EXHIBIT (3)(c)
SELLING GROUP AGREEMENT - SERVICING ONLY
AMERICAN GENERAL EQUITY SERVICES CORPORATION AND
THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK
This Selling Group Agreement - Servicing Only ("Agreement") is made by and
among AMERICAN GENERAL EQUITY SERVICES CORPORATION ("AGESC"), a Delaware
corporation, THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK
("USL"), a Texas domiciled life insurance company, and the following parties:
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("Selling Group Member")
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("Associated Agency")
RECITALS
WHEREAS, USL is a wholly-owned subsidiary of AMERICAN INTERNATIONAL GROUP, INC.
("AIG"), a Delaware corporation;
WHEREAS, USL and AGESC are affiliates pursuant to the insurance laws of the
State of New York;
WHEREAS, USL and AGESC are parties to a distribution agreement whereby USL has
granted AGESC a non-exclusive right to promote the sale of USL products set
forth in Schedule A;
WHEREAS, Selling Group Member and the Associated Agency are affiliates of each
other and neither is an affiliate of USL or AGESC; and
WHEREAS, AGESC, USL, Selling Group Member and the Associated Agency wish to
enter into this Agreement for the purpose of providing for servicing of certain
USL variable universal life insurance policies and variable annuity contracts.
NOW THEREFORE, in consideration of the premises and mutual promises set forth
herein, and intending to be legally bound hereby, the parties agree as follows:
1. PRODUCT DISTRIBUTION.
Subject to the terms, conditions and limitations of this Agreement, the
products covered under this Agreement shall be serviced in accordance
with this section.
(a) Designation of the Parties.
AGESC is a registered broker-dealer and distributor of the variable
universal life insurance policies and variable annuity contracts set
forth in Schedule A (collectively, the "Contracts").
USL is a Texas licensed life insurance company issuing the Contracts.
The Contracts are registered with the Securities and Exchange Commission
(the "SEC").
Selling Group Member is registered with the SEC as a broker-dealer under
the Securities Exchange Act of 1934 ("1934 Act") and under any
appropriate regulatory requirements of state law and is a member in good
standing of the Financial Industry Regulatory Authority ("FINRA"),
unless Selling Group Member is exempt from the broker-dealer
registration requirements of the 1934 Act.
Selling Group Member has FINRA registered representatives who will
service the Contracts.
The Associated Agency is a licensed insurance agency and will be
appointed by USL as an agent of USL as required by the appropriate state
Insurance Department. The relationship between the Associated Agency and
USL is that of an independent contractor.
The FINRA registered representatives affiliated with Selling Group
Member are also appropriately licensed insurance agents of the
Associated Agency and upon approval by USL, will be appointed by USL as
agents of USL with the appropriate Insurance Department ("Sales
Persons"). The relationship between the Sales Persons and Selling Group
Member and the Sales Persons and USL is that of independent contractor.
AGESC hereby appoints Selling Group Member and the Sales Persons to
service the Contracts.
The appointment by AGESC of Selling Group Member and the Sales Persons
and the appointment by USL of the Associated Agency and the Sales
Persons for the servicing of these Contracts is not to be deemed
exclusive in any manner and only extends to servicing of the Contracts.
(b) Responsibilities Of The Parties/Compliance.
(i)SELLING GROUP MEMBER/SALES PERSONS.
Selling Group Member shall be responsible for the servicing
activities of the Sales Persons and shall exercise supervisory
oversight over the Associated Agency and the Sales Persons with
respect to such activities.
Selling Group Member shall be solely responsible for the approval of
suitability determinations related to the selection of any investment
option under the Contracts, in
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compliance with federal and state securities laws and shall supervise
the Associated Agency and the Sales Persons in determining
suitability. Selling Group Member shall hold USL and AGESC harmless
from any financial claim resulting from improper suitability
decisions or failure to supervise the Associated Agency and the Sales
Persons in accordance with federal securities laws and FINRA
regulation.
Selling Group Member will fully comply with the requirements of FINRA
and of the 1934 Act and such other applicable federal and state
securities laws and will establish rules, procedures and supervisory
and inspection techniques necessary to diligently supervise the
activities of the Sales Persons in connection with servicing of the
Contracts. Such supervision shall include, but not be limited to
providing, or arranging for, initial and periodic training in
Contract provisions and benefits. Upon request by AGESC or USL,
Selling Group Member will furnish appropriate records as are
necessary to establish diligent supervision.
Selling Group Member shall pay all costs associated with registering
and complying with the various rules of the SEC and FINRA relating to
broker-dealers.
Selling Group Member shall fully cooperate in any insurance or
securities regulatory examination, investigation, or proceeding or
any judicial proceeding with respect to USL, AGESC, Selling Group
Member and Associated Agency and their respective affiliates, agents
and representatives to the extent that such examination,
investigation, or proceeding arises in connection with the Contracts.
Selling Group Member shall immediately notify AGESC if its
broker-dealer registration or the registration of any of its Sales
Persons is revoked, suspended or terminated. Selling Group Member
shall also immediately notify USL if its broker-dealer registration
is revoked, suspended or terminated.
(ii)THE ASSOCIATED AGENCY/SALES PERSONS.
Associated Agency is authorized to recommend Sales Persons for
appointment by USL to service the Contracts. Associated Agency
warrants that no Sales Person shall provide servicing for the
Contracts until that Sales Person is appropriately licensed and
appointed by USL to service the Contracts. Associated Agency shall be
responsible for all fees required to obtain and/or maintain any
licenses or registrations required by applicable Insurance Law.
Associated Agency will fully comply with the requirements of all
applicable insurance laws and regulations.
Associated Agency shall fully cooperate in any insurance or
securities regulatory examination, investigation, or proceeding or
any judicial proceeding with respect to USL, AGESC, Selling Group
Member and Associated Agency and their respective affiliates, agents
and representatives to the extent that such examination,
investigation, or proceeding arises in connection with the Contracts.
Associated Agency shall immediately notify AGESC if its insurance
license or the license of any of its Sales Persons is revoked,
suspended, or terminated.
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(iii)USL.
USL warrants, represents and covenants that the prospectus(es) and
registration statement(s) relating to the Contracts and all sales
materials, if any, approved by USL with respect to the Contracts,
contain no untrue statements of material fact or omission of a
material fact, the omission of which makes any statement contained
therein materially false or misleading. USL agrees to indemnify and
hold harmless Associated Agency and Selling Group Member from and
against any claims, liabilities and expenses which may be incurred by
any of those parties under the Securities Act of 1933 ("1933 Act"),
the 1934 Act, the Investment Company Act of 1940 (the "1940 Act")
common law, or otherwise, that arise out of a breach of this
paragraph.
USL shall fully cooperate in any insurance or securities regulatory
examination, investigation, or proceeding or any judicial proceeding
with respect to USL, AGESC, Selling Group Member and/or Associated
Agency and their respective affiliates, agents and representatives to
the extent that such examination, investigation, or proceedings arise
in connection with the Contracts.
(iv)AGESC.
AGESC shall fully cooperate in any insurance or securities regulatory
examination, investigation, or proceeding or any judicial proceeding
with respect to USL, AGESC, Selling Group Member and/or Associated
Agency and their respective affiliates, agents and representatives to
the extent that such examination, investigation, or proceedings arise
in connection with the Contracts. AGESC shall immediately notify
Selling Group Member and the Associated Agency if its broker-dealer
registration is revoked, suspended or terminated.
(c) New Products.
USL and AGESC will not propose and USL will not issue any additional or
successor Contracts. This Agreement is solely for the purpose of
servicing Contracts listed on Schedule A.
(d) Sales Material/Books and Records.
Associated Agency, Selling Group Member and Sales Persons shall not
utilize, in their efforts to service the Contracts, any written
brochure, prospectus, descriptive literature, printed and published
material, audio-visual material or standard letters unless such material
has been provided preprinted by USL or unless USL has provided prior
written approval for the use of such literature. In accordance with any
applicable insurance laws and regulations, Associated Agency and/or
Selling Group Member shall maintain complete records indicating the
manner and extent of distribution of any such solicitation material,
shall make such records and files available to USL and/or AGESC and
shall forward such records to USL and AGESC. Additionally, Selling Group
Member and/or Associated Agency shall make such material available to
personnel of state insurance departments, FINRA or other regulatory
agencies, including the SEC, which may have regulatory authority over
USL or AGESC. Associated Agency and Selling Group Member jointly and
severally hold USL, AGESC and their affiliates harmless from any
liability arising from the use of any material which either (i) has not
been specifically approved in
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writing by USL, or (ii) although previously approved, has been
disapproved by USL in writing for further use.
Selling Group Member will reflect all transactions in the Contracts by
Associated Agency and the Sales Persons on the books and records of
Selling Group Member. Selling Group Member hereby designates the
principal place of business of Associated Agency as an Office of
Supervisory Jurisdiction of Selling Group Member.
2. COMPENSATION.
USL will remit to Associated Agency all compensation set forth in the
compensation schedule that was applicable at the time the Contract was
issued and for which compensation is to be paid in compliance with any
applicable insurance laws and regulations. Associated Agency will remit
the compensation otherwise due and payable to Sales Persons to Selling
Group Member which, in turn, will pay the Sales Persons. USL will not
accept or otherwise honor any assignment of compensation by Associated
Agency in connection with the sale of the Contracts, unless such
assignment complies with all applicable insurance laws and regulations.
3. CUSTOMER SERVICE AND COMPLAINTS.
Selling Group Member and Associated Agency consent that USL and/or AGESC
may contact Contract owners, including utilizing information received
from them with respect to the Contract and pursuant to processing any
claims and complaints under a Contract. The parties agree to cooperate
fully in the investigation and processing of any complaint associated
with the sale of the Contracts under this Agreement.
4. INDEMNIFICATION.
Selling Group Member and Associated Agency agree to hold harmless and
indemnify AGESC and USL and each of their respective employees,
controlling persons, officers or directors against any losses, expenses
(including reasonable attorneys' fees and court costs), damages or
liabilities to which AGESC and/or USL or such affiliates, controlling
persons, officers or directors become subject, under the 1933 Act, any
applicable insurance laws or regulations or otherwise, insofar as such
losses, expenses, damages or liabilities (or actions in respect thereof)
arise out of or are based upon any performance, non-performance or
breach of any warranty, representation or covenant of this Agreement by
Selling Group Member, Associated Agency, and/or Sales Persons, or are
based upon any alleged or untrue statement of Selling Group Member,
Associated Agency or Sales Person other than statements contained in the
USL approved sales material for any Contract, or in the registration
statement or prospectus for any Contract.
USL hereby agrees to indemnify and hold harmless Selling Group Member
and Associated Agency and each of their respective employees,
controlling persons, officers or directors against any losses, expenses
(including reasonable attorneys' fees and court costs), damages or
liabilities to which Selling Group Member and/or Associated Agency or
such affiliates, controlling persons, officers or directors become
subject, under the 1933 Act, the 1934 Act, the 1940 Act, any applicable
insurance laws or regulations or otherwise, insofar as such losses,
expenses, damages or liabilities (or actions in respect thereof) arise
out of or are based upon USL's performance, non-performance or breach by
USL or AGESC of any warranty, representation or covenant of
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this Agreement, or are based upon any untrue statement contained in, or
material omission from, the prospectus, the registration statement or
the approved sales materials, if any, for any of the Contracts.
5. FIDELITY BOND.
Associated Agency represents that all directors, officers, employees and
Sales Persons of Associated Agency licensed pursuant to this Agreement
or who have access to funds of USL are and will continue to be covered
by a blanket fidelity bond including coverage for larceny, embezzlement
and other defalcation, issued by a reputable bonding company. This bond
shall be maintained at Associated Agency's expense.
Such bond shall be at least equivalent to the minimal coverage required
under the Conduct Rules of FINRA and endorsed to extend coverage to life
insurance and annuity transactions. Associated Agency acknowledges that
USL may require evidence that such coverage is in force and Associated
Agency shall promptly give notice to USL of any notice of cancellation
or change of coverage.
Associated Agency assigns any proceeds received from the fidelity bond
company to USL to the extent of USL's loss due to activities covered by
the bond. If there is any deficiency, Associated Agency will promptly
pay USL that amount on demand. Associated Agency indemnifies and holds
harmless USL from any deficiency and from the cost of collection.
6. LIMITATIONS ON AUTHORITY.
The Contract forms are the sole property of USL. No person other than
USL has the authority to make, alter or discharge any policy, Contract,
certificate, supplemental contract or form issued by USL. No party has
the right to waive any provision with respect to any Contract or policy;
give or offer to give, on behalf of USL, any tax or legal advice related
to the purchase of a Contract or policy, or make any settlement of any
claim or bind USL or any of its affiliates in any way. No person has the
authority to enter into any proceeding in a court of law or before a
regulatory agency in the name of or on behalf of USL except for
appropriate authorized representatives.
7. ARBITRATION.
The parties agree that any controversy between or among them arising out
of their business or pursuant to this Agreement that cannot be settled
by agreement shall be taken to arbitration as set forth herein. Such
arbitration will be conducted according to the securities arbitration
rules of FINRA then in effect. Arbitration may be initiated by serving
or mailing a written notice.
The arbitrators shall render a written opinion, specifying the factual
and legal bases for the award, with a view to effecting the intent of
this Agreement. The written opinion shall be signed by a majority of the
arbitrators. In rendering the written opinion, the arbitrators shall
determine the rights and obligations of the parties according to the
substantive and procedural laws of the State of New York. Accordingly,
the written opinion of the arbitrators will be determined by the rule of
law and not by equity. The decision of the majority of the arbitrators
shall be final and binding on the parties and shall be enforced by the
courts in New York.
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8. CONFIDENTIALITY AND PROTECTION OF NONPUBLIC PERSONAL INFORMATION.
(A)Confidentiality.
"Confidential Information" of a party shall mean all confidential or
proprietary information, including trade secrets, expressions, ideas,
business practices and Sales Persons of such party in any medium, as
well as the terms of this Agreement, but shall not include NPI (as
defined below) which is subject to separate provisions of this
Agreement. For purposes of this Agreement and unless otherwise
indicated, reference to each party shall include their affiliates,
agents and contractors. All Confidential Information relating to a
party shall be held in confidence by the other party to the same
extent and in at least the same manner as such party protects its own
confidential or proprietary information, but in no case to a lesser
extent than reasonable care under the circumstances requires. No
party shall disclose, publish, release, transfer or otherwise make
available Confidential Information of any other party in any form to,
or for the use or benefit of, any person or entity without the other
parties' consent. Each party shall, however, be permitted to disclose
relevant aspects of the other parties' Confidential Information to
its officers, agents, subcontractors and employees to the extent that
such disclosure is reasonably necessary for the performance of its
duties and obligations under this Agreement; provided, however, that
such party shall take all reasonable measures to ensure that
Confidential Information of the other party or parties is not
disclosed or duplicated in contravention of the provisions of this
Agreement by such officers, agents, subcontractors and employees.
The obligations herein shall not restrict any disclosure by any party
to (a) any governmental and "quasi-governmental" authority having
jurisdiction over such party, pursuant to any applicable state or
federal laws, or (b) by order of any court or government agency
(provided that the disclosing party shall give prompt notice to the
non-disclosing party or parties of such order) and (c) shall not
apply with respect to Confidential Information which (1) is developed
by the other party independently of the Confidential Information of
the disclosing party without violating the disclosing party's
proprietary rights, (2) is or becomes publicly known (other than
through unauthorized disclosure), (3) is disclosed by the owner of
such information to a third party free of any obligation of
confidentiality, (4) is already known by such party without an
obligation of confidentiality other than pursuant to this Agreement
or any confidentiality agreements entered into before the effective
date of this Agreement, or (5) is rightfully received by a party free
of any obligation of confidentiality.
(B)Protection of Nonpublic Personal Information.
(1) Definition of Nonpublic Personal Information.
Nonpublic personal information of customers or consumers ("NPI")
includes, but is not limited to, names, addresses, account balances,
account numbers, account activity, social security numbers, taxpayer
identification numbers, and sensitive, financial and health
information. NPI includes information on each party's forms or in a
database of any kind,
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information created by each party, information collected by or on
behalf of a party, and personally identifiable information derived
from NPI.
There may be instances where each party will have the same NPI that
may be subject to different privacy policies and procedures according
to the notices provided to the customer or consumer by the respective
parties to the Agreement.
(2) Disclosure and Use of NPI.
All NPI that any party obtains as a result of this relationship shall
not be used, disclosed, reused or redisclosed to any third party,
except to carry out the purposes for which the information was
disclosed or as otherwise permitted or required by law. All NPI of
the other parties shall be held in confidence to the same extent and
in at least the same manner as the holding party protects its own
NPI, but in no case in a lesser manner than a reasonable degree of
care under the circumstances.
Each party shall be permitted to disclose relevant aspects of the
other parties' NPI to its officers, agents, subcontractors and
employees only to the extent that such disclosure is reasonably
necessary for the performance of its duties and obligations under the
Agreement; provided that such party shall take all reasonable
measures to ensure that the NPI of the other party or parties is not
disclosed or reproduced in contravention of the provisions of this
Agreement by such party's officers, agents, subcontractors and
employees.
The obligations of this Agreement shall not restrict any disclosure
by any party (a) to any governmental or "quasi' governmental"
authority having jurisdiction thereon, pursuant to any applicable
state or federal laws, or (b) by request or order of any court or
government agency (provided that the disclosing party shall seek
appropriate protections and provide prompt notice to the
non-disclosing party or parties of such order that any other party
will have a reasonable opportunity to oppose the disclosure, request
or order).
The obligations of this Agreement shall not apply to information
which, without breach of obligation of confidentiality: (1) is
independently developed by a party; (2) is or becomes publicly known;
(3) is already known by such party as evidenced by the written
records of such party; or (4) is obtained from an independent source.
(3) Security of NPI.
The parties further agree to establish and maintain policies and
procedures reasonably designed to ensure the confidentiality and
security of NPI. This shall include procedures to protect against any
anticipated threats or hazards to the security or integrity of the
information and unauthorized access to or use of the information. For
reasonable cause, each party may audit the use or disclosure of NPI
upon reasonable written notice to the other party. Each party will
promptly advise the other parties of any breach of obligations of
this Agreement with respect to NPI of which the breaching party is
aware.
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(4) Other Provisions.
The parties agree that they shall abide by the provisions of the
Xxxxx-Xxxxx-Xxxxxx Act and other applicable privacy laws and
regulations and that the obligations described herein shall continue
after termination of this Agreement. Any provision in this Agreement
or any agreement that is inconsistent with the obligations herein
shall be void.
This Agreement comprises the entire agreement among the parties
concerning NPI. There are no oral or implied promises or other
obligations concerning said subject matter that have not been set
forth herein. This Agreement may not be modified without a written
agreement executed by all parties.
9. ANTI-MONEY LAUNDERING COMPLIANCE.
Selling Group Member acknowledges that it is responsible for anti-money
laundering compliance related to retail sales and servicing of Contracts
conducted pursuant to this Agreement. Selling Group Member has established
and implemented policies and procedures reasonably designed to discharge its
obligations pursuant to applicable federal laws and regulations regarding
money laundering, including applicable provisions of U.S. Public Law 107-56,
the USA Patriot Act and specifically the regulations of the U.S. Department
of the Treasury adopted pursuant to Section 352 of the USA Patriot Act,
other applicable regulations of the U.S. Department of the Treasury, and the
Executive Orders related to the U.S. Department of the Treasury's Office of
Foreign Assets Control ("OFAC"). Without limitation, the policies and
procedures are designed to reasonably assure:
(A) That Selling Group Member reasonably believes and believes in fact
that all evidence of identity of a purchaser of a Contract furnished
in connection with an application for the purchase of such Contract is
genuine.
(B) That Selling Group Member reasonably believes and believes in fact
that no premium funds tendered for the purchase of a Contract directly
or indirectly are derived from activities that may contravene U.S.
federal, state or international laws or regulations.
(C) That Selling Group Member reasonably believes and believes in fact
that no applicant for a Contract ("Applicant"), nor any person
controlling, controlled by or under common control with an Applicant,
or a person for whom such Applicant is acting as agent or nominee in
connection with the acquisition of such Contract, or who will have a
beneficial interest in such Contract, is:
(1) a country, territory, organization or person or entity named on
the List of Specially Designated Nationals and Blocked Persons
maintained by OFAC, as such list may be amended from time to time;
(2) a person or entity that resides or has a place of business in a
country or territory named on an OFAC list, or that is designated
as a Non-Cooperative Jurisdiction by the Financial Action Task
Force on Money Laundering, or whose premium funds tendered for the
acquisition of such Contract are transferred from or through any
such country or territory;
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(3) a "foreign shell bank" as such term is described in 31 U.S.C.
Section 5318(j) and U.S. Department of the Treasury regulations
thereunder;
(4) a person or entity that resides in or is organized under the laws
of a jurisdiction designated by the Secretary of the Treasury
pursuant to 31 U.S.C. Section 5318A as a "jurisdiction of primary
money laundering concern;" or,
(5) a "senior foreign political figure," or a "family member" or
"close associate" of such a senior foreign political figure within
the meaning of the GUIDANCE ON ENHANCED SCRUTINY FOR TRANSACTIONS
THAT MAY INVOLVE THE PROCEEDS OF FOREIGN OFFICIAL CORRUPTION
issued by the U.S. Department of the Treasury or, if Selling Group
Member has determined that an applicant or such other person is a
"senior foreign political figure," or a "family member" or "close
associate" of a senior foreign political figure, the broker dealer
has diligently scrutinized the proposed purchase of the Contract
by or for the benefit of such person.
(D) Selling Group Member agrees to certify annually, if requested, that it
has implemented and complied with its anti-money laundering
obligations and will upon reasonable request provide documentation
concerning its anti-money laundering policies, procedures and
processes.
10.GENERAL PROVISIONS.
(a)Waiver.
Failure of any of the parties to promptly insist upon strict
compliance with any of the obligations of any other party under this
Agreement will not be deemed to constitute a waiver of the right to
enforce strict compliance.
(b)Independent Assignment.
No assignment of this Agreement or of commissions or other payments
under this Agreement shall be valid without prior written consent of
USL. Furthermore, except as provided below, this Agreement and any
rights pursuant hereto shall be assignable only upon the written
consent of all of the parties hereto. Except as and to the extent
specifically provided in this Agreement, nothing in this Agreement,
expressed or implied, is intended to confer on any person other than
the parties hereto, or their respective legal successors, any rights,
remedies, obligations, or liabilities, or to relieve any person other
than the parties hereto or their respective legal successors, from any
obligations or liabilities that would otherwise be applicable.
(c)Notice.
Any notice pursuant to this Agreement may be given electronically
(other than vocally by telephone) or by mail, postage paid,
transmitted to the last address communicated by the receiving party to
the other parties to this Agreement.
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(d)Severability.
To the extent this Agreement may be in conflict with any applicable
law or regulation, this Agreement shall be construed in a manner
consistent with such law or regulation. The invalidity or illegality
of any provision of this Agreement shall not be deemed to affect the
validity or legality of any other provision of this Agreement.
(e)Amendment.
This Agreement may be amended only in writing and signed by all
parties. No amendment will impair the right to receive commissions
accrued with respect to Contracts issued and applications procured
prior to the amendment.
(f)Entire Agreement.
This Agreement together with such amendments as may from time to time
be executed in writing by the parties, constitutes the entire
agreement and understanding between the parties in respect to the
transactions contemplated hereby and supersedes all prior agreements,
arrangements and understandings related to the subject matter hereof.
(g)Termination.
This Agreement may be terminated by any party upon 30 days' prior
written notice. It may be terminated for cause, defined as a material
breach of this Agreement, by any party immediately. Termination of
this Agreement shall not impair the right to receive commissions or
service fees accrued prior to the termination except for a termination
due to cause.
(h)Governing Law.
This Agreement shall be governed by and construed and enforced in
accordance with the laws of the State of New York applicable to
contracts made and to be performed in that state, without regard to
principles of conflict of laws.
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By signing below, the undersigned agree to have read and be bound by the terms
and conditions of this Agreement.
Date: ___________________
SELLING GROUP MEMBER: _____________________________________________________
(BROKER-DEALER) (TAX ID #)
Address: _____________________________________________________
_____________________________________________________
Signature: _____________________________________________________
Name & Title: _____________________________________________________
ASSOCIATED AGENCY: _____________________________________________________
(PRIMARY INSURANCE AGENCY) (TAX ID #)
Address: _____________________________________________________
_____________________________________________________
Signature: _____________________________________________________
Name & Title: _____________________________________________________
American General Equity Services Corporation
0000-X Xxxxx Xxxxxxx
Xxxxxxx, XX 00000
Signature: _____________________________________________________
Name & Title: _____________________________________________________
The United States Life Insurance Company in the City of New York
0000-X Xxxxx Xxxxxxx
Xxxxxxx Xxxxx 00000
Signature: _____________________________________________________
Name & Title _____________________________________________________
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