EXHIBIT (e)(5)
THIS FORM MUST BE COMPLETED, SIGNED AND LEFT WITH THE APPLICANT.
Limited Temporary Life Insurance Agreement (Agreement)
THIS AGREEMENT PROVIDES A LIMITED AMOUNT OF LIFE INSURANCE COVERAGE FOR A LIMITED PERIOD OF TIME, SUBJECT
TO THE TERMS AND CONDITIONS SET FORTH BELOW. SUCH INSURANCE IS NOT AVAILABLE FOR ANY RIDERS OR ACCIDENT
AND/OR HEALTH INSURANCE. PLEASE FOLLOW STEPS 1 - 4.
1. CHECK APPROPRIATE COMPANY:
[_] THE UNITED STATES LIFE INSURANCE COMPANY IN XXX XXXX XX XXX XXXX, XXX XXXX, XX
[_] AMERICAN INTERNATIONAL LIFE ASSURANCE COMPANY OF NEW YORK, NEW YORK, NY
In this Agreement, "Company" refers to the insurance company whose name is checked above, which is
responsible for the obligation and payment of benefits under any policy that it may issue. No other
company shown is responsible for such obligations or payments. In this Agreement, "Policy" refers to
the Policy or Certificate applied for in the application. In this Agreement, "Proposed Insured(s)"
refers to the Primary Proposed Insured under the life policy and the Other Proposed Insured under a
joint life or survivorship policy, if applicable.
2. COMPLETE THE FOLLOWING: (PLEASE PRINT)
Primary Proposed Insured ____________________________________________________________________________
Other Proposed Insured ______________________________________________________________________________
(APPLICABLE ONLY FOR A JOINT LIFE OR SURVIVORSHIP POLICY)
Owner (IF OTHER THAN PRIMARY PROPOSED INSURED) ______________________________________________________
Modal Premium Amount Received _______________________________________________________________________
Date of Policy Application __________________________________________________________________________
3. ANSWER THE FOLLOWING QUESTIONS:
Yes No
a. Has any Proposed Insured ever had a heart attack, stroke, cancer, diabetes or
disorder of the immune system, or during the last two years been confined in a
hospital or other health care facility or been advised to have any diagnostic test
(exclude HIV testing) or surgery not yet performed? [_] [_]
b. Is any Proposed Insured age 71 or above? [_] [_]
STOP If the correct answer to any question above is YES, or any question is answered falsely or left
blank, coverage is not available under this Agreement and it is void. This form should not be
completed and premium may not be collected. Any collection of premium will not activate coverage
under this Agreement.
TERMS AND CONDITIONS OF COVERAGE UNDER THIS AGREEMENT
A. ELIGIBILITY FOR COVERAGE: If the correct answer is YES to any of the questions listed above,
temporary insurance is NOT available and this Agreement is void.
Agents do not have authority to waive these requirements or to collect premium by any means including
cash, check, bank draft authorization, credit card authorization, salary savings, government
allotment, payroll deduction or any other monetary instrument if any Proposed Insured is ineligible
for coverage under this Agreement.
B. WHEN COVERAGE WILL BEGIN:
COVERAGE WILL BEGIN WHEN ALL OF THE FOLLOWING CONDITIONS HAVE BEEN MET:
. Part A of the application must be completed, signed and dated; and
. The first modal premium must be paid; and
. Part B of the application must be completed, signed and dated and all medical exam requirements
satisfied.
AGLC101431-NY-2006
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COVERAGE UNDER THIS AGREEMENT WILL NOT EXIST UNTIL ALL OF THE CONDITIONS LISTED
ABOVE HAVE BEEN MET.
The first modal premium will be considered paid, if one of the following valid
items is submitted with Part A of the application and that payment is honored:
(i) a check in the amount of the first modal premium; (ii) a completed and
signed Automatic Bank Draft Agreement; (iii) a completed and signed Credit Card
Authorization form; (iv) a completed and signed salary savings authorization;
(v) a completed and signed government allotment authorization; (vi) a completed
and signed payroll deduction authorization. Temporary life insurance under this
Agreement will not begin if any form of payment submitted is not honored. All
premium payments must be made payable to the Company checked above. Do not leave
payee blank or make payable to the agent. The prepayment for this temporary
insurance will be applied to the first premium due if the policy is issued, or
refunded if the Company declines the application or if the policy is not
accepted by the Owner.
C. WHEN COVERAGE WILL END:
COVERAGE UNDER THIS AGREEMENT WILL END at 12:01 A.M. ON THE EARLIEST OF THE
FOLLOWING DATES:
. The date the policy is delivered to the Owner or his/her agent and all
amendments and delivery requirements have been completed;
. The date the Company mails or otherwise provides notice to the Owner
or his/her agent that it was unable to approve the requested coverage
at the premium amount quoted and a counter offer is made by the
Company;
. The date the Company mails or otherwise provides notice to the Owner
or his/her agent that it has declined or cancelled the application;
. The date the Company mails or otherwise provides notice to the Owner
or his/her agent that the application will not be considered on a
prepaid basis;
. The date the Company mails or otherwise provides a premium refund to
the Owner or his/her agent; or
. 60 calendar days from the date coverage begins under this Agreement.
D. The Company will pay the death benefit amount described below to the
beneficiary named in the application if:
. The Company receives due proof of death that the Primary Proposed
Insured (and the Other Proposed Insured if the application was for a
joint life or survivorship policy) died, while the coverage under this
Agreement was in effect, except due to suicide; and
. All eligibility requirements and conditions for coverage under this
Agreement have been met.
The total death benefit amount pursuant to this Agreement and any other
limited temporary life insurance agreements covering the Primary Proposed
Insured (and the Other Proposed Insured if the application was for a joint
life or survivorship policy) will be the LESSER of:
. The Plan amount applied for to cover the Proposed Insured(s) under the
base life policy; or
. $ 500,000 plus the amount of any premium paid for coverage in excess
of $500,000; or
. If death is due to suicide, the amount of premium paid will be
refunded, and no death benefit will be paid.
4. COMPLETE AND SIGN THIS SECTION:
Any misrepresentation contained in this Agreement or the Receipt and relied
on by the Company may be used to deny a claim or to void this Agreement.
The Company is not bound by any acts or statements that attempt to alter or
change the terms of this Agreement or the Receipt.
I, THE OWNER, HAVE RECEIVED AND READ THIS AGREEMENT AND THE RECEIPT OR THEY
WERE READ TO ME AND AGREE TO BE BOUND BY THE TERMS AND CONDITIONS STATED
HEREIN.
Signature of Owner ____________________________________________________________ Date _____________________
Signature of Primary Proposed Insured _________________________________________ Date _____________________
Signature of Other Proposed Insured (IF APPLICABLE) ___________________________ Date _____________________
Writing Agent Name (PLEASE PRINT) _____________________________________________ Writing Agent # __________
AGLC101431-NY-2006
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