THE TRAVELERS INSURANCE COMPANY o XXX XXXXX XXXXXX x XXXXXXXX, XX X 00000
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VARIABLE LIFE SUPPLEMENT
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This supplement accompanies an application for a Variable Universal Life
Insurance Policy to be issued by The Travelers Insurance Company.
ALL QUESTIONS MUST BE ANSWERED COMPLETELY AND THE APPLICATION AND SUPPLEMENT
MUST BE SIGNED IN ORDER FOR THE COMPANY TO PROCESS THE APPLICATION. MAY BE
REFERENCED BY ATTACHMENT.
Corporation Name
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Tax ID#
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Owner Name
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Tax ID#
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FUND INFORMATION
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Select one or more funds and indicate percentage of allocation. Total must equal
100%; allocations must be whole percentages of 5% or more.
|_| [AIM Capital Appreciation Portfolio % |_| MFS Mid Cap Growth Portfolio %
---- ----
|_| Alliance Growth & Income Portfolio - Class B* % |_| MFS Total Return Portfolio %
---- ----
|_| Alliance Growth Portfolio % |_| PIMCO Total Return Portfolio - Administrative %
Class
---- ----
|_| Alliance Premier Growth Portfolio - Class B % |_| Pioneer Mid-Cap Value VCT Portfolio - Class II * %
---- ----
|_| American Funds Global Growth Fund - Class 2* % |_| Xxxxxx VT International Growth Fund - Class IB %
---- ----
|_| American Funds Growth Fund - Class 2* % |_| Xxxxxx VT Small Cap Value Fund - Class IB %
---- ----
|_| American Funds Growth - Income Fund - Class 2* % |_| Salomon Brothers Variable Capital Fund %
---- ----
|_| Capital Appreciation Fund (JANUS) % |_| Salomon Brothers Variable Investors Fund %
---- ----
|_| Credit Suisse Emerging Markets Portfolio % |_| Salomon Brothers Variable Total Return Fund %
---- ----
|_| Delaware VIP REIT Series % |_| Xxxxxxx VIT EAFE(R)Equity Index Fund %
---- ----
|_| Dreyfus Stock Index Fund* % |_| Xxxxxxx VIT Small Cap Index Fund %
---- ----
|_| Dreyfus VIF Appreciation Portfolio - Initial Shares % |_| Xxxxx Xxxxxx Aggressive Growth Portfolio %
---- ----
|_| Dreyfus VIF Small Cap Portfolio - Initial Shares % |_| Xxxxx Xxxxxx Fundamental Value Portfolio %
---- ----
|_| Equity Income Portfolio (FIDELITY) % |_| Xxxxx Xxxxxx Large Cap Growth Portfolio %
---- ----
|_| Equity Index Portfolio - Class 1 % |_| Social Awareness Stock Portfolio (XXXXX XXXXXX) %
---- ----
|_| Fidelity VIP Contrafund(R)Portfolio - Service Class % |_| Xxxxxxxxx Foreign Securities Fund - Class 2 * %
---- ----
|_| Fidelity VIP Mid Cap Portfolio - Service Class 2 % |_| Travelers Convertible Securities Portfolio %
---- ----
|_| Franklin Small Cap Fund - Class 2 % |_| Travelers Disciplined Mid Cap Stock Portfolio %
---- ----
|_| Janus Aspen Series Balanced Portfolio - Service % |_| Travelers High Yield Bond Trust %
Shares
---- ----
|_| Janus Aspen Series Global Tech. Portfolio - Svc % |_| Travelers Money Market Portfolio %
Shares
---- ----
|_| Janus Aspen Series Worldwide Growth Port. - Svc % |_| Travelers Quality Bond Portfolio %
Shrs
---- ----
|_| Large Cap Portfolio (FIDELITY) % |_| Travelers U.S. Government Securities Portfolio %
---- ----
|_| Lazard International Stock Portfolio % |_| Xxx Xxxxxx Enterprise Portfolio] %
---- ----
|_| MFS Emerging Growth Portfolio %
TOTAL 100 %
*FUNDS ARE NOT AVAILABLE IN CONNECTICUT
SUITABILITY
a) Have you received the prospectus relating to the policy applied for?
_____Yes _____No Date of prospectus:__________________________________ Date
of prospectus supplement(s):
b) Do you understand that the Contract Value and Death Benefit associated with
the policy you have applied for may increase or decrease depending upon the
investment experience of the investment options which you have selected?
_____Yes _____No
c) With this in mind, is the policy in accord with your insurance objectives
and anticipated financial needs? _____Yes _____No
APPLICANT declares to the best of his/her knowledge and belief that all of the
statements made in his/her application and supplement, if required, are complete
and true.
ALL VALUES AND BENEFITS PROVIDED BY THE BASIC POLICY APPLIED FOR ARE VARIABLE
AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. EXCEPT AS STATED IN THE
TEMPORARY INSURANCE AGREEMENT/ADVANCE PAYMENT RECEIPT CORRESPONDING TO THIS
APPLICATION, THE COMPANY WILL APPLY THE FIRST NET PREMIUM PAYMENT TO THE CREDIT
OF THE BASIC POLICY APPLIED FOR AS OF THE VALUATION DATE ON OR NEXT FOLLOWING
THE POLICY DATE.
Except as stated in the Employer-Sponsored Temporary Life Insurance Binder
Agreement, no insurance will take effect until: (1) the policy is delivered to
the Applicant; and (2) the first modal premium is paid in full while the health
and other conditions
relating to insurability remain as described in the
application. No agent is authorized: (1) to make, alter, or discharge any
policy; (2) to waive or change any condition or provision of any policy,
application or receipt; and (3) to accept any risk or to pass on insurability.
The Proposed Insured will be the Applicant of any policy issued on this
application unless otherwise indicated. The right to privacy is protected as
required by law.
Authorized individuals to perform transactions:
Name: Name:
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(PLEASE PRINT) (PLEASE PRINT)
Title: Title:
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Signature: Signature:
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Print Name of Owner/Designated Representative Signature of Owner/Designated Representative
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Print Name of Witness Signature of Witness (LICENSED RESIDENT AGENT)
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Print Name of Principal Signature of Principal
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Print Name of Broker/Dealer Signature of Broker Dealer
THE TRAVELERS INSURANCE COMPANY o XXX XXXXX XXXXXX x XXXXXXXX, XX X 00000
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APPLICATION FOR CORPORATE OWNED LIFE INSURANCE
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NAME OF CORPORATION:
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NAME OF POLICY OWNER:
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ADDRESS OF POLICY OWNER:
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POLICY OWNER TAX ID #: POLICY DATE:
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PLAN OF INSURANCE: Guideline Premium Test Cash Value Accumulation Test
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PREMIUM PAYMENT PLAN: Single Annual Semi-Annual Quarterly Monthly
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DEATH BENEFIT OPTION: Level Death Variable Death Annual Increase Death
----- Benefit ----- Benefit ----- Benefit
BENEFICIARY:
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Is the Beneficiary designation irrevocable? Yes No
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It is agreed that:
1. This application, which includes the attached Schedule A, will be the basis
for any policies issued in response to it.
2. Application is made to Travelers Insurance Company for individual life
insurance policies on the lives of the individuals specified in Schedule A.
3. The amount of insurance for each policy applied for shall be the amount
specified for each individual in Schedule A.
4. Each policy applied for shall be of the plan specified in the Plan of
Insurance section above.
Based on information provided by the Corporation, it is my understanding that
for the most recent 90 days, all of the Proposed Insureds been actively at work
for at least 30 hours per week, at their usual place of business, performing
their regular occupations.
Yes No
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Based on information provided by the Corporation, it is my understanding that
during the most recent 90 days, none of the
Proposed Insureds have been hospitalized or absent from work (other than
recreational days and holidays) for more than 5 workdays.
Yes No
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AGENT'S STATEMENT: Will this insurance replace, change or use the cash value of
any existing insurance policy or annuity on these insureds?
Yes No
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Is this insurance intended to be a 1035 tax-free exchange?
Yes No
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If you answered "Yes" to either of these replacement questions, has the required
replacement forms been completed?
Yes No
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List company name, amount and attach applicable forms required by state in which
application is signed.
Employer-Applicant hereby represents to The Travelers Insurance Company that
based upon applicable state law, it has sufficient insurable interest in the
lives of the proposed insureds to support issuance of the life insurance
contracts applied for. In support of this representation, Employer-Applicant
further represents that it has sought legal counsel and advice with respect to
the facts and issues surrounding issuance of the proposed contracts.
Employer-Applicant acknowledges that The Travelers Insurance Company is issuing
the life insurance contracts applied for in reliance upon these representations.
The Travelers Insurance Company and ______________ [Broker] hereby expressly
agree that the Applicant, including the Employer-Sponsor of the Applicant, is
authorized to disclose every aspect of the proposed life insurance purchase that
is the subject of this application with any and all persons, without limitation
of any kind.
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SIGNATURE OF AGENT SIGNATURE OF OWNER/DESIGNATED REPRESENTATIVE
Dated: Dated:
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SCHEDULE A
PROPOSED DATE OF INITIAL BASE TERM INITIAL PLANNED SMOKER/
INSURED SEX BIRTH SS# POLICY INSURANCE PREMIUM PREMIUM NONSMOKER
DEATH BENEFIT
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I represent that I have read the questions and answers on this application, and
declare that they are complete and true to the best of my knowledge and belief.
Furthermore, I understand that this application will become a part of any policy
issued. I agree that no Agent/Representative of the Company shall: have the
authority to waive a complete answer to any question on this Application;
transfer insurability; make or alter any contract; or, waive any of the
Company's other rights or requirements. I further agree that no insurance shall
take effect unless and until the Policy has been delivered to and accepted by
me; and, the initial modal premium is paid during the lifetime and prior to any
change in health of the Proposed Insured.
Signed for the Policy Owner by the following duly authorized official:
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SIGNATURE TITLE DATE
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PRINT NAME
THE TRAVELERS INSURANCE COMPANY o XXX XXXXX XXXXXX x XXXXXXXX, XX o 06183
SUPPLEMENT FOR SIMPLIFIED ISSUE LIFE INSURANCE
NAME OF PROPOSED INSURED:
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PROPOSED INSURED SSN: PROPOSED INSURED DOB: GENDER:
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NAME OF POLICY OWNER:
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ADDRESS OF POLICY OWNER:
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BENEFICIARY: ---------------------------------------------------------------------------------------
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SIGNATURE OF AGENT
SIGNATURE OF OWNER
Dated: Dated:
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SECTION B:
1. Personal Physician (Give full name, address and telephone number of your
doctor who you consult for routine check-ups and
physicals):
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Date and Reason last consulted:
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2. Proposed Insured: Height Weight
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Amount of weight loss in past 12 months
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(IF WEIGHT LOSS, PLEASE EXPLAIN BELOW)
3. Have you within the past 2 years:
a) Flown or plan to fly as a pilot, student pilot or crew member or intend to do
so in the future?
Yes No
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b) Engaged in scuba diving, vehicle racing, parachute jumping or any form of
motorcycling, or any other hazardous sport or hobby?
Yes No
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4. In the past 10 years have you:
a) Used Drugs not prescribed by a doctor?
Yes No
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b) Been treated for alcoholism?
Yes No
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c) Been advised to have medical treatment or counseling from a commonly
recognized practitioner or organization for alcohol or drug use?
Yes No
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SECTION B CONTINUED:
5. In the past 10 years have you:
a) Been diagnosed or treated for Acquired Immune Deficiency Syndrome (AIDS) by
a member of the medical profession?
Yes No
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b) Been diagnosed or treated for immune deficiency (other than AIDS), anemia
or other blood disorder (other than for HIV)?
Yes No
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c) Had recurrent fever, fatigue or unexplained weight loss?
Yes No
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6. Other than the above, have you ever been diagnosed or treated for:
a) Chest pain, high blood pressure, stroke, or disease of the heart, blood
vessels, or lungs?
Yes No
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b) Diabetes, mental or emotional disorder, disease of the brain or nervous
system, convulsions?
Yes No
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c) Cancer, tumor, disease of the stomach, intestines, liver
or kidneys?
Yes No
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7. Have you been hospitalized in the last five years, been advised to have any
diagnostic test, hospitalization or surgery by any licensed physician,
practitioner or health facility that has not yet been performed?
Yes No
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FOR ALL QUESTIONS ANSWERED "YES," FURNISH DETAILS.------------------------------
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I represent that the above statements are true and complete to the best of my
knowledge and belief. I understand that this application will become a part of
any policy issued . I also understand that any misrepresentations contained in
this application and relied on by the Company may be used to reduce or deny a
claim or void the contract if: (1) it is within its contestable period; and (2)
if such misrepresentation materially affects the acceptance of the risk.
Dated At
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Signature of Proposed Insured (City, State)
Name of Proposed Insured (printed):
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AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
I authorize The Travelers Insurance Company (referred to as The Travelers), its
Reinsurers, insurance support organizations, and their authorized
representatives to obtain medical and other information in order to evaluate
this application for insurance. I authorize any physician, medical practitioner,
hospital, clinic, other medical or medically related facility, insurance
company, the Medical Information Bureau, Inc., employer, consumer reporting
agency, or other insurance coverage, medical care, treatment, supplies or advice
with respect to me to furnish such information to The Travelers, its Reinsurers
or their authorized representatives.
This authorization will be valid from the date signed for a period of 26 months.
I agree that a photographic copy of this authorization is as valid as the
original. Information given in my application, including health care
information, may be made available without my prior authorization to other
insurance companies to which I make application for life or health insurance
coverage or to which a claim is submitted.
I have read this authorization and understand that I have a right to receive a
copy. I acknowledge receipt of the notice regarding: "Notification Regarding Use
and Release of Information to the Medical Information Bureau, Inc. and Other
Life Insurance Companies"
Dated At
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Signature of Proposed Insured (City, State)
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THE TRAVELERS INSURANCE COMPANY
NOTIFICATION REGARDING USE AND RELEASE OF INFORMATION TO THE MEDICAL INFORMATION
BUREAU, INC. AND OTHER LIFE INSURANCE COMPANIES
Any health care information developed is necessary to classify insurance risks,
conduct normal administrative procedures and process claims, and will be used
for those purposes only. No other use of this information will be made without
first obtaining your written consent.
This information will be treated as confidential except that The Travelers
Insurance Company or its Reinsurer(s) may make a brief report to the Medical
Information Bureau, Inc., a non-profit membership corporation of life insurance
companies which operates an information exchange on behalf of its members. Upon
request by another member insurance company to which you have applied for life
or health insurance coverage or to which a claim is submitted, the Bureau will
supply such company with the information it may have in its files.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your files. Medical information will be disclosed
only to your attending physician. If you question the accuracy of information in
the Bureau's file, you may contact the Bureau and seek a correction in
accordance with the procedures set forth in the federal Fair Credit Reporting
Act. The address of the Bureau's information office: Xxxx Xxxxxx Xxx 000, Xxxxx
Xxxxxxx, Xxxxxx, Xxxxxxxxxxxxx 00000, Telephone: (000)000-0000.
The Travelers Insurance Company or its Reinsurer(s) may release information
given in your application file, including health care information, to other life
insurance companies to which you apply for life or health insurance or to which
a claim is submitted.
L-15567-M
The Travelers Insurance Company o Xxx Xxxxx Xxxxxx x Xxxxxxxx, XX o 06183
EMPLOYER-SPONSORED TEMPORARY LIFE INSURANCE BINDER AGREEMENT
This Temporary Life Insurance Binder Agreement (the "Agreement") is made by and
between The Travelers Insurance Company (the "Company") and ____________________
(the "Owner").
In offering this Agreement, the Company has relied upon the attached census of
employees to be insured as well as information provided by the Employer.
While this Agreement is in effect, the Employer is not and will not become a
party to any other Agreement to provide life insurance coverage on any of the
employees listed in the Census without the prior agreement of the Company.
Subject to the terms of this Agreement and in consideration of the deposit
received, temporary life insurance will be provided from the Effective Date for
the qualified Proposed Insureds listed in the census.
1. Definitions:
(a) Proposed Insured - an individual 70 years of age or less applying for
permanent insurance who is listed in this Agreement and has been actively at
work for the last 90 days for at least 30 hours per week.
(b) Effective Date - the date on which temporary life insurance begins.
The Effective Date under this Agreement is __________
(c) Termination Date - the date on which temporary life insurance for
each Proposed Insured ends. It will be the earlier of:
(1) the date on which the policy on the Proposed Insured is issued; or
(2) the date on which a full or partial refund of the Deposit is
mailed to the Employer because an application is declined or
withdrawn; or
(3) days after the Effective date; or
(d) Binder Premium - the amount of premium deposit needed to effect the
temporary life insurance coverage on the Proposed Insureds contemplated by
this Agreement. The Binder Premium for the coverage provided by this
Agreement is $_______
2. Binder Coverage - the amount of temporary life insurance per Proposed Insured
provided by this Agreement is the amount to be applied for as stated on the
attached census subject to a per life maximum of $1,000,000 for all current
applications pending with the Company and its subsidiaries.
3. Death Benefits - For any death benefits to be paid under this Agreement.
Owner must represent and warrant that under applicable state law it has an
insurable interest in the insured employee and has obtained from the insured
employee any consent required by such law.
4. Suicide and Material Misrepresentation - If a Proposed Insured commits
suicide, or death is caused in whole or in part by any intentionally
self-inflicted injury or if there is found to be material misrepresentation on
the application, the Company's only liability as to such a Proposed Insured
shall be return the applicable portion of the premium to the Employer.
5. Beneficiary - any death benefits claimed under this Agreement shall be
payable to the employer unless an alternative beneficiary is named in the
application. 6. Amendments - this Agreement may only be modified or amended in
writing by the Company through its duly authorized officers.
TEMPORARY INSURANCE IS PROVIDED UNDER THE TERMS OF THIS AGREEMENT FOR THE
QUALIFIED ACTIVELY AT WORK PROPOSED INSUREDS WHO ARE LISTED IN THE ATTACHED
CENSUS.
Offered by: Title:
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SIGNATURE DATE TRAVELERS INSURANCE COMPANY
Accepted by:
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COMPANY OFFICER TITLE DATE COMPANY
Witnessed by:
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BROKER DATE BROKER/AGENT # FIRM
