EXHIBIT 1A(5)(a)(ix)
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This receipt is not valid and may not be issued unless ALL of the following
conditions are met:
1. The full Initial Purchase Payment necessary to provide the coverage applied
for must have been paid at the time of this Application.
2. The Proposed Insured must be age [80] or less.
3. ALL answers to Question 12 must be "No."
No representative of Sage Life is authorized to alter or waive any of these
requirements. IF CONDITIONS 2 OR 3 ARE NOT SATISFIED, NO PAYMENT MAY BE
ACCEPTED WITH THE APPLICATION.
TEMPORARY INSURANCE AGREEMENT
SAGE LIFE ASSURANCE OF AMERICA, INC. ("SAGE LIFE")
Received from __________________________________on [date] _____________________
the sum of ______________________________dollars($______________).
The temporary insurance provided by this Agreement is for the coverage afforded
by the Initial Purchase Payment shown in question 4b. of this Application
bearing the same date as this Agreement; except that the total coverage with
Sage Life under this and all other receipts providing temporary insurance will
not exceed $[500,000] on the Proposed Insured, regardless of the total amount(s)
or number of receipts or applications.
If coverage provided by the Initial Purchase Payment is more than $[500,000] of
insurance under this and/or any other Application pertaining to the Proposed
Insured, Sage Life's liability will be no more than $[500,000] plus a return of
Purchase Payment submitted in excess of the Purchase Payment required to provide
$[500,000] of insurance coverage.
Temporary insurance for the Proposed Insured begins on the date of this
Agreement, subject to the terms of the Contract applied for in this Application.
Coverage will end on the earliest of:
1. The date the Contract is issued. (The Contract will replace the
temporary insurance.)
2. The date Sage Life returns the Initial Purchase Payment and mails a
written notice to the Applicant that the insurance has ended for the
Proposed Insured.
3. The date a request for cancellation or withdrawal of this
Application is sent to Sage Life.
4. The date Sage Life's first offer to issue a Contract is not
accepted.
5. The [60th] day after the date of this Agreement, unless the
Agreement has been replaced earlier.
Sage Life's only liability under this Agreement is a refund of the Initial
Purchase Payment if:
1. There is fraud or material misrepresentation in this Application.
2. The Proposed Insured dies by suicide.
I have received a copy of and have read this Agreement. I understand and agree
to all of its terms.
X___________________________________ X_______________________________________
Signature of Proposed Insured Signature of Applicant if other than
(Parent/Guardian if Proposed Insured
Proposed Insured under the
age of 15)
X___________________________________ _______________________________________
Signature of Agent Date
XXXXXX AND GIVE TO PROPOSED INSURED
NOTICE OF INFORMATION PRACTICES
Thank you for your interest in insurance with Sage Life. Your application will
be evaluated as promptly as possible. Since underwriting and administering your
coverage will include the collection of a certain amount of personal information
by Sage Life and its Agent, this notice is intended to tell you more about our
information practices.
Notice of Insurance Information Practices: To issue an insurance contract we
need to obtain information about you as the Proposed Insured. Some of that
information will come from you and some will come from other sources. That
information and any subsequent information collected by us may in certain
circumstances be disclosed to third parties without your specific authorization.
You have a right of access and correction with respect to the information
collected about you except information that relates to a claim or civil
proceeding. If you wish a more detailed explanation of our information
practices, make a written request to Sage Life Assurance of America, Inc.,
Underwriting Department, [000 Xxxxxxxx Xxxxxx, Xxxxx Xxxxx, Xxxxxxxx,
Xxxxxxxxxxx 00000].
Fair Credit Reporting Disclosure: This notice is to inform you that as part of
our normal underwriting procedures in connection with an application for
insurance:
1. An investigative consumer report may be made whereby information is obtained
through personal interviews with your friends, neighbors or other persons
with whom you are acquainted. This inquiry will include information as to
character, general reputation, personal characteristics and mode of living,
except as may be related directly or indirectly to your sexual orientation
with respect to you, members of your family, and others having an interest
in or closely connected with the insurance transaction;
2. Upon your written request, made within a reasonable time after you receive
this notice, additional information as to the nature and scope of the
investigation, if one is made, will be provided. Requests for additional
information should be addressed to Sage Life Assurance of America, Inc.,
Underwriting Department, [000 Xxxxxxxx Xxxxxx, Xxxxx Xxxxx, Xxxxxxxx,
Xxxxxxxxxxx 00000].
Medical Information Bureau Pre-Notice: Information regarding your insurability
will be treated as confidential. Sage Life, or its reinsurer(s) may, however,
make a brief report thereon to the Medical Information Bureau (the "Bureau"), a
non-profit 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 company, the Bureau, upon request, will supply
such company with the information in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. (Medical information will be disclosed
only to your attending physician.) If you question the accuracy of information
in the Bureau's file, you may contact the Bureau and seek a correction in
accordance with the procedures set forth in the Federal Fair Credit Reporting
Act. The address of the Bureau's information office is Post Office Box 000,
Xxxxx Xxxxxxx, Xxxxxx, Xxxxxxxxxxxxx 00000, telephone number (000) 000-0000.
Sage Life may also release information in its file to reinsurers and 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.
