EXHIBIT 1(10)
APPLC
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PRODUCER INSTRUCTIONS
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When To Use This Use this application in the following states:
Application
Alabama Connecticut Illinois Michigan New Mexico Rhode Island Virginia
Alaska Delaware Indiana Montana North Dakota South Dakota Washington
Arizona DC Kansas Nebraska Ohio Tennessee West Virginia
Arkansas Georgia Kentucky Nevada Oklahoma Texas Wisconsin
California Idaho Massachusetts New Hampshire Oregon Utah Wyoming
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Important Reminders The following are guidelines for completing the application:
[_] All signatures must be original (i.e., not stamped, photocopied or faxed).
[_] Complete appropriate sections prior to signing the application. Never sign or let anyone else sign a
blank application.
[_] Do not use dashes, blanks, and/or ditto marks to record answers. If any of these methods are used,
the application will be amended.
[_] Do not use "white out" to make changes. If a change is made to an answer, the appropriate party(ies)
must initial the change. If not initialed by the appropriate party(ies) the application will be
amended. If seven (7) or more changes are made, even if these changes are initialed, a new
application must be completed.
[_] Once the application is signed, no additional information can be added unless the change is made and
initialed by the appropriate party(ies).
[_] Prior to solicitation, the Producer must be licensed in each state where sales activity will take
place. Also, the Producer must be appointed by Pacific Life in that state.
[_] The product being applied for must be approved for sale in the state where the sales activity takes
place.
Note: The Producer/Home Office Administrative Worksheet, which is part of the illustration, will assist
you in completing the application.
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Signature Requirements Party When Signature is Required
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Applicant* Always required. The Applicant is the party that initiates and applies for the
life insurance policy.
Proposed Insured Required if other than Applicant. If the Proposed Insured is under age 16, a
parent or guardian must sign for the Proposed Insured.
Additional Insured If submitting an application for a Second-to-Die life insurance policy or
additional insured term rider.
Owner* If other than the Applicant.
Producer Always required.
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*If a Corporation, the signature and title of an authorized officer other than the Proposed Insured(s) is
required, and the full name of the corporation must be shown. If a Trust, the signature of the Trustee(s)
is required.
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Qualifying For To qualify for temporary life insurance, the Proposed Insured(s) must be:
Temporary Insurance
[_] able to answer "No" to all of the questions on the Temporary Insurance Agreement (TIA); and
[_] over 15 days of age and under the age of 70.
The TIA is limited to $1,000,000 for individual products and $1,500,000 for Second-to-Die products.
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Sales Illustration The complete illustration including the Producer/Home Office Administration Worksheet and Input page(s),
representing how the policy is being applied for, must be submitted with the application. The following
are additional requirements by product type:
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Non-Variable Life Insurance The illustration must be signed by the Applicant and Producer.
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Variable Life Insurance The Illustration Disclosure form must be signed by the
Applicant and Producer, and submitted with the application.
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SPECIAL STATE REQUIREMENTS
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Buyer's Guide The following states require a Buyer's Guide be given to the Applicant prior to taking an application for
non-variable life insurance:
[_] New Hampshire
[_] Wisconsin
Note: The state of Illinois requires that the Buyer's Guide be given to the Applicant prior to accepting
the initial premium.
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AP2001 00-00000-00 05/2001
Pacific Life Insurance Company APPLC
Life Insurance Division - Client Services Department
000 Xxxxxxx Xxxxxx Xxxxx . Xxxxxxx Xxxxx, XX 00000 [LOGO OF PACIFIC LIFE]
(000) 000-0000
APPLICATION FOR LIFE INSURANCE, PART 1
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SECTION A CLIENT INFORMATION
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Proposed Insured 1. Name of Proposed Insured (Print as to appear in policy: First/Middle/Last) 2. Sex
[_] Male [_] Female
Complete for all ---------------------------------------------------------------------------------------------------------------
Life Insurance 3. Date of Birth 4. Age (Nearest birthday) 5. Place of Birth 6. Soc. Sec. #
Policies.
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7. Driver's License # & State 8. Telephone # 9. E-mail Address
( )
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10. Xxxxxxx (Xxxxxx, Xxxx, Xxxxxx, Xxxxx, Xxx Xxxx) 00. How Long
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12. Employer Name & Address (Street, City, County, State, Zip Code) 13. How Long
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14. Occupation 15. Type of Business
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Proposed Additional 16. Name of Additional Proposed Insured (Print as to appear in policy: First/Middle/Last) 17. Sex
Insured [_] Male [_] Female
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Complete for a
Second-to-Die Life 18. Date of Birth 19. Age (Nearest birthday) 20. Place of Birth 21. Soc. Sec. #
Insurance Policy
or for a Term ---------------------------------------------------------------------------------------------------------------
Rider on Another
Covered Person for 22. Driver's License # & State 23. Telephone # 24. E-mail Address
an Individual Life ( )
Insurance Policy. ---------------------------------------------------------------------------------------------------------------
25. Xxxxxxx (Xxxxxx, Xxxx, Xxxxxx, Xxxxx, Xxx Xxxx) 00. How Long
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27. Employer Name & Address (Street, City, County, State, Zip Code) 28. How Long
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29. Occupation 30. Type of Business 31. Relationship to Insured
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Owner 32. Name of Owner(s) (Print as to appear in policy: First/Middle/Last)
Complete only if
Owner is other
than the
Insured(s). If ---------------------------------------------------------------------------------------------------------------
Trust, give name
of trust, trustee 33. Address (Street, City, County, State, Zip Code) 34. Relationship to Insured(s)
and date of trust.
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35. Date of Birth 36. Soc. Sec. # / Tax ID # 37. Telephone # 38. E-mail Address
( )
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Primary Beneficiary 39. Name of Beneficiary (Print as to appear in policy: First/Middle/Last)
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40. Relationship to Insured(s) 41. Soc. Sec. # / Tax ID #
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Contingent 42. Name of Contingent Beneficiary (Print as to appear in policy: First/Middle/Last)
Beneficiary
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43. Relationship to Insured(s) 44. Soc. Sec. # / Tax ID #
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Beneficiary for 45. Name of Beneficiary for Individual Term Rider (Print as to appear in policy: First/Middle/Last)
Individual Term
Rider ---------------------------------------------------------------------------------------------------------------
46. Relationship to Insured 47. Soc. Sec. # / Tax ID #
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AP2001 Page 1 00-00000-00 05/2001
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SECTION A CLIENT INFORMATION (Continued)
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Premium Notices 48. Send Premium Notices to: [_] Insured [_] Owner [_] Other
(If other, give name, relationship and address below)
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49A. Name B. Relationship to Insured(s)
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C. Address (Street, City, County, State, Zip Code)
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50. Method & Frequency of Payment (Select One):
A. Direct B. [_] Electronic Funds Transfer C. List Xxxx (3 or D. [_] Single Premium
[_] Annually (EFT) (Monthly only) Attach more policies)
[_] Semi-Annually voided check and complete EFT [_] Annually
[_] Quarterly Authorization on page 10. [_] Semi-Annually
[_] Quarterly
[_] Monthly
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Amount Paid With 51A. Is an initial premium submitted with this application? [_] Yes [_] No
This Application (Do not submit money unless the Temporary Insurance Agreement (TIA) is completed)
B. If yes, show amount of initial premium and complete the next question. Amount $_____________________
C. Do you understand, accept and agree to the terms of the TIA? [_] Yes [_] No
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Special Policy 52A. [_] Date to Save Age [_] Specific Date Month ______________ Day ______ Year _________
Dating If either box is checked, give policy date and complete below:
B. I understand that insurance charges and expenses begin on the Policy Date [_] Yes [_] No
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Life Insurance In 53. Give details of all life insurance in force on any Proposed Insured. If none, check this box: [_]
Force ---------------------------------------------------------------------------------------------------------------
Will This
Year Policy Be
Insured's Name Company Policy Number Face Amount Issued Replaced?
YES NO
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[_] [_]
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[_] [_]
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[_] [_]
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[_] [_]
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[_] [_]
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[_] [_]
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[_] [_]
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Replacement & 1035 YES NO
Exchange ---------------------------------------------------------------------------------------------------------------
Information 54. Will the policy applied for replace, cause a change in, or involve a cash withdrawal or loan
from any life insurance or annuity on any Proposed Insured's life or in any life insurance or
annuity owned by the Applicant? If yes, give details in "Remarks" and complete any required
replacement forms. [_] [_]
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55. Is this a 1035 exchange? If yes, list the policies to be exchanged in "Remarks." [_] [_]
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56. If a 1035 exchange, will a loan be carried over? If yes, list in "Remarks" the policies and
the loan amount(s) to be carried over. [_] [_]
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2001 Page 2 00-00000-00 05/2001
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SECTION B GENERAL INFORMATION
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General Proposed Insured Additional Insured
Information ---------------------------------------------------------------------------------------------------------------
Complete each 1. Annual earned income from occupation (After deduction of business $ $
question for the expenses)
Proposed and ---------------------------------------------------------------------------------------------------------------
Additional Insured. 2. Other income (State source in "Remarks") $ $
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3. Net Worth $ $
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YES NO YES NO
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4. Do you contemplate leaving the USA for travel or residence? (If yes, [_] [_] [_] [_]
explain in "Remarks")
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5A. Do you plan to fly, or within the last 2 years have you flown, as a
pilot, student pilot, or crewmember? [_] [_] [_] [_]
B. Do you plan to participate in, or within the last 2 years have you
participated in, parachute jumping, scuba diving,
auto/motorboat/motorcycle racing, hang gliding, or mountain climbing? [_] [_] [_] [_]
(If yes to A or B, complete a separate General Questionnaire for each
Proposed/Additional Insured)
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6. Have you ever had insurance declined, rated, modified, cancelled or [_] [_] [_] [_]
not renewed? (If yes, explain in "Remarks")
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7. Have you been convicted of a felony within the past 5 years? (If yes, [_] [_] [_] [_]
explain in "Remarks")
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8. Have you had a driver's license restricted or revoked or been
convicted of 3 or more moving violations within the past 5 years?
(If yes, explain in "Remarks") [_] [_] [_] [_]
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9. Have you applied for any other insurance within the last 3 months? [_] [_] [_] [_]
(If yes, explain in "Remarks")
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10. Have you smoked a cigarette in the last 12 months? [_] [_] [_] [_]
(If yes, give date last smoked) Date:____________ Date:____________
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11. Have you used any other form of tobacco within the last 2 years? [_] [_] [_] [_]
(If yes, give type and date last used) Type:____________ Type:____________
Date:____________ Date:____________
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SECTION C MEDICAL CERTIFICATION
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Medical 1. The attached examination is on the life of:
Certification ---------------------------------------------------------------------------------------------------------------
Proposed Additional Date of
Complete when Insured Insured Name of Insurance Company Examination
submitting a ---------------------------------------------------------------------------------------------------------------
medical [_] [_]
examination of ---------------------------------------------------------------------------------------------------------------
another insurance [_] [_]
company. ---------------------------------------------------------------------------------------------------------------
[_] [_]
Subject to state ---------------------------------------------------------------------------------------------------------------
regulation, [_] [_]
another insurance ---------------------------------------------------------------------------------------------------------------
company's exam may 2. To the best of your knowledge and belief, are the statements in the examination true as of today?
be accepted if the Proposed Insured [_] Yes [_] No (If no, explain in Remarks)
primary/additional Additional Insured [_] Yes [_] No
insured was ---------------------------------------------------------------------------------------------------------------
examined within 3. Has the person who was examined consulted a doctor or other medical practitioner, or received medical or
the past six surgical advice since the date of the examination?
months. Proposed Insured [_] Yes [_] No (If yes, explain in Remarks)
Additional Insured [_] Yes [_] No
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2001 Page 3 00-00000-00 05/2001
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SECTION D POLICY INFORMATION FOR VARIABLE LIFE INSURANCE
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Product/Premium 1. Product Name 2. Planned Annual Premium
$
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Death Benefit 3. Face Amount (Base Only) + Initial Term (ART/APB/LSAPB) Amount + ABR Amount = Total Initial Coverage
$ $ $ $
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Death Benefit 4. Check one: [_] Option A [_] Option B [_] Option C (Face amount plus [_] Option D (Face amount multiplied
Option (Level) (Increasing) premiums less distributions) by a death benefit factor)
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Optional Benefits 5. Individual Life Insurance Products Only 6. Second-to-Die Life Insurance Products Only
A. [_] Term Rider on Other Covered Person $___________ A. [_] Individual Term Rider on the Proposed
B. [_] Accidental Death $_____________________________ Insured $______________________________
C. [_] Children's Term ___ (units) B. [_] Individual Term Rider on the Additional
(Complete Application Part 2, Non-Medical) Insured $______________________________
D. [_] Disability Benefit $___________________________ C. [_] Other__________________________________
E. [_] Guaranteed Insurability $______________________ D. [_] Other__________________________________
F. [_] Waiver of Charges (On Insured) E. [_] Other__________________________________
G. [_] Other__________________________________________ F. [_] Other__________________________________
H. [_] Other__________________________________________
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7. If any optional benefit applied for cannot be approved, should the policy be issued
without it? [_] Yes [_] No
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Premium Allocation 8. Indicate how premiums are to be allocated, until later changed by you or your authorized representative.
The total of the percentages must be 100%. Allocation percentages must be whole numbers.
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Investment Premium Investment Premium Investment Premium
Option % Option % Option %
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Blue Chip _________ Multi-Strategy _________ Inflation Managed _________
Aggressive Growth _________ Equity Income _________ Managed Bond _________
Aggressive Equity _________ Strategic Value _________ Money Market _________
Emerging Markets _________ Growth LT _________ High Yield Bond _________
Diversified Research _________ Focused 30 _________ Large-Cap Value _________
Small-Cap Equity _________ Mid-Cap Value _________ Fixed Account* _________
International Large-Cap _________ International Value _________ Fixed LT Account* _________
Equity _________ Capital Opportunities _________ Other: _________
I-Net Tollkeeper _________ Mid-Cap Growth _________ _________________ _________
Financial Services _________ Global Growth _________ _________________ _________
Health Sciences _________ Equity Index _________ _________________ _________
Technology _________ Small-Cap Index _________ _________________ _________
Telecommunications _________ REIT _________ _________________ _________
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* The Fixed LT Account has less transfer liquidity and may credit a higher current rate of interest than the
Fixed Account. Both fixed account options credit a fixed minimum guaranteed interest rate. See the prospectus
for details.
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Acknowledgement All questions must be answered. YES NO
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To be completed by
the Applicant. 9. Do you understand that the amount and duration of the death benefit may vary, depending
on the investment performance of the variable investment options? [_] [_]
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10. Do you understand that the policy values may increase or decrease, depending on the
investment experience of the variable investment options? [_] [_]
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11. Did you receive the separate account and fund prospectuses (bound together) for the
policy applied for? If yes, give date below. [_] [_]
Date of Separate Account & Fund Prospectuses: _________________________________________________________________
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POLICY VALUES MAY INCREASE OR DECREASE, AND MAY EVEN BE REDUCED TO ZERO AND CAUSE THE POLICY TO LAPSE WITHOUT
VALUE, DEPENDING ON THE EXPERIENCE OF THE VARIABLE INVESTMENT OPTIONS. THE DEATH BENEFIT MAY BE VARIABLE OR
FIXED UNDER SPECIFIED CONDITIONS. A CURRENT ILLUSTRATION OF BENEFITS, INCLUDING DEATH BENEFITS AND HYPOTHETICAL
CASH SURRENDER VALUES, IS AVAILABLE UPON REQUEST.
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AP2001 Page 4 00-00000-00 05/2001
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SECTION D POLICY INFORMATION FOR VARIABLE LIFE INSURANCE (Continued)
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Rebalancing 12. I authorize Pacific Life Insurance Company (PL) to automatically rebalance the variable accounts to the
Optional allocation percentages shown in question 8.
Start Date: Frequency:
______________________ ___________ __________ [_] Quarterly
Month Day Year [_] Semi-Annually
[_] Annually
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Telephone & 13. I authorize PL to act upon my telephone and/or electronic instructions for the following limited requests.
Electronic Check all that apply:
Authorization
[_] Transfer Between Variable [_] Initiate Dollar Cost Averaging [_] Initiate Policy Loans
Optional Investment Options
[_] Rebalance Variable Investment Options [_] Change Future Premium Allocation Instructions
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14. I understand and agree that: Telephone and/or electronic transfers and allocation changes will be subject
to the conditions of the policy, the administrative requirements of PL, and the provisions of the
product's prospectus.
[_] Yes [_] No
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Authorization for 15. To act on my behalf for the following limited requests, including any telephone and/or electronic
Appointment requests I have authorized, I appoint:
Optional _________________________________________ _________________________________________
Print Name Soc. Sec. # or Producer Code
Check all that apply:
[_] Transfer Between Variable [_] Initiate Dollar Cost Averaging [_] Initiate Policy Loans
Investment Options
[_] Rebalance Variable Investment Options [_] Change Future Premium Allocation Instructions
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2001 Page 5 00-00000-00 05/2001
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SECTION E POLICY INFORMATION FOR NON-VARIABLE FLEXIBLE PREMIUM LIFE INSURANCE
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Product/Premium 1. Product Name 2. Planned Annual Premium
$
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Death Benefit 3. Face Amount (Base Only) + Initial Term (ART/APB/LSAPB) Amount + ABR Amount = Total Initial Coverage
$ $ $ $
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Death Benefit 4. Check one: [_] Option A [_] Option B [_] Option C (Face amount plus premiums less distributions)
Option (Level) (Increasing)
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Dividend Option 5. Check one: [_] Cash [_] Increase Accumulated Value
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Optional Benefits 6. Individual Life Insurance Products Only 7. Second-to-Die Life Insurance Products Only
A. [_] Term Rider on Other Covered Person $_______________ A. [_] Individual Term Rider on the Proposed
Insured $____________________________
B. [_] Accidental Death $_________________________________
B. [_] Individual Term Rider on the
C. [_] Children's Term ____________ (units) Additional Insured $_________________
(Complete Application Part 2, Non-Medical)
C. [_] Other________________________________
D. [_] Disability Benefit $______________________________
D. [_] Other________________________________
E. [_] Guaranteed Insurability $_________________________
E. [_] Other________________________________
F. [_] Waiver of Charges (On Insured)
F. [_] Other________________________________
G. [_] Owner Waiver of Charges
(Complete Application Part 2, Non-Medical) G. [_] Other________________________________
H. [_] Payor Waiver of Charges
(Complete Application Part 2, Non-Medical)
I. [_] Supplemental Insured Term
J. [_] Other_____________________________________________
K. [_] Other_____________________________________________
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8. If any optional benefit applied for cannot be approved, should the policy be issued
without it? [_] Yes [_] No
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SECTION F POLICY INFORMATION FOR TERM LIFE INSURANCE
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Product/Face Amount 1. Product Name 2. Face Amount
$
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Optional Benefits 3A. [_] Accidental Death $______________________________ C. [_] Other______________________________________
B. [_] Premium Waiver (On Insured) D. [_] Other______________________________________
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4. If any optional benefit applied for cannot be approved, should the policy be issued
without it? [_] Yes [_] No
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SECTION G POLICY INFORMATION FOR FIXED PREMIUM LIFE INSURANCE
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Product/Face 1. Product Name 2. Face Amount 3. Premium
Amount/Premium $ $
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Optional Benefits 4A. [_] Accidental Death $______________________________ [_] Other_________________________________________
B. [_] AVR/AVP $_______________________________________ [_] Other_________________________________________
C. [_] Term Rider $____________________________________ [_] Other_________________________________________
D. [_] Guaranteed Insurability $_______________________ [_] Other_________________________________________
E. [_] Premium Waiver [_] Other_________________________________________
F. [_] Increasing Death Benefit [_] Other_________________________________________
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5. If any optional benefit applied for cannot be approved, should the policy be issued
without it? [_] Yes [_] No
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Dividend Option 6. Check one: [_] Cash [_] Add to Policy Value
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Extended Insurance 7. Automatic Premium Loan [_] Yes [_] No
Option
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Policy Loan Option 8. Variable Loan Interest Rate [_] Yes [_] No
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2001 Page 6 00-00000-00 05/2001
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SECTION H POLICY INFORMATION FOR AN ADDITIONAL OR ALTERNATE FLEXIBLE PREMIUM LIFE INSURANCE POLICY
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(Select One) Variable Flexible Premium Life Insurance Policy [_] Additional or [_] Alternate
Non-Variable Flexible Premium Life Insurance Policy [_] Additional or [_] Alternate
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Product/Premium 1. Product Name 2. Planned Annual Premium
$
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Death Benefit 3. Face Amount (Base Only) + Initial Term (ART/APB/LSAPB) Amount + ABR Amount = Total Initial Coverage
$ $ $ $
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Death Benefit 4. Check one: [_] Option A [_] Option B [_] Option C (Face amount [_] Option D (Face amount times
Option (Level) (Increasing) plus premiums less the death benefit factor)
distributions)
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Dividend Option 5. Check one: [_] Cash [_] Increase Accumulated Value
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Optional Benefits 6A. B.
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C. D.
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7. If any optional benefit applied for cannot be approved, should the policy be issued
without it? [_] Yes [_] No
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Premium Allocation 8. Indicate how premiums are to be allocated, until later changed by you or your authorized representative.
The total of the percentages must be 100%. Allocation percentages must be whole numbers.
Complete if applying ---------------------------------------------------------------------------------------------------------------
for Flexible
Premium Variable Investment Premium Investment Premium Investment Premium
Life Insurance Option % Option % Option %
Policy.
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Blue Chip _________ Multi-Strategy _________ Inflation Managed _________
Aggressive Growth _________ Equity Income _________ Managed Bond _________
Aggressive Equity _________ Strategic Value _________ Money Market _________
Emerging Markets _________ Growth LT _________ High Yield Bond _________
Diversified Research _________ Focused 30 _________ Large-Cap Value _________
Small-Cap Equity _________ Mid-Cap Value _________ Fixed Account* _________
International Large-Cap _________ International Value _________ Fixed LT Account* _________
Equity _________ Capital Opportunities _________ Other: _________
I-Net Tollkeeper _________ Mid-Cap Growth _________ _________________ _________
Financial Services _________ Global Growth _________ _________________ _________
Health Sciences _________ Equity Index _________ _________________ _________
Technology _________ Small-Cap Index _________ _________________ _________
Telecommunications _________ REIT _________ _________________ _________
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* The Fixed LT Account has less transfer liquidity and may credit a higher current rate of interest than the
Fixed Account. Both fixed account options credit a fixed minimum guaranteed interest rate. See the prospectus
for details.
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NOTE: IF APPLYING FOR AN ADDITIONAL OR ALTERNATE VARIABLE FLEXIBLE PREMIUM LIFE INSURANCE POLICY THE
ACKNOWLEDGEMENT ON PAGE 4, SECTION D, ALSO APPLIES TO THIS POLICY.
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SECTION I POLICY INFORMATION FOR AN ADDITIONAL OR ALTERNATE TERM LIFE INSURANCE POLICY
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(Select One) Term Life Insurance Policy [_] Additional or [_] Alternate
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Product/Face 1. Product Name 2. Face Amount
Amount/ Premium $
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Optional Benefits 3A. B.
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4. If any optional benefit applied for cannot be approved, should the policy be issued
without it? [_] Yes [_] No
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
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AP2001 Page 7 00-00000-00 05/2001
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SECTION J CERTIFICATION OF OWNER'S TAXPAYER ID and Applicant's declarations
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Certification of Under penalty of perjury, I certify that:
Owner's Taxpayer 1. The number shown in this application as my social security number or taxpayer identification number is
Identification # correct; and
2. I am not subject to backup withholding under Section 3406(a)(1)(c) of the Internal Revenue Code. (If
statement is false strike out and initial.)
This certification is required by the Internal Revenue Service before any taxable distribution can be made.
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Declarations The answers provided in this application are true and complete to the best of my knowledge and belief. I
understand and agree that:
1. Except as provided in the terms or conditions of any Temporary Insurance Agreement (TIA) that I may have
received in connection with this application, coverage will take effect when the policy is delivered and
the entire first premium is paid only if at that time the Proposed Insured(s) is alive, and all answers in
this application which are material to the risk are still true and complete.
2. If I have given money with the application and received a TIA and if the coverage amount of the application
exceeds the TIA coverage limits, I understand that if the Proposed Insured(s) die(s) before a policy is
delivered, the death benefit will be limited to the TIA coverage limit.
3. I must inform the Producer or Pacific Life Insurance Company (PL) in writing of any changes in the health
of any Proposed Insured(s) or if any of the statements or answers on this application change prior to
delivery of the policy.
4. My statements and answers in this application must continue to be true as of the date I receive the policy.
5. No Producer is authorized to make or modify contracts or insurance policies on PL's behalf.
6. No Producer may alter the terms of this application, the TIA or the policy, nor can the Producer waive any
of PL's rights or requirements.
7. I believe that the policy(ies) applied for will meet my insurance needs and financial objectives.
8. (NOT APPLICABLE IN WEST VIRGINIA.) Acceptance of a life insurance policy will be ratification of any
administrative change with respect to such policy made by PL as indicated under the title "Home Office
Endorsements," where permitted by state law. All other changes made to the application or policy by PL will
be indicated on an "Application Amendment Form" which must be signed by the Owner, prior to or at the time
of delivery of this policy.
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Any person who knowingly, and with intent to injure, defraud, or deceive any insurance company, files a statement of claim or
provides false, incomplete, or misleading information as part of the information provided to obtain coverage commits a fraudulent
act, which is a crime and may be subject to criminal and civil penalties.
Signed and Dated by the Applicant in:
_____________________________________________________________ _________________________ _______________________________
City State Month/Day/Year
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Signature of Applicant
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X___________________________________________________________________________________________________________________________________
Applicant*
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Signature of Proposed Insured(s) - If Other Than The Applicant or Parent if Proposed Insured is under age 16)
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X___________________________________________________________________________________________________________________________________
Proposed Insured
X___________________________________________________________________________________________________________________________________
Proposed Additional Insured (if applicable)
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Signature of Applicant - If Other Than The Applicant or The Proposed Insured
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X___________________________________________________________________________________________________________________________________
Owner*
*If a Corporation, the signature and title of any authorized officer other than the Proposed Insured(s) is required and the full
name of the corporation must be shown. If a Trust, the signature of the Trustee.
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Producer's Certification
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I certify that I have truly and accurately recorded hereon the information supplied.
X__________________________________________________________________ ___________________________________________________________
Signature of Soliciting Producer Print Soliciting Producer's Name
AP2001 Page 8 00-00000-00 05/2001
Pacific Life Insurance Company AUTH
Life Insurance Division - Client Services Department
000 Xxxxxxx Xxxxxx Xxxxx . Xxxxxxx Xxxxx, XX 00000 [LOGO OF PACIFIC LIFE]
(000) 000-0000
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SECTION K AUTHORIZATION OF THE PROPOSED INSURED(S) TO OBTAIN INFORMATION
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Complete for all I authorize any physician, medical practitioner, hospital, clinic, other medical or medically related facility,
applications. insurance company, the Medical Information Bureau, Inc., consumer reporting agency, state motor vehicle agency
or employer to release to Pacific Life Insurance Company, its subsidiaries, its reinsurer(s) or its legal
representative any information they may have as to diagnosis, treatment and prognosis of any physical or mental
condition and/or any non-medical information, including finances, avocations, occupation, foreign travel,
alcohol and driving record for me and any minor children who are to be insured. Although Federal Regulation
protects information related to drug or alcohol abuse from disclosure, I give permission to collect this
information for those purposes described in the Disclosure Notice. I understand that I can revoke this
permission to collect information related to drug or alcohol abuse at any time, but any revocation will not
affect such information that has already been collected and relied on.
I understand that any information obtained will be used to determine eligibility for insurance and will not be
released to any person or organization except reinsurer(s), the Medical Information Bureau, Inc., and other
persons or organizations performing business or legal services in connection with my application, or as may be
otherwise lawfully required, or as I may further authorize. I also understand that I may revoke this
authorization as it applies to drug and/or alcohol abuse information at any time, except to the extent it will
not affect any action taken or information released prior to the revocation. Such revocation may cause the
denial of this application. I know that I, or my authorized representative, may request a copy of this
authorization. I also acknowledge receipt of the Disclosure Notice.
A photographic copy of this Authorization shall be as valid as the original and shall be valid for two years
from the date shown below.
Signed and Dated by the Proposed Insured(s):
______________________________________________ ____________________ _____________________________
City State Month/Day/Year
X______________________________________________________________________________________________________________
Signature of Proposed Insured (or parent if Proposed Insured is under age 16)
X______________________________________________________________________________________________________________
Signature of Proposed Additional Insured (if applicable)
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AP2001-AUTH Page 9 00-00000-00 05/2001
Pacific Life Insurance Company
Life Insurance Division - Client Services Department
000 Xxxxxxx Xxxxxx Xxxxx . Xxxxxxx Xxxxx, XX 00000 [LOGO OF PACIFIC LIFE]
(000) 000-0000
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SECTION L AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER - MONTHLY BANK DRAFT
------------------------------------------------------------------------------------------------------------------------------------
To be completed by As a convenience to me, I request and authorize you to pay and charge to the bank account referenced below
the Authorized any monthly debit entries on that account by and payable to the order of Pacific Life Insurance Company,
Account Holder. provided there are sufficient collected funds in said account to pay the same upon presentation. I agree
that your rights in respect to each such debit shall be the same as if it were a debit drawn on you and signed
personally by me. This authority is to remain in effect until revoked by me in writing, and until you actually
receive such notice I agree that you shall be fully protected in honoring any such debit.
Pacific Life will determine the monthly draft date based upon my policy effective date. However, any special
drafting requests are indicated below.
Bank Account No._______________________________________________________________________________________________
Bank Account in the Name(s) of: _______________________________________________________________________________
Special Drafting Request: _________________________ (All requests for special dating will be reviewed against
the policy date for eligibility)
Signed and dated at:
______________________________________________ ____________________ _____________________________
City State Month/Day/Year
Signature of Authorized Account Holder:
X___________________________________________________________________________________________________________
A voided check must be attached below. (A blank deposit slip will not be accepted.)
Premium payments can only be drawn from authorized U.S. financial institutions. Some savings and money market
accounts may not qualify.
PLACE VOIDED CHECK HERE
If your check does not state your financial institution's name and address, please list below:
____________________________________________________________________________________________________________
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AP2001-EFT Page 10 00-00000-00 05/2001
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SECTION M PRODUCER INFORMATION
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Producer Report To be answered by the soliciting Producer YES NO
Complete for all ---------------------------------------------------------------------------------------------------------------
applications. 1. Have you personally asked all applicable questions in this application? [_] [_]
(If no, explain in "Remarks")
---------------------------------------------------------------------------------------------------------------
2. Are you aware of any information not given in the application that might affect the
insurability of the Proposed Insured(s)? (If yes, explain in "Remarks") [_] [_]
---------------------------------------------------------------------------------------------------------------
3. Did the Proposed Insured/Additional Insured change his/her name during the past 5 years?
(If yes, give former name(s) in "Remarks") [_] [_]
---------------------------------------------------------------------------------------------------------------
4. To the best of your knowledge, is this life insurance intended to replace, or will it cause
a change in, or involve a loan from any life insurance or annuity on any Proposed Insured's
life or in any life insurance or annuity owned by the Annuitant?
(If yes, give details in "Remarks") [_] [_]
---------------------------------------------------------------------------------------------------------------
5A. If sales materials were used in this sale, did you use only sales materials approved by PL? [_] [_]
B. If sales materials were used in the sale, did you leave sales materials with the Applicant? [_] [_]
---------------------------------------------------------------------------------------------------------------
6. Is application submitted on a:
[_] Medical Basis? [_] Guaranteed Issue Basis?
[_] Non-Medical Basis? [_] Guaranteed to Issue Basis?
---------------------------------------------------------------------------------------------------------------
7. Check appropriate items which have been ordered:
[_] Medical Exam [_] H.O. Specimen
[_] Paramedical Exam [_] Inspection Report
[_] EKG [_] APS __________________________________________
[_] Blood Profile __________________________________________
---------------------------------------------------------------------------------------------------------------
8. If this policy is used to fund a tax qualified plan, indicate type:
[_] Pension/Profit Sharing [_] HR-10 [_] Other (Explain In "Remarks")
------------------------------------------------------------------------------------------------------------------------------------
Business Insurance 1. This life insurance policy is being purchased in conjunction with a:
A. [_] Buy/Sell D. [_] Split Dollar
Complete if B. [_] Employee Fringe Benefit E. [_] Key Employee
applying for C. [_] Deferred Compensation F. [_] Other (Explain in "Remarks")
business
insurance. ---------------------------------------------------------------------------------------------------------------
Amount of
% of Business Insurance Owned by
G. Name of Principal Officers, Partners, or Key Employees Position Owned Business
---------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------
H. What is the current value of the business? $
--------------------------------------------------------------------------------------
--------------------------------
I. What was the annual net profit (before taxes) of business? Last Year 2 Years Ago
$ $
--------------------------------
J. Are other officers, partners or key employees proportionately insured? [_] Yes [_] No (If no, explain
in "Remarks")
------------------------------------------------------------------------------------------------------------------------------------
Juvenile Insurance 1. Did you personally observe the Proposed Insured? [_] Yes [_] No (If no, explain
in "Remarks")
Complete if the ---------------------------------------------------------------------------------------------------------------
Proposed Insured
is under age 16. 2. Are the Proposed Insured's brothers and sisters insured for [_] Yes [_] No (If no, explain
equal amounts? in "Remarks")
---------------------------------------------------------------------------------------------------------------
3A. Name of Person on whom Proposed Insured depends for support: B. Relationship to Insured
---------------------------------------------------------------------------------------------------------------
C. Estimated annual income D. Estimated net worth E. Estimated amount of life insurance
$ $ $
---------------------------------------------------------------------------------------------------------------
4A. Name of Applicant B. Relationship to Insured
---------------------------------------------------------------------------------------------------------------
C. Purpose of Insurance D. Amount of life insurance in force
$
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AP2001-PRPT Page 11 00-00000-00 05/2001
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SECTION N PRODUCER CERTIFICATION
------------------------------------------------------------------------------------------------------------------------------------
Complete for all I certify that to the best of my knowledge and belief: YES NO
applications. ---------------------------------------------------------------------------------------------------------------
A. I have presented to the Company all pertinent facts and have correctly and completely
recorded all required answers. [_] [_]
---------------------------------------------------------------------------------------------------------------
B. I have given the Proposed Insured(s) (or Parent for Juvenile insurance) a copy of the
Disclosure Notice, and any other disclosure notice or statement required by state or
federal law. [_] [_]
---------------------------------------------------------------------------------------------------------------
C. I have fully explained the terms and conditions of the Temporary Insurance Agreement to the
Proposed Insured(s) (or Owner) and have given it to him/her (them). [_] [_]
---------------------------------------------------------------------------------------------------------------
D. I have complied with state and federal laws on cost comparison, illustration and replacement. [_] [_]
---------------------------------------------------------------------------------------------------------------
E. I have reviewed, with my Broker Dealer, as applicable, the purchase of this insurance policy [_] [_]
---------------------------------------------------------------------------------------------------------------
F. If sales activity (including solicitation, application and policy delivery) took place in a state other
than the application state, indicate the states and associated activity. (If needed, use "Remarks" section
below)
State(s)________________________________ Activity_____________________________________________________
------------------------------------------------------------------------------------------------------------------------------------
Signature(s) Of Soliciting Producer(s). Pay Commission as Indicated Below.
X________________________________________________________________ X______________________________________________________________
First Name Listed Below Will Be The Servicing Producer
------------------------------------------------------------------------------------------------------------------------------------
Phone Fax Servicing Producer Comm.
Producer Name Number E-Mail Address Number Office # Code %
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
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------------------------------------------------------------------------------------------------------------------------------------
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Broker Dealer Name__________________________________________________________________________________________________________________
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REMARKS - IDENTIFY QUESTION AND GIVE DETAILS
------------------------------------------------------------------------------------------------------------------------------------
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AP2001-PRPT Page 12 00-00000-00 05/2001
Pacific Life Insurance Company
Life Insurance Division - Client Services Department
000 Xxxxxxx Xxxxxx Xxxxx . Xxxxxxx Xxxxx, XX 00000
(000) 000-0000 [LOGO OF PACIFIC LIFE]
DISCLOSURE NOTICE
DETACH AND LEAVE WITH PROPOSED INSURED(S)
This brief description of our underwriting process is designed to help you to
understand how an application for life insurance is handled, the types and
sources of information we may collect about you, the circumstances under which
we may disclose that information to others and your right, or your authorized
representative's right, to learn the nature and substance of that information
upon written request. The purpose of the underwriting process is to make sure
you qualify for life insurance under the rules of Pacific Life Insurance Company
(PL), and assuming you do, establish the proper premium charge for that
insurance. The goal of the underwriting process is to have the cost of
insurance distributed equitably among all policyowners, so that each individual
pays his or her fair share. To determine your insurability, we must consider
such factors as your medical history, physical condition, occupation and
hazardous avocations. We get this information from various sources.
Application and Medical Records - Your application, including the medical
history, is the primary source of information in the evaluation process. In
addition, we may ask you to take a physical examination or other special test
such as an electrocardiogram. We may also ask for a report from your doctor or
hospital, another insurance company, or the Medical Information Bureau, Inc.
When we do so, we will use the Authorization Of The Proposed Insured(s) To
Obtain Information that you signed.
Medical Information Bureau, Inc. (MIB) - is a non-profit corporation, which
operates an information exchange on behalf of member life insurance companies.
As a member company, we will ask the MIB if it has a record concerning you. If
you previously applied to a member company for insurance, MIB may have
information about you in its file. The purpose of the MIB is to protect member
companies and their policyowners from those who would conceal significant facts
relevant to their insurability. The information, which is obtained from MIB,
may be used only as an alert to the possible need for further independent
investigation. It cannot be used as a basis to make a final underwriting
decision. Information regarding your insurability will be treated as
confidential. PL, its subsidiaries or its reinsurer(s) may, however, make a
brief report to the MIB. If you later apply to another MIB member company for
life or health insurance coverage, or a claim for benefits is submitted to such
a company, the MIB, upon request, will supply the company with the information
it may have about you in its file. PL, its subsidiaries or its reinsurer(s) may
also release information in its file to other life insurance companies to whom
you may apply for life or health insurance, or to whom a claim for benefits may
be submitted. At your request, or your authorized representatives request, the
MIB will arrange disclosure of any information it may have about you in its
file. If you question the accuracy of information on file, you may contact the
MIB and seek a correction in accordance with the procedures set forth in the
federal Fair Credit Reporting Act. The address of the information office of
MIB, Inc. is Post Xxxxxx Xxx 000, Xxxxx Xxxxxxx, Xxxxxx, Xxxxxxxxxxxxx 00000.
Their telephone number is (000) 000-0000.
Investigative Consumer Report - As part of our underwriting procedure, we may
request an investigative consumer report from a consumer reporting agency. A
consumer report confirms and supplements the information on your application
pertaining to employment and residence verification, smoking habits, marital
status, occupation, hazardous avocations and general health. This report may
also cover information concerning your general reputation, personal
characteristics and mode of living, (except as may be related directly or
indirectly to your sexual orientation) including drug and alcohol use, motor
vehicle driving record and any criminal activity. This information may be
obtained through personal interviews with you, your family, friends, neighbors
and business associates. If a report is required and you wish to be personally
interviewed, please let us know and we will notify the consumer reporting
agency. The information contained in the report may be retained by the consumer
reporting agency and subsequently disclosed to other companies to the extent
permitted by the Fair Credit Reporting Act. Investigative consumer reports are
held in strict confidence and used only to evaluate your application on a fair
and equitable basis. You have a right to inspect and obtain a copy of the
report from the consumer reporting agency.
DISCLOSURE TO OTHERS
Personal information obtained about you during the underwriting process is
confidential and will not be disclosed to other persons or organizations without
your written authorization except to the extent necessary for the conduct of our
business. Examples of situations where we may share information about you are
as follows:
. The Producer may retain a copy of your application.
. If reinsurance is required, the reinsurance company would have access to our
application file.
. We may release information to another life insurance company to whom you have
applied for life or health insurance or to whom you have submitted a claim
for benefits, if you have authorized it to obtain such information.
. As stated earlier, we may report information to the Medical Information
Bureau, Inc.
. We will disclose information to government regulatory officials, law
enforcement authorities and others where required by law.
DISCLOSURE TO YOU
In general, you have a right to learn the nature and substance of any personal
information about you in our file upon written request. Whenever an adverse
underwriting decision is made, we will notify you of the reason(s) for the
decision and the source of the information upon which our action is based.
Medical record information, however, will normally be given only to a licensed
physician of your choice. Please refer to the section on MIB, Inc., for that
organization's disclosure procedure. Should you feel that any information we
have is inaccurate or incomplete, please write to: Manager, Risk Selection
Department, PL Insurance Company, 000 Xxxxxxx Xxxxxx Xxxxx, Xxxxxxx Xxxxx,
Xxxxxxxxxx 00000. Your comments will be carefully considered and corrections
made where justified. We hope this Notice will help you to understand how we
obtain and use personal information in the underwriting process, and the ways
you can learn about this information. We are concerned with insuring privacy as
well as lives, and the collection, use and disclosure of personal information is
limited to those specified in this Notice.
AP2001-DISC Page 13 15-23217-00 05/2001
TIA
PACIFIC LIFE INSURANCE COMPANY
Life Insurance Division - Client Services Department [LOGO OF PACIFIC LIFE]
000 Xxxxxxx Xxxxxx Xxxxx . Xxxxxxx Xxxxx, XX 00000
(000) 000-0000
TEMPORARY INSURANCE AGREEMENT (TIA) - LIFE
This TIA provides a limited amount of life insurance coverage, for a limited period of time, subject to the Terms and Conditions
shown below.
Advance payment in the amount of $________ is made in connection with either a request for determination of probable underwriting
class or an application for life insurance (each referred to below as "Request/Application") on:
_______________________________________________________________________________ ________________________________________________
Name of Proposed Insured(s) Request/Application No.
Health Questions
Has any Proposed Insured: Yes No
1. Within the past 90 days been admitted to a hospital or other medical facility, been advised to be admitted, or
had surgery performed or recommended? [_] [_]
2. Within the past 5 years been diagnosed or treated by a member of the medical profession for heart trouble,
stroke, cancer or for Acquired Immune Deficiency (AIDS) or AIDS Related Complex (ARC) or other immune
deficiency disorders? [_] [_]
If any of the above questions are answered YES or LEFT BLANK, or if any Proposed Insured is under 15 days of age or over age 70
(nearest birthday) on the date of this TIA, no representative of Pacific Life Insurance Company (PL) is authorized to accept money,
and NO COVERAGE will take effect under this TIA.
Terms and Conditions
CHECKS MUST BE MADE PAYABLE TO "PACIFIC LIFE INSURANCE COMPANY." DO NOT MAKE CHECKS PAYABLE TO THE PRODUCER OR LEAVE THE PAYEE
BLANK.
Amount of Coverage - $1,000,000 overall maximum for all TIAs ($1,500,000 overall for Second-to-Die life insurance
Requests/Applications)
If money has been accepted by PL as advance payment in connection with a Request/Application and if any Proposed Insured dies (or
for Second-to-Die life insurance Requests/Applications, if both Proposed Insureds die) while this TIA is in effect, PL will pay the
designated beneficiary the lesser of (a) the amount of death benefits, if any, which would be payable under the policy and its
riders if issued as shown in the Request/Application, excluding any accidental death benefits, or (b) $1,000,000 ($1,500,000 for
Second-to-Die life insurance Requests/Applications). PL's aggregate liability under all TIAs in effect shall be subject to this
limitation.
Date Coverage Begins
Temporary life insurance under this TIA will begin on the date of this TIA, but only if a Request/Application has been completed and
signed on the same date.
Date Coverage Terminates (90 day maximum)
Temporary life insurance under this TIA will terminate automatically on the earliest of:
a. 90 days from the date of this TIA;
b. the date any policy is offered in connection with a Request/Application; or
c. five days after the date PL mails notice of termination of coverage and refunds the advance payment.
PL reserves the right to terminate this TIA under any of the following circumstances:
a. 30 days have elapsed since the date of this TIA, and PL has not received in its Home Office the report of the medical
examination, if such examination is required by PL's underwriting rules;
b. PL has determined that any Proposed Insured is not insurable as a standard risk at the time of the Request/Application or the
medical examination, if later; or
c. there are any errors or omissions on the current Request/Application.
Limitations
This TIA does not provide benefits for disability. Fraud or material misrepresentation in the Request/Application or in the answers
to the Health Questions of this TIA invalidates this TIA, and PL's only liability is to refund any premium payment made. If any
Proposed Insured dies by suicide, PL's liability under this TIA is limited to a refund of the payment made. There is no coverage
under this TIA if the check submitted as payment is not honored by the bank on first presentation. No one is authorized to waive or
modify any of the provisions of this TIA.
I HAVE RECEIVED A COPY OF AND HAVE READ THIS TIA AND DECLARE THAT THE ANSWERS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I
UNDERSTAND AND AGREE TO ALL ITS TERMS AND CONDITIONS.
Dated________________________________________________ X____________________________________________________________________________
Month Day Year Signature of Proposed Insured (or parent if Proposed Insured is under age 16)
X____________________________________________________ X____________________________________________________________________________
Signature of Producer/Registered Representative Signature of additional Proposed Insured (if applicable)
NOTICE TO APPLICANT: Please retain your copy of this TIA. The original will be retained by PL. If you do not hear from us regarding
the Request/Application within 100 days from the date of this TIA, notify us at 000 Xxxxxxx Xxxxxx Xx., Xxxxxxx Xxxxx, XX 00000,
Attention: Risk Selection.
Any person who knowingly, and with intent to injure, defraud, or deceive any insurance company, files a statement of claim or
provides false, incomplete, or misleading information as part of the information provided to obtain coverage commits a fraudulent
act, which is a crime and may be subject to criminal and civil penalties.
APO1TI PRODUCER: PROVIDE A PHOTOCOPY OF THIS SIGNED FORM TO ALL SIGNING PARTIES 00-00000-00 05/2001
RISK AVOC
GENERAL QUESTIONNAIRE [LOGO OF PACIFIC LIFE]
PACIFIC LIFE INSURANCE
000 Xxxxxxx Xxxxxx Xxxxx
Xxxxxxx Xxxxx, XX 00000
------------------------------------------------------------------------------------------------------------------------------------
FULL NAME (Print) DATE OF BIRTH
Mo. Day Yr.
------------------------------------------------------------------------------------------------------------------------------------
SECTION A AUTOMOBILE, MOTORCYCLE AND/OR POWER BOAT RACING
------------------------------------------------------------------------------------------------------------------------------------
1. Type of racing? [_] Midget [_] Go-Kart [_] Sports Car [_] Modified Stock [_] Drag Racing [_] Motorcycle
[_] Powerboat [_] Other (explain)___________________________________________________________________________________________
2. Make?________________________________ Model?________________________________ Displacement?__________________________________
Class?_______________________________ Engine Make & Model?________________________________ HP?_______________________________
3 (a) Number of races 12-24 months ago?_______________________________ (b) Past 12 months?____________________________________
(c) Date of last race?_______________________________ (d) Est. next 12 months?______________________________________________
4. Type of race? [_] Midget [_] Sports Car [_] Stock Car [_] Championship [_] Drag [_] Kart [_] Hillclimb
[_] Cross Country [_] Hound & Hare [_] Moto-Cross [_] Other (explain)_____________________________________________________
------------------------------------------------------------------------------------------------------------------------------------
5. Type of course? [_] Paved [_] Dirt [_] Drag Strip [_] Oval [_] Other (explain)______________________________________
------------------------------------------------------------------------------------------------------------------------------------
6. Where do you race? [_] Local? [_] If not, where?______________________________________________________________________________
7. Competition against? [_] Other Cars [_] Clock [_] Straightaway____________________________________________________________
8. Average Speed?________________________ Top Speed?________________________ Average miles per race?__________________________
9. Is your racing? [_] Professional [_] Amateur [_] Other (explain)__________________________________________________________
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SECTION B UNDERWATER DIVING (SKIN OR SCUBA)
------------------------------------------------------------------------------------------------------------------------------------
1. What type of equipment do you use?______________________________________________________________________________________________
2. Location of diving activities?______________________ Diving for pleasure?______________________ Pay?______________________
3. Do you belong to club or association?________________________________ Do you ever dive alone?________________________________
4. Depth of Dives During Past 12 Months Expected Next 12 Months
------------------------------------------------------------------------------------------------------------------------------------
No. Dives Average Time No. Dives Average Time
----------------------------------------------------------------------------------------------
a. Less than 40 feet ______________________________________________________________________________________________
b. 40 feet to 60 feet ______________________________________________________________________________________________
c. 60 feet & over ______________________________________________________________________________________________
d. Maximum depth obtained ______________________________________________________________________________________________
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SECTION C PARACHUTE JUMPING AND SKY DIVING
------------------------------------------------------------------------------------------------------------------------------------
1. Are you now a member of any parachute or sky diving club or association?________________________________________________________
2. Are all of your jumps made under auspices of your club or association?__________________________________________________________
3. (a) Number of jumps 12-24 months ago?______________ (b) Past 12 months?______________ (c) Next 12 months?_______________
4. Do you participate in delayed chute opening competition or other stunts?________________________________________________________
5. Location of jump areas?________________________________________________ Date of last jump?___________________________________
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REMARKS IDENTIFY SECTION AND QUESTION
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
I represent that the foregoing answers and statements are correctly recorded, complete, and true to the best of my knowledge and
belief.
Date______________________________________________ X____________________________________________________________________________
Mo. Day Year Signature of Proposed Insured (or Parent if Proposed Insured is under age 15)
__________________________________________________
Signature of Soliciting Agent
_____________________________
Agency No.
AP7503 00-00000-00 05/2000
Page 1 of 2
RISK AVIA
GENERAL QUESTIONNAIRE [LOGO OF PACIFIC LIFE]
PACIFIC LIFE INSURANCE COMPANY
000 XXXXXXX XXXXXX XXXXX
XXXXXXX XXXXX, XX 00000
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FULL NAME (Print) DATE OF BIRTH
Mo. Day Yr.
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SECTION D AVIATION
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1. Type of Activity: FOR CIVILIAN AND MILITARY PILOTS:
HOURS FLOWN 5. A. Type of license/certificate/rating held (CHECK
--------------------------------------------- APPROPRIATE BOXES):
Last 12 12-24 Mo. All Prior Ext. Next Student [_] Private [_] Commercial [_] ATR [_] IFR [_]
months Ago Years 12 Mo. Instructor [_] Other [_] (SPECIFY "REMARKS")
---------------------------------------------
Civilian Pilot B. Date of last renewal:_________________________________
---------------------------------------------
Military Pilot C. Purpose of flights:___________________________________
---------------------------------------------
Member of Crew D. Total flying hours to date:___________________________
---------------------------------------------
E. Date of last flight:__________________________________
Yes No
2. Have you ever done or do you intend to engage in FOR CREW MEMBERS.
flying for the purpose of exhibition, endurance tests, 6. A. Duties aboard aircraft:_______________________________
racing, stunt flying, testing, air cargo operations,
crop dusting or spraying, or instruction of student B. Purpose of flights:__________________________________
pilots?............................................... [_] [_]
X. Xxxx of last flight:_________________________________
3. A. Have you ever flown or do you intend to fly
outside of the United States?..................... [_] [_] D. Do you plan to take instructions as a pilot?
Yes [_] No [_]
B. Have you ever been involved in any accident (IF "YES", EXPLAIN IN "REMARKS".)
due to flying activities?......................... [_] [_]
C. Have you ever been charged with any violation 7. If aviation activity does not permit standard
of air regulations?............................... [_] [_] unrestricted coverage, please issue as follows:
(IF "YES" TO QUESTIONS 2, 3A OR 3C, EXPLAIN IN "REMARKS".) [_] Full aviation coverage, if available, with appropriate
FOR PILOTS AND CREW MEMBERS OF MILITARY AIRCRAFT: extra premium.
[_] Aviation exclusion rider.
4. Describe type of aircraft flown in (including
alphabetic & numeric code).
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REMARKS IDENTIFY SECTION AND QUESTION
------------------------------------------------------------------------------------------------------------------------------------
I represent that the foregoing answers and statements are correctly recorded, complete, and true to the best of my knowledge and
belief.
Date______________________________________________ X____________________________________________________________________________
Mo. Day Year Signature of Proposed Insured (or Parent if Proposed Insured is under age 15)
__________________________________________________
Signature of Soliciting Agent
_____________________________
Agency No.
AP7503 00-00000-00 05/2000
Page 2 of 2
RISK NONMD
APPLICATION, PART II - NON MEDICAL
PACIFIC LIFE INSURANCE COMPANY [LOGO OF
000 Xxxxxxx Xxxxxx Xxxxx PACIFIC LIFE]
Xxxxxxx Xxxxx, XX 00000
--------------------------------------------------------------------------------
SECTION A COMPLETE ON PROPOSED INSURED (AGE 16 OR OVER)
--------------------------------------------------------------------------------
1. Full Name 2a. Date of Birth 2b. Height 2c. Weight
MO. DAY YR.
FT. IN. LBS.
--------------------------------------------------------------------------------
3. a. Name and address of physician or practitioner last visited:
--------------------------------------------------------------------------
(IF NONE, SO STATE)
b. Date: c. Reason consulted:
MO. YR.
Yes No Details of "Yes" answers.
d. Did any symptoms prompt consultation?............................................. [_] [_] (Identify question, and
e. Was any treatment given or medication prescribed?................................. [_] [_] include diagnoses, dates,
(IF "D" OR "E" ANSWERED "YES", GIVE DETAILS) duration and names and
4. To the best of your knowledge and belief, during the past 10 years, have you had, addresses of all attend-
or been told that you had, or been treated by a member of the medical profession ing physicians and
for: medical facilities.) Use
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS) an additional sheet if
a. Disorder of the eyes, ears, nose, or throat?...................................... [_] [_] necessary.
b. Dizziness, fainting, convulsions, headaches, speech defect, paralysis or stroke,
or mental or nervous disorder?.................................................... [_] [_]
c. Hoarseness or cough, blood spitting, asthma, pneumonia, emphysema, tuberculosis,
or other respiratory system disorder?............................................. [_] [_]
d. Chest pain, high blood pressure, rheumatic fever, murmur, heart attack or other
disorder of the heart or blood vessels?........................................... [_] [_]
e. Jaundice, intestinal bleeding, ulcer, colitis, diverticulitis, hepatitis, or
other disorder of the liver, gallbladder, stomach, or intestines?................. [_] [_]
f. Sugar, albumin, or blood in urine, venereal disease, stone or other disorder of
kidney, bladder, prostate, breasts or reproductive organs?........................ [_] [_]
g. Diabetes; thyroid or other endocrine disorders?................................... [_] [_]
h. Neuritis, sciatica, arthritis, gout, or disorder of the muscles or bones,
including the spine, back, or joints?............................................. [_] [_]
i. Cancer, cyst, tumor or disorder of skin, blood or lymph glands?................... [_] [_]
j. Any disorder(s) of the Immune System, including AIDS (Acquired Immune Deficiency
Syndrome) and ARC (AIDS Related Complex)?......................................... [_] [_]
5. a. Have you within the past 5 years been a patient in a hospital, clinic, sanitarium
or other medical facility?........................................................ [_] [_]
b. Are you now under regular medical observation or taking treatment?................ [_] [_]
6. a. Except as prescribed by a physician, have you used heroin, morphine or other
narcotic drugs in the last 10 years?.............................................. [_] [_]
b. Except as prescribed by a physician, have you used cocaine, LSD, marijuana or
other hallucinogenic agents, or barbiturates, sedatives, tranquilizers or any
amphetamines in the last 5 years?................................................. [_] [_]
c. In the last 5 years have you received treatment for or joined an organization
because of alcoholism or drug addiction?.......................................... [_] [_]
7. Other than as stated in answers above, have you within the past 5 years:
a. Had a checkup, consultation, illness, injury or operation?........................ [_] [_]
b. Had an electrocardiogram, blood test, other test or X-ray?........................ [_] [_]
c. Been advised to have any diagnostic test, hospitalization or surgery which was not
completed?........................................................................ [_] [_]
8. Have you had any change in weight in the past year?.................................. [_] [_]
9. Have either of your parents, brothers or sisters had diabetes, cancer, high blood
pressure, heart disease, or mental illness?.......................................... [_] [_]
(IF "YES", STATE CONDITION, GIVE RELATIONSHIP AND AGE AT ONSET)
10. Parents' Record (COMPLETE BELOW).
--------------------------------------------------------------------------------------------------
IF LIVING IF DECEASED
--------------------------------------------------------------------------------------------------
AGE STATE OF HEALTH AGE AT CAUSE OF DEATH
DEATH
--------------------------------------------------------------------------------------------------
Father
--------------------------------------------------------------------------------------------------
Mother
--------------------------------------------------------------------------------------------------
The above statements are true and complete to the best of my knowledge and
belief. I agree that such statements and answers shall be a part of the
application.
Dated at ______________________ on ___________ X______________________________
CITY STATE MO. DAY YR. SIGNATURE OF PROPOSED INSURED
______________________________________________
WITNESS
Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing
any materially false information or conceals for the 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.
AP9500-P2 Page 1 of 3 15-19536-04 4/2000
RISK NONMD
APPLICATION, PART II - NON MEDICAL
PACIFIC LIFE INSURANCE COMPANY [LOGO OF
000 Xxxxxxx Xxxxxx Xxxxx PACIFIC LIFE]
Xxxxxxx Xxxxx, XX 00000
--------------------------------------------------------------------------------
SECTION B COMPLETE ON ADDITIONAL INSURED (AGE 16 OR OVER)
--------------------------------------------------------------------------------
1. Full Name 2a. Date of Birth 2b. Height 2c. Weight
MO. DAY YR.
FT. IN. LBS.
--------------------------------------------------------------------------------
3. a. Name and address of physician or practitioner last visited:
--------------------------------------------------------------------------
(IF NONE, SO STATE)
b. Date: c. Reason consulted:
MO. YR.
Yes No Details of "Yes" answers.
d. Did any symptoms prompt consultation?............................................ [_] [_] (Identify question, and
e. Was any treatment given or medication prescribed?................................ [_] [_] include diagnoses, dates,
(IF "D" OR "E" ANSWERED "YES", GIVE DETAILS) duration and names and
4. To the best of your knowledge and belief, during the past 10 years, have you had, or addresses of all attend-
been told that you had, or been treated by a member of the medical profession for: ing physicians and
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS) medical facilities.) Use
a. Disorder of the eyes, ears, nose, or throat?..................................... [_] [_] an additional sheet if
b. Dizziness, fainting, convulsions, headaches, speech defect, paralysis or stroke, necessary.
or mental or nervous disorder?................................................... [_] [_]
c. Hoarseness or cough, blood spitting, asthma, pneumonia, emphysema, tuberculosis,
or other respiratory system disorder?............................................ [_] [_]
d. Chest pain, high blood pressure, rheumatic fever, murmur, heart attack or other
disorder of the heart or blood vessels?.......................................... [_] [_]
e. Jaundice, intestinal bleeding, ulcer, colitis, diverticulitis, hepatitis, or
other disorder of the liver, gallbladder, stomach, or intestines?................ [_] [_]
f. Sugar, albumin, or blood in urine, venereal disease, stone or other disorder of
kidney, bladder, prostate, breasts or reproductive organs?....................... [_] [_]
g. Diabetes; thyroid or other endocrine disorders?.................................. [_] [_]
h. Neuritis, sciatica, arthritis, gout, or disorder of the muscles or bones,
including the spine, back, or joints?............................................ [_] [_]
i. Cancer, cyst, tumor or disorder of skin, blood or lymph glands?.................. [_] [_]
j. Any disorder(s) of the Immune System, including AIDS (Acquired Immune Deficiency
Syndrome) and ARC (AIDS Related Complex)?........................................ [_] [_]
5. a. Have you within the past 5 years been a patient in a hospital, clinic, sanitarium
or other medical facility?....................................................... [_] [_]
b. Are you now under regular medical observation or taking treatment?............... [_] [_]
6. a. Except as prescribed by a physician, have you used heroin, morphine or other
narcotic drugs in the last 10 years?............................................. [_] [_]
b. Except as prescribed by a physician, have you used cocaine, LSD, marijuana or
other hallucinogenic agents, or barbiturates, sedatives, tranquilizers or any
amphetamines in the last 5 years?................................................ [_] [_]
c. In the last 5 years have you received treatment for or joined an organization
because of alcoholism or drug addiction?......................................... [_] [_]
7. Other than as stated in answers above, have you within the past 5 years:
a. Had a checkup, consultation, illness, injury or operation?....................... [_] [_]
b. Had an electrocardiogram, blood test, other test or X-ray?....................... [_] [_]
c. Been advised to have any diagnostic test, hospitalization or surgery which was
not completed?................................................................... [_] [_]
8. Have you had any change in weight in the past year?................................. [_] [_]
9. Have either of your parents, brothers or sisters had diabetes, cancer, high blood
pressure, heart disease, or mental illness?......................................... [_] [_]
(IF "YES", STATE CONDITION, GIVE RELATIONSHIP AND AGE AT ONSET)
10. Parents' Record (COMPLETE BELOW).
--------------------------------------------------------------------------------------------------
IF LIVING IF DECEASED
--------------------------------------------------------------------------------------------------
AGE STATE OF HEALTH AGE AT CAUSE OF DEATH
DEATH
--------------------------------------------------------------------------------------------------
Father
--------------------------------------------------------------------------------------------------
Mother
--------------------------------------------------------------------------------------------------
The above statements are true and complete to the best of my knowledge and
belief. I agree that such statements and answers shall be a part of the
application.
Dated at ______________________ on ___________ X______________________________
CITY STATE MO. DAY YR. SIGNATURE OF PROPOSED INSURED
______________________________________________
WITNESS
Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing
any materially false information or conceals for the 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.
AP9500-P2 Page 2 of 3 15-19536-04 4/2000
RISK NONMD
APPLICATION, PART II - NON MEDICAL
PACIFIC LIFE INSURANCE COMPANY [LOGO OF
000 Xxxxxxx Xxxxxx Xxxxx PACIFIC LIFE]
Xxxxxxx Xxxxx, XX 00000
-------------------------------------------------------------------------------------------------------------------
SECTION C COMPLETE IF APPLYING FOR OWNER PREMIUM WAIVER, PAYOR WAIVER,
CHILDREN'S TERM RIDER OR IF PROPOSED INSURED IS UNDER AGE 16.
-------------------------------------------------------------------------------------------------------------------
1. RELATIONSHIP STATE HEIGHT WEIGHT AMOUNT OF AMT. OF INS.
TO PROPOSED DATE OF BIRTH OF (FT./IN.) (POUNDS) INSURANCE CURRENTLY
NAME OF PERSON TO BE COVERED INSURED (MO./DAY/YR.) BIRTH NOW IN FORCE APPLIED FOR
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Note: If payor or owner waiver of charges is being applied for, please
indicate the individual's occupation and the employer's name and address:
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
2a. Name and address of your personal physician, practitioner or health facility
--------------------------------------------------------------------------------
b. Date: c. Reason for and results of last visit
--------------------------------------------------------------------------------
3. Has any person named in Question 1 during the past 10 years had or been told
that he or she had, or been treated for:
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS) Yes No
A. Diabetes, cancer or epilepsy?.....................................[_] [_]
B. Heart murmur, high blood pressure or any heart condition?.........[_] [_]
C. Any disorder(s) of the Immune System, including AIDS (Acquired
Immune Deficiency Syndrome) and ARC (AIDS Related Complex)?.......[_] [_]
4. Has any person named in Question 1:
A. Been in a hospital, sanitarium or other institution for diagnosis,
treatment or a surgical operation within the past 5 years?........[_] [_]
B. Had any medical consultation or treatment within the past 3 years,
other than as stated in any answer above?.........................[_] [_]
(GIVE DETAILS BELOW FOR EACH "YES" ANSWER IN QUESTIONS 3 and 4)
--------------------------------------------------------------------------------
QUESTION FIRST NAME REASON FOR DATE DURATION - NAME AND ADDRESS OF
NO. CONSULTATION RESULT PHYSICIAN
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
DECLARATIONS
--------------------------------------------------------------------------------
I represent that the foregoing answers and statements are correctly recorded,
complete, and true to the best of my knowledge and belief.
I understand that:
1. Except as otherwise provided in any Temporary Insurance Agreement, no
insurance will take effect before the policy for such insurance is delivered
and the first premium paid during the lifetime(s) and before any change in
the health of the Proposed Insured(s). Upon such delivery and payment,
insurance will take effect if the answers and statements in this application
are then true.
2. Acceptance of a life insurance policy will be ratification of any
administrative change with respect to such policy made by the Company in the
space entitled "Home Office Endorsements," where permitted by state law. All
other changes, including policy type and amount of insurance, benefits,
classification or age at issue, must be accepted in writing.
3. No agent or medical examiner is authorized to make or modify contracts or to
waive any of the Company's rights or requirements.
Signed and Dated in:
______________ on _____________ X______________________________________________
CITY STATE MO. DAY YR. Signature of Proposed Insured
(OR PARENT, IF PROPOSED IS UNDER AGE 16)
X______________________________________________
Signature of Owner/Payor
IF OWNER IS A CORPORATION, THE SIGNATURE AND TITLE OF AN AUTHORIZED OFFICER
OTHER THAN THE PROPOSED INSURED IS REQUIRED AND THE FULL NAME OF THE CORPORATION
MUST BE SHOWN.
I certify that I have truly and accurately recorded hereon the information
supplied.
________________ _____________________ _______________________
Signature of Please Print State License ID Number
Soliciting Agent Soliciting Agent Name (Required in Florida)
Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing
any materially false information or conceals for the 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.
AP9500-P2 Page 3 of 3 15-19536-04 4/2000
RISK MED
APPLICATION, PART II - MEDICAL [LOGO OF PACIFIC LIFE]
Pacific Life Insurance Company
000 Xxxxxxx Xxxxxx Xxxxx
Xxxxxxx Xxxxx, XX 00000
------------------------------------------------------------------------------------------------------------------------------------
SECTION A COMPLETE ON PROPOSED INSURED (AGE 16 OR OVER)
------------------------------------------------------------------------------------------------------------------------------------
1. Full Name 2a. Date of Birth 2b. Height 2c. Weight
(MO. DAY YR) FT. IN. LBS.
------------------------------------------------------------------------------------------------------------------------------------
3. a. Name and address of physician
or practitioner last seen:
____________________________________
MO. YR (IF NONE, SO STATE)
b. Date:
c. Reason consulted:
Yes No Details of "Yes" answers. (Identify question;
d. Did any symptoms prompt consultation?........... [_] [_] and include diagnoses, dates, duration and names and
e. Was any treatment given or medication addresses of all attending physicians and medical
prescribed...................................... [_] [_] facilities.) Use an additional sheet if necessary.
(IF "D" OR "E" ANSWERED "YES", GIVE DETAILS)
4. To the best of your knowledge and belief,
during the past 10 years, have you had, or
been told that you had, or been treated
by a member of the medical profession for:
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS)
a. Disorder of the eyes, ears, nose, or throat?... [_] [_]
b. Dizziness, fainting, convulsions, headaches,
speech defect, paralysis or stroke, or mental
or nervous disorder?........................... [_] [_]
c. Hoarseness or cough, blood spitting, asthma,
pneumonia, emphysema, tuberculosis, or other
respiratory system disorder?................... [_] [_]
d. Chest pain, high blood pressure, rheumatic
fever, murmur, heart attack or other disorder
of the heart or blood vessels?................. [_] [_]
e. Jaundice, intestinal bleeding, ulcer, colitis,
diverticulitis, hepatitis, or other disorder
of the liver, gallbladder, stomach, or
intestines?.................................... [_] [_]
f. Sugar, albumin, or blood in urine; venereal
disease; stone or other disorder of kidney,
bladder, prostate, breasts or reproductive
organs?........................................ [_] [_]
g. Diabetes; thyroid or other endocrine
disorders?..................................... [_] [_]
h. Neuritis, sciatica, arthritis, gout, or
disorder of the muscles or bones, including
the spine, back, or joints?.................... [_] [_]
i. Cancer, cyst, tumor or disorder of skin, blood
or lymph glands?
j. Any disorder(s) of the Immune System, including
AIDS (Acquired Immune Deficiency Syndrome) and
ARC (AIDS Related Complex)?.................... [_] [_]
5. a. Have you within the past 5 years been a patient
in a hospital, clinic, sanitarium or other
medical facility?.............................. [_] [_]
b. Are you now under regular medical observation
or taking treatment?........................... [_] [_]
6. a. Except as prescribed by a physician, have you
used heroin, morphine or other narcotic drugs
in the last 10 years?.......................... [_] [_]
b. Except as prescribed by a physician, have
you used cocaine, LSD, marijuana or other
hallucinogenic agents, or barbiturates,
sedatives, tranquilizers or any amphetamines
in the last 5 years?........................... [_] [_]
c. In the last 5 years have you received
treatment for or joined an organization
because of alcoholism or drug addiction?....... [_] [_]
7. Other than as stated in answers above, have you
within the past 5 years:
a. Had a checkup, consultation, illness, injury
or operation?.................................. [_] [_] -----------------------------------------------------------------
b. Had an electrocardiogram, blood test, other Yes No
test or X-ray?................................. [_] [_] 11. a. Do you currently smoke cigarettes?............. [_] [_]
c. Been advised to have any diagnostic test, b. If "Yes", how many a day?______________________
hospitalization or surgery which was not c. Did you ever smoke cigarettes?................. [_] [_]
completed?..................................... [_] [_] d. If "Yes" on 11(c), give date last cigarette
8. Have you had any change in weight in the smoked: MO.______ YR.______
past year?........................................ [_] [_] e. Do you use tobacco in any other form?.......... [_] [_]
9. Have either of your parents, brothers or (IF "YES", SPECIFY TYPE IN "REMARKS")
sisters had diabetes, cancer, high blood pressure, f. Have you used tobacco in any other form within
heart disease, or mental illness?................. [_] [_] the last 24 mos?............................... [_] [_]
(IF "YES", STATE CONDITION, GIVE RELATIONSHIP (IF "YES", SPECIFY TYPE IN "REMARKS")
AND AGE AT ONSET)
10. Parents' Record (COMPLETE BELOW):
IF LIVING IF DECEASED
----------------------------------------------------------------
AGE STATE OF HEALTH AGE AT CAUSE OF DEATH
----------------------------------------------------------------
Father
----------------------------------------------------------------
Mother
----------------------------------------------------------------
The above statements are true and complete to the best of my knowledge and belief. I agree that such statements and answers shall be
a part of the application.
Any Person who, with intent to defraud or knowing that he or 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.
Dated at _____________________________________ on _______________________________ X ____________________________________________
CITY STATE MO. DAY YR. SIGNATURE OF PROPOSED INSURED
____________________________________________________________________________________
WITNESS
AP8601-1 00-00000-00 8/2000
Page 1 of 2
MEDICAL EXAMINER'S REPORT
------------------------------------------------------------------------------------------------------------------------------------
12. Abdomen 18. URINALYSIS
Weight Chest (Full Chest (Forced Relaxed (Dip Stick): Protein___________ Sugar__________
Height (Clothed) Inspiration) Expiration) At Umbilicus
-------------------------------------------------------------------
Ft. In. Lbs. In. In. In. Send specimen to Lab One when:
-------------------------------------------------------------------
Did you weigh? Yes [_] No [_] Did you measure? Yes [_] No [_] (a) There are findings or history of urinary
Weight change in past year?______lbs. [_] Gain [_] Loss-Cause? abnormalities or elevated blood pressure; or
Is appearance unhealthy or older than stated age? [_] Yes [_] No (b) Agent advises amount of insurance requires it.
-------------------------------------------------------------------
13. BLOOD PRESSURE 19. The following are being forwarded:
(RECORD SYST./DIAST. SITTING, THE DIASTOLIC AT CESSATION OF SOUND) [_] Specimen to Lab One*
Initial reading: Syst./Diast. [_] Blood Profile to Lab One*
(IF 140/90 OR OVER, MUST [_] Electrocardiogram to Pacific Life*
GIVE AT LEAST TWO [_] Other
ADDITIONAL READINGS) (*REQUESTOR WILL ORDER WHEN NECESSARY)
-------------------------------------------------------------------
14. PULSE At Rest After Exercise 3 Minutes Later
Rate ___________________________________________________ Examiner's remarks and description of positive findings:
Irregularities Per Min._______________________________________
15. HEART
(a) Is there any cardiovascular disorder? [_] Yes [_] No
(b) Is heart enlarged? [_] Yes [_] No (If yes, describe)
(c) Is murmur present? [_] Yes [_] No (If yes, complete 15d)
-------------------------------------------------------------------
(d) Murmur is: [_] Constant [_] Inconstant
[_] Transmitted [_] Systolic [_] Apical [_] Soft (Gr. 1-2)
[_] Localized [_] Presystolic [_] Basal [_] Mod. (Gr. 3-4)
[_] Diastolic [_] Other [_] Loud (Gr. 5-6)
After exercise [_] Unchanged [_] Increased
[_] Decreased [_] Absent
Show location of:
Apex by [SYMBOL]
Area of murmur by [SYMBOL] [GRAPHIC APPEARS HERE]
Point of greatest intensity by [SYMBOL]
Transmission by [SYMBOL]
(e) Diagnostic Impression:
-------------------------------------------------------------------
16. Is there any abnormality of the following:
(CIRCLE APPLICABLE ITEMS AND GIVE DETAILS) Yes No
(a) Eyes, ears, nose, mouth, pharynx.............. [_] [_]
(IF VISION OR HEARING MARKEDLY IMPAIRED,
INDICATE DEGREE AND CORRECTION)
(b) Skin (incl. scars); lymph nodes; blood
vessels...................................... [_] [_]
(INCL. VARICOSE VEINS)
(c) Nervous system (INCLUDE REFLEXES, GAIT,
PARALYSIS)................................... [_] [_]
(d) Respiratory system........................... [_] [_]
(e) Abdomen (INCLUDING SCARS OR HERNIAS)......... [_] [_]
(f) Genitourinary system......................... [_] [_]
(g) Endocrine system (INCLUDE THYROID AND
BREASTS)..................................... [_] [_]
(h) Musculoskeletal system....................... [_] [_]
(INCLUDE SPINE, JOINTS, AMPUTATIONS, DEFORMITIES)
-------------------------------------------------------------------
17. Have you any pertinent information not brought
out above?........................................ [_] [_]
------------------------------------------------------------------------------------------------------------------------------------
MEDICAL EXAMINER: EXAMINER'S NAME AND OFFICE ADDRESS (PLEASE PRINT)
X_________________________________________________ Name___________________________________________________________
SIGNATURE OF MEDICAL EXAMINER
Street_________________________________________________________
WHEN PAYING FEES WE ARE REQUIRED TO SHOW AND
REPORT SOCIAL SECURITY OR EMPLOYER I.D. NUMBER. PLEASE City___________________________________________________________
GIVE US THIS INFORMATION BELOW.
Include All Hyphens [_____________________________] State__________________________________________________________
Examined at Name of Agent Requesting Examination
[_] My Office [_] Other:________________________ Mail To: Pacific Life Insurance Company
A.M. Risk Selection Dept. - Med. Fee Desk
Date and Hour of Examination___________________ ____ P.M. X.X. Xxx 0000
Xxxxxxx Xxxxx, Xx. 00000-0000
------------------------------------------------------------------------------------------------------------------------------------
AP8601-1 00-00000-00 8/2000
Page 2 of 2
