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LIFE INSURANCE APPLICATION
Aetna Life Insurance and Annuity Co.
000 Xxxxxxxxxx Xxxxxx
Xxxxxxxx, XX 00000-0000
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General ANSWER ALL QUESTIONS IF:
Information [checkmark] New Insurance [ ] Increase Amount $ [ ] Policy No.
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ANSWER QUESTIONS 1, 8 (if applicable), 4, 20, 21 & Policyowner/Taxpayer Id. Number
[ ] Term Conversion/Guaranteed Option $ . Continue $ as term
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[ ] Other Policy Change ANSWER APPLICABLE QUESTIONS
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[ ] Policy Number to be changed/converted
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ST OF DEL [checkmark] STATE OF DELIVERY CT
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(Proposed) 1. Print Full Legal Name (First, Middle, Last)
Insured Xxxx X. Xxx
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Residence Address (Number, Street) P. O. Xxx
000 Xxxx Xxxxxx
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Xxxx, Xxxxx and Zip Code
Xxxxxxxx, XX 00000
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Sex Date of Birth (mm/dd/yy) Place of Birth MVR License # and License State
Male 01/01/62 Xxxx, XX 0000000 CT
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2a. Occupation (Title & Give Exact Duties)
Comptroller
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2b. Employer's Name and Address 2c. Annual Income
ABC CORPORATION $175,000
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2d. Amount of life insurance presently in force:
Aetna $0.00 ADB $0.00 Other Companies $0.00 ADB $0.00
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Are there current negotiations with other companies? [ ] Yes [checkmark] No
If Yes, advise Company and results.
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3. Will life insurance or annuity in any Company be replaced or changed if insurance applied for is
issued? [ ] Yes [checkmark] No
Explain
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Policy 4. Basic Plan Flex. Prem. Var. UL on 2 Insds Face Amount $500,000
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Information Death Benefit Option (if applicable) Option 1
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Dividend Option [ ] Pay in Cash [ ] Reduce premium (not for salary deduction)
[ ] Other [ ] Specify
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Direct Billing Frequency [ ] Annual [ ] Semi-Annual
[ ] Quarterly [checkmark] Monthly (ACP/List Xxxx) Plan
List Supplemental Benefits/Riders & Amounts (e.g. WP, ADB, EPOR, ROPR)
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70059-96 * For CIR - Submit application supplement1
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(Proposed) NON MEDICAL - QUESTIONS 5-19 SHOULD NOT BE COMPLETED FOR TERM
Insured CONVERSIONS OR EXERCISE OF GUARANTEED INSURABILITY OPTION
Information 5. HAVE YOU WITHIN 2 YEARS: (IF YES, EXPLAIN)
a. Flown as a pilot or crew member or intend to do so? (If Yes, furnish
Aviation supplement) . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
b. Engaged in motor vehicle or boat racing, rock or mountain climbing,
hang gliding or sky, skin or scuba diving or intend such activities?
(If Yes, furnish Avocation supplement). . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
c. Had your license suspended or revoked, had 3 or more moving violations,
or been charged with driving under the influence of alcohol or drugs? [ ] Yes [checkmark] No
d. Frequently traveled outside of the United States or intend to do so? . . . . [ ] Yes [checkmark] No
6. HAVE YOU EVER:
a. Had insurance refused, or offered only with an extra premium? . . . . . . . [ ] Yes [checkmark] No
b. Been arrested and convicted for a felony offense? . . . . . . . . . . . . . [ ] Yes [checkmark] No
7. HAVE YOU IN THE LAST 5 YEARS: (IF YES, EXPLAIN)
a. Used hallucinogenic or narcotic drugs not prescribed by a doctor? . . . . . [ ] Yes [checkmark] No
b. Used alcoholic beverages? (Note type, quantity and frequency) . . . . . . . [ ] Yes [checkmark] No
c. Had or been advised to have medical treatment or counseling from a
commonly recognized practitioner or organization for alcohol or drug use?. [ ] Yes [checkmark] No
8. a. Have you smoked cigarettes within the past 12 months? . . . . . . . . . . . [ ] Yes [checkmark] No
Information If Yes, how much? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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b. If No, have you used any other tobacco products within the past 12 months
(e.g. cigar, pipe, smokeless tobacco)? . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
If Yes, have you smoked cigarettes within the past 10 years? . . . . . [ ] Yes [checkmark] No
c. Have you used any nicotine substitutes within the past 12 months
(e.g. patch, gum)? . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
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Height & 9. a. What is your current height? . . . . . . . . . . . . . . . . . . . . . . . . 6'0"
Weight ---------------------
b. What is your current weight? . . . . . . . . . . . . . . . . . . . . . . . . 200lbs
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c. If under age 2, birth weight? . . . . . . . . . . . . . . . . . . . . . . .
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History 10. Have you had a history of heart, lung or liver disorder, stroke, diabetes or
cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
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Attending 11. Name, address and phone number of personal physician, date, reason last seen and results.
Physician Xx. Xxxxx
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00 Xxxxxx Xxxxxx, Xxxxxxxx, XX 00000 (860) 275-0121
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Routine Physical on 9/30/96.
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ADDITIONAL INFORMATION (Give details of YES answers, dates and results) For
additional space please use Addendum Sheet.
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QUES. #
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IF AN EXAM IS REQUIRED AND QUESTION 10 IS ANSWERED "YES" AN MD EXAM IS REQUIRED
70059-96
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(Proposed) PART II - QUESTIONS 12 - 19 REQUIRED EVEN FOR EXAMINED BUSINESS
Insured 12. HAVE YOU EVER IN THE LAST 10 YEARS HAD OR BEEN TREATED
Information FOR: (IF YES, EXPLAIN)
a. Mental or nervous disorder? . . . . . . . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
b. Disease of the nervous system or brain? . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
c. Fainting, seizures, paralysis or stroke? . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
d. Shortness of breath, persistent cough? . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
e. Emphysema or other lung disease? . . . . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
f. Chest pain, high blood pressure, heart attack, heart murmur, disease of the
heart or blood vessels? . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
g. Hepatitis, cirrhosis, or other disease of the liver or pancreas? . . . . [ ] Yes [checkmark] No
h. Ulcer, colitis, chronic diarrhea, or other disorder of the stomach or
intestines? [ ] Yes [checkmark] No
i. Sugar, albumin, blood or pus in urine? . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
j. Disease of the kidneys, reproductive organs or sexually transmitted disease
(other than AIDS)? [ ] Yes [checkmark] No
k. Diabetes, thyroid or glandular disease? . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
l. Arthritis, disease or injury of the muscles, bones or joints? . . . . . . [ ] Yes [checkmark] No
m. Cancer, tumor, cyst, disease of skin or lymph glands? . . . . . . . . . . [ ] Yes [checkmark] No
13. HAVE YOU IN THE LAST 10 YEARS (IF YES, EXPLAIN):
a. Been diagnosed or treated for immune deficiency (other than AIDS), anemia
or other blood disorder by a member of the medical profession? . . . . [ ] Yes [checkmark] No
b. Had recurrent fever, fatigue or unexplained weight loss? . . . . . . . [ ] Yes [checkmark] No
14. Have you in the last 10 years been diagnosed or treated for AIDS/ARC or
had a positive HIV (AIDS virus) antibody test?. . . . . . . . . . . . . . [ ] Yes [checkmark] No
15. OTHER THAN ABOVE, HAVE YOU WITHIN THE PAST 5 YEARS: No
(IF YES, EXPLAIN)
a. Had a checkup, consultation, illness, injury, surgery or diagnostic test? [checkmark] Yes [ ] No
b. Been advised to have any diagnostic test, hospitalization or surgery which
was not completed? . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
16. a. Are you now under observation or treatment? . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
b. Do you need assistance, supervision or use of medical appliances of any [ ] Yes [checkmark] No
kind? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17. Have you within 90 days had or been advised to have surgery or to be admitted
to a medical facility or within 2 years been treated or diagnosed by a physician
for heart disease, stroke, immune disorder (other than AIDS) or cancer? . . [ ] Yes [checkmark] No
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Family 18. a. Do you have a family history of diabetes, heart disease or hereditary
History disease? (If Yes, explain) . . . . . . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No
b. Father, age: 68 health status: healthy if deceased, cause:
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c. Mother, age: 65 health status: healthy if deceased, cause:
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Explanations 19. EXPLANATIONS: Include, nature and severity of condition, frequency of attacks, treatments
received, medication, dates, name, address & phone number of medical attendants and hospitals.
For additional space please use Addendum Sheet.
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QUESTION #
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15a Routine Physical
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70059-96
BENEFICIARY/OWNER INFORMATION
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Beneficiary 20 A. PRIMARY (provide full name and relationship)
Information Xxxx X. Xxx, Wife
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Soc. Sec. # ###-##-####
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B. SECONDARY (If any, provide full name and relationship)
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Unless otherwise requested, if more than one beneficiary is named, payment will be made in equal
shares. If no beneficiary survives the insured, payment will be made to the executors or
administrators of the insured.
C. OTHER [ ] (e.g. Mode Settlement, Trustee under the Will, Individual Creditor. If Creditor -
who will receive any balance.
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Soc. Sec. #
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D. FINAL (check one) [checkmark]Estate of the Insured
[ ] Executors or Administrators of the Survivor of the Beneficiary(ies)
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OWNER POLICYOWNER: THE (PROPOSED) INSURED IS POLICYOWNER UNLESS UNDER AGE 15
OR OTHERWISE REQUESTED.
21. A. PRIMARY (Provide full name, address, relationship and Date of Birth, mm/dd/yy)
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B. SECONDARY (If any, provide full name, address, relationship and Date of Birth, mm/dd/yy)
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C. OTHER [ ]
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D. FINAL: (check one) [ ] Insured
[ ] Insured at legal age in policy delivery state
[checkmark] Executors or Administrators of the Survivor of the Owner(s)
70059-96
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22. Any payment is subject to the terms and conditions of the Temporary Insurance Agreement. If payment
is made, the Temporary Insurance Agreement must be provided and explained.
23. If automatic payment from checking account is selected:
I (we) authorize Aetna Life Insurance and Annuity Company (ALIAC) to debit my (our) checking account
electronically, by paper means or by any other commercially accepted method, to cover premiums and
other payments for my policy(ies). I (we) also authorize my financial institution named on the voided check
attached to charge my account for such payments. If my/our account number or financial institution
change, I (we) authorize ALIAC to accept verbal instructions from me regarding such changes, and to
change this authorization accordingly. This authorization is to remain in full force and effect until ALIAC
has received written notification from me (or either of us) of its termination within a reasonable time
to take action.
[ ] Attach "VOID" Check Date of draw (8th, 20th or 28th)
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Signature of Payor
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24. 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 and confinement in prison.
The answers above are true and complete to the best of knowledge and belief.
I agree that no producer may alter the terms of the application, the Temporary Insurance Agreement or the policy,
nor can the producer waive any of Aetna's rights or requirements.
I agree that coverage can take effect only if the proposed insured is alive, and all answers in this application
material to the risk are still true and complete when the policy is delivered and the entire first premium is
paid.
I agree to advise the Company or producer in writing of any known or suspected changes in the health of the
proposed insured, or of any changes to any answers on this application, prior to delivery of this policy.
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Signature of (Proposed) Insured (Required if age 10 or over) Date
Xxxx X. Xxx 09/01/97
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(Signature of parent if juvenile under age 10) Date
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Signature of Applicant/Policyowner, if other than proposed insured Date
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Signature of Assignee, if applicable Date
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Xxxx Xxxxx Xxx
Xxxxxxxx XX 00000
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Signature of Agent I M Agent Agent License #567 Date 09-01-97
70059-96
