAND
telephone/fax privileges may be discontinued at any time.
________________________________________________________________________________
Signed at (City) State
[__________________________________________________________________] [_________]
Signature of Proposed Primary Insured if age 10 or older Date
[__________________________________________________________________] [_________]
Signature of Proposed Owner (if other than Proposed Primary Insured) Date
[__________________________________________________________________] [_________]
Signature of Parent or Guardian if other than Proposed Owner and Date
Proposed Primary Insured is a minor
[__________________________________________________________________] [_________]
Signature of Agent Date
[__________________________________________________________________] [_________]
Agent's Name (Please print) Agent's ID Number Agent's State Insurance
License Number
[____________________________] [________________] [_________________________]
A12301 11 05/2000
ING [LOGO] RELIASTAR AGENT'S REPORT
[ ] ReliaStar Life Insurance Company, 00 Xxxxxxxxxx Xxxxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxxx 00000
[ ] Security-Connecticut Life Insurance Company, 00 Xxxxxxxx Xxxxx, Xxxx XX
00000
THE FOLLOWING QUESTIONS RELATE TO THE PROPOSED INSURED AND ARE TO BE
ANSWERED BY THE AGENT OR BROKER OF RECORD
(MUST BE COMPLETED FOR ALL APPLICATIONS)
1 To the best of your knowledge and belief, will any existing life or annuity
coverage be replaced, lapsed, surrendered, or borrowed against? [ ] Yes [ ] No
(If "Yes," submit applicable state replacement forms.)
2 Is the Proposed Insured now negotiating for other life insurance or have
coverage pending with other companies? [ ] Yes [ ] No
(If "Yes," provide details.)
[____________________________________________________________________________]
3 If the application is for a Variable Universal Life Insurance policy:
a. Was a Variable Supplement for Life Application completed? [ ] Yes [ ] No
b. Was Part III of the Application completed? [ ] Yes [ ] No
c. Are any Life insurance, annuities, variable investment options, securities
or unmatured CD's being liquidated to purchase this variable life insurance
policy? [ ] Yes [ ] No
4 a. How much life insurance does the Proposed Insured's spouse have with the
Proposed Insured named as beneficiary?
[_________________________________________________________________________]
b. With what companies?
[_________________________________________________________________________]
5 If this application is on a juvenile, please indicate the amount of life
insurance in force on each parent or sibling.
Father $[__________________________________________________________________]
Mother $[__________________________________________________________________]
Siblings $[__________________________________________________________________]
6 Did you use a fact finder or needs analysis tool in connection with this
sale? [ ] Yes [ ] No
7 List business associates or family members on whom applications are being
submitted to this Company.
[____________________________________________________________________________]
REMARKS BY AGENT OR BROKER
ADDITIONAL/ALTERNATE POLICY REQUESTED BY AGENT OR BROKER MUST BE INDICATED IN
THIS SPACE.
PLEASE ATTACH A SEPARATE SIGNED AND DATED SHEET OF PAPER IF ADDITIONAL
SPACE IS NEEDED.
________________________________________________________________________________
[______________________________________________________________________________]
Manager/ Manager/
Agent/Broker Name Agent ID# %Split Agency ID Agency Name
________________________________________________________________________________
[______________________________________________________________________________]
Agent's Signature Date Phone Number Fax Number E-Mail Address
________________________________________________________________________________
[______________________________________________________________________________]
TO BE COMPLETED BY THE MANAGER/GENERAL AGENT
Writing Agent's License for
[ ] ReliaStar Life
[ ] Security-Connecticut Life is: [ ] Inforce [ ] Pending
If applicable, is a Single Case Agreement attached? [ ] Yes No [ ]
Manager/Agency Signature Print Name Agent Number
________________________________________________________________________________
[______________________________________________________________________________]
HOME OFFICE USE ONLY
Amount Voucher# Entry Date
________________________________________________________________________________
[______________________________________________________________________________]
Check # Check Date Sender
________________________________________________________________________________
[______________________________________________________________________________]
A12301 12 05/2000
ING [LOGO] RELIASTAR MONTH-O-MATIC(R) FORM
[ ] ReliaStar Life Insurance Company, 00 Xxxxxxxxxx Xxxxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxxx 00000
[ ] Security-Connecticut Life Insurance Company, 00 xxxxxxxx Xxxxx, Xxxx, XX
00000
Request and Authorization Agreement for Pre-Arranged Payments or Electronic Bank
Debit Plan for Payment of Premiums.
ReliaStar Life Insurance Company or Security-Connecticut Life Insurance Company
(the "Company") is hereby requested and authorized to draw checks or initiate
bank debits to be charged against the account described in the Authorization
below.
Please X one of the boxes below:
[ ] Start new Month-O-Matic(R) Plan
[ ] Add to existing Month-O-Matic(R)
Plan No._____________________
[ ] Change existing bank name or Accounting No.
Policy Number Proposed Insured's Name Monthly Deduction
(First/Middle Initial/Last)
________________________________________________________________________________
[______________________________________________________________________________]
I request the day of withdrawals or debits to my account to be on or about the
_________ of each month. (Any day from the 1st through the 28th of the month may
be selected.)
Bank Account Information and Type (Please check one box: Either Checking or
Saving)
________________________________________________________________________________
[ ] ReliaStar Life
[ ] Security-Connecticut Life
STAPLE
VOIDED CHECK HERE
-NOT DEPOSIT SLIP-
[ ] Checking [ ] Savings [ ] Branch [____________________________________]
Banking Account Number [_______________________________________________________]
Transit Routing Number (9 digits) [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
Name of Bank [_________________________________________________________________]
or Credit Union [______________________________________________________________]
Street [_______________________________________________________________________]
City [______________________________________] State [______] Zip [____________]
________________________________________________________________________________
Terms of the Month-O-Matic(R)Plan
Each debit shall be: (1) in an amount sufficient to pay a proper proportion of
the annual premium at the Company's Month-O-Matic(R)premium rate; (2) notice of
premium due and no further notice of premium shall be given; (3) a receipt for
the amount stated thereon if and when the Company receives actual payment. If a
debit is not honored by the bank upon presentation for payment by the Company,
such action by the bank shall be notice of nonpayment of premium.
The Month-O-Matic(R) Plan for premium payment may be terminated by the
Policyowner or by the Bank Depositor/premium payor by written notice filed with
the Company and may be terminated by the bank in which the account is
maintained. The Company also may terminate without notice if any debit is not
honored upon presentation, otherwise upon 30 days written notice to the
Policyowner. In the event the Plan is terminated for any cause, any unpaid
premiums, and premiums which have due dates that occur on or after the date of
termination, shall be paid directly to the Company at the premium rate and on
the premium due date which would have been applicable to each policy if it had
not been placed under the Month-O-Matic(R) Plan for premium payment. If the
Company is not paid within the time required by the policies, the said policies
shall lapse and have no further value, except as otherwise provided in said
policies.
The Company may, at its discretion from time to time, effect payments by use of
prearranged payments (debit) or an electronic bank debit system.
It is agreed that:
* This authorization shall apply to any conversion, renewal or change made in
said policies.
* The Company encourages the Policyowner to obtain overdraft protection from its
bank to avoid any unhonored withdrawals and associated fees.
* The Company may increase the premium withdrawal amount sufficient to maintain
insurance coverage. Such increase would occur 30 days after providing written
notification of the increase.
AUTHORIZATION AGREEMENT FOR PREARRANGED PAYMENTS (DEBITS)
I (we) authorize Reliastar Life Insurance Company or Security-Connecticut Life
Insurance Company (the "Company") to make variable charges to my (our) checking
or savings account identified above, and authorize the financial institution
named above to withdraw funds from (debit) such account and pay to the Company's
order accordingly. This authorization will remain in effect until the financial
institution has received and has had reasonable time to act on a written request
from me (us) to terminate this agreement.
I have read and understand the above statement:
[________________________] [________________________] [________________________]
Signature of Bank Account Social Security/Tax I.D. Date Signed
Owner Number
[________________________] [________________________] [________________________]
Applicants Signature Social Security/Tax I.D. Date Signed
Number
A12301 13 05/2000
ING [LOGO] RELIASTAR GOVERNMENT/MILITARY ALLOTMENT
[ ] ReliaStar Life Insurance Company, 00 Xxxxxxxxxx Xxxxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxxx 00000
[ ] Security-Connecticut Life Insurance Company, 00 Xxxxxxxx Xxxxx, Xxxx, XX
00000
1 Payor's Name: [______________________________________________________________]
2 Social Security Number: [____________________________________________________]
3 Amount of Allotment: [_______________________________________________________]
4 Date First Allotment Should Begin: [_________________________________________]
[ ] New Allotment [ ] Change in Allotment
[$_______] to[$_______]
5 Payor's Status: [ ] Active [ ] Retired
6 Payor's Branch/Company Blanket Codes: [ ] Army-290 (Company Code K002541)
[ ] Navy/Airforce-N025309
[ ] Marine Corps-0213
[ ] Retired-USA USN USMC USAF-318
[ ] Coast Guard-Individual Allotment
(Retired & Active Coast Guard)
A12301 14 05/2000
