EXHIBIT
1(10)(b)
Form of Application
16
EMPLOYER MASTER APPLICATION (Part 1A) and TEMPORARY LIFE INSURANCE
AGREEMENT
Group Flexible Premium Adjustable Life Insurance
To: [_] Massachusetts Mutual Life Insurance Co. [_] MML Bay State Life Insurance Co.
Home and Principal Administrative Office: Principal Administrative Office:
Xxxxxxxxxxx, Xxxxxxxxxxxxx 00000-0000 Xxxxxxxxxxx, Xxxxxxxxxxxxx 00000-0000
For New Life Insurance Under Employer - Sponsored Plans
Employer Data
1.) Name:
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2.) Business Address:
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Street & No. City State Zip Code
3.) Payroll Administrator:
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4.) Primary Contact (include telephone number):
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5.) Taxpayer ID No.:
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6.) Nature of Business:
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Proposed Insured Data
For each Proposed Insured, the attached census lists: Full Name, Social Security
Number, Date Of Birth, Sex and, for the first Certificate Year, Selected Face
Amount
7.) Number of Eligible Participants:
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8.) Have all eligible participants been actively-at-work on a full-time basis
during the 90 days prior to their participation in the plan for the Employer or
its affiliate(s)? (disregard vacations and absences of less than 7 days)
Yes No; If "No," give detailed explanation in no. 21.
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9.) Are any eligible participants receiving or applying to
receive disability benefits as of the date they become
eligible to participate in the plan?
Yes No
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10.) Is every Proposed Insured a citizen of and resident
in the USA?
Yes No
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If "No," is citizenship and residence of each Proposed
Insured indicated on the census?
Yes No
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Life Insurance Data (Please check (X) on the appropriate line if you desire the
specified feature.)
11.) Variable Rider Option: Yes No
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12.) Other Electable Riders:
Waiver of Monthly Charges Rider
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Accidental Death & Dismemberment (AD&D)
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13.) Death Benefit Option:
Option A - Selected Face Amount
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Option B - Selected Face Amount plus Account Value
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14.) Loan Interest Rate:
Adjustable 6% Fixed
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15.) Formula for Determining Benefit Schedule:
1 - % of Salary (Specify. Salaries must be included with census data)
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2 - Flat or Class Plan (specify)
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3 - Other (specify)
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16.) Plan Effective Date (for all certificates on Proposed Insureds listed on
attached census):
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17.) Modal Term:
a.) Annual Semi-Annual Quarterly Monthly
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b.) Amount of Employer additional premium (if any):
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Frequency for Employer additional premium:
Annual Semi-Annual Quarterly Monthly
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18.) Owner: as designated by the Proposed Insured on the Part 1B
19.) Beneficiary: as designated by the Proposed Insured on the Part 1B
20.) Will the insurance now being applied for replace or change, or is it
intended to replace or change, any insurance or annuity, in whole or in part,
issued by this or any other company? Yes No
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If "Yes," give company name, policy number, amount and plans in no. 21.
21.) Remarks:
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22.) Premium remitted with this Application $ .
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Temporary Insurance Agreement
23.) The Employer applies for temporary life insurance on the life of each
Proposed Insured listed in the attached census:
Yes No; If "No,"the following provisions of this section do not apply.
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24.) The effective date of the temporary insurance agreement is the latest of:
(i) The date we receive from the Employer an amount of premium not
less than one-fourth of the sum of the annual modal term premiums
for the certificates applied for;
(ii) The date this Application (Part 1A) is signed by one of our
Officers; or
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(iii) The date chosen by the Employer (please specify date) .
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During the temporary insurance period, the amount of premium received will be
held in a suspense account.
25.) The amount of temporary insurance on the life of a Proposed Insured is:
The Selected Face Amount for the first Certificate Year, as shown
----- in the census; or
Other - (Provide formula) .
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In no event however, may the amount of temporary insurance be greater than our
Guaranteed Issue limits.
26.) Any temporary insurance on the life of a Proposed Insured will terminate at
the earliest of:
(i) The date the permanent life insurance applied for in this
application takes effect on the life of that Proposed Insured;
(ii) The date the Proposed Insured fails to meet any requirements to
qualify for the permanent insurance applied for;
(iii) The date 90 days after the effective date of the temporary
insurance; or
(iv) The date the Employer's written notice of termination of the
insurance is received by us at our Principal Administrative
Office.
27.) Temporary Insurance Beneficiary Designation:
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If the temporary insurance on the life of a Proposed Insured terminates for the
reason specified above in no. 26(i), the amount of premium paid with this
Application that was allocated to the certificate on the life of that Proposed
Insured will be applied as premiums under that permanent life insurance
certificate. If the temporary insurance on the life of a Proposed Insured
terminates for any other reason, we will refund the amount of premium paid with
this Application that was allocated to the certificate on the life of that
Proposed Insured, less a mortality charge. This mortality charge will be for the
period from the effective date of the temporary insurance to, but not including,
the termination date. The mortality charge for that Proposed Insured will be
based on the amount of temporary insurance on the Proposed Insured's life, and
the term rate from the attached Table of Temporary Insurance Rates for the
Proposed Insured's age.
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Acknowledgment and Signature
The person(s) signing below acknowledge and agree that:
The Application - This is part of an application for permanent life insurance.
The application includes this Part 1A and its attached census and Table of
Temporary Insurance Rates, the Part 1B (which has been or which will be
completed by the Proposed Insured), any Part 2 that may be required, and any
amendments or supplements to either Part. To the best of the knowledge and
belief of the person(s) signing below, all statements in this application are
complete and true and were truly recorded. Each person signing below adopts all
the statements made in the application and agrees to be bound by them. This
Application (Part 1A) is valid until withdrawn by the Employer by written notice
to us at our Principal Administrative Office. Withdrawal of this Application
(Part 1A) shall not necessarily affect its use with applications submitted prior
to the date we receive such notice.
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Our Liability - A minimum amount of premium may be paid to the agent in exchange
for temporary life insurance as discussed above in the Temporary Insurance
Agreement section. If this is done, we shall be liable only as set forth in that
Agreement. If that amount of premium is not paid, we shall have no liability
unless and until:
- The application has been approved by us at our Principal Administrative
Office; and
- The first premium has been paid during the lifetime of the
Proposed Insured; and
- The Proposed Insured is actively working during the 90 days prior to
their participation in the plan for the Employer or its affiliate(s); and
- The policy, contract or certificate of coverage has been delivered to the
person named as Owner in the certificate; and
- At the time of payment and delivery, all statements in the application
which are material to the risk are complete and true as though they were
made at that time.
If any of these conditions are not met, the policy, contract or certificate of
coverage and rider(s) applied for shall not take effect.
Authority of Agents - No agent can change the terms of this application or any
policy, contract or certificate issued by us. No agent can waive any of our
rights or requirements, or extend any time for payment.
Changes and Corrections - Any change or correction of the application will be
shown on an Amendment of Application attached to the policy, contract or
certificate. Acceptance of any policy, contract or certificate of coverage
issued shall be acceptance of any change or correction of the application we
made. However, unless otherwise indicated in this application, any correction or
change of amount, classification, plan of insurance or riders must be agreed to
in writing.
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Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines or confinement in
prison.
For the Employer:
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Print Name and Title of Person Signature of Authorized Person
Authorized to Sign for the Employer
Signed at on
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City State Date
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For the Life Insurance Company specified above
(if temporary insurance applied for):
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Print Name and Title of Officer Authorized Officer's Signature Date
to Sign for Life Insurance Company
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Will the Insurance now being applied for replace, or change, or is it intended to replace or change, any insurance or
annuity, in whole or in part, issued by this or any other company? If "yes," I have complied with all state replacement
requirements. Yes No
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General Agent Submitting Application Signature of Soliciting Registered Representative / Agent
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